PDF Metabolic Effects of Psychotropic Drugs (Modern Trends in Pharmacopsychiatry Vol 26)

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Antipsychotics: Classification and Side Effects – Psychiatry - Lecturio

INR All the latest offers delivered right to your inbox! We Accept. While some of these combinations are supported by clinical trials, many are of unproven efficacy. These trends put patients at increased risk of drug-drug interactions with uncertain gains for quality of care and clinical outcomes.

In many clinical situations, use of more than 1 psychotropic medication from the same or a different class is indicated. In routine psychiatric practice, however, patients often receive psychiatric medication combinations that are not well supported by controlled clinical trials. Much remains to be learned regarding patterns of psychotropic polypharmacy in routine psychiatric practice.

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It is not known, for example, which combinations are most common in community practice, whether the likelihood of receiving these medication combinations has changed in recent years, and which patients are most likely to receive these medication combinations. Delineating within- and across-class psychotropic polypharmacy trends may inform evaluations of risk of adverse effects and drug-drug interactions 19 , 26 , 27 and sources of the increasing share of mental health expenditures accounted for by medications. This report examines recent trends in psychotropic polypharmacy in a large and representative sample of visits to US office-based psychiatrists between the mids and mids.

We explore trends in within- and between-class psychotropic polypharmacy focusing on some of the most common combinations of psychotropic medications in outpatient psychiatric practice. We further examine patterns of psychotropic polypharmacy according to patient sociodemographic and clinical characteristics. The analysis is limited to visits to psychiatrists because psychiatrists tend to treat the most severely ill mental health patients and have the most extensive training and experience prescribing psychotropic medications.

The survey response rate varied from For each visit, the physician or a member of the physician's staff provided information about patient sociodemographic and clinical characteristics as well as psychotropic medications prescribed, supplied, or administered at the visit. Psychotropic medications were ascertained based on generic names. Starting from , the maximum number of medications recorded was increased to 8. To make the years comparable for this study, we limited the maximum number of medications to 6 in all years.

We focused on the 4 major classes of psychotropic medications for adults: antidepressants, antipsychotics, mood stabilizers, and sedative-hypnotics. Antidepressants included amitriptyline hydrochloride, amoxapine, bupropion, citalopram, clomipramine hydrochloride, desipramine hydrochloride, doxepin hydrochloride, duloxetine hydrochloride, escitalopram oxalate, fluoxetine, fluvoxamine, imipramine, isocarboxazid, maprotiline, mirtazapine, nefazodone hydrochloride, nortriptyline hydrochloride, paroxetine hydrochloride, phenelzine sulfate, protriptyline hydrochloride, sertraline hydrochloride, tranylcypromine sulfate, trazodone hydrochloride, trimipramine, and venlafaxine hydrochloride.

Antipsychotics included aripiprazole, chlorpromazine hydrochloride, clozapine, fluphenazine, haloperidol, loxapine, mesoridazine, molindone hydrochloride, olanzapine, perphenazine, pimozide, quetiapine fumarate, risperidone, thioridazine, thiothixene, trifluperazine hydrochloride, and ziprasidone hydrochloride.

Sedative-hypnotics included alprazolam, butabarbital, chlordiazepoxide, chloral hydrate, chlorazepate, clonazepam, diazepam, diphenhydramine, eszopiclone, estazolam, flurazepam hydrochloride, hydroxyzine, lorazepam, meprobamate, nitrazepam, oxazepam, phenobarbital, secobarbital, temazepam, triazolam, zaleplon, and zolpidem tartrate.

We also assessed other psychotropic medications for calculation of the total number of prescribed medications. These included acamprosate calcium, amphetamine, atenolol, atomoxetine hydrochloride, benztropine mesylate, buprenorphine hydrochloride, buspirone hydrochloride, clonidine hydrochloride, dexmethylphenidate hydrochloride, dextroamphetamine, disulfiram, donepezil hydrochloride, gabapentin, galantamine hydrobromide, guanfacine hydrochloride, methadone hydrochloride, methylphenidate hydrochloride, metoprolol, modafinil, nadolol, naltrexone hydrochloride, naloxone hydrochloride, oxcarbazepine, pemoline, pregabalin, propranolol, rivastigmine tartrate, topiramate, and trihexyphenidyl hydrochloride.

Finally, selegiline, benztropine, and trihexyphenidyl were counted among psychotropic medications only if the patient did not have an additional diagnosis of Parkinson disease. Up to 3 diagnoses were recorded for each visit. These diagnoses were given in Specific diagnoses included major depression codes For the same reason, we combined dysthymia and other affective disorders.

In addition, the total number of psychiatric diagnoses in each visit were dichotomized into 1 diagnosis vs more than 1 diagnosis. Analyses were conducted in 2 stages. In the first stage, we examined time trends in the number of psychotropic medications prescribed using bivariate and multivariate binary logistic models. Survey year was transformed by subtracting from the year and dividing the results by Thus, the transformed value was 0 for and 1 for The odds ratios ORs associated with this transformed variable of survey year represent a change in odds of psychotropic polypharmacy during the entire study period ie, To assess variation in associations of patient and visit characteristics across years, interaction terms with survey year were introduced into the model and tested one by one.

Significant interaction terms suggest variations in time trends across groups. In the second stage, these bivariate and multivariate analyses were repeated for each specific combination of the 4 medication classes. The same variables described earlier were entered into the multivariate models. Analyses were conducted using the Stata 10 software. Between and , the percentage of visits in which any psychotropic medications were prescribed increased from Similarly, the percentage of visits with 2 or more psychotropic medications increased from The median number of medications prescribed per visit doubled from 1 in to 2 in The mean number increased by The time trend persisted in a multivariate model adjusting for demographic and clinical characteristics of visits Table 1.

The percentage of visits in which 2 or more psychotropic medications were prescribed increased more slowly among visits with an anxiety disorder diagnosis In contrast, visits were less likely to involve 2 or more medications if they were made by men compared with women, self-paying patients compared with those covered by private insurance, and new patients compared with returning patients Table 1.

The top section of Table 2 presents numbers and percentages of visits to psychiatrists in which each major medication class and combination were prescribed. During the study period, antidepressants Combinations of antidepressants with sedative-hypnotics Over time, the percentages of visits in which combinations of antidepressants and antipsychotics or combinations of 2 or more antipsychotics or 2 or more antidepressants were prescribed significantly increased Table 2 , middle and lower sections.

In contrast, combinations of mood stabilizers and sedative-hypnotics with each other and with other medication groups did not appreciably change Table 2 , middle and lower sections. The results of multivariate analyses of within—psychotropic medication class combinations were generally consistent with the bivariate analyses Table 3.

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The time trend for 2 or more sedative-hypnotics, which was not statistically significant in bivariate analyses, became significant in the multivariate model Table 3. Specific psychotropic medication combinations were significantly more commonly prescribed for some patient groups than others Table 3. Combinations of 2 or more antidepressants, for example, were significantly more common in visits by patients aged 45 to 64 years compared with visits by patients aged 18 to 44 years, women compared with men, and patients with mood and anxiety disorders compared with other diagnoses Table 3.

A combination of 2 or more antipsychotics was significantly more common in visits with a diagnosis of schizophrenia compared with other diagnoses and in visits paid for with public compared with private insurance Table 3. This medication combination was less common in visits with a diagnosis of other depressive disorders. Over time, the prevalence of visits with 2 or more antipsychotics modestly decreased in the treatment of major depression 1.

The prevalence of visits with 2 or more mood stabilizers did not change across survey years. However, such visits were many times more common in the treatment of bipolar disorder compared with other diagnoses 5. Two or more sedative-hypnotics were more commonly prescribed in visits by women than by men, visits with a diagnosis of anxiety disorder than other diagnoses, visits with more than 1 psychiatric diagnosis than those with 1 diagnosis, and visits covered by Medicare than other payers.

Furthermore, interaction terms of survey year with the 65 years and older age group, diagnosis of schizophrenia, and Medicare insurance coverage were statistically significant, indicating that time trends were significantly different across these groups. Over time, multiple sedative-hypnotics became more commonly prescribed in visits by patients younger than 65 years 3. This medication combination also became more common in visits by patients with diagnoses other than schizophrenia 3. The combination of 2 or more sedative-hypnotics also became less commonly prescribed in Medicare-insured visits 7.

The association of survey year with prescription of antidepressant-antipsychotic combinations persisted in multivariate analysis Table 4. Antidepressant-antipsychotic combinations were also more commonly prescribed in visits by women than men; visits with diagnoses of major depression, bipolar disorder, and schizophrenia than other diagnoses; visits with more than 1 psychiatric diagnosis; and visits covered by public insurance or payment arrangements other than private insurance or self-pay, but less commonly in visits by the 65 years and older age group than younger patients Table 4.

Antidepressant—mood stabilizer combinations were more common in visits with a bipolar or schizophrenia diagnosis than those with other diagnoses and by new compared with returning patients Table 4. Antidepressant and sedative-hypnotic combinations occurred disproportionately in visits by patients aged 45 to 64 years, visits with a diagnosis of major depression or anxiety disorder, and visits covered by Medicare.

This combination was less commonly prescribed in visits by men, minorities, and self-paying patients Table 4. Antipsychotic—mood stabilizer combinations were significantly more common in visits with a bipolar disorder or schizophrenia diagnosis compared with other diagnoses. By contrast, this combination was less commonly prescribed among visits by older patients compared with younger patients and among those with depressive disorders, anxiety disorders, and new patients as compared with returning patients Table 5.

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Antipsychotic and sedative-hypnotic combinations were significantly more common in visits by patients aged 45 to 64 years than the younger age group, visits with a diagnosis of bipolar disorder or schizophrenia, visits with more than 1 diagnosis, and visits with public insurance than other payment sources. This combination was less commonly prescribed for visits by older adults than younger adults, men than women, and new than returning patients Table 5. Finally, mood stabilizer—sedative-hypnotic combinations were more commonly prescribed in visits by patients aged 45 to 64 years compared with younger adults and visits with a bipolar or schizophrenia diagnosis compared with other diagnoses Table 5.

The results of this study should be interpreted in the context of several limitations. First, this is an observational study and although the multivariate analyses adjust for a number of patient and visit characteristics, the range of variables is limited and multivariate methods cannot rule out residual confounding due to unmeasured differences among patient groups across survey years. Thus, results should be interpreted with caution. Second, the analyses were limited to office-based psychiatric practices.

The trends and patterns in psychotropic polypharmacy may not generalize to other treatment settings. Thus, psychotropic polypharmacy is not limited to psychiatric practices. Third, because of the cross-sectional survey design, it is not possible to determine previous clinical response to monotherapy regimens or the course of medication treatment or to measure the effects of trends in psychotropic polypharmacy on clinical outcomes.

For patients who receive care from several physicians, the survey may underestimate the number of psychotropic medications actually taken by individual patients. Furthermore, results for the less common medication combinations, such as combinations of 2 or more mood stabilizers, should be interpreted with caution. Sixth, diagnoses might not be exactly comparable across time. For example, patients given a diagnosis of bipolar disorder in might be somewhat different from those given this diagnosis in Without expert validation or structured interviews, it is not possible to examine these variations.

Finally, because NAMCS records visits rather than patients, some patient duplication may have occurred during the 1-week sampling period. Despite these limitations, this report represents the first national study of psychotropic polypharmacy trends in office-based psychiatric practice to our knowledge. Between and , there was a substantial increase in the proportion of patient visits in which 2 or more psychotropic medications were prescribed.

During this period, the proportion of visits in which 3 or more psychotropic medications were prescribed increased from fewer than 1 in 5 to nearly 1 in 3. Significant time trends appeared to be mainly limited to concomitant prescription of 2 or more antidepressants or antipsychotics as well as combinations of antipsychotics and antidepressants. With the exception of combinations of 2 or more sedative-hypnotics, none of the other combinations involving mood stabilizers or sedative-hypnotics showed a significant increase across time in multivariate analysis.

This finding is consistent with other reports indicating an increase in the use of antidepressant and antipsychotic medications in recent years. Much of the available literature on psychotropic polypharmacy has focused on antipsychotic polypharmacy. While the evidence for added benefit of antipsychotic polypharmacy is limited, there is growing evidence regarding the increased adverse effects associated with such combinations.

Metabolic Effects of Psychotropic Drugs - Google книги

For example, a double-blind controlled study of risperidone added to clozapine in refractory schizophrenia found no evidence for improved outcome in the combined-treatment group compared with the clozapine-alone group but did find a significantly greater increase in fasting blood glucose level in the combined-treatment group.

Concerns have been also voiced about increased risk of QT prolongation in concomitant use of ziprasidone with low-potency conventional antipsychotic medications eg, thioridazine , 44 as well as worsening of psychosis due to displacement of antipsychotic medications from the D 2 receptor when aripiprazole is added as a concomitant treatment.

The evidence for combining antidepressants from different classes is somewhat stronger than other medication combinations. The merits of antidepressant combinations in treatment of other psychiatric conditions are unknown. Antidepressant combinations also carry increased risks for adverse effects. The risks of serotonin syndrome and hypertensive crisis when combining monoamine oxidase inhibitors with other antidepressants are well known.

Fluoxetine, sertraline, and paroxetine are potent inhibitors of cytochrome P 2D6 and could potentially lead to marked elevations in concentration of desipramine and nortriptyline.