Polypharmacy in patients with schizophrenia.

BACKGROUND: Polypharmacy in patients with schizophrenia is a common practice with little basis in well-controlled studies. The objective of this report is to describe the changes in prescription practices with psychotropic medications for patients diagnosed with schizophrenia in 1995 and 2000. METHOD: The medical records of patients who were discharged from our facility in 1995 and 2000 with the diagnosis of schizophrenia (DSM-IV criteria) were reviewed. The psychotropic medications at discharge were compared. The incidence of adverse drug reactions and indicators of patient outcome were also compared. RESULTS: 459 records were reviewed for 1995 and 584 were reviewed for 2000. Patients discharged in 2000 were significantly more likely to receive antidepressants, mood stabilizers, anxiolytics, and multiple antipsychotics than patients discharged in 1995 (p < .0001). Patients discharged in 2000 were given significantly fewer anticholinergics (p < .0001). There was a large increase in the use of divalproex. No patients were discharged on treatment with more than 1 antipsychotic in 1995, whereas in 2000, 15.9% of patients were. The most common antipsychotic combination was haloperidol and olanzapine. Paralleling the increased use of polypharmacy, there were significantly fewer adverse drug reactions in 2000 than in 1995 (p = .002). In addition, patients with schizophrenia who were discharged in 2000 had significantly shorter lengths of stay (p < .0001) and were significantly more likely to be discharged to the community than to a state hospital (p = .0001). CONCLUSION: This study found that acutely ill hospitalized patients with schizophrenia are being treated with more psychotropic medications, including more than 1 antipsychotic. These changes are coincidental with a decrease in adverse drug reactions and an improvement in indicators of patient outcome.

Accelerated Antidepressant Response in Geriatric Inpatients.

Six elderly depressed inpatients were treated for 2 weeks with low doses of nortriptyline and fluoxeline in combination. All patients showed significant reductions in depressive symptoms with minimal side effects. Clinical improvement appeared unrelated to whether plasma levels of nortriptyline were therapeutic. The implications of this regimen for accelerated antidepressant response as well as the limitations of this report are discussed.

Reducing restraint use in a public psychiatric inpatient service.

The use of behavioral restraint in psychiatric inpatients can have physically and emotionally damaging effects. However, staff may view the use of restraint as a routine and acceptable means of maintaining safety. The goal of this project was to reduce the use of restraint in a public psychiatric inpatient service that serves an economically disadvantaged urban population. Six interventions that primarily involved changing staff behavior were made to reduce the use of restraint. These included better identification of restraint-prone patients, a stress/anger management group for patients, staff training on crisis intervention, development of a crisis response team, daily review of all restraints, and an incentive system for the staff. The rate of restraint use (number of restraints/1000 patient-days) during the 3 years before the interventions was compared with the rate during the 2 years after the interventions. There was a significant decrease in the rate of restraint use after the restraint reduction initiatives were implemented. The reduction was not accompanied by a sustained increase in incidents of assault, suicidal behavior, or self-injury.

Vitamin d deficiency among psychiatric inpatients.

OBJECTIVE: Previous studies in northern Europe and Australia have indicated that vitamin D deficiency is common in psychiatric patients. This study aimed to determine the prevalence of vitamin D deficiency among psychiatric inpatients in a large North American city. The association of vitamin D status with clinical characteristics was also explored, and subgroups of patients that are more vulnerable to vitamin D deficiency were identified. METHOD: This descriptive study looked at 107 unselected consecutive admissions to a psychiatric inpatient service in New York City between September and early December 2010. All patients were aged 18 years and older. Psychiatric diagnoses were established by attending psychiatrists as part of the routine assessment using criteria from the DSM-IV. Serum levels of 25-hydroxyvitamin D were measured by high-performance liquid chromatography, tandem mass spectrometry. A vitamin D-deficient state was defined as serum 25-hydroxyvitamin D level ≤ 20 ng/mL. RESULTS: Fifty-six (52.3%) patients were classified as deficient in vitamin D. Age and 25-hydroxyvitamin D level were significantly correlated (P = .001). Seventy-one percent of patients from age 18 to 34 years were deficient in vitamin D; this rate was significantly higher than the rate of deficiency in older patients (P = .017). No significant relationships were found between 25-hydroxyvitamin D level and gender, race/ethnicity, glycosylated hemoglobin, body mass index, and major psychiatric diagnostic categories. CONCLUSIONS: A high percentage of psychiatric inpatients are deficient in vitamin D. Younger patients were more at risk for deficiency. Screening for vitamin D deficiency should be part of the health assessment of patients with major psychiatric illnesses.

Comparative effectiveness of second-generation antipsychotics and haloperidol in acute schizophrenia.

BACKGROUND: There is little information on the comparative effectiveness of second-generation antipsychotic agents. AIMS: To determine if any of five second-generation antipsychotics or haloperidol is more effective in treating acutely ill patients with schizophrenia, schizoaffective disorder or schizophreniform disorder. METHOD: A sample of 327 newly admitted patients were randomised to open-label treatment with aripiprazole, haloperidol, olanzapine, quetiapine, risperidone or ziprasidone for a minimum of 3 weeks. Measures of effectiveness were improvement in mental status so that the patient no longer required acute in-patient care, and changes in Brief Psychiatric Rating Scale (BPRS) scores. RESULTS: By the first measure, haloperidol (89%), olanzapine (92%) and risperidone (88%) were significantly more effective than aripiprazole (64%), quetiapine (64%) and ziprasidone (64%). Changes in BPRS ratings were not significant among treatments. CONCLUSIONS: Haloperidol, olanzapine and risperidone are superior to aripiprazole, quetiapine and ziprasidone for the acute treatment of psychosis in hospitalised patients with schizophrenia, schizoaffective disorder or schizophreniform disorder.