Antipsychotic prescribing for vulnerable populations: a clinical audit at an acute Australian mental health unit at two-time points

McMillan, Sara S.; Jacobs, Sara; Wilson, Louise; Theodoros, Theo; Robinson, Gail; Anderson, Claire; Mihala, Gabor; Wheeler, Amanda J.

Abstract

Background: Antipsychotics are recognised as a critical intervention for schizophrenia and bipolar disorder. Guidelines globally endorse the routine practice of antipsychotic monotherapy, at the minimum effective dose. Even in treatmentresistant schizophrenia, clozapine use is endorsed before combining antipsychotics. This aim of this study was to review antipsychotic polytherapy alone, high-dose therapy alone, polytherapy and highdose prescribing patterns in adults discharged from an inpatient mental health unit at two time-points, and the alignment of this prescribing with clinical guideline recommendations. Additionally, associations with polytherapy and high-dose antipsychotic prescribing, including patient and clinical characteristics, were explored.
Methods: A retrospective clinical audit of 400 adults (200 patients at two different time-points) discharged with at least one antipsychotic. Preliminary findings and education sessions were provided to physicians between Cohorts. Outcomes (polytherapy alone, high-dose therapy alone, polytherapy and high-dose therapy) were compared between
study Cohorts using chi-squared and rank-sum tests. Associations between outcomes and covariates were assessed
using multivariable logistic regression.
Results: Most patients (62.5%) were discharged on a single antipsychotic within the recommended dose range. There
was a clear preference for prescribing second generation antipsychotics, and in this respect, prescribing is aligned with current evidence-based guidelines. However, sub-optimal prescribing practices were identified for both Cohorts in relation to polytherapy and high-dose antipsychotic rates. Involuntary treatment, frequent hospitalisations and previous clozapine use significantly increased the risk of all three prescribing outcomes at discharge.
Conclusions: In a significant minority, antipsychotic prescribing did not align with clinical guidelines despite increased training, indicating that the education program alone was ineffective at positively influencing antipsychotic prescribing practices. Further consideration should be given when prescribing antipsychotics for involuntary patients, people with frequent hospitalisations, and those who have previously trialled clozapine.

Citation

McMillan, S. S., Jacobs, S., Wilson, L., Theodoros, T., Robinson, G., Anderson, C., …Wheeler, A. J. (2017). Antipsychotic prescribing for vulnerable populations: a clinical audit at an acute Australian mental health unit at two-time points. BMC Psychiatry, 17(1), Article 139. https://doi.org/10.1186/s12888-017-1295-1

• Journal Article Type: Article
• Acceptance Date: Mar 31, 2017
• Publication Date: Apr 13, 2017
• Deposit Date: Apr 26, 2017
• Publicly Available Date: Apr 26, 2017
• Journal: BMC Psychiatry
• Electronic ISSN: 1471-244X
• Publisher: Springer Verlag
• Peer Reviewed: Peer Reviewed
• Volume: 17
• Issue: 1
• Article Number: 139
• DOI: https://doi.org/10.1186/s12888-017-1295-1
• Keywords: Audit, Antipsychotics, Mental Illness
• Public URL: https://nottingham-repository.worktribe.com/output/855963
• Publisher URL: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-017-1295-1