Antipsychotic polypharmacy and clozapine prescribing patterns: evolution and correlates before and after a psychiatric hospitalisation

Abstract

Background: Antipsychotic polypharmacy (APP) prescribing and clozapine underuse are considered inappropriate prescribing in schizophrenia. Psychiatric hospitalisations may be suitable occasions to re-evaluate patient pharmacotherapy and to switch to monotherapy. Objectives: To explore the evolution of APP and other psychotropic prescribing patterns during psychiatric hospitalisations, to detect characteristics associated with APP on admission and at discharge, and to examine clozapine prescribing patterns. Design: We performed a retrospective observational study based on electronic health records. Methods: Data on adult inpatients diagnosed with schizophrenia spectrum disorders were collected retrospectively from 6 Belgian hospitals in 2020-2021. Results: Of the 516 patients included, APP prescribing increased significantly from 47.9% on hospital admission to 59.1% at discharge. On admission and at discharge, APP was associated with prior clozapine use (ORadmission = 2.53, CI = 1.1–5.84, ORdischarge = 11.01, CI = 4.45–27.28), treatment with a first-generation antipsychotic (ORadmission = 26.79, CI = 13.08–54.86, ORdischarge = 25.2, CI = 12.2–52.04), increased antipsychotic exposure (ORadmission = 8.93, CI = 5.13–15.56, ORdischarge = 19.89, CI = 10–39.54), and a greater number of hypno-sedatives (ORadmission = 1.88, CI = 1.23–2.88, ORdischarge = 4.18, CI = 2.53–6.91). APP was negatively associated with involuntary admission (ORadmission = 0.31, CI = 0.14–0.7, ORdischarge = 0.3, CI = 0.13–0.68). When using an alternative definition of monotherapy (i.e. including patients with an add-on low-dose antipsychotic for sleep disorders), alcohol use disorder (ORadmission = 0.26, CI = 0.13–0.54) and higher age (ORdischarge = 0.53, CI = 0.29–0.95) were negatively associated with APP, and living in a residential facility (ORdischarge = 2.39 CI = 1.21–4.71) and a higher daily dosage of benzodiazepines during the stay (ORdischarge = 1.32 CI = 1.03–1.69) increased the odds of being discharged on APP. On admission, 9.3% of patients were being treated with clozapine. Although 28.1% of patients were eligible for clozapine treatment, only 11% of patients were discharged with a clozapine prescription. For 7 of the 10 patients with a new clozapine prescription, it was directly prescribed in combination with another antipsychotic, without a prior trial of clozapine monotherapy. Conclusion: Suboptimal prescriptions of antipsychotics in patients with schizophrenia persist after psychiatric hospitalisations and are associated with identifiable characteristics.

Impact of a Caffeine Restriction Policy on Inpatients With Schizophrenia

“…First, antipsychotics are seldom deprescribed during a hospital stay, as we have previously shown, and antipsychotic drug regimens at discharge might thus not thoroughly translate patients' symptoms severity. 13 Second, our methodology differed from previously published studies, which were interventional trials aimed at testing symptom changes with detailed scales (eg, Brief Psychiatric Rating Scale). Only one study also monitored prescribing patterns by recording changes in the number of "as needed" antipsychotics and anxiolytics.…”

“…Data collected in our previous study were used for the control group (ie, without caffeine available). 13 Data of the exposed group (ie, with caffeine available) were collected between January and April 2022 from electronic health records and the hospital prescribing software. The study protocol was approved by the ethics committee of the Beau Vallon hospital.…”

Prescribing and deprescribing trends in schizophrenia: An overview of inpatients in Belgium and in the Canadian province of Québec

“…Retrospective data were collected in 2020-2021 in a tertiary care hospital in Montréal, Québec, Canada, and in six Belgian hospitals. 27 Prescribing patterns were extracted from local prescribing software and other characteristics (e.g. demographics, comorbidities) from patient medical records.…”

“…Factors for which data were collected include demographics, disease and hospitalization characteristics, comorbidities, antipsychotic treatment and co-treatment. These factors were taken into account as they are associated with the use of APP 27,28 and may therefore increase or reduce the likelihood of deprescribing. 29 The full list of these factors is available in Table S1.…”

Global Neuropsychopharmacological Prescription Trends in Adults with Schizophrenia, Clinical Correlates and Implications for Practice: A Scoping Review

“…Prior or current clozapine use [100,104,107] Involuntary admission [107] On first-generation antipsychotics [38,63,107] Use of risperidone as principal treatment [27] On long-acting injectables [27,28,38,48,50,104] Less satisfaction with treatment [63] On antidepressants [104] Increased frequency of outpatient visits to psychiatry services (for users new to antipsychotic polypharmacy) [58] On mood stabilizers, including lithium [58,65] Longer duration of treatment/time to treatment discontinuation [41] On anti-Parkinsonian drugs [58,100] Greater number of inpatient visits [99] On anticholinergic agents [104] On benzodiazepines [63] Use of quetiapine/paliperidone as principal treatment [27] Poor adherence to antipsychotic treatment [100] Antipsychotic exposure or concomitant treatment with other psychoactive drugs [27,107] Being on more classes of psychotropics [99] Higher antipsychotic doses [38,48,54,104] High-dose antipsychotic prescription [63,75] On maintenance therapy [58] Hospitalization of >30 days [75] Higher number of emergency services visits [58,99] Being institutionalized [104] Inpatient treatment in the past year [45,…”