Reducing the rates of prescribing high-dose antipsychotics and polypharmacy on psychiatric inpatient and intensive care units:results of a 6-year quality improvement programme

BACKGROUND: There is no conclusive evidence that either high doses or combinations of antipsychotics are more effective than standard doses or monotherapy alone. Nonetheless, prescription of both remains prevalent in the UK. In 2006 the South London and Maudsley NHS Foundation Trust (SLAM) participated in a national survey of prescription of antipsychotic medications, organized by the Prescribing Observatory for Mental Health. Over half of the patients on SLAM inpatient or psychiatric intensive care units were prescribed a high-dose antipsychotic or a combination of antipsychotics. Prescribing high-dose antipsychotics and polypharmacy in SLAM was found to be among the highest in the UK. AIM: To assess the impact of a 6-year quality improvement programme aimed at reducing the rates of prescribing high-dose antipsychotics and polypharmacy on SLAM inpatients and psychiatric intensive care units. RESULTS: There was a significant reduction between baseline and final survey in the rates of prescription of both high-dose antipsychotics and polypharmacy on SLAM inpatients and intensive care units (58% versus 10% p < 0.0001 and 57% versus 16%, p < 0.0001 respectively). The proportion of patients at final survey prescribed a high-dose antipsychotic and a combination was substantially lower in SLAM than in the national sample (10% versus 28%, p < 0.0001 and 16% versus 38%, p < 0.0001 respectively). CLINICAL IMPLICATIONS: A sustained change in the prescribing culture of an organization can be achieved through a targeted improvement programme

A prospective year-long follow-up of lurasidone use in clinical practice: factors predicting treatment persistence

Background: Our aim was to follow up patients prescribed lurasidone over 1 year to determine factors predicting treatment persistence.Methods: We used noninterventional, observational, prospective follow up of patients consecutively prescribed lurasidone in a large inner-city NHS mental health trust. We also performed retrospective analysis of outcomes from patient case notes.Results: Data were available for 69 patients consecutively prescribed lurasidone, of whom three (4%) were lost to follow up. Out of the 66 patients not lost to follow-up, 21 (32%) remained on lurasidone at 1 year. The main reasons for discontinuation were perceived ineffectiveness (49% of discontinuers) and adverse effects (36% of discontinuers), whilst a further seven refused all treatment. Median treatment time on lurasidone was 154 days (95% confidence interval (CI), 33-275). Patients who were not treatment-resistant had a substantially reduced risk of discontinuation, relative risk (RR) 0.18 [95% CI 0.08, 0.41,p&lt; 0.001]. Medium doses (&gt;37-74 mg) of lurasidone reduced the risk of discontinuation by 75% [RR 0.25 (95% CI 0.11, 0.58,p= 0.001)]; high doses (&gt;74-148 mg) reduced the risk of discontinuation by 86% [RR 0.14 (95% CI 0.06, 0.35,p&lt; 0.001)]. Risk of discontinuation was approximately doubled when the reason for prescribing lurasidone was poor tolerability of prior treatment [RR 2.01 (95% CI 1.05, 3.85,p= 0.035)].Conclusion: The likelihood of treatment continuation with lurasidone can be vastly improved by targeting individuals most likely to benefit and by using optimal doses.</p

Haloperidol decanoate long-acting injection (HDLAI):Results of a 1-year mirror-image study

Background: We sought to determine clinical outcomes of the prescribing of haloperidol decanoate long-acting injection (HDLAI) at 1 year. Method: A 1-year mirror-image study of 84 inpatients initiated on HDLAI. Admissions and bed days in the year preceding HDLAI were compared with the year after initiation. Predictors for discontinuation were evaluated. Results: At 1 year, 33% of patients remained on treatment. Patients starting HDLAI because of nonadherence were more likely to stop treatment [relative risk (RR) 1.72; 95% confidence interval (CI) 1.01, 2.91; p = 0.044] whilst patients with a longer duration of illness were more likely to remain on treatment (RR 0.88; 95% CI 0.78, 1.00; p = 0.050). In the bed days cohort overall, ( n = 65), there was a significant reduction in mean hospital admissions (1.4/patient/year to 0.6/patient/year; p = 0.0001) but not bed days (55.6/patient to 45.0/patient; p = 0.07) in the year following HDLAI initiation compared with the year before. Continuers had a significant reduction in mean bed days (53.1 to 4.0; p = 0.0002) and hospital admissions (1.5 to 0.2; p = 0.0001). Discontinuers demonstrated a significant reduction in hospital admissions (1.5 to 0.8; p = 0.0001) but not bed days (56.7 to 64.5; p = 0.83). Conclusion: HDLAI was associated with a high treatment discontinuation rate. Hospital admissions fell in the year after HDLAI but there was no change in bed days. Our study suggests that patients with a longer duration of illness and patients initiated on HDLAI for reasons other than poor adherence may benefit from HDLAI initiation. </jats:sec