Trends in antipsychotic prescribing for approved and unapproved indications to Medicaid-enrolled youth in Philadelphia, Pennsylvania between 2014 and 2018

Background Antipsychotic prescribing to Medicaid-enrolled youth has been the target of numerous policy initiatives, including prior authorization and quality monitoring programs, which often target specific populations. Whether these efforts have changed the level or composition of antipsychotic prescribing is unclear. Methods Using 2014–2018 administrative claims data for Medicaid enrollees aged 21 years and under in Philadelphia, Pennsylvania, we measured antipsychotic prescription fills overall and for youth without an approved indication (autism, bipolar disorder, or psychosis). We then assessed whether trends differed for populations that have been targeted by policy initiatives, including younger children and foster care-enrolled youth. We also identified the most common approved and unapproved indications and examined whether the treatment duration of antipsychotic prescriptions differed based on whether the youth had an approved or unapproved indication. Results Overall, the number of Medicaid youth with an antipsychotic prescription fill halved between 2014 and 2018. Youth aged 17 years and under and foster care-enrolled youth, who were targeted by prior authorization and quality improvement efforts, experienced larger declines. Roughly half of prescriptions were for unapproved indications in both 2014 and 2018; the most common unapproved indication was ADHD, and the treatment duration was shorter for unapproved indications compared to approved indications. Conclusions Antipsychotic prescribing to Medicaid-enrolled youth is declining, particularly among populations that have been targeted by policy initiatives like prior authorization and quality monitoring programs. Despite the fact that these initiatives often assess diagnostic criteria, half of antipsychotic prescriptions were for unapproved indications in both 2014 and 2018. More research is needed to gauge whether this prescribing is appropriate.

The Prevalence of and Documented Indications for Antipsychotic Prescribing in Irish Nursing Homes

Background: Antipsychotic medications are often used ‘off-licence’ to treat neuropsychiatric symptoms and disorders of aging and to manage behavioural and psychological symptoms of dementia despite the warnings of adverse effects. Objective: To establish the prevalence of and documented indication for antipsychotic medication use in the Irish nursing home setting. Setting: This study was conducted in six nursing homes located in Co. Cork, Ireland. Method: A retrospective, cross-sectional study was employed. All patients who met the inclusion criteria (≥65 years, residing in a nursing home on a long-term basis) were eligible for inclusion. There were 120 nursing home residents recruited to the study. Main Outcome Measure: The prevalence of antipsychotic medication use in nursing home residents (with and without dementia). Results: The overall prevalence of antipsychotic prescribing was found to be 48% and patients with dementia were significantly more likely to be prescribed an antipsychotic compared to those without dementia (67% vs. 25%) (χ2 (1, N = 120) = 21.541, p < 0.001). In the cohort of patients with dementia, there was a trend approaching significance (p = 0.052) of decreasing antipsychotic use with increasing age (age 65–74 = 90%; age 75–84 = 71%; age 85 and over = 58%). An indication was documented for 84% of the antipsychotic prescriptions in this cohort. Conclusion: The findings of this study highlight that high rates of antipsychotic medication use remains an issue in Irish nursing homes. Further work should explore factors in influencing prescribing of these medications in such settings.

Antipsychotic prescribing for patients with intellectual disabilities and challenging behaviours

Purpose Review of antipsychotic prescribing practices, rationale and follow-up using an internationally standardized audit can be an effective tool to encourage and monitor best practices. The purpose of this study is to audit the current prescribing pattern for people with intellectual disabilities and challenging behaviours in Qatar. Design/methodology/approach This study was based on the challenging behaviour management guidelines recommended by the Royal College of Psychiatrists. All current electronic medical records in the Mental Health Service-Hamad Medical Corporation were examined to identify patients with intellectual disabilities who received antipsychotics for challenging behaviour. Demographic variables, such as age, sex and nationality, were collected. In addition, details of psychiatric diagnoses, prescribed psychotropic medications and diagnoses of epilepsy were also collected. For patients who were prescribed antipsychotic medication, the clinical rationale for such medication was collected along with evidence of side effect monitoring to allow performance against the audit standards to be measured. Findings This is the first audit on prescribing practices in people with intellectual disability and challenging behaviour in the state of Qatar. The results of this study regarding the pattern of prescribing practices for patients with intellectual disability and challenging behaviour reflect the limitation in knowledge and experience among non-specialist practitioners within mental health service. The result may be helpful to support the development of specialist service provision to improve the care for such vulnerable group. The result may also help other medical centres and clinicians by providing an improved understanding of possible deviations from the best medical practices. Originality/value This is the first audit on prescribing practices in people with intellectual disability and challenging behaviour in the state of Qatar. The study is also noteworthy as, to the best of the authors’ knowledge, it is one of only a few studies on antipsychotic prescribing for patients with intellectual disability and challenging behaviour in the Middle East; therefore, it will be useful in raising awareness and promoting the best practices in the Middle East region. This study is also among the first few studies that were designed based on the four audit standards by the Royal College of Psychiatrists in this area.

The links between the amount of antipsychotic medication prescribed at GP practice level, local demographic factors and medication selection

AimsTo examine the factors that relate to antipsychotic prescribing in general practices across England and how these relate to cost changes in recent years.BackgroundAntipsychotic medications are the first-line pharmacological intervention for severe mental illnesses(SMI) such as schizophrenia and other psychoses, while also being used to relieve distress and treat neuropsychiatric symptoms in dementia.Since 2014 many antipsychotic agents have moved to generic provision. In 2017_18 supplies of certain generic agents were affected by substantial price increases.MethodThe study examined over time the prescribing volume and prices paid for antipsychotic medication by agent in primary care and considered if price change affected agent selection by prescribers.The NHS in England/Wales publishes each month the prescribing in general practice by BNF code. This was aggregated for the year 2018_19 using Defined Daily doses (DDD) as published by the World Health Organisation Annual Therapeutic Classification (WHO/ATC) and analysed by delivery method and dose level. Cost of each agent year-on-year was determined.Monthly prescribing in primary care was consolidated over 5 years (2013-2018) and DDD amount from WHO/ATC for each agent was used to convert the amount to total DDD/practice.ResultDescriptionIn 2018_19 there were 10,360,865 prescriptions containing 136 million DDD with costs of £110 million at an average cost of £0.81/DDD issued in primary care. We included 5,750 GP Practices with practice population >3000 and with >30 people on their SMI register.Effect of priceIn 2017_18 there was a sharp increase in overall prices and they had not reduced to expected levels by the end of the 2018_19 evaluation year. There was a gradual increase in antipsychotic prescribing over 2013-2019 which was not perturbed by the increase in drug price in 2017/18.RegressionDemographic factorsThe strongest positive relation to increased prescribing of antipsychotics came from higher social disadvantage, higher population density(urban), and comorbidities e.g. chronic obstructive pulmonary disease(COPD). Higher %younger and %older populations, northerliness and non-white (Black and Minority Ethnic (BME)) ethnicity were all independently associated with less antipsychotic prescribing.Prescribing FactorsHigher DDD/general practice population was linked with higher %injectable, higher %liquid, higher doses/prescription and higher %zuclopenthixol. Less DDD/population was linked with general practices using higher %risperidone and higher spending/dose of antipsychotic.ConclusionHigher levels of antipsychotic prescribing are driven by social factors/comorbidities. The link with depot medication prescriptions, alludes to the way that antipsychotics can induce receptor supersensitivity with consequent dose escalation.

Patterns of antipsychotic prescribing in first episode psychosis – differences between acute and early intervention services

AimsThis study aimed to evaluate the patterns of antipsychotic prescribing in patients with first episode psychosis (FEP) at the time of their initial treatment and over the first year with the Early Intervention Service (EIS). It was hypothesised that different care teams would have a preference for certain antipsychotic medications and that initial medication choice would be continued through the first year.BackgroundResearch indicates that with the exception of clozapine, all antipsychotics are equally as effective. However, anecdotally it has been observed that inpatient and crisis teams and EIS have differing initial medication choices.MethodAn analysis of the North West Sussex EIS caseload (n = 67) was conducted. The first antipsychotic prescribed and initiating team was recorded. Prescribed medication for those that had completed 12 months (n = 43) with EIS after initial prescription was recorded. An analysis was performed of prescribing choice by initial care team (acute vs EIS vs other community services) with the frequency with which medication was changed during treatment.Result97% (n = 65) of patients were started on an antipsychotic. Initial medication choice was olanzapine (44.8%, n = 30), aripiprazole (22.4%, n = 15), risperidone (20.9%, n = 14), quetiapine (6%, n = 4) and zuclopenthixol were least common (1.5%, n = 2). At the 12 month point 51.2% (n = 22 of 43) had switched and 16.3% (n = 7 of 43) had discontinued.The most common medication started by acute services was olanzapine (56.0%, n = 28 of 50), though of those who completed 12 months this had been switched in 53% of cases (n = 9 of 17). EIS most commonly initiated aripiprazole or risperidone (37.5% each n = 4). At 6 and 12 month follow-up by EIS, the most commonly prescribed antipsychotic was aripiprazole (24 patients 40.7%, and 14 patients 32.6% respectively).ConclusionThere was a clear preference for olanzapine as initial treatment of First Episode of Psychosis in the region. On breakdown it was apparent that there was a split in prescribing choices between more sedating medication in acute services and less sedating medication in EIS. Given that most patients changed to less sedating and less metabolic active medications over their first year it is not clear why alternative options are not used at the start of treatment. Future research will focus on clinician's rationale for initial prescribing choice. This will look for any underlying bias toward specific medications.

Antipsychotic prescribing in dementia

AimsThe majority of people with dementia will develop one or more behavioural or psychological symptoms of dementia (BPSD) as the illness progresses. Treating these symptoms in diverse residential environments is a challenge, with frequent prescribing of antipsychotic medications. The risks and limited benefits of antipsychotic use in this context are well recognised, prompting national guidelines in Ireland to improve prescribing patterns.1) Assess the frequency and appropriateness of prescribing of antipsychotic medication in older adults with BPSD referred to Psychiatry of Old Age service in the West of Ireland (Sligo) by comparing with best practice guidelines.2) Address identified deficits via quality improvement initiatives within department.MethodAudit standards were set using draft National Clinical Guidelines and NICE guidelines for prescribing in dementia to develop a study specific audit tool.Items assessed included: the frequency of review of antipsychotic use, whether or not non-pharmacological methods were trialled, if there was an assessment of benefit of the antipsychotic and discussion or risks, if a reduction/discontinuation of antipsychotic was considered, if metabolic monitoring was achieved.Clinical records for all patients actively under the care of the clinical team with a diagnosis of BPSD were assessed using this tool at the time of the study.Result49 patients with BPSD were attending the service in this time period. 58% (n = 29) of the entire cohort were prescribed an antipsychotic, most commonly quetiapine. Patients cared for at home showed the lowest levels of antipsychotic use at 50% (n = 18), while those who were in nursing home (80%, n = 8) and hospital care (100%, n = 3) showed higher rates, though this sample size was too small to demonstrate statistical significance, χ2 = 5.12 p = 0.077.Exploration of non pharmacological management of BPSD, documentation of discussion of risks of AP medication (metabolic, cardiovascular, falls, sedation, extrapyramidal), attempt at dose reduction or antipsychotic withdrawal were all achieved in less than 45% of cases (range 33–45%).ConclusionThis audit revealed higher than expected rates of antipsychotic prescribing in our BPSD cohort. It also revealed suboptimal documentation around the use of antipsychotics in this population during clinical interactions.A subsequent intervention to the proforma assessment tool to prompt these discussions improved these behaviours, there was no impact on the rates of antipsychotic prescribing.Despite increased attention regarding the limited benefits of antipsychotic medication in BPSD their use remains widespread. Due attention must be given to changing this practice in order to protect this vulnerable patient group.