Study explores rate of antipsychotic polypharmacy among patients discharged from psychiatric hospitals

In recent years, measures have been introduced to reduce the rate of "antipsychotic polypharmacy"—taking more than one antipsychotic drug—among patients with schizophrenia and other serious mental illnesses. But at least 12 percent of patients are still prescribed multiple antipsychotics after an inpatient stay at a state psychiatric hospital, according to an analysis of U.S. data in the July Journal of Psychiatric Practice®, published by Wolters Kluwer.

"Antipsychotic polypharmacy continues at a high enough rate to impact nearly 10,000 patients with a diagnosis of schizophrenia each year in state psychiatric inpatient hospitals," write Glorimar Ortiz, Vera Hollen, and Lucille Schacht, of the National Association of State Mental Health Program Directors Research Institute (NRI) in Falls Church, Virginia, which supported the study. The results "provide insights into quality initiatives that could help further reduce the use of antipsychotic polypharmacy and reduce practices that are not consistent with best-practice guidelines," the researchers write.

Despite New Best Practice Guidelines, Many Patients Receive Multiple Antipsychotics
The study included data on more than 86,000 adult patients discharged from 160 state psychiatric inpatient hospitals during 2011. Data were obtained from the Behavioral Healthcare Performance Measurement System—a comprehensive proprietary national database maintained by the NRI, representing 80 percent of all US state psychiatric hospitals.

Most schizophrenia treatment guidelines recommend against using antipsychotic polypharmacy, or using it only as a last resort. Taking more than one antipsychotic can increase the risk for complications—including drug interactions, medication side effects, and metabolic disorders—without improving outcomes. More complex medication regimens may also increase the risk that patients won't follow their prescribed treatment.

In 2011, the Joint Commission introduced performance measures to reduce antipsychotic polypharmacy. Those standards defined some situations where using more than one antipsychotic is scientifically validated: multiple failed attempts at single-drug treatment, adjusting doses to work toward single-drug therapy, or to augment the effects of the antipsychotic drug clozapine.

The data showed that 12 percent of patients were discharged with a prescription for multiple antipsychotic drugs. Of the discharged patients who were prescribed at least one antipsychotic medication, 18 percent were prescribed more than one antipsychotic.

The most common reason for antipsychotic polypharmacy was to "reduce symptoms"—cited for 37 percent of patients. Meanwhile, only 36 percent met one of the three criteria established by The Joint Commission for appropriate use of multiple antipsychotics.

Two factors were identified as strong predictors of antipsychotic polypharmacy: a diagnosis of schizophrenia and an inpatient stay of 90 days or more. The researchers note that 40 percent of patients at state psychiatric inpatient hospitals have a diagnosis of schizophrenia, while nearly 20 percent experience a longer hospital stay—"suggesting a high-risk population needing special attention."

The results highlight the need for continued efforts to reduce the rate of antipsychotic polypharmacy. "Low percentages for the three appropriate justifications suggest that implementation of the proposed best practices are taking place at a low rate," Ms. Ortiz and coauthors write. They believe their findings suggest that need for revised standards and definitions that are more appropriate for psychiatric inpatient hospitals.