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Aims: The objective of the present study was to identify schizophrenia inpatients who had their original regimen augmented with additional antipsychotics during acute inpatient care, and to clarify the factors associated with these additions.
Methods: The subjects were 204 schizophrenia inpatients at 34 acute care hospitals, of whom 42 (20.6%) had further antipsychotics added to their medication regimen during hospitalization.
Results: Compared with patients who were not prescribed additional antipsychotics, the subjects were typically discharged with higher dosages of antipsychotics, principally low-potency medications. Patients who exhibited aggressive behavior, who had no physical illness, or whose psychiatrists preferred typical antipsychotics, were more likely to be prescribed additional new antipsychotics.
Conclusions: Alternative approaches such as intensive care for aggressive patients and educational intervention with psychiatrists may prove useful in stabilizing patients without adding new antipsychotics unless absolutely necessary, and in simplifying medication regimens.
PRESCRIPTION CHANGE FOR acute inpatients with schizophrenia is critical. During hospitalization, psychiatrists are able to overhaul prescription regimens in an environment with 24-h staff monitoring. The first aim of prescribing medication in the acute phase is sedation of positive symptoms. To that end, antipsychotics may be added and/or increased depending on the effect of initial treatment; a temporary addition and/or increase can be effective for acute treatment. However, if the additional or increased antipsychotics are still being taken after symptoms have subsided, long-term polypharmacy will result. Polypharmacy for schizophrenia patients remains prevalent,1,2 although the importance of simplifying prescription has been recognized.
Certainly, temporary addition in the acute phase or in the course of switching to newer antipsychotics is sometimes necessary. However, we should not forget that once new antipsychotics are added to a regimen, it is difficult to wean patients off additional medications and many become stuck in the supplementary regimen.3,4 If the addition of new antipsychotics potentiates polypharmacy, we must clarify the phenomenon and its related factors. As far as could be determined, no studies have examined the effect of new supplementary antipsychotics.
Previous studies suggested that prescription practices were associated with various factors. They noted that patient clinical and demographic factors and psychiatrist demographic factors and perception of medication were associated with prescription.5–8 We assume that these factors might also be related to the addition of antipsychotics. If these phenomena and related factors were clarified, important clues for avoiding needless addition of antipsychotics might be identified.
The aim of the present study was to identify those schizophrenic inpatients in acute inpatient care units for whom additional antipsychotics had been prescribed, and to clarify patient and psychiatrist factors associated with the addition of new antipsychotics.
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In the present multicenter study psychiatrists prescribed additional antipsychotics toapproximately 20% of inpatients during hospitalization. Results indicate that these patients exhibited aggressive behavior and had no physical illness. Interestingly, these patients were seen more frequently by psychiatrists who generally preferred to prescribe typical antipsychotics.
In the current study approximately 20% of the inpatients had new antipsychotics addition during hospitalization, a much higher rate than that in the Loosbrock et al. study in which 7% of the outpatients had their original antipsychotic therapy augmented with an additional antipsychotic within 1 year.17 This difference could be the effect of the present subjects being in acute inpatient care. Even so, the results of the present study suggest that the addition of new antipsychotics during acute care treatment is common in Japan. This may be because clozapine, an atypical antipsychotic effective for treatment-resistant schizophrenic patients, has yet to be approved for use in Japan. Other possible factors range from reluctance among Japanese psychiatrists to simplify prescription practices, to inadequate staffing.
In the present study there was no difference between dosage levels prescribed for the addition group and non-addition group at admission; but by the time of discharge the addition group had been prescribed significantly higher dosages of antipsychotics than the non-addition group. This result is consistent with the finding of Centorrino et al. who reported that inpatients with polypharmacy were prescribed higher dosages of antipsychotics than those with monopharmacy at discharge, while there was no difference between the groups at admission.18 It is impossible to make a simple comparison between the present study and the Centorrino et al. study because our study does not compare polypharmacy with monopharmacy. However, it does conclude that adding antipsychotics to a treatment regimen during acute care results in a significant increase in the total dosage of antipsychotics at discharge.
The rate of typical antipsychotic use, especially low-potency antipsychotics, was higher at discharge in the addition group than the non-addition group. This finding concurs with previous studies reporting that less frequent use of atypical antipsychotics was a predictor for polypharmacy.5,19,20 It is important to consider the risk of patients being prescribed additional low-potency antipsychotics after discharge: patients are more likely to be prescribed these after discharge, resulting in polypharmacy. Further research is required on the use of low-potency antipsychotic combinations.
In the present study the addition group was significantly more prone to aggression. As Brieden et al. suggested, pharmacological treatment of acute, persistent, and repetitive aggression poses a serious challenge for staff members as well as other patients.21 Some research has examined the use of pharmacological treatment to decrease aggression.22 However, the efficacy of adding new antipsychotics to the original antipsychotic regimen to control aggression is not currently recommended. Therefore, the urgent temporary addition of antipsychotics might be required in some situations. However, with patients prescribed new antipsychotics for the purpose of sedating aggression, psychiatrists need to avoid excessive consecutive polypharmacy.
Patients with physical illness had fewer new antipsychotics added during hospitalization. Psychiatrists have to pay attention to drug interactions and the side-effects of antipsychotics on physical illness when prescribing for patients with a physical illness such as hepatic, renal, or cardiovascular disease. The present study confirms that standard clinical practice is adhered to by Japanese psychiatrists. Physical illness can be an important criterion in deciding whether to add new antipsychotics to a regimen.
The study indicates that a psychiatrist's preference for typical antipsychotics predicts that they will add new antipsychotics to a patients' medication regimen; this means that the addition of antipsychotics depends on a preference for typical antipsychotics, regardless of a patient's actual clinical condition. This demonstrates the effect of psychiatrist factors on prescription practices and is consistent with some previous studies. For example, Ito et al. reported that multiple medications and excessive dosing were influenced by psychiatrist skepticism towards the use of algorithms.7 In a survey on long-acting depot antipsychotics, Patel et al. noted that psychiatrist knowledge about depots was positively associated with use.8
Recently, certain studies have emphasized the importance of educational intervention to disseminate evidence-based medication guidelines to improve pharmacological treatment.23–26 Given the results of the current study, educational programs for psychiatrists regarding their preference for typical or atypical antipsychotics is critical to facilitating more simplified prescription practices, especially with those psychiatrists who prefer typical antipsychotics.
These results should be interpreted cautiously because there are certain limitations. It could not be clarified when and why additional antipsychotics were prescribed during hospitalization. Prescription during hospitalization was examined, but could not be followed up after discharge; it is possible that some subjects' prescriptions are simplified after discharge; longitudinal follow up is needed in future studies. As to patient evaluation, psychiatric symptoms assessed by validated measures were not used, given the burden on psychiatrists. In addition, institutional factors such as staffing should have been examined. Finally, there might be different reasons for adding new antipsychotics and for psychiatrist attitudes toward prescription, according to whether subjects were experiencing their initial episode and had relapsed.
Further study is needed regarding effective non-pharmacological treatment of aggression such as temporary seclusion and restraint, special care nursing,27 and educational programs for psychiatrists regarding their antipsychotic preference in order to facilitate simplified prescription practices.
In conclusion, the present study shows that one-fifth of schizophrenia inpatients with aggressive behavior but no physical illness were prescribed additional antipsychotic medication by psychiatrists who preferred typical antipsychotics. It might be more useful to continue treatment regimens without additional antipsychotics, simplify prescription practices, use alternative approaches or intensive care for aggressive patients, and promote educational programs among psychiatrists.