McMillan Sara S, Jacobs Sara, Wilson Louise, Theodoros Theo, Robinson Gail, Anderson Claire, Mihala Gabor, Wheeler Amanda J
Menzies Health Insitute, Griffith University, Brisbane, Australia.
Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK.
BMC Psychiatry. 2017 Apr 13;17(1):139. doi: 10.1186/s12888-017-1295-1.
Antipsychotics are recognised as a critical intervention for schizophrenia and bipolar disorder. Guidelines globally endorse the routine practice of antipsychotic monotherapy, at the minimum effective dose. Even in treatment-resistant schizophrenia, clozapine use is endorsed before combining antipsychotics. This aim of this study was to review antipsychotic polytherapy alone, high-dose therapy alone, polytherapy and high-dose prescribing patterns in adults discharged from an inpatient mental health unit at two time-points, and the alignment of this prescribing with clinical guideline recommendations. Additionally, associations with polytherapy and high-dose antipsychotic prescribing, including patient and clinical characteristics, were explored.
A retrospective clinical audit of 400 adults (200 patients at two different time-points) discharged with at least one antipsychotic. Preliminary findings and education sessions were provided to physicians between Cohorts. Outcomes (polytherapy alone, high-dose therapy alone, polytherapy and high-dose therapy) were compared between study Cohorts using chi-squared and rank-sum tests. Associations between outcomes and covariates were assessed using multivariable logistic regression.
Most patients (62.5%) were discharged on a single antipsychotic within the recommended dose range. There was a clear preference for prescribing second generation antipsychotics, and in this respect, prescribing is aligned with current evidence-based guidelines. However, sub-optimal prescribing practices were identified for both Cohorts in relation to polytherapy and high-dose antipsychotic rates. Involuntary treatment, frequent hospitalisations and previous clozapine use significantly increased the risk of all three prescribing outcomes at discharge.
In a significant minority, antipsychotic prescribing did not align with clinical guidelines despite increased training, indicating that the education program alone was ineffective at positively influencing antipsychotic prescribing practices. Further consideration should be given when prescribing antipsychotics for involuntary patients, people with frequent hospitalisations, and those who have previously trialled clozapine.
抗精神病药物被认为是治疗精神分裂症和双相情感障碍的关键干预措施。全球指南均支持采用最低有效剂量的抗精神病药物单一疗法的常规做法。即使是在难治性精神分裂症中，也建议在联合使用抗精神病药物之前先使用氯氮平。本研究的目的是回顾在两个时间点从住院精神科病房出院的成年人中单独使用抗精神病药物联合治疗、单独使用高剂量治疗、联合治疗和高剂量处方模式，以及这种处方与临床指南建议的一致性。此外，还探讨了与联合治疗和高剂量抗精神病药物处方相关的因素，包括患者和临床特征。
对400名至少使用一种抗精神病药物出院的成年人（两个不同时间点各200名患者）进行回顾性临床审计。在各队列之间向医生提供初步研究结果和教育课程。使用卡方检验和秩和检验比较研究队列之间的结果（单独联合治疗、单独高剂量治疗、联合治疗和高剂量治疗）。使用多变量逻辑回归评估结果与协变量之间的关联。
大多数患者（62.5%）在推荐剂量范围内使用单一抗精神病药物出院。明显更倾向于开具第二代抗精神病药物，在这方面，处方与当前基于证据的指南一致。然而，在联合治疗和高剂量抗精神病药物使用率方面，两个队列均存在次优处方做法。非自愿治疗、频繁住院和既往使用氯氮平显著增加了出院时所有三种处方结果的风险。
尽管培训有所增加，但仍有相当一部分患者的抗精神病药物处方不符合临床指南，这表明仅靠教育计划不足以积极影响抗精神病药物的处方做法。在为非自愿患者、频繁住院患者以及既往试用过氯氮平的患者开具抗精神病药物时应进一步考虑。
