0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

Articles   |    
Variation in Long-Term Antipsychotic Polypharmacy and High-Dose Prescribing Across Physicians and Hospitals
Eric A. Latimer, Ph.D.; Adonia Naidu, M.Sc., R.N.; Erica E. M. Moodie, Ph.D.; Robin E. Clark, Ph.D.; Ashok K. Malla, M.B.B.S., F.R.C.P.C.; Robyn Tamblyn, Ph.D.; Willy Wynant, M.S.
Psychiatric Services 2014; doi: 10.1176/appi.ps.201300217
View Author and Article Information

Dr. Latimer and Dr. Malla are with the Department of Psychiatry, McGill University, and the Douglas Mental Health University Institute, Montreal, Quebec, Canada (e-mail: eric.latimer@mcgill.ca). Ms. Naidu is with the Douglas Mental Health University Institute, Montreal. Dr. Moodie, Dr. Tamblyn, and Mr. Wynant are with the Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal. Dr. Clark is with the Center for Health Policy and Research, University of Massachusetts Medical School, Shrewsbury. Preliminary results from this study were presented at the Canadian Association for Health Services and Policy Research in Toronto, Ontario, May 11–14, 2010.

Copyright © 2014 by the American Psychiatric Association

Abstract

Objectives  This study had two aims: to measure the prevalence of long-term prescribing of high doses of antipsychotics and antipsychotic polypharmacy in a large Canadian province and to estimate the relative contributions of patient-, physician-, and hospital-level factors.

Methods  Government hospital discharge, physician, and pharmaceutical claims data were linked to identify individuals with schizophrenia who in 2004 had antipsychotics available to them for at least 11 months. Individuals on a high dose throughout that period, as well as individuals on multiple concurrent antipsychotics (polypharmacy), were identified. Logistic and generalized linear mixed models using patient-, physician-, and hospital-level predictors were estimated.

Results  Among the 12,150 individuals identified, 11.9% were on a high dose and 10.4% on antipsychotic polypharmacy continually, with 3.7% in both groups. After adjustment for potential confounders, analyses showed that systematic propensity for physicians to prescribe high doses accounted for 10.9% of the remaining unexplained variance, and physicians as a group who prescribed high doses across a hospital or psychiatry department accounted for 3.0%. For antipsychotic polypharmacy the corresponding percentages were 9.7% and 6.2%. Even after adjustment, the variation in high-dose prescribing and antipsychotic polypharmacy remained substantial.

Conclusions  Long-term high-dose and antipsychotic polypharmacy prescribing appeared partly driven by some physicians’ and some hospitals’ propensities to prescribe in this way independently of patient characteristics. Given the weight of the evidence against high-dose prescribing and antipsychotic polypharmacy, measures addressed to physicians and hospitals most likely to prescribe high doses, antipsychotic polypharmacy, or both should be considered.

Abstract Teaser
Figures in this Article

Your Session has timed out. Please sign back in to continue.
Sign In Your Session has timed out. Please sign back in to continue.
Sign In to Access Full Content
 
Username
Password
Sign in via Athens (What is this?)
Athens is a service for single sign-on which enables access to all of an institution's subscriptions on- or off-site.
Not a subscriber?

Subscribe Now/Learn More

PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing PsychiatryOnline@psych.org or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Anchor for Jump
Table 1Sample characteristics of patients with schizophrenia who received high-dose or multiple concurrent antipsychotics for at least 11 months in 2004
Table Footer Note

a Subset with antipsychotic prescriptions covering at least 11 months during 2004

Table Footer Note

b Denominators for percentages are 7,430 in full sample, 1,123 for antipsychotic polypharmacy, and 922 for high dose.

Table Footer Note

c Numbered for anonymity

Table Footer Note

d Denominators: 7,810 for full sample, 944 for antipsychotic polypharmacy, and 1,031 for high dose

Anchor for Jump
Table 2Predictors of long-term high-dose antipsychotic prescription among patients with schizophreniaa
Table Footer Note

a Models 1a and 2a were estimated with logistic regression; model 3a was a generalized linear mixed model, estimated with Stata’s GLLAMM procedure.

Table Footer Note

b Log likelihood=–4,329.24; pseudo-R2=.0241

Table Footer Note

c Log likelihood=–4,130.69; pseudo-R2=.0234

Table Footer Note

d Log likelihood=–4,050.71; random effects: physician variance=.42, hospital variance=.12; percentage of variance: patient factors=86.0%, physician factors=10.9%, hospital factors=3.0%

Table Footer Note

e Exponentiated coefficient from the GLLAMM

Table Footer Note

f Numbered for anonymity

Anchor for Jump
Table 3Predictors of use of long-term antipsychotic polypharmacy among patients with schizophreniaa
Table Footer Note

a Models 1b and 2b were estimated with logistic regression; model 3b was a generalized linear mixed model, estimated with Stata’s GLLAMM procedure.

Table Footer Note

b Log likelihood=–3,700.84; pseudo-R2=.0886

Table Footer Note

c Log likelihood=–3,512.54; pseudo-R2=.0919

Table Footer Note

d Log likelihood=–3,451.52; random effects: physician variance=.38, hospital variance=.24. Percentage of variance: patient factors=84.1%, physician factors=9.7%, hospital factors=6.2%

Table Footer Note

e Exponentiated coefficient from the GLLAMM

Table Footer Note

f Numbered for anonymity

+

References

Buchanan  RW;  Kreyenbuhl  J;  Kelly  DL  et al:  The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements.  Schizophrenia Bulletin 36:71–93, 2010
[CrossRef] | [PubMed]
 
Gaebel  W;  Weinmann  S;  Sartorius  N  et al:  Schizophrenia practice guidelines: international survey and comparison.  British Journal of Psychiatry 187:248–255, 2005
[CrossRef] | [PubMed]
 
Kreyenbuhl  J;  Buchanan  RW;  Dickerson  FB  et al:  The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009.  Schizophrenia Bulletin 36:94–103, 2010
[CrossRef] | [PubMed]
 
NICE:  Schizophrenia: Full National Clinical Guideline on Core Interventions in Primary and Secondary Care .  London,  Royal College of Psychiatrists, 2003
 
National Collaborating Centre for Mental Health:  The NICE Guidelines on Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care (Update) .  London,  British Psychological Society and the Royal College of Psychiatrists, 2010
 
Baptista  T:  Body weight gain induced by antipsychotic drugs: mechanisms and management.  Acta Psychiatrica Scandinavica 100:3–16, 1999
[CrossRef] | [PubMed]
 
Melkersson  KI;  Hulting  AL;  Rane  AJ:  Dose requirement and prolactin elevation of antipsychotics in male and female patients with schizophrenia or related psychoses.  British Journal of Clinical Pharmacology 51:317–324, 2001
[CrossRef] | [PubMed]
 
Elie  D;  Poirier  M;  Chianetta  J  et al:  Cognitive effects of antipsychotic dosage and polypharmacy: a study with the BACS in patients with schizophrenia and schizoaffective disorder.  Journal of Psychopharmacology 24:1037–1044, 2010
[CrossRef] | [PubMed]
 
Glassman  AH;  Bigger  JT  Jr:  Antipsychotic drugs: prolonged QTc interval, torsade de pointes, and sudden death.  American Journal of Psychiatry 158:1774–1782, 2001
[CrossRef] | [PubMed]
 
Fleischhacker  WW;  Uchida  H:  Critical review of antipsychotic polypharmacy in the treatment of schizophrenia.  International Journal of Neuropsychopharmacology 2:1–11, 2012
 
Correll  CU;  Rummel-Kluge  C;  Corves  C  et al:  Antipsychotic combinations vs monotherapy in schizophrenia: a meta-analysis of randomized controlled trials.  Schizophrenia Bulletin 35:443–457, 2009
[CrossRef] | [PubMed]
 
Joukamaa  M;  Heliövaara  M;  Knekt  P  et al:  Schizophrenia, neuroleptic medication and mortality.  British Journal of Psychiatry 188:122–127, 2006
[CrossRef] | [PubMed]
 
Baandrup  L;  Gasse  C;  Jensen  VD  et al:  Antipsychotic polypharmacy and risk of death from natural causes in patients with schizophrenia: a population-based nested case-control study.  Journal of Clinical Psychiatry 71:103–108, 2010
[CrossRef] | [PubMed]
 
Tiihonen  J;  Suokas  JT;  Suvisaari  JM  et al:  Polypharmacy with antipsychotics, antidepressants, or benzodiazepines and mortality in schizophrenia.  Archives of General Psychiatry 69:476–483, 2012
[CrossRef] | [PubMed]
 
Latimer  E;  Wynant  W;  Clark  R  et al:  Underprescribing of clozapine and unexplained variation in use across hospitals and regions in the Canadian province of Québec.  Clinical Schizophrenia and Related Psychoses 7:33–41, 2013
[CrossRef] | [PubMed]
 
Zhu  B;  Ascher-Svanum  H;  Faries  DE  et al:  Cost of antipsychotic polypharmacy in the treatment of schizophrenia.  BMC Psychiatry 8:19, 2008
[CrossRef] | [PubMed]
 
Barnes  TR;  Paton  C:  Antipsychotic polypharmacy in schizophrenia: benefits and risks.  CNS Drugs 25:383–399, 2011
[CrossRef] | [PubMed]
 
Kane  JM;  Correll  CU:  Pharmacologic treatment of schizophrenia.  Dialogues in Clinical Neuroscience 12:345–357, 2010
[PubMed]
 
Harrington  M;  Lelliott  P;  Paton  C  et al:  The results of a multi-centre audit of the prescribing of antipsychotic drugs for in-patients in the UK.  Psychiatric Bulletin 26:414–418, 2002
[CrossRef]
 
Chong  MY;  Tan  CH;  Fujii  S  et al:  Antipsychotic drug prescription for schizophrenia in East Asia: rationale for change.  Psychiatry and Clinical Neurosciences 58:61–67, 2004
[CrossRef] | [PubMed]
 
Xiang  YT;  Wang  CY;  Si  TM  et al:  Antipsychotic polypharmacy in inpatients with schizophrenia in Asia (2001–2009).  Pharmacopsychiatry 45:7–12, 2012
[CrossRef] | [PubMed]
 
Weissman  EM:  Antipsychotic prescribing practices in the Veterans Healthcare Administration: New York metropolitan region.  Schizophrenia Bulletin 28:31–42, 2002
[CrossRef] | [PubMed]
 
Wilkie  A;  Preston  N;  Wesby  R:  High dose neuroleptics: who gives them and why? Psychiatric Bulletin 25:179–183, 2001
[CrossRef]
 
Harrington  M;  Lelliott  P;  Paton  C  et al:  Variation between services in polypharmacy and combined high dose of antipsychotic drugs prescribed for in-patients.  Psychiatric Bulletin 26:418–420, 2002
[CrossRef]
 
Correll  CU;  Shaikh  L;  Gallego  JA  et al:  Antipsychotic polypharmacy: a survey study of prescriber attitudes, knowledge and behavior.  Schizophrenia Research 131:58–62, 2011
[CrossRef] | [PubMed]
 
Leslie  DL;  Rosenheck  RA:  Adherence of schizophrenia pharmacotherapy to published treatment recommendations: patient, facility, and provider predictors.  Schizophrenia Bulletin 30:649–658, 2004
[CrossRef] | [PubMed]
 
Tamblyn  R;  Laprise  R;  Hanley  JA  et al:  Adverse events associated with prescription drug cost-sharing among poor and elderly persons.  JAMA 285:421–429, 2001
[CrossRef] | [PubMed]
 
Ito  H;  Koyama  A;  Higuchi  T:  Polypharmacy and excessive dosing: psychiatrists’ perceptions of antipsychotic drug prescription.  British Journal of Psychiatry 187:243–247, 2005
[CrossRef] | [PubMed]
 
Segal  SP;  Cohen  D;  Marder  SR:  Neuroleptic medication and prescription practices with sheltered-care residents: a 12-year perspective.  American Journal of Public Health 82:846–852, 1992
[CrossRef] | [PubMed]
 
Paton  C;  Barnes  TR;  Cavanagh  MR  et al:  High-dose and combination antipsychotic prescribing in acute adult wards in the UK: the challenges posed by prn prescribing.  British Journal of Psychiatry 192:435–439, 2008
[CrossRef] | [PubMed]
 
Lelliott  P;  Paton  C;  Harrington  M  et al:  The influence of patient variables on polypharmacy and combined high dose of antipsychotic drugs prescribed for in-patients.  Psychiatric Bulletin 26:411–414, 2002
[CrossRef]
 
Faries  D;  Ascher-Svanum  H;  Zhu  B  et al:  Antipsychotic monotherapy and polypharmacy in the naturalistic treatment of schizophrenia with atypical antipsychotics.  BMC Psychiatry 5:26, 2005
[CrossRef] | [PubMed]
 
Procyshyn  RM;  Honer  WG;  Wu  TK  et al:  Persistent antipsychotic polypharmacy and excessive dosing in the community psychiatric treatment setting: a review of medication profiles in 435 Canadian outpatients.  Journal of Clinical Psychiatry 71:566–573, 2010
[CrossRef] | [PubMed]
 
Ganguly  R;  Kotzan  JA;  Miller  LS  et al:  Prevalence, trends, and factors associated with antipsychotic polypharmacy among Medicaid-eligible schizophrenia patients, 1998–2000.  Journal of Clinical Psychiatry 65:1377–1388, 2004
[CrossRef] | [PubMed]
 
Gilmer  TP;  Dolder  CR;  Folsom  DP  et al:  Antipsychotic polypharmacy trends among Medicaid beneficiaries with schizophrenia in San Diego County, 1999–2004.  Psychiatric Services 58:1007–1010, 2007
[CrossRef] | [PubMed]
 
Ranceva  N;  Ashraf  W;  Odelola  D:  Antipsychotic polypharmacy in outpatients at Birch Hill Hospital: incidence and adherence to guidelines.  Journal of Clinical Pharmacology 50:699–704, 2010
[CrossRef] | [PubMed]
 
Tapp  A;  Wood  AE;  Secrest  L  et al:  Combination antipsychotic therapy in clinical practice.  Psychiatric Services 54:55–59, 2003
[CrossRef] | [PubMed]
 
Humberstone  V;  Wheeler  A;  Lambert  T:  An audit of outpatient antipsychotic usage in the three health sectors of Auckland, New Zealand.  Australian and New Zealand Journal of Psychiatry 38:240–245, 2004
[CrossRef] | [PubMed]
 
Essock  SM;  Schooler  NR;  Stroup  TS  et al:  Effectiveness of switching from antipsychotic polypharmacy to monotherapy.  American Journal of Psychiatry 168:702–708, 2011
[CrossRef] | [PubMed]
 
Ivers  N;  Jamtvedt  G;  Flottorp  S  et al:  Audit and feedback: effects on professional practice and healthcare outcomes.  Cochrane Database of Systematic Reviews 6:CD000259, 2012
[PubMed]
 
Constantine  RJ;  Andel  R;  Tandon  R:  Trends in adult antipsychotic polypharmacy: progress and challenges in Florida’s Medicaid program.  Community Mental Health Journal 46:523–530, 2010
[CrossRef] | [PubMed]
 
Wheeler  A;  Humberstone  V;  Robinson  E  et al:  Impact of audit and feedback on antipsychotic prescribing in schizophrenia.  Journal of Evaluation in Clinical Practice 15:441–450, 2009
[CrossRef] | [PubMed]
 
Hazra  M;  Uchida  H;  Sproule  B  et al:  Impact of feedback from pharmacists in reducing antipsychotic polypharmacy in schizophrenia.  Psychiatry and Clinical Neurosciences 65:676–678, 2011
[CrossRef] | [PubMed]
 
Black  LL;  Greenidge  LL;  Ehmann  T  et al:  A centralized system for monitoring clozapine use in British Columbia.  Psychiatric Services 47:81–83, 1996
[PubMed]
 
References Container
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Related Content
Articles
Books
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 53.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 1.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 1.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 22.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 22.  >
Topic Collections
Psychiatric News
APA Guidelines
PubMed Articles