Prescription of Antipsychotics for Sedation Rather than Treating Psychosis
The following article highlights what many of us suspected
and observed: the unfortunate prescription of antipsychotics for aggression
rather than for psychosis. This appears to be a matter of convenience or
method of sedation, and is certainly not FDA approved. Thanks to Chris Haupty
for providing this.
New Study Examines "Real World" Antipsychotic Prescribing Practices for
Children and Adolescents
from The Brown University Child and Adolescent Psychopharmacology Update
Posted 01/09/2003
Among psychiatric inpatient youth, physicians are known to prescribe atypical
antipsychotics more for aggression than for psychosis, and these clinicians
agree closely with research experts on what the optimal prescribing strategies
are.
Yet in practice, there are great disparities among physicians in the
prescribed use of antipsychotics to treat aggression in children and
adolescents in hospitals and other restricted settings.
Those are among the findings presented in the study, "'Real World' Atypical
Antipsychotic Prescribing Practices in Public Child and Adolescent Inpatient
Settings," published in Schizophrenia Bulletin.
The research, along with the results of multi-site clinical trials involving
the use of risperidone to treat aggression in youth, is informing the first --
and imminent -- set of clinical practice guidelines for prescribing atypical
antipsychotics to aggressive youth.
"The other shoe is going to drop when the guidelines are published in
February" in the Journal of the American Academy of Child & Adolescent
Psychiatry, said a study author, Peter S. Jensen, M.D. Jensen is the Ruane
Professor of Child Psychiatry with Columbia University's Center for the
Advancement of Children's Mental Health, as well as the center's director. The
guidelines are known as TRAAY, which stands for Treatment Recommendations for
the Use of Antipsychotics for Aggressive Youth.
New York state, where Jensen and his colleagues conducted their research, is
the first state to express its intent to adopt TRAAY; the New York State
Office of Mental Health (OMH) expects to roll out the guidelines in spring or
summer, Jensen told The Brown University Child & Adolescent Psychopharmacology
Update (CPU).
While the guidelines concentrate on use of the atypical agents, they contain
brief reviews of some other medications, another study author, Elizabeth
Pappadopulos, Ph.D., told CPU. Pappadopulos, the center's director of
medication best practices programs, added that the guidelines will be most
useful to clinicians who work with young people with severe psychiatric
disorders.
Clinical practice guidelines are especially important given that atypical
agents have supplanted traditional neuroleptics as first-line treatments for
adults with schizophrenia and other psychotic disorders. A similar trend is
occurring among younger psychiatric patients. But data on the newer
medications' safety and efficacy for this population are only starting to
emerge, and concerns about side effects remain.
Study Details
The prescribing practices study by Jensen, Pappadopulos and their colleagues
comprised three complementary elements involving several public inpatient
facilities in New York state: Focus groups, a clinician survey and a chart
review.
The focus groups were set up to help the researchers better understand what
influences physicians' decisions to prescribe antipsychotics. The research
team convened group discussions with clinical and executive directors,
psychiatrists, physicians, nurses, pharmacists, psychologists, social workers
and other mental health professionals at 12 public child and adolescent
psychiatric facilities in New York.
More than 140 professionals participated over five months during 2000 and
2001. The two-hour sessions probed problems and factors influencing assessment
and diagnosis, and the decision to use antipsychotics. Questions also centered
on beliefs and attitudes about, and current uses of, the atypical agents.
The second study component was a survey to ascertain physicians' preferred
antipsychotic-prescribing practices and whether these practices matched those
recommended by the research.
Jensen's team selected two physician groups. The"clinical expert" group
comprised 25 doctors from four of the New York facilities. The "research
expert" group comprised 18 researchers with ongoing scientific programs
designed to explore the use of atypical agents in pediatric populations.
The team administered a 33-item survey adapted from expert consensus
guidelines for behavioral disorders and mental retardation. The physicians in
both groups read clinical vignettes that described frequently encountered
situations and were asked to rate the appropriateness of possible treatment
alternatives on a 9-item Likert scale.
The third study component consisted of auditing patient charts at three of the
New York facilities. The goal was to examine the prevalence of best practices
by identifying the diagnostic and demographic categories that represented the
heaviest use of antipsychotics.
The three facilities were of similar size, and each exclusively treated
children and adolescents. The team looked over the charts of 100 discharged
patients for demographics, diagnosis, medications, doses, physician rationale
and the tracking of side effects and treatment outcomes.
Cases of discharged patients were reviewed in consecutive order starting on a
random date in March 2001. The team considered only the cases of patients aged
10 to 18 with no "medical" disorder, and who were hospitalized for no more
than one year and whose inpatient stay included treatment with an
antipsychotic at some point. The averages were, respectively: 14.3 years, 2.4
diagnoses and 111.6 inpatient days.
Study Findings
The findings revealed wide variances in prescribing practices, with little
light shed on the rationale for medication strategies or on patient outcomes.
The charts reflected that no patient underwent systematic tracking of target
symptoms. Only 14 percent of patients had their medication side effects
monitored regularly. Only forty-four percent had their weight regularly
tracked. Sixty-two percent were prescribed at least one typical, or older
antipsychotic as a standing medication or on an emergency basis.
"All the things we should do as doctors and want to do and like to do -- often
they're not there," in the medical record, Jensen said.
Even so, the clinical and research physicians agreed on what they believe the
optimal practices are. These include using atypical antipsychotics as a
second-line approach after other approaches -- such as psychosocial treatment
-- have been ruled out, and favoring the newer atypical antipsychotics over
the typical agents and traditional neuroleptics, Jensen said. Physicians also
agreed that when atypical antipsychotics are used, the dosing strategy should
be to "start low, go slow, taper slow."
Calling this finding of consensus "a pleasure and a surprise," he said, "There
is nearly perfect one-to-one agreement" between "the highfalutin researchers
and the doctors in the trenches."
Why, then, the gap between knowing and executing the preferred practices?
The obstacles are many, and include: social pressure when staff report
especially disruptive or dangerous patient behavior; limited staff resources;
managed-care limits on the length of inpatient stays; and the move away from
the use of seclusion and restraint, making "standing doses of atypical
antipsychotics...the treatment of choice of aggressive and disruptive
inpatient youth," according to the study authors.
The authors acknowledged several study limitations. The findings from the
relatively small sample of patients and limited number of facilities may not
lend themselves to generalizations, either about inpatient settings or about
most hospitalized youth.
The survey might have been enhanced by expanding questions to include
psychosocial interventions as well as medication, the authors wrote. And
focus-group discussions may have been constrained by social factors such as
how comfortable participants felt with each other.
Areas of Concern
One of most important points to be gleaned from this study, according to the
authors, is the fact that young patients with aggression are being excluded
from research.
"Antipsychotics are administered to children and adolescents in public
inpatients settings in high proportions for complex comorbid conditions
involving aggression," the authors point out. "Ironically, this real-world
patient population is excluded from clinical research, leaving clinicians to
rely on clinical experience rather than empirical evidence," they add.
The researchers flagged two other areas of concern. One is that the numbers
and amounts of medications the youths were using on admission to a facility
were "very similar" to the numbers and amounts they were using upon discharge.
The researchers had expected an adjustment in the medication regimen during
that time, which averaged 3 3/4 months.
The lack of change in regimen "makes it difficult to determine whether and how
changes in medication might affect patient outcomes," the researchers wrote.
But they conceded that it might take three months in a stable environment for
the medication's therapeutic benefits to be realized.
The other concern involved the practice of polypharmacy, or prescribing two or
more medications. Because there were few changes in the numbers of drugs
administered, the researchers questioned whether "physicians at these
facilities tend to sustain, rather than initiate, the use of polypharmacy."
The rationale for physicians' prescribing practices could not be gleaned from
patient charts, nor did the charts contain much evidence of continuity in
medication use.
But a rationale for medication strategy is "particularly important given the
great concern over antipsychotics' side effects," a concern that clinicians
themselves repeatedly raised during focus groups, the researchers wrote.
Further Study
They identified several areas for further study, one being developing
evidence-based treatment recommendations for young people with complex
co-morbid disorders. Youths in restricted placement settings represent an
unusually severe and comorbid patient population and receive psychiatric
medications besides anti-psychotics. But this group typically is excluded from
research, the authors noted.
More research also is needed about the obstacles that thwart clinicians'
intentions to prescribe in the ways they identify as "extremely appropriate."
The researchers said that meaningful treatment improvements will only stem
from a "scientifically informed model of physician behavioral change."
Funding Information
The study was funded by New York's OMH, and a private grant to the Columbia
center.
Brown University Child and Adolescent Psychopharmacology Update
5(1):1-3, 2003. © 2003 Manisses Communications Group, Inc.
Last Updated on
04/14/04
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