Off-label use of antidepressants, antipsychotics, and mood-stabilizers in psychiatry.

Off-label drug prescribing in psychiatry is increasing. Many psychotropic drugs are approved for psychopathologic syndromes rather than based on international standard diagnostic classification systems which might facilitate the clinical decision for off-label prescriptions. The objective of this study was to analyze the prevalence and category of off-label use of psychotropic drugs. The study was conducted in 10 psychiatric hospitals in Germany over a period of 2 years. Prescription data of all patients were retrospectively analyzed after identification of antidepressants, antipsychotics, and mood-stabilizers, which were classified as off-label according to the German prescribing information and diagnostic classification according to ICD-10. In total, 53,909 patient cases (46% female) with a mean age of 46.8 (SD: 18) years were included in the study. 30.2% of the cases received at least one off-label prescription of a psychotropic drug during hospital stay. Off-label prevalence rates differed markedly between different diagnostic groups (ICD-10 F0/G3: 47%, F1: 33%, F2: 25%, F3: 21%, F4: 27%, F6: 46%, F7: 84%). The most often off-label prescribed drugs were quetiapine and mirtazapine for organic mental disorders (F0/G3), valproate and quetiapine in patients with disorders due to psychoactive substance use (F1), valproate in patients with psychotic disorders (F2), and risperidone and olanzapine in patients with affective disorders (F3). The prevalence rate of psychotropic off-label prescriptions is high if restricted to product description and ICD-10 diagnosis. Therefore, current psychiatric guidelines should drug-specifically issue this problem by defining psychiatric off-label indications based on a clear benefit-risk assessment.

"A real eye opener" - development, implementation and evaluation of a seminar on interprofessional teamwork in GP specialty training.

Introduction: The successful treatment of a multitude of chronic diseases is largely dependent on effective interprofessional collaboration. In Germany, many healthcare employees feel unprepared for the challenges of interprofessional teamwork. Can a seminar designed by an interprofessional team for an interprofessional target group improve mutual understanding and provide the basis for successful interprofessional collaboration? Methodological approach: For the development of the seminar, Kern's model for curriculum development was used, which includes the following six steps: problem identification, needs analysis, goal definition (learning objectives and learning content), educational strategies, implementation and evaluation. The all-day event brought together physiotherapists, pharmacists, medical assistants and doctors undergoing specialist training in family medicine. Representatives of the various professions were recruited through multiple channels (associations, pharmacist societies, alumni-networks, etc.). Practical examples and role-play were used to develop a better understanding of each other's professions and to support goal-oriented and appreciative communication among them. The seminar belongs to the curriculum provided by the Hesse Competence Center for Specialist Training in General Practice and has so far taken place three times. The evaluation was carried out by means of a detailed, self-designed questionnaire with five open and 20 closed questions. The statistical analysis was mainly descriptive (mean value, minimum, maximum and SD). Results: Overall, 29 persons have participated in the workshops (eleven doctors undergoing specialist training, six physiotherapists, six pharmacists, six medical assistants). Overall, the seminar was rated very highly. Individual aspects of the seminar's design, such as relevance and practice-orientation, as well as an assessment of whether the seminar contributed towards increasing participants' ability to collaborate with other professionals, were rated positively. In addition, a pre-post comparison of self-assessed ability to collaborate interprofessionally showed significant improvement. Discussion: This highly interactive one-day seminar design contributed towards improving understanding for other professions and communication skills. In order to achieve a broad-based improvement in interprofessional collaboration over the long term, this or similar concepts should be employed more extensively. Conclusions: The results suggest that participants in interprofessional seminars consider them to improve interprofessional collaboration.

Pharmacotherapy, drug-drug interactions and potentially inappropriate medication in depressive disorders.

INTRODUCTION: The aim of this study was to describe the number and type of drugs used to treat depressive disorders in inpatient psychiatry and to analyse the determinants of potential drug-drug interactions (pDDI) and potentially inappropriate medication (PIM). METHODS: Our study was part of a larger pharmacovigilance project funded by the German Innovation Funds. It included all inpatients with a main diagnosis in the group of depressive episodes (F32, ICD-10) or recurrent depressive disorders (F33) discharged from eight psychiatric hospitals in Germany between 1 October 2017 and 30 September 2018 or between 1 January and 31 December 2019. RESULTS: The study included 14,418 inpatient cases. The mean number of drugs per day was 3.7 (psychotropic drugs = 1.7; others = 2.0). Thirty-one percent of cases received at least five drugs simultaneously (polypharmacy). Almost one half of all cases received a combination of multiple antidepressant drugs (24.8%, 95% CI 24.1%-25.5%) or a treatment with antidepressant drugs augmented by antipsychotic drugs (21.9%, 95% CI 21.3%-22.6%). The most frequently used antidepressants were selective serotonin reuptake inhibitors, followed by serotonin and norepinephrine reuptake inhibitors and tetracyclic antidepressants. In multivariate analyses, cases with recurrent depressive disorders and cases with severe depression were more likely to receive a combination of multiple antidepressant drugs (Odds ratio recurrent depressive disorder: 1.56, 95% CI 1.41-1.70, severe depression 1.33, 95% CI 1.18-1.48). The risk of any pDDI and PIM in elderly patients increased substantially with each additional drug (Odds Ratio: pDDI 1.32, 95% CI: 1.27-1.38, PIM 1.18, 95% CI: 1.14-1.22) and severity of disease (Odds Ratio per point on CGI-Scale: pDDI 1.29, 95% CI: 1.11-1.46, PIM 1.27, 95% CI: 1.11-1.44), respectively. CONCLUSION: This study identified potential sources and determinants of safety risks in pharmacotherapy of depressive disorders and provided additional data which were previously unavailable. Most inpatients with depressive disorders receive multiple psychotropic and non-psychotropic drugs and pDDI and PIM are relatively frequent. Patients with a high number of different drugs must be intensively monitored in the management of their individual drug-related risk-benefit profiles.