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 Table of Contents  
BRIEF COMMUNICATION
Year : 2016  |  Volume : 21  |  Issue : 1  |  Page : 48-54

Evaluation of psychotropic prescription patterns at the time of discharge from inpatient unit of a tertiary care general hospital psychiatric unit


1 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Psychiatry, All Institute of Medical Science, Jodhpur, Rajasthan, India

Date of Web Publication10-May-2016

Correspondence Address:
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-8990.182090

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  Abstract 

Objectives: This study aimed to evaluate the prescription pattern of inpatients admitted in the psychiatric unit of a tertiary care hospital at the time of discharge from the inpatient setting. Material and Methods: In this retrospective chart review data of 496 patients admitted in the psychiatric unit of a tertiary care hospital in northern India diagnosed with an International Classification of Diseases-10 diagnosis of psychotic, affective and neurotic disorder were extracted and analyzed. Results: In all diagnostic groups, olanzapine was the most commonly prescribed antipsychotic followed by risperidone. Very few patients (8.8%) received typical antipsychotics. Venlafaxine was the most commonly prescribed antidepressant; other frequently prescribed antidepressants were fluoxetine, amitriptyline, and sertraline. Among the mood stabilizers, prescription of valproate exceeded that of lithium. In all the groups, more than half of the patients were prescribed benzodiazepines, clonazepam being the most commonly prescribed agent, followed by lorazepam. The mean numbers of psychotropic medications were highest in the bipolar disorder group. Very few patients received the combination of drugs belonging to the same class i.e.,, receiving two antidepressants or two antipsychotics. Conclusion: Olanzapine, venlafaxine, valproate and clonazepam are the most commonly prescribed antipsychotic, antidepressants, mood stabilizers and benzodiazepines, respectively.

Keywords: Antidepressants, antipsychotic, benzodiazepines, inpatients, mood stabilizers, prescription, psychotropics


How to cite this article:
Grover S, Nebhinani N, Chakrabarti S, Avasthi A, Mattoo SK, Basu D, Kulhara P, Malhotra S. Evaluation of psychotropic prescription patterns at the time of discharge from inpatient unit of a tertiary care general hospital psychiatric unit. J Mental Health Hum Behav 2016;21:48-54

How to cite this URL:
Grover S, Nebhinani N, Chakrabarti S, Avasthi A, Mattoo SK, Basu D, Kulhara P, Malhotra S. Evaluation of psychotropic prescription patterns at the time of discharge from inpatient unit of a tertiary care general hospital psychiatric unit. J Mental Health Hum Behav [serial online] 2016 [cited 2019 Dec 11];21:48-54. Available from: http://www.jmhhb.org/text.asp?2016/21/1/48/182090


  Introduction Top


Psychiatric disorders constitute an enormous public health problem that places social and economic burden on patients and their families. Management of psychiatric disorders involves use of psychopharmacological agents and nonpharmacological measures. Treatment selection is influenced by setting, expert opinions, treatment guidelines, financial resources, availability, comorbid disorders, specific clinical symptoms, prior treatment history, associated side effects of medication, and risk of drug-drug interaction.[1],[2]

Several studies have evaluated the psychotropic prescription patterns in psychiatric outpatient setting,[3],[4],[5],[6],[7],[8] inpatient setting,[2],[9],[10],[11],[12],[13],[14],[15],[16] and in both the treatment settings (sample size 510–8649)[17],[18] from different countries of the world. Indian literature is mainly from outpatient settings (sample size 100–10214).[19],[20],[21],[22],[23],[24],[25] Only three studies have focused on patients from inpatient setting,[26],[27],[28] that too of small sample size and are exclusively on patients with schizophrenia. One is from long-term treatment facility (n = 171) of psychiatric institution [26] and other two are from general hospital psychiatry units (n = 178 and n = 29).[27],[28] These studies have reported rising trends for use of atypical antipsychotics [27],[28] and benzodiazepines.[26]

Inpatient population is usually at the severe end of the illness. Evaluation of prescription patterns in this setting is of paramount importance in understanding the current treatment practices and improvement in future prescribing patterns in terms of safety and effectiveness.[2] Accordingly the aim of the study was to evaluate the prescription pattern at the time of discharge from the hospital of inpatients admitted in the psychiatric unit of a tertiary care hospital in north India.


  Material and Methods Top


Study setting

The study was carried out at the psychiatric inpatient unit of a multi-specialty tertiary-care hospital in North India. Patients are managed by a three tier system involving a junior resident (trainee resident), a senior resident (qualified psychiatrist) and consultant in charge of the patient. Diagnoses are made by consultant in charge according to the International Classification of Diseases (ICD)-10 Classification of Mental and Behavioural Disorders (clinical descriptions and diagnostic guidelines)[29] after detail history taking from the patient and their close family members, mental state examination and investigations. Depending on the clinical status, the patients are treated with pharmacotherapy, electroconvulsive therapy, psychotherapeutic interventions and combinations of these modalities. Medications are chosen in consultation with the caregivers and also with the patients, wherever feasible. Certain medications (trifluoperazine, chlorpromazine, fluphenazine decanoate, imipramine, and lithium) are available free of cost from the hospital dispensary; for medications other than these, family/patient has to purchase the same.

Demographic and certain clinical data (i.e., diagnosis, management and advice at discharge) of all the inpatients are coded on a computer-based registry on regular basis. For this retrospective chart review, data of all inpatients admitted during the period of January 1, 2009 to December 31, 2011 and diagnosed with an ICD-10 diagnosis of psychotic, affective and neurotic stress related and somatoform disorder (F2-F4) were extracted from the computer-based registry. Their demographic and clinical data, including diagnosis, comorbidities and prescription at time of discharge were extracted. Patients diagnosed with disorder other than psychotic, affective and neurotic, stress related and somatoform disorders were excluded.

For this study, prescriptions handed over to the patient at the time of discharge were evaluated. The prescribed medications were grouped into broad categories of antidepressants, antipsychotics, mood stabilizers, and sedatives. Further categorization for example, use of subcategories like typical and atypical antipsychotics was done as per the requirement. The study was approved by the Institute Ethics Review Board.

Frequencies with percentages were calculated for nominal and ordinal variables and mean and standard deviation (SD) were calculated for continuous variables using the SPSS version 14.0 for Windows (Chicago, Illinois, USA).


  Results Top


During the study period of 3 years (January 1, 2009 to December 31, 2011), 514 patients were admitted, of whom 496 had the diagnosis of psychotic, affective and neurotic disorder (F2-F4) as per ICD-10 category. Data of these patients was extracted.

Demographic details

The sociodemographic details of the study sample are shown in [Table 1]. The mean age of the study sample was 34.85 (SD: 15.45) years, with majority of the patients in the age group of 21–40 years. More than half of the subjects were educated beyond matriculation, were of male gender, married, not on paid job and belonged to nuclear family. About three-fourth of the subjects were Hindus and from urban locality. Most of the patients were admitted for management of acute disturbances.
Table 1: Sociodemographic profile of patients admitted in psychiatry ward (n=496)

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Diagnostic details

The commonest primary diagnostic group was of psychotic disorder (40.7%) of which schizophrenia (30.8%) was the most common diagnosis. Other details are shown in [Table 2]. Among the patients with mania/bipolar disorder, majority of them were diagnosed with bipolar disorder, current episode mania. In the unipolar depression group, the most common diagnostic group was that of first episode depression and in the neurotic and stress related disorder the most common diagnosis was that of obsessive compulsive disorder (OCD). Very few patients (4.4%) had comorbid substance dependence and only 6.8% had another comorbid psychiatric diagnosis.
Table 2: Diagnostic breakup out of F2--F4 diagnostic groups (n=496)

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About one-third (30.4%) patients had one or more physical comorbidities involving the neurological (epilepsy-26, Parkinson's disease-2, head injury-4), cardiovascular (hypertension-74, coronary artery disease-2), endocrinological (diabetes mellitus-46, diabetes insipidus-1, hypothyroidism-3, hyperthyroidism-2), dermatological (psoriasis-3, dermatitis-2, urticaria-12, scabies-4, vitiligo-1), hepatogical (chronic hepatitis-2, chronic liver disease-1, cholelithiasis-2), orthopedic (prolapsed intervertebral disc-2), urological (benign prostrate hyperplasia-4, urinary tract infection-4), immunological (systemic lupus erythematosus-1, rheumatoid arthritis-1), pulmonary (asthma-4, chronic obstructive pulmonary disoease-1), and other disorders (deep vein thrombosis-1, bladder carcinoma-1).

Prescription patterns

Antipsychotics

All the patients with psychotic disorder were on at least one antipsychotic. Three-forth patients with mania/bipolar disorder and two-fifth patients with unipolar depression and minority of patients with neurotic and stress related disorders (10%) also received antipsychotics. All the patients with neurotic and stress related disorders who were prescribed antipsychotic were diagnosed with OCD. The commonest antipsychotic used irrespective of the diagnostic category was olanzapine (36.1% in psychotic group and 46.2% in manic/bipolar disorder group), followed by risperidone (24.2% in psychotic group and 14.7% in manic/bipolar disorder group). Clozapine (20.8%) was the third most commonly used antipsychotic in the psychotic group and quetiapine (10.8%) in the affective disorder group. Very few patients received typical antipsychotics and depot preparations (8.8%) [Table 3].
Table 3: Prescription of psychotropic medications (n=496)

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Antidepressants

As shown in [Table 3], all the patients with unipolar depression and neurotic and stress related disorders were on antidepressants. One-third of patients in psychotic disorder group and one-fourth of patients in bipolar disorder group were also receiving antidepressants. Venlafaxine (50%) was the most common antidepressant in patients with affective disorders, followed by mirtazapine (12.6%) and fluoxetine (11.9%) in unipolar depression group and fluoxetine and sertraline (4.9% each) in bipolar disorder group. In the neurotic and stress related disorder group, fluoxetine (27.5%) was the commonest antidepressant, followed by escitalopram (20.6%) and sertraline (15.5%). In psychotic disorder group, amitriptyline (14.3%) was the most common antidepressant as it was co-prescribed for clozapine induced sialorrhea.

Mood stabilizers

Majority of patients (89.2%) in mania/bipolar disorder group were on a mood stabilizer. Valproate was used in 55.9% and lithium was used in 35.4% of patients in this group. In minority of the patients (three in bipolar disorder group and five in psychosis group) mood stabilizers with antiepileptic properties were also prescribed to manage their comorbid epilepsy.

Sedative-hypnotics

Three-fourth of entire sample was on one or another sedative medication. In all the groups, more than two-third of the patients were prescribed benzodiazepines or some other sedative. In all the three diagnostic groups, clonazepam was the most commonly prescribed agent (38.1%–60.4%), followed by lorazepam (9.7%–26.2%) and nitrazepam (4.9–8.6%).

Nutritional supplements

Eight six patients (17.3%) received nutritional supplements, of which 43 patients (8.7%) were on multivitamins and twenty patients (4%) were on iron and folic acid.

Mean number of psychotropic medications

Eighty-two patients were on single psychotropic agent and rest 414 patients (83.4%) were receiving two or more psychotropic agents. The mean number of psychotropic medications was highest in the bipolar disorder group (3.05) and least in the neurotic, stress related, and somatoform disorders (1.84). Very few patients received the combination of same group of drugs, i.e., polypharmacy (use of more than one agent from the same group of medications), for example, two antipsychotics (8.2%), two antidepressants (6.2%), two mood stabilizers (1.8%) and two sedatives (benzodiazepines and nonbenzodiazepines) (9.5%). Antipsychotic polypharmacy was 16% in psychotic disorder group, 6.8% in bipolar disorder group, and 2.2% in unipolar depression group. Antidepressant polypharmacy was 13.4% in unipolar depression group, 5.1% in neurotic disorder group, 4.9% in bipolar disorder group, and 2.4% in psychotic disorder group. Only 7.8% of patients were receiving more than one classical mood stabilizer. Sedative polypharmacy was 8.6%–11.1% across the diagnostic groups.


  Discussion Top


Certain important observations are evident from the present study. Majority of patients were on single medication from a particular group, i.e., one antipsychotic or one antidepressant. This finding suggests that in general there is an effort to follow the recommendations of treatment guidelines before using combinations.

Mean number of psychotropics were highest in bipolar disorder group (3.05) and least in neurotic, stress related, and somatoform disorders group (1.84). This finding is concordance with the earlier study from our centre which evaluated prescription patterns of outpatients and reported maximum psychotropic load in bipolar disorder group.[22] This may be explained by the nature and severity of the disorder, presence of aggression, sleep disturbances and anxiety symptoms etc., in this group of disorder. Further, treatment guidelines also recommend use of combinations (mood stabilizer and an antipsychotic) as first line treatment if required in patients with bipolar disorder/mania. Accordingly, it can also be said that the higher medication load in this group could be due to the nature of the illness and also the available knowledge about management of these disorders.

Similar to earlier studies [8],[9],[14],[30] it was observed that antipsychotics are the most commonly prescribed psychotropic medication. This could be due to the diagnostic profile of patients, as the commonest diagnostic category of patients in the present study was that of psychotic disorders.

Among the antipsychotic prescriptions, significantly high proportions of patients (92%) were on atypical antipsychotic medications. This finding is similar to most of recent studies which have evaluated the prescription of inpatients and outpatients.[7],[8],[14],[16],[20],[22],[31],[32] Similarly, like many of the recent studies, olanzapine and risperidone were the most commonly prescribed antipsychotics across different diagnostic groups.[8],[11],[14],[19],[22],[23],[27] However, in contrast to the previous studies which have reported low rate of prescription of clozapine,[22],[27] about 21% of patients with psychotic disorders were prescribed clozapine in the present study. This difference could be due to higher proportion of patients who are refractory to treatment admitted to the inpatient setting, compared to the outpatient setting. The low prescription rate of first generation antipsychotics (FGAs) (8.8%) as seen in the present study is in accordance with some of the earlier studies which have evaluated prescription pattern of inpatients with schizophrenia.[27],[28] The high prescription rate of atypical antipsychotics could be due to claims of their better tolerability profile, especially in relation to the extrapyramidal side effects.

Very few patients with psychotic disorders were receiving mood stabilizers, which is significantly less than the figures of 19.5–23.7% reported in a study which has evaluated the use of adjunctive mood stabilizers in patients with schizophrenia.[33] However, the proportion of patients with psychotic disorders receiving mood stabilizers in the present study was higher than that seen in the outpatients,[22] suggesting that the prescription patterns vary across treatment setting and are possibly influenced by severity of the illness and comorbid disorders.

One-third patients with psychotic disorders were also receiving antidepressant medications, which is similar to earlier reports,[2],[34] but much higher than reported for patients seeking treatment at the outpatient setting.[22] This difference could be due to the difference in the illness severity, comorbidity and possibly be due to differences in the intensity of evaluation various treatment settings.

Our findings in psychosis group are in line with a recent study examining the use of psychotropic medications in schizophrenia patients in selected East and Southeast Asian countries/territories.[35] This study also suggests that decline in the use of FGAs and antipsychotic polypharmacy, increase prescription of second generation antipsychotics and antidepressants and almost stable prescribing trends for benzodiazepines and mood stabilizers.[35]

In bipolar disorder/mania group, three-fourth of the sample was prescribed antipsychotic medications, which is much higher than the 11% to 27% reported in some of the studies from other countries [3],[5],[6] and somewhat higher than our outpatient clinic data (65%).[22] Olanzapine was the most commonly prescribed antipsychotic in bipolar patients, followed by risperidone. The rate of olanzapine prescription in the bipolar group is much higher in the present study compared with some of the other reports.[3],[5],[6] This difference could be possible emergence of olanzapine as a mood stabilizer as has been recommended in some of the recent treatment guidelines for bipolar disorder.[36]

In the bipolar group, about one-fourth of the patients were also receiving antidepressant medications, much less than earlier reports from other countries.[3],[5],[6] Lower use of antidepressants found in the present study can explained with the bipolar subtypes, as one-fourth (27 out of 102) of patients with bipolar disorders had current episode depression. Further, lower prescription rate of antidepressants also possibly reflects the concerns for a possible switch to mania with antidepressants, as has been reported in literature.[22] Though due to treating team's preference or patient's clinical profile bupropion was prescribed to only minority of patients. More than three-fourth (82%) of the patients with bipolar disorder were receiving benzodiazepines. This figure is much higher than that reported from the West [5],[14] as well as from India.[22],[23] Higher rate of benzodiazepine use may be reflection of its use as adjunct with mood stabilizers or antipsychotics in initial period of treatment especially in patients with aggression, disruption and intense anxiety symptoms. However, this also reflects that although used as a co-prescription, benzodiazepines are usually not stopped by the time of discharge, which suggests that there is a need to improve the prescription pattern and to limit the use of benzodiazepines to the shortest possible duration.

Majority of the patients with bipolar disorder were receiving mood stabilizers and valproate was more often used compared to lithium, which is similar to the recent literature.[3],[6],[22],[24],[37] This may be due to patients' profile, clinicians' preference, side effect profile and ease in initiating valproate. Similar to our findings, a recent study on prescription pattern for bipolar patients reported that majority of patients with bipolar disorder receive a combination of mood stabilizer and antipsychotics, with valproate being most commonly used mood stabilizer, and lesser utilization of antidepressant.[38]

In the depression group, about half of the patients were prescribed venlafaxine and another one-third were prescribed selective serotonin reuptake inhibitor (SSRI). These findings are quite different from earlier studies [21],[22],[30],[34],[39],[40] where SSRI remained the commonest antidepressant. This difference could be due to severity of depression, as most of the inpatients have severe depression in which venlafaxine is preferred over SSRIs.[41],[42] Similar to an earlier study from outpatient clinic at our centre (14%),[30] in index study, 13.4% patients with depressive disorders were receiving two antidepressants. While a study from another country has reported higher antidepressant polypharmacy rate of 32%.[9]

Nearly two-fifth of patients in the depression group were receiving antipsychotics, which was similar to an earlier report.[9] Similar to previous reports from India,[20],[22] majority of patients with depression (85%) were prescribed benzodiazepines, with clonazepam being the most common benzodiazepine, followed by lorazepam. Such a high benzodiazepine prescription could be due to associated or anticipated anxiety, insomnia, and agitation in this population of depressed patients, which are common indications for prescribing benzodiazepines.

In the present study, all the patients suffering from neurotic, stress related, and somatoform disorder group were prescribed antidepressants and about two-third were prescribed benzodiazepines. SSRIs as a class of antidepressant drug were the most commonly prescribed to manage their anxiety and depressive symptoms, with fluoxetine being the commonest followed by escitalopram. As in depression group, clonazepam was the most common benzodiazepine. The antidepressant and benzodiazepine prescription rates are comparable to earlier study from our outpatient setting.[22]

To conclude, findings of the present study suggest that olanzapine, venlafaxine, and clonazepam are the most commonly prescribed antipsychotic, antidepressants, and benzodiazepines, respectively. Among the mood stabilizers valproate is more often used when compared to other mood stabilizers. Polypharmacy was reasonably low for specific class of psychotropics.

Is there any difference in the prescription pattern between inpatients and outpatients?

When the data of this study, was compared with the study from our centre which evaluated the prescriptions of outpatients,[22] certain similarities and differences were noted. In terms of similarities, there was no difference in the most commonly used antipsychotic, antidepressant, mood stabiliser and benzodiazepines prescribed. However, significantly higher proportion of inpatients with psychotic disorders was prescribed clozapine (20.8% vs. 0.6%). In terms of antidepressants, significantly higher proportion of inpatients with depressive disorders was prescribed venlafaxine (50% vs. 12.5%). These differences possibly reflect the differences in the severity of illness across different treatment settings, their indication, side effect profile and psychiatrists' attitudes.

Our study has several limitations, as the study evaluated the prescription data at discharge from inpatient setting, which could be influenced by the clinical status at discharge, and certain medications like benzodiazepines, second antidepressant/antipsychotic/mood stabilizer might have been given for shorter duration only just for symptomatic relief or as part of cross tapering. We did not document the dosing schedule, side effects, and therapeutic effects of the given treatment. Information about prn medications and other psychotropics medications such as trihexyphenidyl, propranolol etc., was not collected. We also did not evaluate factors like cost, treatment adherence, and supervision. Moreover, our study was limited to an inpatient unit of a tertiary care, multi-specialty, teaching center.

Future studies should try to overcome these limitations. There is a need for national and international multicentric studies involving larger study population. There is also a need to understand the role of psychiatrists' expertise, choice, patients' variables, scientific evidence and rationality behind selection of particular medications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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