Association Between Neighborhood Context and Psychotropic Polypharmacy Use Among High-Need Children.

OBJECTIVE: The authors explored whether neighborhood context is associated with psychotropic polypharmacy and psychotherapy among a cohort of children with high needs for psychiatric and general medical care. METHODS: Electronic health record data from a large health care system were used in a cross-sectional design to examine psychotropic polypharmacy and psychotherapy in 2015-2019 among children ages 2-17 years (N=4,017) with geocoded addresses. Inclusion criteria were a diagnosis of a mental health condition, an intellectual and developmental disability, or a complex medical condition and one or more clinical encounters annually over the study period. Polypharmacy was defined as two or more psychotropic drug class prescriptions concurrently for ≥60 days. Psychotherapy was defined as receipt of any psychotherapy or adaptive behavior treatment. Neighborhood context (health, environment, education, and wealth) was measured with the Child Opportunity Index. Multilevel generalized linear mixed models with random intercept for census tracts were used to assess the associations between individual and neighborhood characteristics and psychotropic polypharmacy and psychotherapy. RESULTS: Moderate (vs. low) child opportunity was associated with higher odds of polypharmacy (adjusted OR [AOR]=1.79, 95% CI=1.19-2.67). High (vs. low) child opportunity was associated with higher odds of psychotherapy (AOR=2.15, 95% CI=1.43-3.21). Black (vs. White) race (AOR=0.51, 95% CI=0.37-0.71) and Hispanic ethnicity (AOR=0.44, 95% CI=0.26-0.73) were associated with lower odds of polypharmacy. CONCLUSIONS: Among high-need children, neighborhood Child Opportunity Index, race, and ethnicity were significantly associated with treatment outcomes in analyses adjusted for clinical factors. The findings underscore concerns about structural disparities and systemic racism and raise questions about access.

Polypharmacy to Clozapine Monotherapy in Treatment-Resistant Schizophrenia: A Case Report and Review of the Literature.

This case report discusses a 25-year-old Middle Eastern female with a 14-year history of schizophrenia, managed as an inpatient for nearly eight years. Initially referred to a psychiatrist at age 12, with one-year-long concerns about preoccupation with the idea of having a serious illness, depressed mood, decreased appetite, social withdrawal, and aggression, she underwent multiple admissions, various medication combinations, and electroconvulsive therapy but remained resistant to treatment until clozapine monotherapy was initiated in 2023. After starting clozapine, improvements were noted in speech, communication, and eye contact, though negative symptoms and bouts of aggression persisted. This case highlights the efficacy of clozapine monotherapy in managing treatment-resistant schizophrenia after years of ineffective polypharmacy treatment. The importance of clozapine in treating treatment-resistant schizophrenia cannot be understated. Despite its efficacy, clozapine is often underutilised globally due to concerns about adverse effects and the need for blood monitoring, leading to the overuse of antipsychotic polypharmacy. This polypharmacy is associated with higher adverse event rates, increased costs, and uncertain long-term safety. This case report demonstrates the successful management of treatment-resistant schizophrenia with clozapine monotherapy. The patient's significant improvement supports the need to prioritise clozapine, highlighting its benefits over polypharmacy and advocating for its broader use to enhance patient outcomes.

Trends in central nervous system-active polypharmacy among people with multiple sclerosis.

BACKGROUND: People with multiple sclerosis (pwMS) are at risk of concurrently using multiple central nervous system (CNS)-active drugs, yet the prevalence of CNS-active polypharmacy remains unmeasured in pwMS. OBJECTIVE: The objective is to measure the prevalence of CNS-active polypharmacy in pwMS. METHODS: This serial, cross-sectional study measured CNS-active polypharmacy in people with MS in the United States from 2008 to 2021 using insurance claims data. CNS-active polypharmacy was defined as the concurrent prescription of ⩾3 CNS-active drugs for >30 continuous days. CNS-active drugs included antidepressants, antiepileptics, antipsychotics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants. RESULTS: The number of subjects included at each time point ranged from 23,917 subjects in 2008 to 55,797 subjects in 2021. In 2021, subjects with CNS-active polypharmacy were more likely to be 46-65 years of age and have CNS-related comorbidities compared to those without CNS-active polypharmacy. From 2008 to 2021, the age-adjusted prevalence of CNS-active polypharmacy among female subjects increased from 19.8% (95% confidence interval (CI) = 19.1-20.4) to 26.4% (95% CI = 25.9-26.8) versus 15.9% (95% CI = 14.8-17.0) to 18.6% (95% CI = 17.9-19.2) in male subjects. CONCLUSION: The prevalence of CNS-active polypharmacy has increased among people with MS with a growing disparity by sex.

Prevalence of Psychotropic Medication Use and Psychotropic Polypharmacy in Autistic Adults With or Without Intellectual Disability.

The aim of this study was to compare the rates of psychotropic medication use and psychotropic polypharmacy between autistic adults with and without intellectual disability (ID) and to examine factors associated with psychotropic medication use and psychotropic polypharmacy in autistic adults, stratified by the presence of ID. We conducted a retrospective medical chart review of outpatients with an autism diagnosis aged 18 years and older. The rates of psychotropic medication use and psychotropic polypharmacy were compared between autistic adults with and without ID. Subsequently, logistic regression analyses were performed to identify factors associated with psychotropic medication use and psychotropic polypharmacy in autistic adults with ID and those without ID, respectively. The rates of prevalence of psychotropic medication use and polypharmacy were significantly higher in participants with ID than those without ID (78.6% vs. 58.8% and 49.3% vs. 31.2%; p-values < 0.05). Age, gender, race, residence, presence of mood disorders, presence of schizophrenia, absence of anxiety disorder, number of psychiatric comorbidities, and presence of behaviors that challenge were significantly associated with these outcomes, depending on the presence/absence of ID. The need to optimize pharmacotherapy in autistic adults, stratifying by the presence of ID, is highlighted.

Effectiveness of medical fee revisions for psychotropic polypharmacy in patients with mood disorders in Japan: An interrupted time-series analysis using a nationwide inpatient database.

BACKGROUND: This study aimed to evaluate the effects of medical fee revisions aimed to reduce psychotropic polypharmacy in Japan on the proportion of psychotropic polypharmacy in discharge prescriptions for patients with major depressive disorder (MDD) or bipolar disorder (BD) using a nationwide inpatient database. METHODS: In this retrospective cohort study, we used the Diagnosis Procedure Combination database to identify patients with MDD or BD discharged between April 2012 and March 2021. We targeted medical fee revisions in October 2014, April 2016, and April 2018. The major outcome was the monthly proportion of psychotropic polypharmacy in prescription at discharge using the criteria following the April 2018 revision (antidepressants ≥3, antipsychotics ≥3, anxiolytics ≥3, hypnotics ≥3, or sum of anxiolytics and hypnotics ≥4). We performed interrupted time series analyses to evaluate the changes in level and trend between pre- and post-revisions. RESULTS: We identified 63,289 and 33,780 patients with MDD and BD respectively in the entire study period. In both the patient groups, there were significant decreases in the proportion of psychotropic polypharmacy at revision in October 2014, and no significant trend and level change at revision were observed in April 2016 and April 2018, with a few exceptions. CONCLUSIONS: The medical fee revisions aimed to reduce psychotropic polypharmacy in Japan might have had a limited impact on discharge prescriptions for patients with MDD and BD.

Pediatric Psychotropic Polypharmacy: An Evaluation of the Correlates and Prevalence Across Assessment Cycles in the National Health and Nutrition Examination Survey.

Background: Pediatric psychotropic polypharmacy (PPP) is the prescription of more than one medication targeting psychiatric disorders among people younger than 18 years. Recent data suggested that PPP rates may be plateauing. Few studies have evaluated this question in large, nationally recruited samples. Objective: The National Health and Nutrition Examination Survey was used to examine the correlates and prevalence of PPP across assessment cycles. Independent assessments were obtained biannually between 2013 and 2018. Methods: Eleven thousand four hundred thirty-nine participants (4-17 years; Mage = 8.69 years; standard deviation = 5.16) were included in analyses. The Anatomic Therapeutic Chemical coding scheme was employed to classify medications, and participants were characterized as taking psychotropic medication if the medication was associated with a psychiatric diagnosis code. Participants self-reported past month medication use. Logistic regressions were used to examine correlates of pediatric psychotropic monotherapy compared with psychotropic polypharmacy. Results: Across assessments, 1.2% of respondents reported using two or more psychotropic medications. This estimate is lower than has been observed in specialized samples, but higher than other work using national samples. There was a small, significant difference in PPP across assessment cycles, such that rates of PPP were higher at the latter assessments. Correlates of PPP accorded with prior work, including male gender, increasing age, and markers of low socioeconomic status. The most robust predictor was having seen a mental health professional in the past year. Conclusions: This study documents that ∼1% of U.S. participants from a nationally recruited sample endorsed PPP. Findings are situated in the broader literature and the need for additional, prospective data to better characterize those trends in the United States and around the world. Key Takeaway Points It is known that many children and adolescents in the United States take more than one psychotropic medication, although few studies have examined trends in large, nationally recruited datasets. This study adds to this literature by documenting the prevalence of pediatric psychotropic polypharmacy in a large, unselected sample (i.e., 1.2%) and shows that rates were slightly higher at subsequent assessment intervals. Plain Language Summary Many kids take more than one medication for psychological problems. We analyzed data from ∼11,000 children and adolescents from across the United States, evaluated between 2013 and 2018. The number of kids taking multiple medications for psychological problems was different (higher) when measured later in time. Being a boy, being older, living in poverty, and having seen a mental health professional in the past year were associated with taking multiple medications for psychological problems. Implications for Managed Care Pharmacy These findings suggest rates of pediatric psychotropic polypharmacy (PPP) remain high in the United States, and correlate with male gender, poverty, and having recently seen a mental health professional. Relative to White children and adolescents, Black participants were less likely and Hispanic participants more likely to endorse PPP. Policy considerations include fully educating families and practitioners about the benefits as well as potential downsides of PPP and additional intervention options for mental health problems.

The Effect of the NorGeP-NH on Quality of Life and Drug Prescriptions in Norwegian Nursing Homes: A Randomized Controlled Trial.

BACKGROUND: The effect of the Norwegian General Practice-Nursing Home (NorGeP-NH) criteria has never been tested on clinical outcomes in nursing home (NH) residents. We performed a cluster-randomized trial in Norwegian NHs and tested the effect of NorGeP-NH on QoL (primary outcome), medication prescriptions, and physical and mental health (secondary outcomes) for the enrolled residents; Methods: Fourteen NHs were randomized into intervention NHs (iNHs) and control NHs (cNHs). After baseline data collection, physicians performed NorGeP-NH on the enrolled residents. We assessed the difference between cNHs and iNHs in the change in primary outcome from baseline to 12 weeks and secondary outcomes from baseline to eight and 12 weeks by linear mixed models; Results: One hundred and eight residents (13 lost to follow-up) and 109 residents (nine lost to follow-up) were randomized to iNHs and cNHs, respectively. Difference in change in QoL at 12 weeks between cNHs and iNHs was not statistically significant (mean (95% CI)): -1.51 (-3.30; 0.28), p = 0.101). We found no significant change in drug prescriptions over time. Difference in depression scores between cNHs and iNHs was statistically significant after 12 weeks. CONCLUSIONS: Our intervention did not affect QoL or drug prescriptions, but reduced depression scores in the iNHs. NorGeP-NH may be a useful tool, but its effect on clinical outcomes may be scarce in NH residents. Further studies about the effectiveness of NorGeP-NH in other healthcare contexts and settings are recommended.

Defining polypharmacy: in search of a more comprehensive determination method applied in a tertiary psychiatric hospital.

AIMS: This cross-sectional pharmacoepidemiologic study examined the prevalence of polypharmacy and psychotropic polypharmacy among inpatients in a tertiary psychiatric hospital in Belgium. METHODS: Current prescriptions of all inpatients suffering from mental disorders were extracted from the hospital Computerized Physician Order Entry. Two methods were used to examine definitive polypharmacy (defined as the concomitant use of at least five medicines): number of medicines per active component and per prescription. Psychotropic polypharmacy was defined as the concomitant use of at least two psychotropic medicines, based on the first counting, i.e., per active component. RESULTS: In 292 included patients, the prevalence of definitive polypharmacy was 65.8%, with a mean number of 6.8 ± 4.2 medicines per patient. The most prevalent medicines were related to the central nervous system (55.7%), followed by medicines related to the gastro-intestinal (17.6%) and cardiovascular (9.4%) systems. A prevalence of psychotropic polypharmacy of 78.1% was observed, with a mean of 3.0 ± 1.7 psychotropic medicines per patient. Psychotropic polypharmacy was classified in same-class (71.5%), multi-class (82.5%), augmentation (20.6%), and adjuvant (35.5%) polypharmacy. CONCLUSION: These findings are consistent with previous reports of highly prevalent polypharmacy in patients with mental disorders. Although, in some cases, polypharmacy can be an important part of good clinical practice, the high prevalence of both polypharmacy and psychotropic polypharmacy emphasizes that attention must be paid to the potentially associated risks. Consensus on the definition and method of determination of polypharmacy is needed to support further research.

Polypharmacy and psychotropic polypharmacy in adults with intellectual disability: a cross-sectional total population study.

BACKGROUND: Adults with intellectual disability (ID) are prescribed high levels of medication, with polypharmacy and psychotropic polypharmacy common. However, reported rates vary between studies, and there has been an over-reliance on obtaining data from convenience samples. The objective of this study was to determine the prevalence of medication use and polypharmacy in a population-level sample of adults with IDs. Factors associated with polypharmacy and psychotropic polypharmacy are explored. METHODS: We used a total population sample of 217 adults with IDs known to services in Jersey (sampling frame n = 285). The Anatomical Therapeutic Chemical classification system was used to categorise medications that participants were currently taking on a regular basis. We examined associations of polypharmacy and psychotropic polypharmacy with socio-economic status, health and demographic variables using univariate and multivariate analyses. RESULTS: A total of 83.4% of participants were prescribed medication, with high doses common. Of the participants, 38.2% were exposed to polypharmacy while 23% of participants were exposed to psychotropic polypharmacy. After controlling for demographic, health and socio-economic characteristics, polypharmacy was significantly associated with older age, increased severity of ID, living in a residential setting and having increased comorbidities. Psychotropic polypharmacy was associated with being male, being aged 50+ years and having had a psychiatric diagnosis over the life course. Being prescribed psychotropic drugs above the defined daily dose was not associated with having had a psychiatric diagnosis over the life course, suggesting the possibility of 'off label' prescribing. CONCLUSIONS: Our results indicate that medication use, in high doses, alongside polypharmacy and psychotropic polypharmacy are highly prevalent in adults with ID. The exposure to multiple medications increases the risk of developing adverse drug events, drug-drug interactions and medication-related problems. Future population-level, prospective cohort studies should examine the prevalence of polypharmacy and psychotropic polypharmacy using standardised definitions and consider the potential impact of adverse drug events, drug-drug interactions and medication-related problems in this population.

Psychotropic polypharmacy and its association with health-related quality of life among cancer survivors in the USA: a population-level analysis.

PURPOSE: Cancer survivors that use multiple psychotropic medications are at an increased risk of psychotropic polypharmacy. We examined the association between psychotropic polypharmacy and health-related quality of life (HRQoL) among cancer survivors living in the USA. METHODS: We used the Medical Expenditure Panel Survey (MEPS) data for 2010, 2012, and 2014 to identify adult cancer survivors. Psychotropic polypharmacy was defined as use of at least two classes of psychotropic prescription medications. The physical component summary (PCS) and the mental component summary (MCS) were obtained from the 12-item Short Form Health Survey version 2 to measure HRQoL. Adjusted ordinary least square regressions were performed to evaluate the association between psychotropic polypharmacy and HRQoL. RESULTS: Among 31 million US cancer survivors (weighted from a sample of 2609), 16.3% reported psychotropic polypharmacy. Lung cancer survivors had the highest prevalence of psychotropic polypharmacy (22.5%), followed by survivors of breast cancer (17.8%), colorectal, and other gastrointestinal cancers (16.0%). The unadjusted PCS and MCS scores for those with psychotropic polypharmacy were significantly lower than those without psychotropic polypharmacy, overall, and for each cancer type. In multivariable regressions, cancer survivors with psychotropic polypharmacy had significantly lower PCS scores (ß = - 3.63, p < 0.0001) and MCS scores (ß = - 2.28, p = 0.0138) compared to those without psychotropic polypharmacy. CONCLUSION: Cancer survivors requiring multiple psychotropic medications have poorer quality of life.

Psychotropic drugs use and psychotropic polypharmacy among persons with Alzheimer's disease.

Psychotropic drugs are frequently used for the treatment of behavioural and psychological symptoms of dementia in persons with Alzheimer's disease (AD). Evidence for benefits are limited and concerns have been raised about the safety, especially for the concomitant use of multiple psychotropic drugs. The objective of this study was to investigate prevalence of psychotropic drug and psychotropic polypharmacy (PPP) use and associations with PPP among persons with and without AD, from five years before until four years after AD diagnosis at time points every six months. Data is a part of the nationwide MEDALZ cohort, including all community-dwelling persons who received a clinically verified diagnosis of AD between 2005 and 2011 in Finland (n = 70,719). Register-based data included purchased prescription drugs, comorbidities, and hospital discharge diagnoses. Prevalence and factors associated with PPP were studied with logistic regression. The prevalence of psychotropic drug use, especially use of antipsychotics and antidepressants, increased during the course of AD. The use of ≥ 2 psychotropic drugs increased from 5.9% five years before to 18.3% four years after AD diagnosis. The most frequently used combination was antipsychotics and antidepressants. Predictors for PPP were younger age (< 75 years), female sex and history of psychiatric disease. The use of acetylcholinesterase inhibitors was inversely associated with PPP. The high prevalence of PPP is concerning because of possible higher risks for adverse effects and events.

Reducing psychotropic pharmacotherapy in patients with severe mental illness: a cluster-randomized controlled intervention study.

BACKGROUND: Many patients with mental illness receive psychotropic medicine in high dosages and from more than one drug. One of the consequences of this practice is obesity, which is a contributing factor to increased physical morbidity and premature death. METHODS: Our study was a cluster-randomized intervention study involving 6 facilities and 174 patients diagnosed with severe mental illnesses (73% schizophrenia). The intervention period was 12 months and consisted of teaching sessions with the staff and evaluating the patients' intake of psychotropic medication. At index, 44% met criteria for obesity and 76% met criteria for overweight. Waist circumferences were 108 cm for men and 108 cm for women. Olanzapine, clozapine and quetiapine were the most common prescribed antipsychotics. Mean values of daily doses of antipsychotic were 2.5. RESULTS: The intervention showed no significant differences between the intervention and control group regarding psychotropic treatment. At follow up, independent of intervention, patients receiving antipsychotic polypharmacy had a larger waist circumference compared with patients receiving antipsychotic monotherapy of 9.8 cm (1.5-18.1) (p = 0.028). DISCUSSION AND CONCLUSION: We found both a high prevalence of obesity and that the patients received treatment with antipsychotic polypharmaceutics in high dosages. Active awareness did not change practice and we must think of other ways to restrict treatment with psychotropics in this group of patients.

Psychotropic medication use and polypharmacy in children with autism spectrum disorders.

OBJECTIVE: The objectives of this study were to examine rates and predictors of psychotropic use and multiclass polypharmacy among commercially insured children with autism spectrum disorders (ASD). METHODS: This retrospective observational study used administrative medical and pharmacy claims data linked with health plan enrollment and sociodemographic information from 2001 to 2009. Children with ASD were identified by using a validated ASD case algorithm. Psychotropic polypharmacy was defined as concurrent medication fills across ≥ 2 classes for at least 30 days. Multinomial logistic regression was used to model 5 categories of psychotropic use and multiclass polypharmacy. RESULTS: Among 33,565 children with ASD, 64% had a filled prescription for at least 1 psychotropic medication, 35% had evidence of psychotropic polypharmacy (≥ 2 classes), and 15% used medications from ≥ 3 classes concurrently. Among children with polypharmacy, the median length of polypharmacy was 346 days. Older children, those who had a psychiatrist visit, and those with evidence of co-occurring conditions (seizures, attention-deficit disorders, anxiety, bipolar disorder, or depression) had higher odds of psychotropic use and/or polypharmacy. CONCLUSIONS: Despite minimal evidence of the effectiveness or appropriateness of multidrug treatment of ASD, psychotropic medications are commonly used, singly and in combination, for ASD and its co-occurring conditions. Our results indicate the need to develop standards of care around the prescription of psychotropic medications to children with ASD.