Antipsychotic Polypharmacy Among Patients With Schizophrenia in Africa: A Systematic Review and Meta-Analysis.

OBJECTIVES: In Africa, antipsychotic polypharmacy (APP) is increasing due to a high antipsychotic dose prescribing, repeated psychiatric hospitalization, uncontrolled psychotic symptoms, and greater side effect burden. Therefore, the aim of this review and meta-analysis is to assess the prevalence and correlates of APP among patients with schizophrenia in Africa. METHODS: A systematic search was performed from August 1 to 31, 2020, on PubMed, MEDLINE, Google Scholar, and Science Direct databases to select articles based on the inclusion criteria. Meta-Analysis of Observational studies in Epidemiology guidelines were employed. Cross-sectional observational studies that reported APP and/or its correlates in schizophrenia patients in English language published in peer-reviewed journals without time limits were included in the review. The quality of included articles was assessed using Newcastle-Ottawa quality assessment tool. Prevalence and correlates of APP were the outcome measures of this review and meta-analysis. Open Meta Analyst and RevMan version 5.3 software were used for meta-analysis. A random effect model was used to synthesize data based on the heterogeneity test. RESULTS: Six studies that involved 2154 schizophrenia patients met the inclusion criteria in this review and meta-analysis. The quality of included studies ranges from 6.5 to 10 based on the Newcastle-Ottawa quality assessment tool. The pooled prevalence of APP among patients with schizophrenia was 40.6% with 95% confidence interval: 27.6% to 53.7%. Depot first-generation antipsychotics and oral first-generation antipsychotics were the most commonly prescribed APP combinations. Socio-demographic, clinical, and antipsychotic treatment characteristics were significantly associated with APP. There was a wide variation in the correlates of APP assessed by studies and the way that association/correlations was determined and reported. CONCLUSIONS: APP is common and highly prevalent. Advanced age, male gender, longer duration of schizophrenia, hospital admission, and longer antipsychotic treatment were correlates of APP in Africa.

Trends in antipsychotic prescribing for approved and unapproved indications to Medicaid-enrolled youth in Philadelphia, Pennsylvania between 2014 and 2018.

BACKGROUND: Antipsychotic prescribing to Medicaid-enrolled youth has been the target of numerous policy initiatives, including prior authorization and quality monitoring programs, which often target specific populations. Whether these efforts have changed the level or composition of antipsychotic prescribing is unclear. METHODS: Using 2014-2018 administrative claims data for Medicaid enrollees aged 21 years and under in Philadelphia, Pennsylvania, we measured antipsychotic prescription fills overall and for youth without an approved indication (autism, bipolar disorder, or psychosis). We then assessed whether trends differed for populations that have been targeted by policy initiatives, including younger children and foster care-enrolled youth. We also identified the most common approved and unapproved indications and examined whether the treatment duration of antipsychotic prescriptions differed based on whether the youth had an approved or unapproved indication. RESULTS: Overall, the number of Medicaid youth with an antipsychotic prescription fill halved between 2014 and 2018. Youth aged 17 years and under and foster care-enrolled youth, who were targeted by prior authorization and quality improvement efforts, experienced larger declines. Roughly half of prescriptions were for unapproved indications in both 2014 and 2018; the most common unapproved indication was ADHD, and the treatment duration was shorter for unapproved indications compared to approved indications. CONCLUSIONS: Antipsychotic prescribing to Medicaid-enrolled youth is declining, particularly among populations that have been targeted by policy initiatives like prior authorization and quality monitoring programs. Despite the fact that these initiatives often assess diagnostic criteria, half of antipsychotic prescriptions were for unapproved indications in both 2014 and 2018. More research is needed to gauge whether this prescribing is appropriate.

High-dose antipsychotic therapy and reflective prescribing: development of an online tool for rapid, easy calculation of antipsychotic total daily dose.

OBJECTIVE: Safe and effective antipsychotic prescribing is a fundamental skill in psychiatric practice; however, antipsychotic medications are not without risk. These risks are increased when antipsychotics are prescribed in high doses, with or without polypharmacy. Decision-making regarding antipsychotic prescribing can be hampered by a lack of readily available or easily approachable tools for calculating and interpreting total daily doses, especially when antipsychotic polypharmacy is involved. Our objective was to create an accessible method for calculating antipsychotic total daily dosing. METHODS: We have developed an online calculator for determining antipsychotic total daily dose using information on recommended maximum total daily dosing based on the British National Formulary. RESULTS: This calculator is free, easy to implement and allows for users to input a large variety of possible antipsychotic dosing regimens. CONCLUSIONS: It is hoped that this tool will allow clinicians to readily review their prescribing practice, inform decision-making and improve patient safety outcomes. Further research may be appropriate to determine the impact of this tool on these intended goals.

Academic detailing among psychiatrists - feasibility and acceptability.

Purpose Research has shown that academic detailing (AD), which includes repeated in-person educational messages in an interactive format in a physician's office, is among the most effective continuing medical education (CME) forms for improving prescribing practices and reducing drug costs. The purpose of this paper is to investigate AD's feasibility and acceptability as an educational tool among psychiatrists and its ability to facilitate positive changes in antipsychotic prescribing. Design/methodology/approach All psychiatrists practicing in Southwestern Ontario, Canada were invited to participate. Participants (32/299(10.7 percent)) were provided with two educational sessions by a healthcare professional. Participants evaluated their AD visits and completed a pre- and post-AD questionnaire measuring various prescribing practice aspects. Findings A total of 26 out of 32 (81.3 percent) participants completed the post-AD evaluation; most of them (61.5 percent, n=16) felt that AD gave noteworthy information on tools for monitoring side-effects and 50.0 percent ( n=13) endorsed using these in practice. In total, 13 participants (50.0 percent) felt that the AD sessions gave them helpful information on tools for documenting polypharmacy use, which 46.2 percent ( n=12) indicated they would implement in their practice. No significant differences were found between participants' pre- and post-assessment prescribing behaviors. Practical implications There is great need for raising AD program's awareness and improving physician engagement in this process locally, provincially and nationally. Originality/value To the authors' knowledge, this is the first AD program in Canada to target specialists solely. Participant psychiatrists accepted the AD intervention and perceived it as a feasible CME method.

Antipsychotic prescribing patterns in children and adolescents attending Australian general practice in 2011 and 2017.

Background: Antipsychotics are increasingly prescribed to children and adolescents worldwide, but little is known about reasons for prescribing. We aimed to examine patterns of paediatric antipsychotic prescribing in Australian primary care services in 2011 and 2017, including diagnoses, sociodemographic characteristics, off-label prescribing, and psychotropic co-prescribing. Methods: Retrospective analysis of electronic health records (EHRs) using a large Australian general practice database (MedicineInsight). Diagnoses of mental disorders were extracted from EHRs and associated with antipsychotic prescriptions within the same calendar year for three age-groups: 0-9, 10-14, and 15-18-year-olds. Results: In 2017, children/adolescents with mental health diagnoses were more likely to be prescribed antipsychotics (2.9% of 27,412 patients) than in 2011 (2.0% of 8418 patients; absolute difference +0.9, 95% CI + 0.5, +1.4). The likelihood was greater for patients with bipolar disorders (21.6% vs. 41.5%), eating disorders (1.1% vs. 7.2%), and autism without behavioural problems (3.7% vs. 6.1%). Depression/anxiety (adjusted 26.8% of patients 2011; 30.8% 2017) was the most common diagnosis associated with antipsychotics in both years. Most antipsychotics were prescribed off-label (69.8% 2011; 79.7% 2017; absolute difference +9.8, 95% CI + 1.54, +18.4). Off-label prescribing increased most among those aged 15-18-years, females, and patients living in outer regional/remote/very remote communities and the most disadvantaged areas. The three most frequently prescribed antipsychotics in both years were risperidone, quetiapine, and olanzapine. Psychotropic co-prescribing among patients receiving antipsychotic prescriptions was approximately 69% in both years. Conclusions: Prescribing antipsychotics for mental health diagnoses to children/adolescents attending Australian general practices was more frequent in 2017 than 2011, and most commonly associated with depression/anxiety diagnoses. In both years, most prescribing was off-label. The majority of patients were co-prescribed other classes of psychotropics along with antipsychotics.

Clozapine prescribing practice and trends in Qatar: First national observational study.

BACKGROUND: Clozapine is the gold standard in the management of treatment-resistant schizophrenia. Despite its clinically proven efficacy clozapine utilization is variable globally and published evidence is suggestive of its underutilization. Research from the Arab region on clozapine utilization is limited. The aim of our descriptive observational study was to evaluate the prescribing practice of clozapine and its sociodemographic and clinical corelates in the State of Qatar. METHODS: The study is a retrospective case-note review of all patients maintained on clozapine, in the calendar year 2020. Data were collected on sociodemographic characteristics of the patients; antipsychotic trials before initiating clozapine; and clinical characteristics of the patients, including their diagnoses leading to prescription of clozapine, duration of illness, psychiatric hospitalizations, and co-morbidities. RESULTS: During the study period, 100 patients were maintained on clozapine. Patients were mostly Qatari and non-Qatari Arab males. Prescription rates were significantly different for Qatari patients when compared to non-Qatari patients. Most patients had a chronic illness with the age of onset of illness in early adulthood and were diagnosed with schizophrenia or schizoaffective disorder. The mean daily dose of clozapine was 325 mg. Eighty percent of the patients received two or more antipsychotic trials before initiating clozapine. Sixty-eight percent of the patients had more than two antipsychotic trials before initiating Clozapine. One third of patients had no history of psychiatric hospitalizations, and one quarter had five or more previous psychiatric hospitalizations. Of the psychiatric comorbidities, mood and substance use disorders were common. Of medical comorbidities, endocrine and metabolic disorders were common. CONCLUSION: Despite apparent underutilization, the Clozapine prescribing rates in Qatar are comparable to countries with plasma monitoring systems when framed within Qatar's unique demographic context. However, there still is a significant delay in Clozapine initiation despite its clinical superiority. STRENGTHS AND LIMITATIONS OF THIS STUDY: First study on Clozapine utilization from the Middle-East and North-Africa region. This study examined prescribing of clozapine in a national cohort of patients in Qatar. Provides insight into sociodemographic and clinical correlates of clozapine prescribing in a country with 90% migrants. Limited by the completeness of the information contained in the patients' medical charts.

Antipsychotic initiation and new diagnoses excluded from quality-measure reporting among Veterans in community nursing homes contracted by the Veterans Health Administration in the United States.

OBJECTIVES: To assess whether prevailing antipsychotic use rates in community nursing homes (CNH) influence new initiation of antipsychotics and diagnosis with antipsychotic indications among Veterans. METHODS: We used linked 2013-2016 Veterans Administration (VA) data, Medicare claims, Nursing Home Compare, and Minimum Data Set (MDS) assessments. The exposure was the proportion (in quintiles) of all CNH residents prescribed antipsychotics in the quarter preceding a Veteran's admission date. Using adjusted logistic regression, we analyzed two outcomes measured using MDS: antipsychotic initiation, and new diagnosis of an antipsychotic quality-measure exclusionary condition (i.e., schizophrenia, Tourette's syndrome, or Huntington's disease). RESULTS: Among 8201 Veterans without an indication for antipsychotics at baseline, 21.1% initiated antipsychotics and 3.5% were newly diagnosed with any exclusionary diagnosis after CNH admission. Schizophrenia accounted for almost all (96.8%) the new diagnoses. Antipsychotic initiation increased with higher CNH antipsychotic use rates: OR = 2.55, 95% CI: 2.08--3.12, quintile 5 versus 1. CNHs with the highest prevalent use of antipsychotics were associated with increased odds of Veterans acquiring an exclusionary diagnosis (OR = 2.09, 95% CI: 1.32-3.32, quintile 5 vs. 1). CONCLUSIONS: Incident antipsychotic use is common among Veterans admitted to CNHs. CNH antipsychotic prescribing practices are associated with Veterans being newly diagnosed with antipsychotic prescription indications, primarily schizophrenia.

Rationalising Antipsychotic Prescribing in Dementia (RAPID) complex intervention: A mixed-methods feasibility intervention study.

Background: To help address the issue of inappropriate antipsychotic prescribing to nursing home residents with dementia, the 'Rationalising Antipsychotic Prescribing in Dementia' (RAPID) complex intervention was developed, comprising staff education and training, academic detailing and a novel resident assessment tool. Objectives: The primary objective was to assess the feasibility and acceptability of the RAPID complex intervention in a nursing home setting. The secondary objective was to describe associated trends in psychotropic prescribing, falls, and behavioural symptoms. Methods: A mixed-methods feasibility intervention study in one large nursing home in Ireland was undertaken between 07/2017 and 01/2018. Focus groups and semi-structured interviews were conducted with nursing home staff and GPs at the end of the 3-month follow up period to assess participants' experience of the intervention. Quantitative measurements included pre- and post-course evaluation and psychotropic prescribing rates. Results: Sixteen nursing home staff members attended the two education and training days (21% attendance rate), and four GPs participated in the academic detailing sessions (100% attendance rate). Participants of the focus groups and interviews (n = 18) found the education and training beneficial for their work and expressed a desire to continue educating new staff after the study's completion. However, there was limited usage of the resident assessment tool. Participants also offered recommendations to enhance the intervention.The proportion of dementia residents prescribed at least one regular antipsychotic was stable over the 3-months pre-intervention at 45% (n = 18), and at baseline at 44% (n = 19) but decreased slightly to 36% (n = 14) at 3-months post-intervention. At the same time the absolute number of 'PRN' psychotropics administered monthly to dementia residents decreased substantially from 90 at baseline to 69 at 3-months post-intervention. Conclusion: The RAPID complex intervention was broadly feasible to conduct and may be acceptable to stakeholders. However, before it can be evaluated in larger scale studies, certain protocol modifications and further exploratory work are required to improve implementation.

A description of antipsychotic prescribing patterns based on race in the inpatient behavioral health setting.

BACKGROUND AND AIMS: A growing body of research shows that race contributes to disparities in mental health services utilization and influences the clinical diagnostic process. To our knowledge, no studies on current practice in the Unites States have documented whether these disparities impact the prescription of antipsychotic medications across individual patients based on race. Consequently, this study aims to describe the prescribing patterns of antipsychotic medications in the inpatient setting based on patients' race, and to explore appropriateness of therapy based on Food and Drug Administration labeling and avoidance of inappropriate polypharmacy. METHODS: Single-centered, retrospective, chart review of 398 psychiatric patients in the inpatient setting and who had a psychiatric diagnosis that warranted a prescription for an antipsychotic medication at the time of discharge. Frequencies were computed to describe differences in demographic variables (race, health insurance type, age, and gender), medical conditions (diagnosis, commodities, hospitalization status, antipsychotic medications, etc.), and screening tests (lipid panel, hemoglobin, urine and illicit drug use). Logistic regression, analysis of variance, and hypothesis tests were used to analyze the data. RESULTS: Significant differences were not found in total chlorpromazine equivalent dose equivalencies by race or insurance. However, patients of involuntary admission status, past medication trials, a diagnosis of schizophrenia or bipolar disorder, and who lacked family support had higher total daily doses of antipsychotics upon discharge. Inappropriate therapy was significantly related to differences in increasing age and a diagnosis of insomnia. CONCLUSION: This single-centered study described patterns of antipsychotic prescribing based on race in an inpatient psychiatry facility. Future studies, using larger and more diverse sample populations, are recommended to elucidate the role that patients' race, admission status, and family support play in the dose and appropriateness of antipsychotics prescribed for mental health care.

Effectiveness of confidential reports to physicians on their prescribing of antipsychotic medications in nursing homes.

BACKGROUND: Antipsychotic medication use in nursing homes is associated with potential for harms. In Ontario, Canada, an agency of the provincial government offers nursing home physicians quarterly audit and feedback on their antipsychotic prescribing. We compared the characteristics of physicians who did and did not engage with the intervention, and assessed early changes in prescribing. METHODS: This population-level, retrospective cohort study used linked administrative databases to track prescribing practices in nursing homes pre-intervention (baseline), immediately post-initiative (3 months), and at follow-up (6 months). Exposure variables identified whether a physician signed up to participate (or not) or viewed the feedback following sign up (or not). Differences in the proportion of days that residents received antipsychotic medications at 6 months compared to baseline by exposure(s) were assessed using a linear mixed effects regression analysis to adjust for a range of resident, physician, and nursing home factors. Benzodiazepine and statin prescribing were assessed as a balance and tracer measures, respectively. RESULTS: Of 944 eligible physicians, 210 (22.3%) signed up to recieve the feedback report and 132 (13.9%) viewed their feedback. Physicians who signed up for feedback were more likely to have graduated from a Canadian medical school, work in urban nursing homes, and care for a larger number of residents. The clinical and functional characteristics of residents were similar across physician exposure groups. At 6 months, antipsychotic prescribing had decreased in all exposure groups. Those who viewed their feedback report had a signicantly greater reduction in antipsychotic prescribing than those who did not sign up (0.94% patient-days exposed; 95% CI 0.35 to 1.54%, p = 0.002). Trends in prescribing patterns across exposure groups for benzodiazepines and statins were not statistically significant. INTERPRETATION: Almost a quarter of eligible physicians engaged early in a voluntary audit and feedback intervention related to antipsychotic prescribing in nursing homes. Those who viewed their feedback achieved a small but statistically significant change in prescribing, equivalent to approximately 14,000 fewer days that nursing home residents received antipsychotic medications over 6 months. This study adds to the literature regarding the role of audit and feedback interventions to improve quality of care.

Public reporting of antipsychotic prescribing in nursing homes: population-based interrupted time series analyses.

BACKGROUND: Although sometimes appropriate, antipsychotic medications are associated with increased risk of significant adverse events. In 2014, a series of newspaper articles describing high prescribing rates in nursing homes in Ontario, Canada, garnered substantial interest. Subsequently, an online public reporting initiative with home-level data was launched. We examined the impact of these public reporting interventions on antipsychotic prescribing in nursing homes. METHODS: Time series analysis of all nursing home residents in Ontario, Canada, between 1 October 2013 and 31 March 2016. The primary outcome was the proportion of residents prescribed antipsychotics each month. Balance measures were prescriptions for common alternative sedating agents (benzodiazepines and/or trazodone). We used segmented regression to assess the effects on prescription trends of the newspaper articles and the online home-level public reporting initiative. RESULTS: We included 120 009 nursing home resident admissions across 636 nursing homes. Following the newspaper articles, the proportion of residents prescribed an antipsychotic decreased by 1.28% (95% CI 1.08% to 1.48%) and continued to decrease at a rate of 0.2% per month (95% CI 0.16% to 0.24%). The online public reporting initiative did not alter this trend. Over 3 years, there was a net absolute reduction in antipsychotic prescribing of 6.0% (95% CI 5.1% to 6.9%). Trends for benzodiazepine prescribing did not change as substantially during the period of observation. Trazodone use has been gradually increasing, but its use did not change abruptly at the time of the mass media report or the public reporting initiative. INTERPRETATION: The rapid impact of mass media on prescribing suggests both an opportunity to use this approach to invoke change and a warning to ensure that such reporting occurs responsibly.

Exploring service users', carers' and professionals' perspectives and experiences of current antipsychotic prescribing: A qualitative study.

Objectives Shared decision-making is the pinnacle of patient-centred care; mental health stakeholders value shared decision-making but find it difficult to enact. The objective was to compare and synthesise mental health stakeholder views on antipsychotic prescribing in one NHS Trust, to understand potential reasons for the difficult enactment of shared decision-making in practice. Methods We conducted 12 interviews and 5 focus groups with 33 mental health stakeholders, after obtaining their informed consent. They shared their experiences in and perceptions of antipsychotic prescribing and were recruited from Manchester Mental Health and Social Care Trust. Results Stakeholders agreed that successful shared decision-making demands a collaborative approach. We elucidated a striking divergence in views of the decision-making process and understanding of collaboration. Nurses, consultants and the pharmacist seemed most satisfied with the amount of collaboration but most pessimistic about the scope for it. Carers and most service users did not feel that there was any collaboration. Discussion Comparison of perspectives demonstrated the complexity of shared decision-making which is not addressed in current operational definitions or policy or nursing practice initiatives. The findings have the potential to progress initiatives in the mental health field from those that emphasise the need for shared decision-making to those that develop tools to promote shared decision-making.

Exploring the potential implementation of a tool to enhance shared decision making (SDM) in mental health services in the United Kingdom: a qualitative exploration of the views of service users, carers and professionals.

BACKGROUND: As a response to evidence that mental health service users and carers expect greater involvement in decisions about antipsychotic medication choice and prescribing, shared decision-making (SDM) has increasingly come to be viewed as an essential element of person-centred care and practice. However, this aspiration has yet to be realised in practice, as service users and carers continue to feel alienated from healthcare services. Existing understanding of the factors affecting the use of tools to support SDM is limited to inter-individual influences and wider factors affecting potential implementation are underexplored. AIM: To explore the potential use of a tool designed to enhance collaborative antipsychotic prescribing from the perspectives of secondary care mental health service users, carers and professionals. METHODS: We conducted a qualitative study (semi-structured interviews and focus groups) using a convenience sample of 33 participants (10 mental health service users, 10 carers and 13 professionals) involved in antipsychotic prescribing in one Trust in the North of England. Participants were asked about the potential implementation of a tool to support SDM within secondary mental health services. Framework analysis incorporating the use of constant comparative method was used to analyse the data. RESULTS: The study identified a divergence in the views of service users and professionals, including a previously undocumented tendency for stakeholder groups to blame each other for potential implementation failure. This dissonance was shaped by meso and macro level influences relating to paternalism, legislative frameworks, accountability and lack of resources. Participants did not identify any macro level (policy or structural) facilitators to the use of the tool highlighting the negative impact of mental health contexts. Our study indicated that inter-individual factors are likely to be most important to implementation, given their potential to transcend meso and macro level barriers. CONCLUSIONS: Consideration of the meso and macro level influences identified areas for potential intervention, including challenging professionals' and service users' perceptions of each other, rebalancing the notion of accountability within services and introducing new means for service user feedback on the quality of SDM. Multi-level strategies for facilitating the implementation of tools to support SDM are also presented.

Mental health pharmacists views on shared decision-making for antipsychotics in serious mental illness.

Background People diagnosed with serious mental illnesses (SMIs) such as schizophrenia and bipolar affective disorder are frequently treated with antipsychotics. National guidance advises the use of shared decision-making (SDM) in antipsychotic prescribing. There is currently little data on the opinions of health professionals on the role of SDM. Objective To explore the views and experiences of UK mental health pharmacists regarding the use of SDM in antipsychotic prescribing in people diagnosed with SMI. Setting The study was conducted by interviewing secondary care mental health pharmacists in the UK to obtain qualitative data. Methods Semi-structured interviews were recorded. An inductive thematic analysis was conducted using the method of constant comparison. Main outcome measure Themes evolving from mental health pharmacists on SDM in relation to antipsychotic prescribing in people with SMI. Results Thirteen mental health pharmacists were interviewed. SDM was perceived to be linked to positive clinical outcomes including adherence, service user satisfaction and improved therapeutic relations. Despite more prescribers and service users supporting SDM, it was not seen as being practised as widely as it could be; this was attributed to a number of barriers, most predominantly issues surrounding service user's lacking capacity to engage in SDM and time pressures on clinical staff. The need for greater effort to work around the issues, engage service users and adopt a more inter-professional approach was conveyed. Conclusion The mental health pharmacists support SDM for antipsychotic prescribing, believing that it improves outcomes. However, barriers are seen to limit implementation. More research is needed into overcoming the barriers and measuring the benefits of SDM, along with exploring a more inter-professional approach to SDM.