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:

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

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

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

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

Of persons taking any antipsychotic

Of the persons taking two antipsychotics (2,230)

Of the persons taking two atypicals (1,948)

Cost Associated with Antipsychotic Polypharmacy

Single Antipsychotic

2 or More Antipsychotics

3 or More Antipsychotics

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.

Conversion Chart for Antipsychotic Medications

Based on Chlorpromazine 100 mg

Typical Antipsychotics

Generic Name
Chlorpromazine
Haloperidol
Haloperidol D
Fluphenazine
Fluphenazine D
Loxapine
Mesoridazine
Molindone
Prochlorperazine
Thioridazine
Thiothixene
Trifluoperazine
Perphenazine

Trade Name
Thorazine
Haldol
Haldol D
Prolixin
Prolixin D
Loxitane
Serentil
Moban
Compazine
Mellaril
Navane
Stelazine
Trilafon

Dose Equivalence
100 mg
2 mg
 
2 mg
 
10 mg
50 mg
10 mg
15 mg
100 mg
3 mg
4 mg
8 mg

Daily Dose Range
25-800 mg
1-100 mg
25-300 mg
2-60 mg
12.5-100 mg
20-100 mg
25-400 mg
15-200 mg
40-150 mg
50- 800 mg
5-120 mg
4-60 mg
8-64 mg

Atypical Antipsychotics

Clozapine
Olanzapine
Risperidone
Quetiapine
Ziprasidone
Aripiprazole

Clozaril
Zyprexa
Risperdal
Seroquel
Geodon
Abilify

50 mg
5 mg
2 mg
75 mg
60 mg
7.5 mg

150-900 mg
5-15 mg
4-16 mg
150-800 mg
40-160 mg
10-30 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:

The most common reasons identified for multiple antipsychotics included:

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.