Behavioral Pharmacy Partnership Practice Information

Psychiatric Medications in the Health Net Pharmacy Program

Of the approximately 467,000 persons in MO HealthNet as of December 2007, 35% take a psychiatric medication.

Of adults taking psychiatric medications during 10/1/07 – 12/31/07:

• 21% take an atypical antipsychotic
• 3% take a typical antipsychotic
• 52% take an antidepressant
• 15% take a mood stabilizer/anticonvulsant
• 38% take a benzodiazepine anti-anxiety medication

Of children taking psychiatric medications during 10/1/07 – 12/31/07:

• 27% take an atypical antipsychotic
• 1% take a typical antipsychotic
• 24% take an antidepressant
• 17% take a mood stabilizer/anticonvulsant
• 3% take a benzodiazepine anti-anxiety medication

Of adults on psychiatric medication during 10/1/07 – 12/31/07:

• 35% take only one
• 21% take two
• 15% take three
• 11% take four
• 7% take five
• 11% take more than 5

Of children on psychiatric medication during 10/1/07 – 12/31/07:

• 60% take only one
• 23% take two
• 11% take three
• 4% take four
• 1% take five
• 1% take more than 5

Best Practices that Improve Care and Reduce Costs

Avoid Unnecessary New Starts

Before starting a new medication ask your patient how often they miss doses of the medications they have already been prescribed. They may be symptomatic due to missing doses of their current medication.

Discontinue Ineffective Medications

Before starting a new medication consider if any current medications can be discontinued. Eliminating unnecessary medications reduces side effects and increases compliance with the remaining medication regimen.

Complete Cross Tapers

When doing a new medication trial always complete the cross-taper by discontinuing the old medication. It's the only way to be certain the patient can't do well on the new medication alone.

Minimize Dosing Requirements

Avoid asking patients to take medication more than once or twice a day. Giving TID and QID dosing increases the likelihood of missed doses and medication errors. Once a day is best if possible.

Antipsychotic Prescribing Practice in Missouri Health Net

Of persons taking any psychiatric medication (177,348) 29.6% take an antipsychotic

• Children 1-17 years old - 24.7%
• Adults 18-64 years old - 32.0%
• Elderly 65+ years old - 24.7%

Of persons taking any antipsychotic

• 85.5% take an atypical
• 6.6% take a dose above the recommended dose
• 10.9% take a dose below the recommended dose
• 4.3% take 2 antipsychotics
• 0.2% take 3 antipsychotics

Of the persons taking two antipsychotics (2,230)

• 87% take two atypicals
• 5% take two typicals
• 8% take one typical and one atypical

Of the persons taking two atypicals (1,948)

• 23% take both below the recommended dose (449)
• 19% take both above the recommended dose (365)
• 31% take one above and one below (597)
• 27% take one or both within the recommended dose range (537)

Cost Associated with Antipsychotic Polypharmacy

Single Antipsychotic

• 29.6% of persons taking a psychiatric medication take an antipsychotic.
• The average monthly cost of the antipsychotic is $238.64.

2 or More Antipsychotics

• 7.9% of persons who take an antipsychotic take 2 or more.
• For this group the average monthly cost of antipsychotics is $607.38 a month.
• The cost of other psychiatric medications they take in addition to antipsychotics raises their average monthly per person cost to $875.06.

3 or More Antipsychotics

• Of persons taking an antipsychotic medication 0.6% take 3 or more antipsychotics.
• The average monthly cost of antipsychotics in this group is $960.41 per month.
• Including their additional psychiatric medications, their total average monthly costs is $1,279.01.

Changes in Antipsychotic Polypharmacy Prescribing Among Recipients of These Mailings

In the 9 months that we have been sending you mailings we have seen significant reductions in antipsychotic polypharmacy.

• During this period 1,469 providers were identified as prescribing 2 or more antipsychotics for over 60 days and received letters regarding this practice. 44% (639 prescribers) no longer are engaging in this practice.
• During the 9 months 4,400 were identified as receiving 2 or more antipsychotics for over 60 days. 60% (2,646 patients) are no longer receiving multiple antipsychotics.

Conversion Chart for Antipsychotic Medications

Based on Chlorpromazine 100 mg

Perry, P.J., Alexander, B., Liskow, B.I. (1997). Psychotropic drug handbook (7th ed.). Washington DC, American Psychiatric Press, Inc.

Physician's desk reference, 58th edition. (2004). Montvale, NJ, Thompson PDR.

Woods, S. W. (2003). Chlorpromazine equivalent doses for the newer atypical antipsychotic. Journal of Clinical Psychiatry 64 (6), 663-667.

Mortality in Schizophrenia: A Journal Article Review

Mortality in Schizophrenia

Antipsychotic polypharmacy and absence of adjunctive antichollinergics over the course of a 10-year prospective study. Source British Journal of Psychiatry. 173:325-9, 1998 Oct. ISSN 0007-1250 by John L. Wadington, Hanafy A. Youssef and Anthony Kinsella.

Method

88 long-term psychiatric inpatients with Schizophrenia were followed prospectively over a ten-year period. Predictors of Survival were identified among demographic, clinical and treatment variables.

Results

Patients receiving more than one antipsychotic medication concurrently had a relative risk of dying of 2.46 compared to patients who received only a single antipsychotic at a time.

The increased mortality did not appear to be a result of more severe psychiatric illness since other measures of severity of illness were not associated with increased mortality such as:

• There was no increase in mortality with increasing average daily dose of antipsychotics
• No increase of mortality with increasing total duration of exposure or life-time intake of antipsychotics
• No increase of mortality associated with the number of different antipsychotics given sequentially (non-concurrently)
• No increased mortality associated with measured indexes of symptom severity including negative symptoms and cognitive domains.

The most common reasons identified for multiple antipsychotics included:

• Administering a sedating antipsychotic to facilitate sleep and
• combining an oral antipsychotic with an injectable antipsychotic

Conclusion

The authors noted that the limitations of this study included a modest number of cases, uncertainty as to how generalizable the finding is outside of inpatient populations and whether the increasing use of atypical antipsychotics could lead to different outcomes. Their overall conclusions were that antipsychotics polypharmacy is associated with a reduced survival over a ten-year prospective period and that there is little to no systemic evidence to justify antipsychotic polypharmacy.

Article available upon request.