Background: Psychotropic drugs have had a remarkable impact in psychiatric practice. The continuous monitoring of prescription and drug utilization studies may help to identify the problem involved in therapeutic decision and promote rational prescribing. Very few studies from India have evaluated the prescription pattern of Psychiatrists. Present study was undertaken to analyze the prescription pattern and drug used in psychiatric Out Patients of private practitioners of Central India.Methods: One thousand prescriptions were collected by undergraduate students from chemist and analysed. Study parameter like demographic profile of patients viz. age, sex, diagnosis were recorded. Basic drug indicators, the prescribing pattern of antipsychotics and other categories of drugs were also recorded. The most common and, top brands of anti psychotics were analyzed .Inappropriate prescription if any were recorded and analyzed further.Result: The most common psychotropic drugs were anti-anxiety in 361(36.1%) and antidepressants 130 (13%) prescribed for various psychiatric disorder. Usage of Sedative Hypnotics 104(10.4%), anti-psychotics 90(9%) and anticonvulsants 80 (8%) drugs in prescriptions. The incidence of polypharmacy (22%) was common occurrence in prescriptions. The commonest combination prescribed was of tricyclic antidepressant with benzodiazepines. Central anti-cholinergic was commonly prescribed with anti psychotics.Conclusions: Anti-anxiety drug (benzodiazepines) was the most frequently prescribed class of psychotropic drugs in various psychiatry disorders. The prescribing prevalence of Alprazolam with different brand names was more than that of other benzodiazepines. The combination of different psychotropic drugs were also prescribed

Chakravorty, Ashish D.

Deshmukh, Ragini

Shamkuwar, Chetna A.

Shrivastava, Meena P.

English

International Journal of Basic & Clinical Pharmacology

 www.ijbcp.com             International Journal of Basic & Clinical Pharmacology | November-December 2013 | Vol 2 | Issue 6    Page 777 IJBCP    International Journal of Basic & Clinical Pharmacology Print ISSN: 2319-2003 | Online ISSN: 2279-0780 Research Article Pattern of prescription and drug use in psychiatry out patient department of private practitioners of Central India Chetna A. Shamkuwar1*, Ashish D. Chakravorty1, Meena P. Shrivastava2, Ragini Deshmukh3                INTRODUCTION Psychiatric disorders are common in medical practice and may present either as a primary disorder or a co-morbid conditions. Depression occurs frequently in patients with neurological disorders particularly cerebrovascular disorders, Parkinson’s disease, dementia, multiple sclerosis and traumatic brain injury, diabetes mellitus, hypothyroidism, cancer etc. HIV is frequently associated with features of depression, most commonly depressed mood and memory impairment.1 Mood disorders may also be secondary to chronic administration of specific medication like antihypertensives.2 Studying prescription pattern provides opportunity to monitor therapeutic trends. Many studies from western countries have reported prescription pattern of various psychotropic medication. These studies have looked into national prescription patterns3, age and gender difference in antipsychotic prescription.4 Setting standards and assessing quality of case through performance and review should become part of everyday clinical practice.5 The recent proliferation of new drugs, their widespread use and powerful action, the rising recognition of immediate and delayed adverse effects and rising concern about the cost of drug have stimulated a new interest in the manner in which physician prescribe drugs.6 ABSTRACT Background: Psychotropic drugs have had a remarkable impact in psychiatric practice. The continuous monitoring of prescription and drug utilization studies may help to identify the problem involved in therapeutic decision and promote rational prescribing. Very few studies from India have evaluated the prescription pattern of Psychiatrists. Present study was undertaken to analyze the prescription pattern and drug used in psychiatric Out Patients of private practitioners of Central India. Methods: One thousand prescriptions were collected by undergraduate students from chemist and analysed. Study parameter like demographic profile of patients viz. age, sex, diagnosis were recorded. Basic drug indicators, the prescribing pattern of antipsychotics and other categories of drugs were also recorded. The most common and, top brands of anti psychotics were analyzed .Inappropriate prescription if any were recorded and analyzed further.  Result: The most common psychotropic drugs were anti-anxiety in 361(36.1%) and antidepressants 130 (13%) prescribed for various psychiatric disorder. Usage of Sedative Hypnotics 104(10.4%), anti-psychotics 90(9%) and anticonvulsants 80 (8%) drugs in prescriptions. The incidence of polypharmacy (22%) was common occurrence in prescriptions. The commonest combination prescribed was of tricyclic antidepressant with benzodiazepines. Central anti-cholinergic was commonly prescribed with anti psychotics. Conclusions: Anti-anxiety drug (benzodiazepines) was the most frequently prescribed class of psychotropic drugs in various psychiatry disorders. The prescribing prevalence of Alprazolam with different brand names was more than that of other benzodiazepines. The combination of different psychotropic drugs were also prescribed.  Keywords: Prescribing pattern, Private Practitioner, Psychotropic, Antipsychotics, Antidepressants doi: 10.5455/2319-2003.ijbcp20131220  1Department of Pharmacology, Government Medical College & Hospital, Nagpur, Maharashtra, India 2Department of Pharmacology, 3Medical Officer, Indira Gandhi Government Medical College, Nagpur, Maharashtra, India  Received: 27 September 2013 Accepted: 8 October 2013  *Correspondence to: Dr. Chetna A. Shamkuwar, Email: chelsycosmos@rediffmail.com  © 2013 Shamkuwar CA et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Shamkuwar CA et al. Int J Basic Clin Pharmacol. 2013 Dec;2(6):777-782 International Journal of Basic & Clinical Pharmacology | November-December 2013 | Vol 2 | Issue 6    Page 778 In developing country, almost all psychotropic medications available world wide are readily available in India. However, very few studies from India have evaluated prescription patterns of Psychiatrists. Some studies which have evaluated antipsychotic prescription pattern in India are limited by sample size.7,8 Hence present study was undertaken to analyze the prescription pattern and drugs used in psychiatric Out Patients of private practitioners of Central India. METHODS This study was carried out at tertiary care hospital. Prescriptions were collected from chemist at different point of central India for a period of 4 month. Data of 1000 patients were collected by IInd year MBBS students, as a part of ongoing research project. The prescriptions were studied for one encounter. The prescriptions were analyzed on the basis of following parameters 1. Demographic data 2. Diagnosis 3. Number of drugs per patients 4. Duration of therapy 5. Fixed dose combinations 6. Any advice given to the patients The study protocol was approved by institutional Ethics Committee. The data was analysed by simple proportion. RESULTS Total 1000 prescriptions were studied. Out of which diagnosis was mentioned only in 396 prescriptions. Table 1: Depicts demographic profile of the patients. Total demographic profiles for 537 patients were recorded from the prescriptions. Out of it, 299 were males and 238 were females. Maximum number of patients i.e. 134 belonged to age group 31-40 years (72 males and 62 females). Least number of patients i.e. 5 were enrolled in age group >70 years (4 male and 1 female). Inappropriate demographic data was noted from 463 prescriptions, out of which, in 292 patients age was not mentioned and in 171 patient’s sex was not mentioned. Table 2: Table shows the details of diagnosis of the patient. Out of one thousand (1000) prescriptions, diagnosis was mentioned in only 396 prescriptions. Among the diagnosed patients, Psychosis was the commonest psychiatric disorder (n=64, 6.4%). 57 (5.7%) patients were of anxiety. Other common complaints were schizophrenia (n= 52) and depression (n= 45). Table 3: This shows prescribing frequency of psychotropic and different categories of drugs. Table 1: Demographic profile of the patients. Variables Number (%) Age in years  01-10 52(9.8%)  11-20 37(6.89%) 21-30 119(22.16%) 31-40 134(24.95%) 41-50 103(19.18%) 51-60 71(13.22%) 61-70 16(2.98%) >70  5(0.93%)  Sex  Male 299 (29.9) Female 238 (23.8)  Table 2: Diagnosis of patients. Diagnosis Number (%) Psychosis 64 (6.4) Anxiety 57 (5.7) Schizophrenia 52 (5.2) Depression 45 (4.5) Hypertension 44 (4.4) Seizure 40(4.0) Ischemic Heart Disease 15(1.5) Dementia 11(1.1) Migraine 09(0.9) Insomnia 08(0.9) Acid Peptic Disease 08(0.8)  Bipolar Disorder 07(0.7) Peripheral Neuropathy 06(0.6) Diabetes Mellitus 06(0.6) Hemiplegia 05(0.5) Respiratory infection 04(0.4)  Angina 04(0.4) Hypothyroidism 03(0.3) Alcohol Withdrawal 03(0.3) Pyogenic Meningitis 02(0.2) Contusion 02(0.2) Irritable Bowel Syndrome 01(0.1) Total 396 (39.6) Shamkuwar CA et al. Int J Basic Clin Pharmacol. 2013 Dec;2(6):777-782 International Journal of Basic & Clinical Pharmacology | November-December 2013 | Vol 2 | Issue 6    Page 779 Table 3: Prescription of psychotropic and other drugs.  Categories  Number (%)     Anti-anxiety agents 361 (36.1)   Antidepressants 130 (13.0)   Sedative Hypnotics 104 (10.4)   Antipsychotic 90 (9.0)   Anticonvulsants 80 (8.0)   Miscellaneous 73 (7.3)   Anti-hypertensives 47 (4.7)   Antibiotics 20 (2.0)   Antacids 16 (1.6)   Antiemetics 17 (1.7)   Analgesics 27 (2.7)   Anti angina 13 (1.3)   Anti diabetics 12 (1.2)   Laxatives 04 (0.4)   Diuretics 03 (0.3)   Anti parkinsons 03 (0.3)  The prescribing frequency of anti-anxiety 361(36.1%) and antidepressants 130(13%) were the most common categories of psychotropic drugs. The other psychotropic drugs prescribed in psychiatry OPD in descending order of frequency were Sedative Hypnotics 104(10.4%), anti-psychotics 90(9%) and anticonvulsants 80(8%). In other categories of drug viz. miscellaneous 73(7.3%), antihypertensive 47(4.7%) were the most commonly prescribed drugs.  Table 4 Shows the various combinations of psychotropic drugs which were prescribed. Total 223 patients received the combination regimes. The combination of Tricyclic antidepressants and benzodiazepines were most widely preferred by psychiatrists. The other combinations were of antipsychotic and central anticholinergic. Table 5 depicts the Top Ten Brands among the psychotropic drugs. Lorpam( Lorazapam) was at the top table followed by Melzep (Clonazepam) and Alprax (Alprazolam). Table 6 revealed various problems encountered in these prescriptions. Most common error found was diagnosis was not mentioned in (604). Other errors noted were absence of duration of treatment (306) and absence of age and sex. Table 4: Prescribed combination of psychotropic drugs. Brand name  Generic name  Number Amixide Amitrptylline HCl 5mg+ chlordiazepoxide 5mg 17 Psycalm plus Trifluperazine HCl 5mg + trihexiphenydyl HCl 2mg 14 Trinicamln forte Chlorpromazine 50mg+ Benzhexol 2 mg + Trifluoperazine HCl 5mg 5 Depsonil DZ  Imipramine HCl 25mg + Diazepam 2mg 5 Anzal Plus Propanolol 20mg + alprazolam 0.25mg 5 Trinicalm plus Trifluperazine HCl 5mg + trihexyphenydyl HCl 2mg 2 Benzyzine Trifluperazine 10mg + benzhexol HCl 2mg 2 Libotryp Chlodiazepoxide 5mg + Amitryptyline HCl 12.5mg 2 Omez – D  Omeprazole + domperidone 2 Epiphen Phenytoin sodium 100mg + phenobarbitone 30mg 2 Amlong-AT Amlodepine 5mg + Atenolol 50mg 2 Tancodep Imipramine + diazepam 1 Trizine-S Trifluperazine HCl 5mg + triphexyphenydyl HCl 5mg  1 Tenoclor Atenolol 25mg + chlorthalidone 12.5mg  1 Total  61 Table 5: Top Ten Brands among the psychotropic drugs. Brand Name Generic Name Number  Lorpam Lorazepam  40 Melzep Clonazepam  28 Alprax Alprazolam  26 Oliza Olanzepine 25 Psycalm plus Trifluperazine + rihexyphenidyl 22 Depsonil Imipramine 17 Alzolam Alprazolam 15 Amixide Amitryptilline + Chlodiazepexoide 17 Trika Alprazolam 14 Restyl Alprazolam  14 Total  218 Shamkuwar CA et al. Int J Basic Clin Pharmacol. 2013 Dec;2(6):777-782 International Journal of Basic & Clinical Pharmacology | November-December 2013 | Vol 2 | Issue 6    Page 780 Table 6: Problems observed in prescription. Problem Description Number % Diagnosis not written 604 (60.4) Duration of treatment not written 306 (30.6) Age not written 292 (29.2) Sex not written 171 (17.1)  Figure 1 depicts total number of drugs per prescriptions. Maximum patient’s i.e. in 324 patients two drugs were prescribed. 310 patients were prescribed three drugs, while35 patients were given more than 6 drugs.  Figure 1: Number of drugs prescribed per prescription.  Figure 2 depicts the duration of treatment. In 266 patients, treatment was given for 16-30 days, 241 patients were on treatment for 1-15 days, while the drug therapy was continued for more than 90days in 25patients.  Figure 2: Duration of treatment. Figure 3 shows drugs prescribed by Generic and Brand Name. Total 1647 were prescribed by brand name and only 47 drugs were by generic name.  Figure 3: Drugs prescribed by Generic and Brand Name. DISCUSSION A prescription by a doctor may be taken as reflection of physician’s attitude to the disease and the role of drug in its treatment. It also provides an insight into the nature of health care delivery system.9 This study indicates general trends in prescribing. As many as 1647 (97.23%) drugs were prescribed by brand name. The aim of generic prescribing is to reduce cost through substitution of less expensive formulation for drugs prescribed by brand names.10 These are issues for concern and can be redressed to some extent by prescriber education. The study elucidates inappropriate demographic data as in total 463 patients age, sex was not mentioned. In 604 (60.4%) patients diagnosis was not mentioned. This indicates that majority of the prescribers do not adhere to the ideal pattern of the prescription writing.11 Over prescribing in 22% (4 or more) of the prescriptions indicates the increasing tendency of poly pharmacy.12 Average number of drugs per prescriptions is an important index of prescription audit. It is preferable to keep the mean number of drugs per prescription as low as possible since multiple drugs lead to increased risk of drug interaction.13 In this study, duration was not stated in 306 (30.6%) prescriptions. This lapse on the part of physician needs to be brought to the notice of prescribers. It is important as many psychotropic drugs are potentially toxic and have to be prescribed for different periods, sometimes longer depending on individual patient.  Prescription order is an important transaction between the physician and patient. It brings into focus the diagnostic acumen and therapeutic proficiency of the physician with Shamkuwar CA et al. Int J Basic Clin Pharmacol. 2013 Dec;2(6):777-782 International Journal of Basic & Clinical Pharmacology | November-December 2013 | Vol 2 | Issue 6    Page 781 instructions for palliation or restoration of the patients health.14 In our study benzodiazepines were the most frequently prescribed class of psychotropic drugs. They are remarkably useful and efficacious in a wide range of conditions for short term or intermittent use.15 However, with long term use the adverse effects (memory impairment, depression, tolerance, dependence etc.) outweigh the benefits, which should be minimized by rational prescribing. Guidelines for the rational use of benzodiazepines recommend their use for short term (maximum for four week) or intermittent courses in minimum effective doses, to be prescribed only when symptoms are severe.16 Likewise prescribing prevalence of Alprazolam with different brand names was more than twice than that of other benzodiazepine observed in our study. Majority of studies with Alprazolam demonstrated efficacy for the treatment of anxiety disorders, panic disorders and depression.17 Combination preparations of psychotropic drugs were prescribed in 61(6.1%) patients. Fixed dose combinations should be selected, only when the combination have proven advantage in therapeutic effect, safety or compliance over single compounds administered separately.18 The justification for such cause could not be ascertained in the present study. The combination of tricyclic antidepressant with benzodiazepines was the most common combination prescribed by psychiatrist. The others were anti-psychotic with central anti-cholinergic. Specific advice given to the patients was mentioned in 80 patients only. CONCLUSION Present study demonstrated that alprazolam, clonazepam and olanzapine are the commonly prescribed anti-psychotropic drugs. Anti-anxiety drug (Benzodiazepines (BZD) usage was extensive as they were prescribed in almost all types of psychiatric illnesses. Rational use of BZD requires consideration and attention to dose and duration of usage as well as drug interactions with other psychotropic drugs.  Our study has some limitations. We focused on the first prescription and this may not necessarily reflect the true clinical situation. Depending on the response in many patients, further medications may have been added or deleted.  We did not document the dose and dosing schedule of the treatment given. We also did not evaluate factors like treatment adherence, availability of supervision, concerns of the patients about side effects, and adherence to treatment guidelines while prescribing. ACKNOWLEDGEMENTS The authors express their thanks to 2nd MBBS students of Indira Gandhi Government Medical College, Nagpur for helping in data collection. Funding: None Conflict of interest: None Ethical approval: The study protocol was approved by the Institutional Ethics Committee REFERENCES 1. Victor I Rew. Mental Disorder, Harrisons Principle of Internal Medicine 17th edn. 2008: 2710-2723. 2. Herbert E Ward and Albert J. Azzaro. Drugs used in Mood Disorders, Modern Pharmacology with clinical Application, 6th edn, 2004: 385-396. 3. Bauer M, Monz BU, Montejo AL, Quail D, Dantchev N, Demyttenaerek,et al. Prescribing patterns of antidepressants in Europe: result from the factors influencing Depression Endpoints Research Study.Eur Psychiatry 2008; 23:66-73.  4. Smith S. Gender difference in antipsychotic prescribing .Int Rev Psychiatr Scand 2011; 123: 459-65. 5. Patterson HR.The problem of audit and Research, JR College Gen Pract 1986;36:196. 6. Stolley PD, Lasagne L. Prescribing pattern of Physician. J Chron Dis. 1969;22: 395-405. 7. Trivedi JK, Dayani M, Yadav VS, Rai SB. Antipsychotic drug prescription pattern for schizophrenia: observation from general hospital psychiatry unit. Indian J Psychiatry 2010;52:279. 8. Grover S, Avasthi A. Anti-psychotic prescription pattern: A preliminary survey of Psychiatrists in India. Indian J Psychiatry 2010;52: 279.  9. Laporte JR. Towards a healthy use of Pharmaceuticals. Development Dialogue.1988;  48-55. 10. Uppal R, Sharma PL. Prescribing trends in internal medicine International Journal of Clinical Pharmacology Therapy and Toxicology. 22(7) 375-376,1984. 11. Budhiraja RD. Manual of Practical Pharmacy 2nd edn. Bombay; Popular Prakashan. 1993;6. 12. Ansari KU. Rational drug therapy- Do we achieve it? Antiseptic 1987; 84: 357-60. 13. Nies SA, Spielberg SP. Principle of therapeutics In : Hardman IG, Limbard LE, Motinoff PB, Ruddon R Weas. Goodman & Gilman’s The Pharmacological basis of therapeutics 9th edn. New York; Mc Graw Hill Press;1996: 43-62. 14. Benet LZ. Principle of prescription order writing and patients compliance . In: Goodman AG, Rall TW, NiesAS, Taylor P (eds). Goodman and Shamkuwar CA et al. Int J Basic Clin Pharmacol. 2013 Dec;2(6):777-782 International Journal of Basic & Clinical Pharmacology | November-December 2013 | Vol 2 | Issue 6    Page 782 Gilman’s The pharmacological basis of therapeutics. 8thed. New York : Pergamon Press Inc. 1991: 1640. 15. Heather A. Toxicity and Adverse consequence of Benzodiazepine use.psychiatric Annals.1995;5:p 158-165. Available from: http: //www.benzo.org.uk /ashox.htmaccessed 17 feb 2011. 16. Ashton H. Guidelines for the rational use of Benzodiazepines. Drugs 1994;48:25-40.  17. Jonas JM, Cohon MS. A comparison of the safety and efficacy of Alprazolam versus other agents in the treatment of anxiety, panic and depression: a review of literature. J Clin Psychiatry 1993 Oct ; 54 Suppl 25-45; Discussion 46-8. 18. World Health Organization. The use of essential drugs WHO Technical Report Series 825.Geneva: World Health Orginzation; 1992.          doi:10.5455/2319-2003.ijbcp20131220 Cite this article as: Shamkuwar CA, Chakravorty AD, Shrivastava MP, Deshmukh R. Pattern of prescription and drug use in psychiatry out patient department of private practitioners of Central India. Int J Basic Clin Pharmacol 2013;2:777-82. 

Pattern of prescription and drug use in psychiatry out patient department of private practitioners of Central India

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Pattern of prescription and drug use in psychiatry out patient department of private practitioners of Central India

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