Factors associated with high-dose antipsychotic prescriptions in outpatients with schizophrenia: An analysis of claims data from a Japanese prefecture.

BACKGROUND: Antipsychotics are commonly prescribed in high doses in combination with multiple psychotropic drugs. This study focused on the high-dose antipsychotic prescriptions in patients with schizophrenia, while aiming to identify their associations with patients' characteristics and concurrent psychotropic prescriptions. METHODS: This cross-sectional study used claims data from a prefecture in Japan, between October 2014 and March 2015, to investigate antipsychotic prescriptions in adult outpatients with schizophrenia. The objective variable was the presence/absence of a high-dose prescription. The explanatory variables included sex, age (category), presence of comorbid conditions, and the use of psychiatrist's therapy. RESULTS: After exclusion, a total of 13 471 patients with schizophrenia were analyzed. The frequency of high-dose prescriptions was higher in men, with chlorpromazine-equivalent values highest in the age ranges of 45-54 and 35-44 years for men and women, respectively. Patients aged below 65 years with cerebrovascular diseases showed a decrease in high-dose prescriptions. There was a high frequency of polypharmacy psychotropic drug use in combination with a high-dose antipsychotic prescription in patients aged below 65 years. CONCLUSION: High-dose antipsychotics are often used in combination with several psychotropic agents in patients with schizophrenia. Our findings emphasize the need to evaluate the prescribing behavior of physicians to avoid high-dose antipsychotic prescriptions for improved patient care.

Melancholic and reactive depression: a reappraisal of old categories.

BACKGROUND: The dominant diagnostic model of the classification of depression today is unitarian; however, since Kurt Schneider (1920) introduced the concept of endogenous depression and reactive depression, the binary model has still often been used on a clinical basis. Notwithstanding this, to our knowledge, there have been no collective data on how psychiatrists differentiate these two conditions. We therefore conducted a survey to examine how psychiatrists in Japan differentiate patients with major depressive disorder who present mainly with melancholic features and those with reactive features. METHODS: Three case scenarios of melancholic and reactive depression, and one-in-between were prepared. These cases were designed to present with at least 5 symptoms listed in the DSM-IV-TR with severity being mild. We have sent the questionnaires regarding treatment options and diagnosis for those three cases on a 7-point Likert scale (1 = "not appropriate", 4 = "cannot tell", and 7 = "appropriate"). Five hundred and two psychiatrists from over one hundred hospitals and community clinics throughout Japan have participated in this survey. RESULTS: The melancholic case resulted significantly higher than the reactive case on either antidepressants (mean ± SD: 5.9 ± 1.2 vs. 3.6 ± 1.7, p < 0.001), hypnotics (mean ± SD: 5.5 ± 1.1 vs. 5.0 ± 1.3, p < 0.001), and electroconvulsive therapy (mean ± SD: 1.5 ± 0.9 vs. 1.2 ± 0.6, p < 0.001). On the other hand, the reactive case resulted in significantly higher scores compared to the melancholic case and the one- in-between cases in regards to psychotherapy (mean ± SD: 4.9 ± 1.4 vs. 4.3 ± 1.4 vs. 4.7 ± 1.5, p < 0.001, respectively). Scores for informing patients that they suffered from "depression" were significantly higher in the melancholic case, compared to the reactive case (mean ± SD: 4.7 ± 1.7 vs. 2.2 ± 1.4, p < 0.001). CONCLUSIONS: Japanese psychiatrists distinguish between major depressive disorder with melancholic and reactive features, and thus choose different treatment strategies regarding pharmacological treatment and psychotherapy.

The impact of prolactin-raising antipsychotics on bone mineral density in patients with schizophrenia: findings from a longitudinal observational cohort.

To examine the effect of prolactin-raising antipsychotics on bone mineral density (BMD), data of 164 schizophrenia patients who received ≥2 dual-energy x-ray absorptiometry scans were analyzed (49.3% men; mean ± SD age: 58.5 ± 11.0 years; duration of treatment: 26.7 ± 13.8 years). Patients were divided into a prolactin-raising antipsychotic (n=141) or prolactin-sparing (n=23) group, and time x group interaction was examined using mixed effect model. Although the BMD difference did not reach significance over 3.4 ± 1.6 years, a significant antipsychotic-class vs. time interaction was found (p=0.011), indicating a negative impact of prolactin-raising antipsychotics on BMD. Large-scale, randomized-controlled data are required to replicate and extend these findings.