Acute psychiatric admissions from an out-of-hours Casualty Clinic; how do referring doctors and admitting specialists agree?

BACKGROUND: Over the last decades there has been an increasing pressure on the acute psychiatric wards in Norway. The major contributor to psychiatric acute admissions at the University Hospital of North Norway in the city of Tromsø in 2001 was the GP-based Tromsø Casualty Clinic, only open out-of-hours. We explored all acute psychiatric referrals from Tromsø Casualty Clinic in 2001. The purpose of the study was to characterize the admissions and assess the agreement between the referring doctors and the hospital specialists according to the need for hospitalization, agreement on application of the law and the diagnostic evaluation to assess whether the admissions were appropriate. METHODS: Retrospective, record based, descriptive study comprising 101 psychiatric acute referrals from the Tromsø Casualty Clinic to the psychiatric acute wards at the University Hospital of North Norway. RESULTS: The specialists accepted all referrals except one, they mostly agreed upon the diagnoses suggested by the referring doctors and they mostly confirmed the application of the law. Seventy-five percent of the admissions took place during weekends, public holidays or nighttimes. Diagnoses of psychoses or suicidal attempts accounted for 76 % of the total referrals. Substance abuse was noted for 43 %, and in 22 % of all admissions the patients had stopped taking their psychopharmacological medication. The police assisted the referring doctors in one third of all admissions, and was the legal representative in 52 out of 59 involuntary admissions. Thirty percent of the admissions were first- time admissions. Thirty-two percent of the hospital stays lasted for three days or less. Median length of stay was 6.5 days. CONCLUSION: The casualty clinic physicians and the hospital specialists mostly agreed in their evaluation of patients indicating that most of the admissions were appropriate. The police was more often involved in the involuntary admissions than intended in the law. The proportion of patients with substance abuse was significant. Alternative treatment strategies should be developed for non-psychotic patients in need of short-term stays

Pharmacological treatment of patients with MS : A retrospective study with focus on treatment with AEDs and polytherapy with other CNS active drugs

MS patients are often suffering from chronic pain. Pain is a debilitating symptom and treatment is associated with undesirable adverse reactions, especially long-term treatment where tolerance and dependence issues are concerning. Therefore, antiepileptic drugs are frequently being used in the management of chronic pain. Antiepileptic drugs are among the most susceptible drugs to be involved in pharmacokinetic as well as pharmacodynamic interactions. MS patients often use several different types of CNS-active drugs, yet little research has been done to highlight potential polypharmacy issues. The aim of this study was to investigate the pharmacological treatment of MS patients at the rehabilitation centre for MS, Hakadal, Norway, with regards to current knowledge on polypharmacy, with particular focus on antiepileptic drugs. Medical records from 2009 to 2011 were reviewed and an overview of drug dosages and combinations used by patients at MSSH was created. The present study demonstrated that one third of MS patients used either an AED (antiepileptic drug) or TCA (tricyclic antidepressant) and that one fifth used two or more. There was no difference in age, gender or degree of disability of the patients using these drugs. Polytherapy was widespread, with up to 19 concomitant drugs in use. Although the AEDs are well-known for their pharmacokinetic interactions, this is not of particular concern for MS patients since they mainly used newer AEDs (pregabalin and gabapentin) with little propensity to interact. Pharmacodynamic interactions are of greater concern since more than half of the patients used an opioid, a benzodiazepine or baclofen in addition to their AED/TCA therapy. One third of the patients were elderly and careful considerations regarding pharmacokinetics and possible excessive adverse reactions are of importance. More focus on individualisation of treatment by implementation of therapeutic drug monitoring of AEDs and TCAs and attention to potential pharmacodynamics interactions may be further treatment concerns

Antiepileptic and Antidepressive Polypharmacy in Patients with Multiple Sclerosis

Objective. Patients with multiple sclerosis (MS) are often suffering from neuropathic pain. Antiepileptic drugs (AEDs) and tricyclic antidepressants (TCAs) are commonly used and are susceptible to be involved in drug interactions. The aim of this retrospective study was to investigate the prevalence of use of antiepileptic and antidepressive drugs in MS patients and to discuss the theoretical potential for interactions. Methods. Review of the medical records from all patients treated at a dedicated MS rehabilitation centre in Norway between 2009 and 2012. Results. In total 1090 patients attended a rehabilitation stay during the study period. Of these, 342 (31%; 249 females) with mean age of 53 (±10) years and EDSS 4.8 (±1.7) used at least one AED (gabapentin 12.7%, pregabalin 7.7%, clonazepam 7.8%, and carbamazepine 2.6%) or amitriptyline (9.7%). Polypharmacy was widespread (mean 5.4 drugs) with 60% using additional CNS-active drugs with a propensity to be involved in interactions. Age, gender, and EDSS scores did not differ significantly between those using and not using AED/amitriptyline. Conclusion. One-third of MS patients attending a rehabilitation stay receive AED/amitriptyline treatment. The high prevalence of polypharmacy and use of CNS-active drugs calls for awareness of especially pharmacodynamic interactions and possible excessive adverse effects