Antipsychotic Polypharmacy Rate Remains High Following Hospital Discharge

Despite greater scrutiny on this practice in recent years, too many patients with schizophrenia and other serious mental illnesses are discharged from inpatient hospital stays while still taking multidrug regimens of antipsychotic medications.

Despite efforts in recent years to reduce the rate of antipsychotic polypharmacy among patients with schizophrenia and other serious mental illnesses, the practice continues with enough frequency that nearly 10,000 patients with schizophrenia are affected annually in state psychiatric inpatient hospitals, according to a recent study. Published in the Journal of Psychiatric Practice, the study found an antipsychotic polypharmacy prevalence of 12% in this patient population.

These results “provide insights into quality initiatives that could help further reduce the use of antipsychotic polypharmacy and reduce practices that are not consistent with best-practice guidelines,” wrote Glorimar Ortiz, Vera Hollen, and Lucille Schacht, PhD, of the National Association of State Mental Health Program Directors Research Institute (NRI), in Falls Church, VA, which supported the study.

For the cross-sectional study, Ortiz and colleagues analyzed all discharges for 86,034 patients aged 18 to 64 years from state psychiatric inpatient hospitals during the 2011 calendar year. Their goal was to explore antipsychotic medication prescribing practices and to find the prevalence of patients discharged with no antipsychotic medications, on antipsychotic monotherapy, and on antipsychotic polypharmacy. For patients discharged on antipsychotic polypharmacy, the study explored the adjusted rates of antipsychotic polypharmacy, the reasons patients were discharged on antipsychotic polypharmacy, the proportion of antipsychotic polypharmacy by mental health disorder, and the characteristics associated with being discharged on antipsychotic polypharmacy. Data were obtained from the Behavioral Healthcare Performance Measurement System, a proprietary national database representing 80% of state psychiatric hospitals in the United States.

The study was spurred on by a lack of knowledge regarding the impact of the Joint Commission’s performance measures to reduce antipsychotic polypharmacy, introduced in 2011. Ortiz and colleagues noted that the standards state that antipsychotic polypharmacy is scientifically validated following multiple failed attempts at single-drug treatment, when adjusting doses to work toward single-drug therapy, or to augment the effects of clozapine.

The study found that among the discharged patients receiving at least one antipsychotic medication, 18% were on antipsychotic polypharmacy. The most common reason for antipsychotic polypharmacy was to “reduce symptoms,” which was noted in 37% of cases. However, only 36% of patients met any of the three criteria from the Joint Commission, noted above, for appropriate use of multiple antipsychotics.

The strongest predictors of antipsychotic polypharmacy being prescribed were having a diagnosis of schizophrenia and an inpatient length of stay of 90 days or more. These findings are particularly concerning, given that 40% of patients at state psychiatric inpatient hospitals have a schizophrenia diagnosis and that nearly 20% experience a longer hospital stay, “suggesting a high-risk population needing special attention,” according to Ortiz and colleagues.

“Low percentages for the three appropriate justifications suggest that implementation of the proposed best practices are taking place at a low rate,” wrote Ortiz and coauthors. “Further analysis of the clinical presentation of these patients may highlight particular aspects of the illness and its previous treatment that are contributing to practices outside the best-practice guideline. An increased understanding of trend data, patient characteristics, and national benchmarks provides an opportunity for decision-making that is sensitive to the patient’s needs and cognizant of the hospital’s accomplishments in adopting best practices.”