Antipsychotic prescribing in Black and White hospitalised patients.

Abstract

Ethnicity may affect the prescribing of antipsychotic treatment. Previous UK studies conducted in south London have found few differences in antipsychotic prescribing quality for Black and White patients. This larger multicentre study examined the effect of ethnicity on antipsychotic prescribing quality in areas serving the largest proportions of Black patients in the UK. A cross-sectional survey with collection of multiple confounding factors potentially affecting outcomes in eight secondary care units in England over a three month period. Participants were Black or White inpatients prescribed regular antipsychotics on the day of the survey. Antipsychotic dose (expressed as a percentage of licensed maximum), high dose (being prescribed antipsychotic medication above maximum dose), polypharmacy (more than one antipsychotic prescribed), type (typical or atypical antipsychotic) and costs were the main outcome measures. Data were collected for 938 patients. There were no significant differences in any outcome by ethnicity: dose (adjusted percentage difference 0.97 [95% confidence interval (CI) -4.28, 6.22], p = 0.72); high dose (adjusted odds ratio (AOR) 0.98 [CI 0.63, 1.51], p = 0.92); polypharmacy prescribed (AOR 1.15 [CI 0.87, 1.51], p = 0.33); polypharmacy administered (AOR 1.08 [CI 0.78, 1.49], p = 0.66); use of typical antipsychotics (AOR 1.25 [CI 0.87, 1.79], p = 0.22); and cost (adjusted effect size 1.75 [CI -9.81, 13.31], p = 0.77). Antipsychotic prescribing practice did not differ between Black and White patients.

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Journal of Psychopharmacology
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DOI: 10.1177/0269881109387841
2011 25: 704J Psychopharmacol
Anne Connolly, David Taylor, Anna Sparshatt and Victoria Cornelius
Antipsychotic prescribing in Black and White hospitalised patients


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Original Paper
Antipsychotic prescribing in Black and White
hospitalised patients
Anne Connolly1, David Taylor1, Anna Sparshatt1and
Victoria Cornelius2
Abstract
Ethnicity may affect the prescribing of antipsychotic treatment. Previous UK studies conducted in south London have found few differences in
antipsychotic prescribing quality for Black and White patients. This larger multicentre study examined the effect of ethnicity on antipsychotic
prescribing quality in areas serving the largest proportions of Black patients in the UK. A cross-sectional survey with collection of multiple confounding
factors potentially affecting outcomes in eight secondary care units in England over a three month period. Participants were Black or White inpatients
prescribed regular antipsychotics on the day of the survey. Antipsychotic dose (expressed as a percentage of licensed maximum), high dose (being
prescribed antipsychotic medication above maximum dose), polypharmacy (more than one antipsychotic prescribed), type (typical or atypical anti-
psychotic) and costs were the main outcome measures. Data were collected for 938 patients. There were no significant differences in any outcome by
ethnicity: dose (adjusted percentage difference 0.97 [95% confidence interval (CI) ?4.28, 6.22], p¼0.72); high dose (adjusted odds ratio (AOR) 0.98
[CI 0.63, 1.51], p¼0.92); polypharmacy prescribed (AOR 1.15 [CI 0.87, 1.51], p¼0.33); polypharmacy administered (AOR 1.08 [CI 0.78, 1.49],
p¼0.66); use of typical antipsychotics (AOR 1.25 [CI 0.87, 1.79], p¼0.22); and cost (adjusted effect size 1.75 [CI ?9.81, 13.31], p¼0.77).
Antipsychotic prescribing practice did not differ between Black and White patients.
Keywords
Antipsychotics, ethnicity, prescribing
Introduction
Black patients are more likely to be hospitalised and detained
in UK psychiatric hospitals compared with their White coun-
terparts (Singh et al., 2007; Tyrer et al., 2006). Prescribing of
antipsychotics may also be affected by ethnicity. Differences
in dose, (Diaz and de Leon, 2002; Segal et al., 1996; Walkup
et al., 2000) type (Kreyenbuhl et al., 2003; Kuno and
Rothbard, 2002) and number (Taylor, 2004) of antipsychotics
prescribed have been described, predominantly in American
studies. These findings have resulted in accusations of insti-
tutional racism in mental health services (Norfolk, 2003).
Previously we have examined the effect of ethnicity on the
prescribing of antipsychotics in the UK both in our trust
(National Health Service (NHS) provider of secondary care
mental health services) (Connolly et al., 2007) and more
recently in our neighbouring mental health trusts (Connolly
and Taylor, 2008). Neither study revealed major differences in
the quality of antipsychotic prescribing but statistical power
was somewhat limited, few inpatient units were studied and
the geographical area under investigation was restricted to
south London. The undertaking of larger pharmacoepidemio-
logical (e.g. computer database) studies is precluded by the
need to collect data on and correct for numerous potential
confounders of prescribing practice. This extent of data col-
lection is best undertaken in inpatient units where data can be
readily and accurately recorded. In the present study our aim
was to examine the influence of ethnicity (specifically being
Black or White) on antipsychotic prescribing practice in inpa-
tient units serving populations with the largest proportions of
Black people in the UK.
Method
Ten mental health trusts were approached to take part in the
study. These trusts were chosen because they were serving
populations with the largest proportions of Black patients
in the UK (Healthcare Commission, 2007). Nine trusts
agreed to take part and eight, (Barnet, Enfield & Harringey
(BEH), Camden & Islington (C&I), Central & North West
London (CNWL), East London & City (ELC), Manchester
Mental Health & Social Care Trust (Manchester), North East
1Pharmacy Department, Maudsley Hospital, London, UK.
2Nutrition and Respiratory Biomedical Research Units, Southampton
General Hospital, UK.
Corresponding author:
Anne Connolly, Pharmacy Department, Maudsley Hospital, Denmark Hill,
London SE5 8AZ, UK
Email: anne.connolly@slam.nhs.uk
Journal of Psychopharmacology
25(5) 704–709
! The Author(s) 2010
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London (NEL), Nottinghamshire Healthcare (Nottingham),
and South London & Maudsley (SLaM)), completed the data
collection during late 2008 and early 2009. We sought and
obtained individual trust approvals for the study through
local clinical audit channels. All data were anonymised at
source and participants were not identifiable by the data ana-
lyst (Anne Connolly [AC]).
The main outcomes of the study were dose (expressed as a
percentage of licensed maximum [Yorston and Pinney, 2000]),
being prescribed antipsychotic medication above maximum
British National Formulary (BNF) dose (British Medical
Association and Royal Pharmaceutical Society of Great
Britain, 2008), polypharmacy (more than one antipsychotic
prescribed), type of antipsychotic (typical or atypical antipsy-
chotic) and costs. These were determined by reference to each
patient’s medication chart and to standard reference texts for
dose (BNF) and cost (MIMS, 2008).
Subjects
Patients included were all adult inpatients on acute general
psychiatry wards, designated Black or White, and were pre-
scribed and taking one or more regular antipsychotics on the
day of the data collection (or had received a when-required
‘p.r.n.’(pro re nata) dose in the last 24 hours). Recording of
ethnicity is mandatory for all inpatients and patients were
classed as Black (Black British, Black African, Black
Caribbean, Black other) or White (White British, White
Irish, White other) according to their medical notes (as cate-
gorised by the Office for National Statistics) (Office for
National Statistics, 2001). Mixed race patients were excluded
in this analysis. All suitable patients on acute general psychi-
atry wards within each trust were included over a three month
period in 2008/2009: none was excluded except for reasons
above.
Data collection
Data were collected by pharmacists or doctors working
within each trust. Each data collector was trained by one of
the authors (AC). Potential confounders were predetermined
and the following were determined by reference to casenotes:
age; current legal status; current substance misuse; diagnosis;
duration of illness; education; employment status; forensic
history (previous conviction or currently charged with an
offence); gender; history of or current non-compliance; lan-
guage; length of current admission; number of previous
admissions; previous antipsychotic treatments; previous treat-
ment with current antipsychotic medication; race of patient’s
consultant; smoking status; weight. The remaining confoun-
ders i.e. anticholinergic prescribed regularly, length of current
antipsychotic treatment and route of administration were col-
lected from prescription charts.
Statistical analysis
Justification for sample size. We performed a ‘power’
calculation before starting the study. A sample size of 788
was calculated to be required to have an 80% chance of
detecting a 5% (55% vs 50%) absolute difference for our
main outcome (percentage maximum dose) between Black
and White patients (assuming a standard deviation of 25)
Data analysis. We aimed to compare the five outcomes
between our two groups (Black and White patients) and to
adjust the resulting comparisons for the effect of confounding
variables. Centre was not included as a confounder in the
data analysis but we did examine whether or not prescribing
practice varied by centre. Data collection forms were checked
for accuracy and completeness three times before entry onto a
database. In addition, the database was again checked against
paper records after all the data had been entered.
Baseline demographic and clinical characteristics were
analysed by ethnicity. The null hypothesis was that Black
patients were prescribed the same total median dose of anti-
psychotics as White patients. A linear regression model was
then used to investigate whether there was a difference
between Black and White patients for the continuous out-
comes of dose and cost of treatment. Confounding variables
to be included in the model were selected using a stepwise
forward selection procedure with a selection criterion of
10% and removal criterion of 20%. Where the relationship
between continuous potential confounding variables and the
outcomes could not be assumed to be linear (a requirement
for regression modelling) and transforming variables did not
induce a linear relationship, restricted cubic splines were
applied. The fit of each model and the influence of observa-
tions were examined. This modelling produced an adjusted
effect size (i.e. median percentage difference for dose and
median cost difference) for ethnicity for the outcomes of
dose and cost. A similar approach was used for the binary
outcomes of high dose, polypharmacy and prescribing of typ-
ical drugs, but using logistic regression modelling. This
modelling allowed the calculation of adjusted odds ratios
(AORs). Identification of confounding variables was as
described above. The fit of each model was examined using
residual analysis.
Initially a complete case analysis was performed for each
of the regression models i.e. where only patients with com-
plete covariate data were included in the model. However,
excluding patients without full information may result in
biased estimates. Consequently, values were imputed for
patients with missing covariate data using a multiple imputa-
tion method. For each variable an appropriate regression
model was specified. Five datasets containing imputed
values were created then each data set was analysed and the
relevant parameters were averaged across the data to give a
single estimate. The analysis was performed using the func-
tion ICE in Stata version 10. The adjusted results reported are
for the imputed data sets.
Results
We collected data on 938 patients from eight centres of which
541 (57.7%) were White and 397 (42.3%) Black. SLaM pro-
vided 199 (21.2%) subjects, CNWL 148 (15.8%), ELC 121
(12.9%), BEH 109 (11.6%), C&I 98 (10.4%), NEL 94 (10%),
Manchester 89(9.5%), and
Demographic and clinical characteristics of these patients
Nottingham80(8.5%).
Connolly et al. 705
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by ethnicity and centre are described in Tables 1 and 2. Not
all confounder data were available for all subjects at the time
of the survey. The proportion of complete confounder data
was 94.6% (18,627 complete data points) and outcome data
100%; missing data were imputed as described. Each outcome
model was adjusted for multiple confounders.
Outcomes are described in Figures 1–6. There were no
significant differences in any outcome by ethnicity.
Discussion
Main findings
In this multicentre study of antipsychotic prescribing practice
in Black and White patients we found no significant differ-
ences in dose, high dose, polypharmacy, or type and cost of
treatment, after adjustment for multiple confounding factors.
Our study included a large number of patients from different
parts of the UK. The numerous associations found between
potential confounders and outcomes confirm the necessity for
adjustment of these factors.
Table 1. Demographic and clinical categories by ethnicity
Variable (n) White n¼541 (%) Black n¼397 (%)
Centre (938)
SLaM
CNWL
ELC
BEH
C&I
NEL
Manchester
Nottingham
88 (44.2)
91 (61.5)
45 (37.2)
51 (46.8)
59 (60.2)
68 (72.3)
73 (82)
66 (82.5)
111 (55.8)
57 (38.5)
76 (62.8)
58 (53.2)
39 (39.8)
26 (27.7)
16 (18)
14 (17.5)
Gender (938)
Male
Female
323 (59.7)
218 (40.3)
267 (67.3)
130 (32.7)
Employment (921)
Unemployed
Employed
Student
Retired
Education (858)
Primary
Secondary
6th form/to 18 years
University
475 (90.5)
22 (4.2)
5 (0.9)
23 (4.4)
360 (90.9)
18 (4.5)
16 (4)
2 (0.5)
67 (13.9)
276 (57.3)
95 (19.7)
44 (9.1)
48 (12.7)
205 (54.1)
91 (24)
35 (9.2)
Language (916)
Not English
English
41 (7.9)
481 (92.1)
48 (12.2)
346 (87.8)
Smoking status (896)
Smoker
Non-smoker
Diagnosis (875)
Schizophrenia
Other
389 (76.9)
117 (23.1)
265 (67.9)
125 (32.1)
314 (64.3)
174 (35.7)
306 (79.1)
81 (20.9)
Race of Consultant (912)
White
Mixed
Asian
Black
Chinese/other
358 (67.5)
6 (1.1)
75 (14.2)
60 (11.3)
31 (5.8)
254 (66.5)
4 (1)
45 (11.8)
56 (14.7)
23 (6)
Previous treatment with
current antipsychotic (841)
Yes 292 (62.4)248 (66.5)
Mental Health Act Status (934)
Informal
Sectioned (compulsorily
detained in hospital)
199 (37.1)
338 (62.9)
92 (23.2)
305 (76.8)
Forensic History (863)
Yes179 (37.1)191 (50.1)
Previous antipsychotics (812)
None
1
2 to 5
?6
92 (20.5)
116 (25.9)
203 (45.3)
37 (8.3)
86 (23.6)
71 (19.5)
181 (49.7)
26 (7.1)
(continued)
Table 1. Continued
Variable (n)White n¼541 (%)Black n¼397 (%)
Previous admissions (871)
None
1
2 to 5
?6
Non-compliance history (874)
Yes
46 (9.5)
48 (9.9)
172 (35.6)
217 (44.9)
48 (12.4)
44 (11.3)
151 (38.9)
145 (37.4)
373 (76.1)322 (83.9)
Route (938)
Oral
Intramuscular
432 (79.9)
109 (20.1)
280 (70.5)
117 (29.5)
Regular anticholinergic use (918)
Yes86 (16.3) 65 (16.6)
Substance misuse (892)
Yes216 (43) 188 (48.2)
Table 2. Continuous demographic and clinical categories by ethnicity
Variable (n¼complete)
Median age in years (95% CI),
n¼938
Median duration of illness
in days (95% CI), n¼840
Median weight in kilograms
(95% CI), n¼833
Median length of admission
in days (95% CI), n¼926
Median length of treatment
with current antipsychotic
in days (95% CI), n¼831
White
(n¼541)
42 (40, 43)
Black
(n¼397)
35 (33, 37)
3950 (3387, 4380) 2920 (2190, 3285)
77 (75, 79)80 (78, 83)
57 (49, 62) 58 (50, 67)
40 (31, 46)40 (35, 51)
CI: confidence interval
706Journal of Psychopharmacology 25(5)
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Comparison with previous studies
Most of the studies examining antipsychotic use by ethnicity
have been completed in the US. Differences in antipsychotic
treatment in Black and White patients included; a greater
likelihood of receiving an antipsychotic (Delbello et al.,
2000; Flaskerud and Hu, 1992; Szarek and Goethe, 2003),
higher doses (Diaz and de Leon, 2002; Segal et al.,
1996; Walkup et al., 2000), older drugs (Daumit et al.,
2003; Fleck et al., 2002) and more frequent use of depot for-
mulations (Arnold et al., 2004; Kuno and Rothbard, 2002).
These studies adjusted, unlike the present study, for only a
£80 (CI 67, 92)
£83 (CI 74, 93)
£0
£20
£40
£60
£80
£100
Adjusted cost difference in pounds 1.75
(CI -9.81, 13.31), p=0.77
White Black
Figure 6. Median cost of antipsychotic treatment.
difference in pounds 1.08 (CI ?10.6, 12.8), p¼0.86.
Unadjusted cost
40.7%
(CI 36.5, 44.9)
49.1%
(CI 44.1, 54.1)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Adjusted odds ratio 1.15
(CI 0.87, 1.51), p=0.33
White Black
Figure 3. Proportion for whom polypharmacy prescribed.
odds ratio 1.41 (CI 1.08, 1.83), p¼0.01.
Unadjusted
28.5%
(CI 24.1, 33.2)
21.7%
(CI 18.3, 25.4)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Adjusted odds ratio 1.25
(CI 0.87, 1.79), p=0.22
WhiteBlack
Figure 5. Proportion prescribed a typical antipsychotic.
odds ratio 1.44 (CI 1.06, 1.94), p¼0.02.
Unadjusted
10.90%
(CI 8.4, 13.8)
11.60%
(CI 8.6, 15.2)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Adjusted odds ratio 0.98
(CI 0.63, 1.51), p= 0.92
WhiteBlack
Figure 2. Proportion receiving high dose (>100% maximum
dose).Unadjusted odds ratio 1.07 (CI 0.71, 1.61), p¼0.74.
58.3%
50.0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
WhiteBlack
% Maximum dose
Adjusted percentage
difference 0.97
(CI -4.28, 6.22), p=0.72
Figure 1. Median dose*.
?3.04, 7.61) p¼0.4.
Unadjusted percentage difference 2.28 (CI
20.9%
(CI 17.7, 24.8)
24.4%
(CI 20.3, 29.0)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Adjusted odds ratio 1.08
(CI 0.78, 1.49), p=0.66
WhiteBlack
Figure 4. Proportion for whom polypharmacy
administered.Unadjusted odds ratio 1.22 (CI 0.9, 1.67), p¼0.2.
Connolly et al. 707
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few confounding factors affecting the prescribing of antipsy-
chotics. Outcomes from these studies may not be comparable
with ours because of differences in design and other factors
related to healthcare settings and practices in different coun-
tries at different times.
There are few UK studies examining ethnicity and anti-
psychotic use. One survey (Lloyd and Moodley, 1992) found
no significant differences (after adjustment for five confound-
ing variables) in doses of antipsychotics taken by Black and
White patients. However Black patients were more likely than
White to be receiving a depot and at a significantly higher
dose. Other UK studies, which were not designed to specifi-
cally examine prescribing by ethnicity, have not found an
effect of race on antipsychotic high-dose use (Paton et al.,
2008) and polypharmacy (Lelliott et al., 2002). Our recent
cross-sectional survey of antipsychotic prescribing quality
and ethnicity included several hundred patients from three
NHS mental health trusts and again accounted for multiple
confounding factors (Connolly et al., 2007; Connolly and
Taylor, 2008). Overall these surveys found few differences
between Black and White patients for the same outcomes
we have used in this study although higher costs of antipsy-
chotic medication and polypharmacy were significantly more
likely in Black patients.
Limitations
Limitations of our study include the cross-sectional design
(which allows examination of prescribing practice only at a
single time point) and the inability to obtain data on con-
founding factors for all patients. Also we recruited centres
for this study by approaching mental health trusts containing
the largest populations of Black and minority ethnic group
patients. These centres, because of their ethnically diverse
patient population, may be in some way more or less likely
to demonstrate prejudicial prescribing in an environment of
multicultural tolerance and prescriber diversity (Goldacre
et al., 2004). Nonetheless, in our previous study (Connolly
and Taylor, 2008) we included one centre that had a predom-
inantly White population and found no differences in antipsy-
chotic prescribing quality between centres. We did not include
centre as a potential confounder in this study because we
considered variation in prescribing by centre to be an out-
come rather than a confounder. A separate analysis including
centre as a confounder did not alter our results. Finally, con-
fidence intervals around some outcome measures were wider
than anticipated. This was a result of larger than expected
variances and because of the number of confounding vari-
ables identified and accounted for.
Conclusions
There have long been concerns expressed by patients, carers
(Department of Health, 2003; South London and Maudsley
NHS Trust, 2005) and the UK government (Norfolk, 2003)
about differences in the prescribing of antipsychotics by race.
Our study addresses these concerns and our findings suggest
that across eight NHS trusts the quality of prescribing of
antipsychotics is not substantially different for Black and
White patients.
Acknowledgement
All authors had full access to all of the data in the study and can take
responsibility for the integrity of the data and the accuracy of the
data analysis.
Funding
This work was supported by a research grant awarded by Delivering
Race Equality (DRE) in Mental Healthcare Programme, part of the
Mental Health Equalities Programme in the National Mental Health
Development Unit. The DRE did not contribute to the design, data
collection, analysis or interpretation, writing or submission for
publication.
Conflict of interest statement
None
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