Antipsychotic prescribing for vulnerable populations: a clinical audit at an acute Australian mental health unit at two-time points

Abstract

BackgroundAntipsychotics are recognised as a critical intervention for schizophrenia and bipolar disorder. Guidelines globally endorse the routine practice of antipsychotic monotherapy, at the minimum effective dose. Even in treatment-resistant schizophrenia, clozapine use is endorsed before combining antipsychotics.This aim of this study was to review antipsychotic polytherapy alone, high-dose therapy alone, polytherapy and high-dose prescribing patterns in adults discharged from an inpatient mental health unit at two time-points, and the alignment of this prescribing with clinical guideline recommendations. Additionally, associations with polytherapy and high-dose antipsychotic prescribing, including patient and clinical characteristics, were explored.MethodsA retrospective clinical audit of 400 adults (200 patients at two different time-points) discharged with at least one antipsychotic. Preliminary findings and education sessions were provided to physicians between Cohorts. Outcomes (polytherapy alone, high-dose therapy alone, polytherapy and high-dose therapy) were compared between study Cohorts using chi-squared and rank-sum tests. Associations between outcomes and covariates were assessed using multivariable logistic regression.ResultsMost patients (62.5%) were discharged on a single antipsychotic within the recommended dose range. There was a clear preference for prescribing second generation antipsychotics, and in this respect, prescribing is aligned with current evidence-based guidelines. However, sub-optimal prescribing practices were identified for both Cohorts in relation to polytherapy and high-dose antipsychotic rates. Involuntary treatment, frequent hospitalisations and previous clozapine use significantly increased the risk of all three prescribing outcomes at discharge.ConclusionsIn a significant minority, antipsychotic prescribing did not align with clinical guidelines despite increased training, indicating that the education program alone was ineffective at positively influencing antipsychotic prescribing practices. Further consideration should be given when prescribing antipsychotics for involuntary patients, people with frequent hospitalisations, and those who have previously trialled clozapine.

Is higher psychotropic medication burden associated with involuntary treatment under the Mental Health Act? A four-year Australian cohort study

“…This study was novel in that we comprehensively explored (i) prescribing across psychotropic medications rather than solely focusing on antipsychotic treatment, and (ii) psychotropic medication burden in terms of polypharmacy (with respect to four psychotropic groups; antipsychotics, antidepressants, mood stabilisers and benzodiazepines) and high-dose treatment (with respect to three psychotropic groups; antipsychotics, antidepressants and benzodiazepines). In summary, this study found that the prescribing pattern of psychotropic medication, specifically antipsychotics, aligns with other Australian and international research [7,[13][14][15][16][17][18]. That is, individuals treated involuntarily under the MHA at discharge were significantly more likely to be prescribed antipsychotic treatment, antipsychotic polypharmacy and/or high-dose antipsychotic treatment at discharge.…”

“…This four-year cohort study extends our earlier research [15], by reviewing all psychotropic medications prescribed at the point of inpatient discharge, (i.e. not just antipsychotics), and by increasing the number of cohorts included.…”

“…Research exploring the use of medication and alignment with clinical practice guidelines for this vulnerable population is limited, however, research does suggest an increased likelihood of experiencing treatment outside of clinical practice recommendations such as polypharmacy (i.e. receiving two or more medicines from the same therapeutic group) [7,13], and psychotropic medications used in doses higher than recommended [14,15].…”

“…To date, most research has focused on discrete elements of antipsychotic prescribing, particularly injectable antipsychotics, polypharmacy and/or high doses, rather than encompassing psychotropics as a whole category [7,[13][14][15][16][17][18][19]. Australian and New Zealand research includes studies that have established an association between involuntary community treatment and increased likelihood of long-acting injectable antipsychotics compared to oral antipsychotics [7,16,17].…”

“…Australian and New Zealand research includes studies that have established an association between involuntary community treatment and increased likelihood of long-acting injectable antipsychotics compared to oral antipsychotics [7,16,17]. Additionally, a Queensland study reported that inpatients treated involuntarily were significantly more likely to be discharged on antipsychotic polytherapy, high antipsychotic dose, and antipsychotic polytherapy combined with high dose [15]. However, in contrast to McMillan et al [15], a smaller study of antipsychotic polypharmacy in schizophrenia/schizoaffective disorder in a metropolitan Western Australian hospital found voluntary MHA status was significantly associated with increased rates of polypharmacy [19].…”