Racial disparities with PRN medication usage in inpatient psychiatric treatment.

Racial disparities in psychiatric diagnoses and treatment have significant public health implications, contributing to inequities in healthcare outcomes. We specifically examined racial disparities regarding pro re nata (PRN), or as needed, medications. Data from 14,616 encounters across 2019-2020 within Community Health Network's inpatient psychiatric setting in Indianapolis, Indiana were included in this study. Due to the demographic sample size, analyses were narrowed to Black and White patients. Primary outcomes included comparisons across race for all PRN administrations and PRN administrations of antipsychotics vs. non-antipsychotics. Logistic regression was used to examine associations between race and PRN administrations by medication category, including all antipsychotics vs. non-antipsychotics overall, hydroxyzine, and lorazepam, independently. Significant differences in the percentage of administrations between Black and White patients were observed. Black patients received more PRN medications overall (71.0%) compared to White patients (67.7%) (p < 0.01). Further, while 17.7% of Black patients were administered PRN antipsychotics, this was true for only 8.2% of White patients (p < 0.001). When comparing antipsychotic PRNs with non-antipsychotic, hydroxyzine, and lorazepam PRNs, independently, Black patients were 58% (OR 1.58, p < 0.001), 109% (OR 2.09, p < 0.001), and 32% (OR 1.32, p < 0.001), more likely to receive antipsychotic PRNs, respectively, than White patients, controlling for sex, age, length of stay, and psychotic disorder diagnosis. Our study identifies yet another area of medical care with significant racial disparities. In this analysis of PRN medications during psychiatric admission, we identified significant differences in medication utilization by race. This information provides a basis for further investigation of disparities in patient-centered data.

Slow your role: How slowing clozapine titration can prevent recurrent NMS.

Ms. D. was a 57-year-old Caucasian female with a past psychiatric history of schizoaffective disorder bipolar type and unspecified anxiety disorder. She presented to the psychiatric unit with cognitive blunting, poverty of thought content, looseness of associations, and inability to respond to questions with meaningful responses. In addition, the patient presented with medical symptoms including rigidity, acute rhabdomyolysis, and elevated liver function tests (LFTs). She was transferred to the inpatient medical unit for stabilization. After acute stabilization, she was transferred back to the psychiatric unit for treatment. A thorough review of the patient's history revealed she had prior episodes of atypical NMS with trials of multiple typical and atypical antipsychotics at therapeutic doses and with clinically appropriate titration schedules. These trials included clozapine, which is known to have decreased likelihood of NMS symptoms. The patient was stabilized during admission, but later decompensated and required re-admission in the months following. At that time, clozapine was reinstituted at very low doses and with a slower titration schedule. This approach was successful in ameliorating the patient's symptoms and without recurrence of NMS. In this case report, we discuss the importance of identifying atypical NMS in patients treated with typical and atypical antipsychotics, and propose that successful treatment of these patients may be possible with slower and gradual titration of clozapine.