Antipsychotic polypharmacy: A survey study of prescriber attitudes, knowledge and behavior

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Abstract

Objective

Although common in psychiatric practice, reasons for antipsychotic polypharmacy (APP) have remained unclear.

Methods

Single-site, semi-structured interview study of prescribers at a psychiatric teaching hospital inquiring about APP attitudes and behaviors, including frequency, preferred combinations, rationale and concerns.

Results

Forty-four prescribers reported using APP in 17.0 ± 10.0% of antipsychotic-treated patients. Although clinicians themselves initiated APP in only 23.3 ± 27.0% of cases, they did not attempt conversion to antipsychotic monotherapy in 40.9 ± 37.7%, despite reported successful conversion in 28.0 ± 30.8% of cases. The following reasons justified most APP (0–10): cross-titration (9.2 ± 1.4), failed clozapine trial (8.2 ± 2.2), randomized controlled evidence (8.0 ± 2.0), and clozapine intolerance (7.7 ± 2.6). Prescribers felt “moderately” (5.0 ± 1.9) concerned about APP (0–10), mostly due to chronic side effects (7.6 ± 2.0), lack of evidence (7.1 ± 2.2), non-adherence risk (6.7 ± 2.3) and mortality risk (6.7 ± 3.2), while increased cost (4.9 ± 2.5) and higher total antipsychotic dose (4.2 ± 2.9) ranked lowest. Comparing high with low APP prescribers (> 10% vs. ≤ 10% of patients; mean: 36.1 ± 19.8 vs. 3.4 ± 3.4, p < 0.0001), no differences emerged on 25/26 ratings regarding APP justification and 9/9 ratings regarding concerns. In a multivariate analyses, only attending status (OR = 10.3, p = 0.0043) and endorsing a specific APP preference (OR = 21.4, p = 0.011) predicted APP use > 10% (r2:0.35, p < 0.0001), yet no uniformly preferred APP strategy emerged.

Conclusions

High APP prescribers had more clinical experience, less concerns about APP and more likely a preferred APP choice, although no overall preferred strategy emerged. Otherwise, high and low APP prescribers shared attitudes toward APP. Both had inherited most of their APP cases and were reluctant to convert patients to antipsychotic monotherapy.

Section snippets

Setting and procedures

All inpatient and outpatient prescribers at the Zucker Hillside Hospital were contacted to participate in this study. This included psychiatrists, nurse practitioners, and third- and fourth-year psychiatry residents. Prescribers were interviewed between December 2006 and April 2007, using a newly developed, semi-structured questionnaire, the Prescriber's Reasons for Antipsychotic Combination Treatment Questionnaire (PRACT-Q, available upon request from the first author). Prescribers unable to

Prescriber demographics

Forty-four prescribers (22 attending and 22 resident/fellow level clinicians) of 59 eligible clinicians (74.6%) participated in this study. Prescriber characteristics are summarized in Table 1.

Antipsychotic polypharmacy prescribing

Among patients treated with antipsychotics, practitioners estimated that 17.0 ± 10.0% of patients were receiving antipsychotic polypharmacy (Table 1). Atypical antipsychotic combinations predominated 63.5 ± 35.0%. Although clinicians estimated to have self-initiated antipsychotic polypharmacy in only 23.3 ± 

Discussion

This study found that most prescribers provided appropriate justifications for antipsychotic polypharmacy, and that 75% of their cases of polypharmacy had been inherited. Furthermore, clinicians were reluctant to reduce the number of antipsychotics in more than 40% of cases, although they reported this was successful in 28% of cases. Similarly, a prior co-treatment with antipsychotic polytherapy was reported being a strong predictor of future polypharmacy (Biancosino et al., 2005).

Although no

Role of funding source

Funding for this study was supported in part by The Zucker Hillside Hospital Mental Advanced Center for Intervention and Services Research for the Study of Schizophrenia (MH090590) from the National Institute of Mental Health, Bethesda, Md. The NIMH had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Contributors

Dr. Correll designed and managed the study, designed the prescriber questionnaire, and conducted literature searches and statistical analyses. Dr. Shaikh, Nachbar and Olshanskiy conducted the prescriber interviews and entered the data. Dr. Correll wrote the first draft of the manuscript and Dr. Gallego, Dr. Kishimoto and Dr. Kane helped reviewed the content of the manuscript. All authors contributed to and have approved the final manuscript.

Conflict of interest

Dr. Correll has been a consultant and/or advisor to or has received honoraria from: Actelion, AstraZeneca, Boehringer-Ingelheim, Bristol-Myers Squibb, Cephalon, Eli Lilly, GSK, Hoffmann-La Roche, IntraCellular Therapies, Lundbeck, Medicure, Merck, Ortho-McNeill/Janssen/J&J, Otsuka, Pfizer, Schering-Plough, and Sepracor/Sunovion, Takeda and Vanda. He has sat on the Data Safety Monitoring Board for Supernus and has received grant support from the Feinstein Institute for Medical Research, the

Acknowledgments

Supported in part by The Zucker Hillside Hospital Mental Advanced Center for Intervention and Services Research for the Study of Schizophrenia (MH090590) from the National Institute of Mental Health, Bethesda, Md.

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