Evidence-Based Psychiatric Treatment in a State Hospital: Prevalence of Antipsychotic Polypharmacy

Background and Purpose: Social workers provide treatment to individuals diagnosed with psychotic disorders and are actively involved with their clients' use of psychiatric medications as part of interdisciplinary treatment teams, often addressing medication adherence and psychoeducation. This study examined the use of evidence-based psychiatric treatment for psychotic disorders by assessing the use of antipsychotic polypharmacy, the prescription of multiple antipsychotics simultaneously. Antipsychotic polypharmacy has been identified as a treatment strategy not meeting the threshold of evidence-based treatment, with a lack of controlled evidence demonstrating efficacy. The potential for adverse effects in antipsychotic polypharmacy is well-known, and a link between between antipsychotic polypharmacy and client mortality has been posited. Given the controversial nature of this practice and the emerging commitment to evidence-based psychiatric treatment, empirical investigation is warranted. While outpatient and VA populations have been studied extensively, there are few recent studies of state hospital populations.

Methods:This study took place in a state hospital in the Southern United States. All state hospital inpatients diagnosed with psychotic disorders admitted under civil commitment between January 1, 2000 and July 1, 2005 were included (n=267). Clinical, demographic and medication data were derived from administrative databases. Antipsychotic polypharmacy was operationalized as co-prescription of ≥2 antipsychotics ≥60 days. Inpatients were categorized as recipients of either antipsychotic polypharmacy or monotherapy and compared across demographic and clinical variables. Demographic variables included age, race, education, and marital status. Clinical variables included seclusion and restraint incidents, number of lifetime admissions, and medical comorbidity, as well as Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) scores. Data analyses consisted of descriptive statistics, contingency tables, and logistic regression. Confidence intervals for effect sizes were used in lieu of statistical significance testing.

Results: There were 95 patients (35.6%) who had at least one episode of antipsychotic polypharmacy. Most such clients (n=59, 62.1%) were prescribed polypharmacy at admission. There was no clinically significant association between polypharmacy status and any of the continuous clinical variables such as PANSS scores or number of hospitalizations. The primary findings were that male gender was associated with an increased risk of antipsychotic polypharmacy (OR=2.57, 95% CI 1.50, 4.37), as was Length of Stay exceeding one year (OR=3.12, 95% CI 1.86, 5.27). Race, age, and other demographics were unrelated to polypharmacy status. Clients prescribed antipsychotic polypharmacy had increased odds of hyperlipidemia and adverse neurological effects (OR=~1.5).

Conclusion and Implications: Men may receive antipsychotic polypharmacy more often due to a perceived danger of physical aggressiveness. Gender differences have been posited regarding negative symptoms, structural brain abnormalities, and response to antipsychotics, and these findings may be relevant. Patients who are judged as treatment resistant may receive both extended hospitalizations and antipsychotic polypharmacy, and this may explain the association between these variables.  Overall, these findings suggest that antipsychotic polypharmacy is a treatment decision not well explained by the available clinical and demographic variables. Mezzo-level interventions to reduce the use of antipsychotic polypharmacy are available, and administrators in state hospital settings should consider their implementation.