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Psychiatric Drug Use Among Patients of a Community Mental Health Service

Patterns and Implications

  • Original Research Article
  • Published:
Disease Management & Health Outcomes

Abstract

Background and objective

Patients of community mental health services frequently self-report experiencing adverse drug reactions (ADRs). The objective of this study was to assess and discuss the pattern of psychiatric drug use observed among patients of a community mental health service in Sydney, Australia.

Methods

This descriptive study was conducted from July 2005 to March 2006. Trained pharmacists conducted semi-structured interviews (30–45 minutes each) with 56 patients receiving psychiatric drugs and community-based case management for a long-term or persistent bipolar mood disorder or psychotic illness. The pharmacists reviewed drug charts, obtained community pharmacy dispensing records, and contacted other healthcare providers to compile a complete drug use record for each patient. These included prescription, non-prescription, and complementary and alternative medicines (CAMs). Patients’ drug use records were analyzed using eight psychiatric drug use indicators: (i) high dose antipsychotics; (ii) antipsychotic polypharmacy; (iii) atypical polypharmacy; (iv) multiple ‘when required’ drugs; (v) sub-therapeutic doses of mood stabilizers; (vi) hypnotic prescribing; (vii) psychiatric therapeutic duplication (same therapeutic class); and (viii) ≥3 psychiatric drugs. Drug use records were also screened for ‘potentially significant’ drug-drug interactions using the Thomson Micromedex Drug-Reax® System.

Results

The mean number of items (prescription drugs, non-prescription drugs, and CAMs) taken by each patient interviewed by the pharmacists was 7.80 ± 4.66. This included 2.91 ± 1.31 different psychiatric drugs by generic name, 0.86 ± 1.71 CAMs, and 1.00 ± 1.53 other non-prescription drugs. Twenty-eight patients (50%) were taking ≥2 psychiatric drugs from the same therapeutic class, and 23 (41%) were prescribed ≥2 antipsychotic drugs concurrently. Twenty-six patients (46%) were prescribed ≥1 antipsychotic drug at a dose exceeding that recommended in treatment guidelines. Potential drug-drug interactions were identified for 37 (66%) of the patients interviewed, with one or more potentially major drug-drug interactions being identified for 24 patients (43%).

Conclusions

Psychiatric drugs were frequently used in combinations and doses outside those recommended in treatment guidelines. This highlights the importance of developing strategies to prevent and detect ADRs. Hence, regular and routine reviews of all drugs prescribed for patients of community mental health services may be warranted to minimize the risk of serious ADRs or drug-drug interactions.

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Notes

  1. Therapeutic Guidelines: Psychotropic Version 5 are Australian guidelines prepared by an expert writing group and represent independent consensus opinion based on the evidence available at the time of publication.

References

  1. Steffens DC, Krishnan KR, Helms MJ. Are SSRIs better than TCAs? Comparison of SSRIs and TCAs: a meta-analysis. Depress Anxiety 1997; 6: 10–8

    Article  PubMed  CAS  Google Scholar 

  2. Gareri P, De Fazio P, Stilo M, et al. Conventional and atypical antipsychotics in the elderly: a review. Clin Drug Invest 2003; 23: 287–322

    Article  CAS  Google Scholar 

  3. Lambert TJR, Chapman L, Bell S, et al. Diabetes, psychotic disorders and antipsychotic therapy: a consensus statement. Med J Aust 2004; 181: 544–8

    PubMed  Google Scholar 

  4. Castle DJ, Morgan V, Jablensky A. Antipsychotic use in Australia: the patients’ perspective. Aust N Z J Psychiatry 2002; 36: 633–41

    Article  PubMed  Google Scholar 

  5. Happell B, Manias E, Roper C. Wanting to be heard: mental health consumers’ experiences of information about medication. Int J Ment Health Nurs 2004; 13: 242–8

    Article  PubMed  Google Scholar 

  6. Keks NA, Alston K, Hope J, et al. Use of antipsychotics and adjunctive medications by an inner urban community psychiatric service. Aust N Z J Psychiatry 1999; 33: 896–901

    Article  PubMed  CAS  Google Scholar 

  7. Snowdon J, Day S, Baker W. Why and how antipsychotic drugs are used in 40 Sydney nursing homes. Int J Geriatr Psychiatry 2005; 20: 1146–52

    Article  PubMed  Google Scholar 

  8. Oborne CA, Hooper R, Chi Li K, et al. An indicator of appropriate neuroleptic prescribing in nursing homes. Age Ageing 2002; 31: 435–9

    Article  PubMed  Google Scholar 

  9. Owen RR, Thrush CR, Kirchner JE, et al. Performance measurement for schizophrenia: adherence to guidelines for antipsychotic dose. Int J Qual Health Care 2000; 12: 475–82

    Article  PubMed  CAS  Google Scholar 

  10. Leslie DL, Rosenheck RA. Use of pharmacy data to assess quality of pharmacotherapy for schizophrenia in a national health care system: individual and facility predictors. Med Care 2001; 39: 923–33

    Article  PubMed  CAS  Google Scholar 

  11. Harrington M, Lelliott P, Paton C, et al. The results of a multi-centre audit of prescribing of antipsychotic drugs for inpatients in the UK. Psychiatr Bull 2002; 26: 414–8

    Article  Google Scholar 

  12. Paton C, Lelliott P. The use of prescribing indicators to measure the quality of care in psychiatric inpatients. Qual Saf Health Care 2004; 13: 40–5

    Article  PubMed  CAS  Google Scholar 

  13. Meagher D, Moran M. Sub-optimal prescribing in an adult community mental health service: prevalence and determinants. Psychiatr Bull 2003; 27: 266–70

    Article  Google Scholar 

  14. Callaly T, Trauer T. Patterns of use of antipsychotic medication in a regional community mental health service. Australas Psychiatry 2000; 8: 220–4

    Article  Google Scholar 

  15. Viola R, Csukonyi K, Doro P, et al. Reasons for polypharmacy among psychiatric patients. Pharm World Sci 2004; 26: 143–7

    Article  PubMed  Google Scholar 

  16. How to investigate drug use in health facilities. Geneva: World Health Organization, 1993

  17. Schmidt IK, Fastbom J. Quality of drug use in Swedish nursing homes: a follow up study. Clin Drug Invest 2000; 20: 433–46

    Article  Google Scholar 

  18. van Dijk KN, Pont LG, de Vries CS, et al. Prescribing indicators for evaluating drug use in nursing homes. Ann Pharmacother 2003; 37: 1136–41

    Article  PubMed  Google Scholar 

  19. Oborne CA, Hooper R, Swift CG, et al. Explicit, evidence-based criteria to assess the quality of prescribing to elderly nursing home residents. Age Ageing 2003; 32: 102–8

    Article  PubMed  Google Scholar 

  20. Oborne CA, Batty GM, Maskrey V, et al. Development of prescribing indicators for elderly medical inpatients. Br J Clin Pharmacol 1997; 43: 91–7

    Article  PubMed  CAS  Google Scholar 

  21. Elliott RA, Woodward MC, Oborne CA. Indicators of prescribing quality for elderly hospital inpatients. Aust J Hosp Pharm 2001; 31: 19–25

    Google Scholar 

  22. Harvey CA, Fielding JM. The configuration of mental health services to facilitate care for people with schizophrenia. Med J Aust 2003; 178: S49–52

    PubMed  Google Scholar 

  23. Alderman CP, Kiepfer B. Complementary medicine use by psychiatry patients of an Australian hospital. Ann Pharmacother 2003; 37: 1779–84

    Article  PubMed  Google Scholar 

  24. Bell JS, Whitehead P, Aslani P, et al. Drug related problems in the community setting: pharmacists’ findings and recommendations for people with mental illnesses. Clin Drug Invest 2006; 26: 415–25

    Article  Google Scholar 

  25. MacLennan AH, Myers SP, Taylor AW. The continuing use of complementary and alternative medicine in South Australia: costs and beliefs in 2004. Med J Aust 2006; 184: 27–31

    PubMed  Google Scholar 

  26. Carney SL. Medication accuracy and general practitioner referral letters. Intern Med J 2006; 36: 132–4

    Article  PubMed  CAS  Google Scholar 

  27. Cockayne NL, Duguid M, Shenfield GM. Health professionals rarely record history of complementary and alternative medicines. Br J Clin Pharmacol 2004; 59: 254–8

    Article  Google Scholar 

  28. Bell JS, Whitehead P, Aslani P, et al. Design and implementation of an educational partnership between community pharmacists and consumer educators in mental health care. Am J Pharm Educ 2006; 70: 28

    Article  PubMed  Google Scholar 

  29. Therapeutic guidelines: psychotropic version 5. Melbourne (Australia): Therapeutic Guidelines Limited, 2003

  30. Australian medicines handbook. Adelaide (Australia): Australian Medicines Handbook Pty Ltd, 2006

  31. Thomson MicroMedex. Drug-Reax® system [online]. Available from URL: http://www.micromedex.com/products/drugreax/ [Accessed 2006 Nov 18]

  32. Beaubrun G, Gray GE. A review of herbal medicines use psychiatric disorders. Psychiatr Serv 2000; 51: 1130–4

    Article  PubMed  CAS  Google Scholar 

  33. Rathbone J, Zhang L, Xia J, et al. Chinese herbal medicine for schizophrenia. Cochrane Database Syst Rev 2005; (4): CD003444

    PubMed  Google Scholar 

  34. Joy CB, Mumby-Croft R, Joy LA. Polyunsaturated fatty acid supplementation for schizophrenia. Cochrane Database Syst Rev 2006; (3): CD001257

    PubMed  Google Scholar 

  35. Coxeter PD, McLachlan AJ, Duke CC, et al. Herb-drug interactions: an evidence based approach. Curr Med Chem 2004; 11: 1513–25

    Article  PubMed  CAS  Google Scholar 

  36. Henderson L, Yue QY, Bergquist C, et al. St John’s wort (Hypericum perforatum): drug interactions and clinical outcomes. Br J Clin Pharmacol 2002; 54: 349–56

    Article  PubMed  CAS  Google Scholar 

  37. Jiang X, Williams KM, Liauw WS, et al. Effect of St John’s wort and ginseng on the pharmacokinetics and pharmacodynamics of warfarin in healthy subjects. Br J Clin Pharmacol 2004; 57: 592–9

    Article  PubMed  CAS  Google Scholar 

  38. Davis JM, Chen N. Dose response of dose equivalence of antipsychotics. J Clin Psychopharmacol 2004; 24: 192–208

    Article  PubMed  CAS  Google Scholar 

  39. Taylor D, Paton C, Kerwin R. The Maudsley 2005–2006 prescribing guidelines. London: Taylor and Francis; 2005

    Google Scholar 

  40. Robinson MJ, Levenson JL. The use of psychotropics in the medically ill. Curr Psychiatry Rep 2000; 2: 247–55

    Article  PubMed  CAS  Google Scholar 

  41. Kawai N, Yamakawa Y, Baba A, et al. High-dose of multiple antipsychotics and cognitive function in schizophrenia: the effect of dose reduction. Prog Neuropsychopharmacol Biol Psychiatry 2006; 30: 1009–14

    Article  PubMed  CAS  Google Scholar 

  42. Chadwick B, Waller DG, Edwards JG. Potential hazardous drug interactions with psychotropics. Adv Psychiatr Treat 2005; 11: 440–9

    Article  Google Scholar 

  43. Trenton A, Currier GW, Zwemer F. Fatalities associated with therapeutic use and overdose of atypical antipsychotics. CNS Drugs 2003; 17: 307–24

    Article  PubMed  CAS  Google Scholar 

  44. van de Weide J, van Baalen-Benedek EH, Kootstra-Ros JE. Metabolic ratios of psychotropics as indication of cytochrome P450 2D6/2C19 genotype. Ther Drug Monit 2005; 27: 478–83

    Article  PubMed  Google Scholar 

  45. Mulder H, Herder A, Wilmink FW, et al. The impact of cytochrome P450-2D6 genotype on the use and interpretation of therapeutic drug monitoring in long-stay patients treated with antidepressant and antipsychotic drugs in daily psychiatric practice. Pharmacoepidemiol Drug Saf 2006; 15: 107–14

    Article  PubMed  CAS  Google Scholar 

  46. Meltzer HY. Treatment-resistant schizophrenia: the role of clozapine. Curr Med Res Opin 1997; 14: 1–20

    Article  PubMed  CAS  Google Scholar 

  47. Chakos M, Lieberman J, Hoffman E, et al. Effectiveness of second generation antipsychotics in patients with treatment resistant schizophrenia: a review and meta-analysis of randomized trials. Am J Psychiatry 2001; 158: 518–26

    Article  PubMed  CAS  Google Scholar 

  48. McEvoy JP, Lieberman JA, Stroup TS, et al. Effectiveness of clozapine versus olanzapine, quetiapine and risperidone in patients with chronic schizophrenia who did not respond to prior atypical antipsychotic treatment. Am J Psychiatry 2006; 163: 600–10

    Article  PubMed  Google Scholar 

  49. Lerner V, Bergman J, Borokov A, et al. Augmentation with amisulpride for schizophrenic patients nonresponsive to antipsychotic monotherapy. Clin Neuropharmacol 2005; 28: 66–71

    Article  PubMed  CAS  Google Scholar 

  50. Zink M, Knopf U, Henn FA, et al. Combination of clozapine and amisulpride in treatment resistant schizophrenia: case reports and review of the literature. Pharmacopsychiatry 2004; 37: 26–31

    Article  PubMed  CAS  Google Scholar 

  51. Munro J, Matthiasson P, Osborne S, et al. Amisulpride augmentation of clozapine: an open non-randomized study in patients with schizophrenia partially responsive to clozapine. Acta Psychiatr Scand 2004; 110: 292–8

    Article  PubMed  CAS  Google Scholar 

  52. Lim S, Pralea S, Schnitt J, et al. Possible increased efficacy of low-dose clozapine when combined with aripiprazole [letter]. J Clin Psychiatry 2004; 65: 1284

    Article  PubMed  Google Scholar 

  53. Ziegenbein M, Wittmann G, Kropp S. Aripiprazole augmentation of clozapine in treatment resistant schizophrenia: a clinical observation. Clin Drug Invest 2006; 26: 117–24

    Article  CAS  Google Scholar 

  54. Josiassen RC, Joseph A, Kohegyi E, et al. Clozapine augmented with risperidone in the treatment of schizophrenia: a randomized, double blind, placebo-controlled trial. Am J Psychiatry 2005; 162: 130–6

    Article  PubMed  Google Scholar 

  55. Honer WG, Thornton AE, Chen EYH, et al. Clozapine alone versus clozapine and risperidone with refractory schizophrenia. N Engl J Med 2006; 354: 472–82

    Article  PubMed  CAS  Google Scholar 

  56. Stahl SM. Antipsychotic polypharmacy: evidence-based prescribing or prescribing-based evidence? Int J Neuropsychopharmacol 2004; 7: 113–6

    Article  PubMed  Google Scholar 

  57. Tapp AM, Wood AE, Kilzieh N, et al. Antipsychotic polypharmacy: do the benefits justify the risks? [letter] Ann Pharmacother 2005; 39: 1759–60

    Article  PubMed  Google Scholar 

  58. Centorrino F, Goren JL, Hennen J, et al. Multiple versus single antipsychotic agents for hospitalized psychiatric patients: case-control study of risks versus benefits. Am J Psychiatry 2004; 161: 700–6

    Article  PubMed  Google Scholar 

  59. Centorrino F, Fogarty KV, Sani G, et al. Use of combinations of antipsychotics: McLean Hospital inpatients 2002. Hum Psychopharmacol 2005; 20: 485–92

    Article  PubMed  CAS  Google Scholar 

  60. Waddington JL, Youssef HA, Kinsella A. Mortality in schizophrenia: antipsychotic polypharmacy and absence of adjunctive anticholinergics over the course of a 10-year prospective study. Br J Psychiatry 1998; 173: 325–9

    Article  PubMed  CAS  Google Scholar 

  61. Fleming J, Chetty M. Psychotropic drug interactions with valproate. Clin Neuropharmacol 2005; 28: 96–101

    Article  PubMed  CAS  Google Scholar 

  62. Spina E, Pisani F, Perucca F. Clinically significant drug interactions with carbamazepine. Clin Pharmacokinet 1996; 31: 198–214

    Article  PubMed  CAS  Google Scholar 

  63. LaPointe NMA, Curtis LH, Chan KA, et al. Frequency of high risk use of QT prolonging medications. Pharmacoepidemiol Drug Saf 2006; 15: 361–8

    Article  Google Scholar 

  64. Curtis LH, Ostbye T, Sendersky V, et al. Prescription of QT prolonging drugs in a cohort of about 5 million outpatients. Am J Med 2003; 114: 135–41

    Article  PubMed  CAS  Google Scholar 

  65. Lambert T, Velakoulis D, Pantelis C. Medical comorbidity in schizophrenia. Med J Aust 2003; 178: S67–70

    PubMed  Google Scholar 

  66. Drug interactions: cytochrome P450 system. Defining genetic influences on pharmacologic responses [online]. Available from URL: http://medicine.iupui.edu/flockhart/ [Accessed 2006 Sep 27]

  67. de Leon J. Atypical antipsychotic dosing: the effect of smoking and caffeine. Psychiatr Serv 2004; 55: 491–3

    Article  PubMed  Google Scholar 

  68. Dereme DL, Baldessarini RJ. Clozapine toxicity associated with smoking cessation. Am J Ther 2005; 12: 469–71

    Article  Google Scholar 

  69. The clinical effectiveness and cost effectiveness of newer atypical antipsychotic drugs for schizophrenia. Technology appraisal TA042. London: National Institute for Health and Clinical Excellence, 2002. Available from URL: http://www.nice.org.uk/page.aspx?.o=ta043 [Accessed 2006 Sep 27]

  70. Taylor D, Young C, Esop R, et al. Testing for diabetes in hospitalised patients prescribed antipsychotic drugs. Br J Psychiatry 2004; 185: 152–6

    Article  PubMed  Google Scholar 

  71. Merrill DB, Dec GW, Goff DC. Adverse cardiac effects associated with clozapine. J Clin Psychopharmacol 2005; 25: 32–41

    Article  PubMed  CAS  Google Scholar 

  72. Hazell L, Shakir SAW. Under reporting of adverse drug reactions: a systematic review. Drug Saf 2006; 29: 385–96

    Article  PubMed  Google Scholar 

  73. van Grootheest K, van Puijenbroek EP, de Jong-van den Berg LTW. Do pharmacists’ reports of adverse drug reactions reflect patients’ concerns? Pharm World Sci 2004; 26: 155–9

    Article  PubMed  Google Scholar 

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Acknowledgments

Natasa Gisev and J. Simon Bell contributed equally to the preparation of this manuscript and are joint first authors. J. Simon Bell is now based at the University Of Helsinki (Helsinki, Finland). Natasa Gisev was funded to undertake this initiative through the Vacation Scholarship Programme at the Faculty of Pharmacy, University of Sydney. The work was performed as part of a larger study funded by the Australian Government Department of Health and Ageing via the Third Community Pharmacy Agreement. J. Simon Bell has received honoraria and/or grant funding from Eli Lilly, AstraZeneca, and Alphapharm. Andrew McLachlan has acted as a consultant to the Australian Government, undertaken consultancies for Alphapharm, Novartis, CSL Bioplasma, and Arrow, and received grant funding from GlaxoSmithKline. Manoranjenni Chetty has received grant funding from Mayne Pharma. Timothy Chen has received honoraria and/or grant funding from Pfizer, AstraZeneca, Merck Sharp & Dohme, and Mundipharma. All authors declare they have no direct conflict of interest.

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Authors and Affiliations

  1. Faculty of Pharmacy, University of Sydney, Sydney, New South Wales, Australia

    Natasa Gisev, J. Simon Bell (Senior Lecturer), Andrew J. McLachlan, Manoranjenni Chetty & Timothy F. Chen

  2. Faculty of Pharmacy, University of Helsinki, Helsinki, Finland

    J. Simon Bell (Senior Lecturer)

  3. Centre for Research and Education on Ageing, Concord Repatriation General Hospital, Concord, New South Wales, Australia

    Andrew J. McLachlan

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  1. Natasa Gisev
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  2. J. Simon Bell
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Correspondence to J. Simon Bell.

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Gisev, N., Bell, J.S., McLachlan, A.J. et al. Psychiatric Drug Use Among Patients of a Community Mental Health Service. Dis-Manage-Health-Outcomes 14, 369–376 (2006). https://doi.org/10.2165/00115677-200614060-00006

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