Prescription patterns in psychiatric compulsory care: polypharmacy and high-dose antipsychotics

Abstract

Background Antipsychotic polypharmacy and prescription of high-dose antipsychotics are often used for the treatment of psychotic symptoms, especially in compulsory psychiatric care although there is lack of evidence to support this practice and related risks for patients. Aims We aimed to investigate prescription patterns in patients with psychosis under compulsory psychiatric treatment in Cyprus and to identify predictors for pharmaceutic treatment patterns. Method This was a nationwide, descriptive correlational study with cross-sectional comparisons, including 482 patients with compulsory admission to hospital. Sociodemographic and clinical data were collected. Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Prescribed medication patterns, including use of medication pro re nata (PRN, when required), were recorded. Results Antipsychotic polypharmacy with a PRN schema was reported in 33.2% (n = 160) of the participants. Polypharmacy without a PRN schema was reported in 5.6% (n = 27) of the participants. We found that 27.2% (n = 131) of the participants were prescribed high-dose antipsychotics without PRN included; and 39.2% (n = 189) prescribed high-dose antipsychotics with PRN included. In the logistic regression analyses, predictors for prescription of high-dose antipsychotics were male gender, positive psychiatric history, receiving state benefits and a negative history of substance use. Male gender was the only predictor for polypharmacy without a PRN schema whereas male gender, negative family psychiatric history, receiving state benefits and the total score on the positive symptoms PANSS subscale were predictors for polypharmacy with a PRN schema included. Conclusions A high frequency of polypharmacy and use of medication PRN beyond clinical guidelines has been reported for the first time in psychiatric compulsory care in Cyprus; revision in antipsychotic prescription is needed.

The characteristics of discharge prescriptions including pro re nata psychotropic medications for patients with schizophrenia and major depressive disorder from the survey of the “Effectiveness of guidelines for dissemination and education in psychiatric treatment (EGUIDE)” project

“…In this study, the QI values decreased with the inclusion of PRN prescriptions for all QIs except no prescription ratio of mood stabilizers and antiepileptics. A previous study suggested that the polypharmacy ratio increases when PRN prescriptions are included [ 36 ], and a similar trend might be observed in this study. Furthermore, a positive correlation was found between QI values for regular prescriptions and the QI ratio for both schizophrenia and MDD.…”

Nurses' use of pro re nata medication in adult acute mental healthcare settings: An integrative review

“…Another study in a Canadian psychiatric intensive care unit revealed one quarter of patients' PRN antipsychotic orders exceeded the recommended maximum dose in a day (Casol et al, 2021). High use of PRN medication in acute mental healthcare settings was linked to polypharmacy problems (Kaikoushi et al, 2021; Martin et al, 2017). However, polypharmacy is expected among patients with severe mental symptoms and/or limited response to medication treatments (Kaikoushi et al, 2021).…”

“…High use of PRN medication in acute mental healthcare settings was linked to polypharmacy problems (Kaikoushi et al, 2021; Martin et al, 2017). However, polypharmacy is expected among patients with severe mental symptoms and/or limited response to medication treatments (Kaikoushi et al, 2021).…”

“…A study of patients under psychiatric compulsory care indicated 98.1% patients had PRN prescriptions, 39.2% patients had high-dose antipsychotics prescriptions, and 33.2% patients meet the polypharmacy criteria (Kaikoushi et al, 2021). Another study in a Canadian psychiatric intensive care unit revealed one quarter of patients' PRN antipsychotic orders exceeded the recommended maximum dose in a day (Casol et al, 2021).…”

Cognitive impairment in adults under compulsory psychiatric care: association with psychotic symptoms and high-dose antipsychotics

“…22 Other studies showed a link between prolonged experience of mental health problems, including psychotic symptoms, and advanced therapeutic schemas in terms of high doses of antipsychotics. 25 One way to interpret the present association between cognitive impairment, general psychotic symptoms and prescription of high doses of antipsychotics is that high-dose antipsychotics and cognitive impairment are attributable to the severity of the underlining disease. Indeed, there is evidence that cognitive decline in psychosis starts at least a decade before the onset of psychotic symptoms, and this is more profound in individuals with schizophrenia, who experience a decrease in IQ at a rate of 0.35 points per year.…”