An audit of first prescription of new patients attending a psychiatry walk-in-clinic in north India

Abstract

Background:

Although almost all psychotropic medications available worldwide are readily available in India, there is meager data in this country on the prescription patterns of psychiatrists.

Aim:

To study the first prescription handed over to patients attending the psychiatry outpatient clinic of a tertiary care hospital.

Materials and Methods:

Data of all patients (for the period of January 1, 2009 to November 30, 2010; diagnosed with an ICD-10 diagnosis of F2-F4) were extracted from the computer-based registry and analyzed.

Results:

Ten thousand two hundred and fourteen (10 214) patients were diagnosed to have a diagnosis of F2-F4 ICD-10 category. In all diagnostic groups, olanzapine was the most commonly prescribed antipsychotic followed by risperidone. Very few patients (8%) received typical antipsychotic medication. In all diagnostic groups, escitalopram was the most commonly prescribed antidepressant; other frequently prescribed antidepressants were sertraline, paroxetine, and venlafaxine. Among the mood stabilizers, valproate was preferred over lithium. In all the groups, more than half of the patients were prescribed benzodiazepines, clonazepam being the most commonly prescribed agent, followed by lorazepam. The mean number of psychotropic medications was highest in the bipolar disorder group. Very few patients received the combination of same group of drugs.

Conclusions:

Olanzapine, escitalopram, and clonazepam are the most commonly prescribed antipsychotic, antidepressants, and benzodiazepines, respectively. Valproate was preferred over lithium as a mood stabilizer. In general, the prescription trends were in accordance to the recommendations of various treatment guidelines, except for the use of benzodiazepines, which was higher.

Introduction

Studying prescription patterns provides opportunity to monitor therapeutic trends. Many studies from western countries have reported prescription patterns of various psychotropic medications. These studies have looked into national prescription patterns,[1] prescription patterns in general practice, and specialist care,[2] age, and gender differences in antipsychotic prescription,[3] prescription patterns of antidepressants,[4] mood stabilizers in bipolar disorder patients,[5] and rate of use of anti-cholinergic agents in psychiatric patients.[6] A few surveys of prescription patterns of various psychotropics from Asian centers too are available.[4,7]

Although a developing country, almost all psychotropic medications available worldwide are readily available in India. However, very few studies from India have evaluated prescription patterns of psychiatrists. Some studies which have evaluated antipsychotic prescription patterns in India are limited by sample size varying from 100 to 270 patients.[8,9] Two surveys of psychiatrists are also available, one specifically evaluating the prescription of clozapine,[10] and the other assessing the prescription patterns for antipsychotics in general.[9] Occasional studies have evaluated prescription patterns for antidepressants.[11] Availability of limited data provided impetus for the present study, which aims to study the first prescription handed over to patients attending the psychiatry outpatient clinic of a tertiary care hospital.

Material and Methods

This study was carried out at a tertiary care multispecialty hospital in North India where patients can walk in to the psychiatry outpatient on their own or are referred to the outpatient services by doctors working in other specialties in the hospital, private psychiatrists, or psychiatrists working in other government hospitals and general practitioners as well. The outpatient services function 6 days a week (Monday to Saturday). On an average, 25 to 30 new patients are seen in the outpatient services every day, besides 160 to 170 old patients who come for follow-up visits.

Certain antipsychotics (trifluoperazine, chlorpromazine, and fluphenazine decanoate), antidepressant (imipramine), and lithium are available free of cost to the patients from the hospital dispensary.

The department where this study was conducted has eight faculty members in Psychiatry with varying length of clinical experience and 12 Senior Residents (qualified Psychiatrist), who have at least 3 years of clinical experience in psychiatry. All Senior Residents in the department are posted on a rotational basis for a period of 6 months in the Walk-in-clinic which is the point of first contact with the services rendered by the department for most patients. Patients attending the psychiatry walk-in-clinic can be seen by a Senior Resident posted in the walk-in-clinic (4 in number—two for general psychiatry patients, one for children and adolescent age group, and one for the psychosexual disorders and marital problems) or a faculty member and a management plan is initiated. In some cases, the Senior Resident after initial evaluation discusses the case with one of the faculty members and the management is then formulated. All diagnoses are made according to the ICD-10 Classification of Mental and Behavioural Disorders (Clinical Descriptions and Diagnostic guidelines).

All Senior Residents and Faculty members have the liberty to choose and prescribe medication (s) in liaison with patients and their family members. Most of the patients and their family members prefer to take medications as per the choice of their clinicians and hence, are often prescribed psychotropics for which they have to pay from their own pocket. Freedom to prescribe any medication coupled with easy availability of most of psychotropics in India offers opportunity to prescribe any antipsychotic, antidepressant, mood stabilizer, or benzodiazepine.

The information of initial clinical evaluation along with the sociodemographic data are coded on a computer-based registry on regular basis. Since January 1, 2009, information with respect to medications prescribed was also added to the coding program.

For this retrospective study, data of all patients (aged more than 14 years and diagnosed with an ICD-10 diagnosis of F2-F4 who registered with the Walk-in-clinic during the period of January 1, 2009 to November 30, 2010) were extracted from the computer-based registry. Besides the data with respect to prescription, the sociodemographics and the clinical diagnosis made at the first assessment were also extracted. There was no exclusion criterion for the study. The study was approved by the research review committee of the department. Frequencies with percentages were calculated for nominal and ordinal variables and mean and standard deviation were calculated for continuous variables using the SPSS version 14.0 for Windows (Chicago, Illinois, USA). Chi-Square test and t-tests were used for comparisons.

Results

During the study period of approximately 2 years (January 1, 2009 to November 30, 2010), a total of 15 136 new patients were registered, of this 10 214 were diagnosed to have a diagnosis of F2-F4 ICD-10 category.

The sociodemographic profile of the sample is depicted in Table 1.

Table 1.

Sociodemographic profile of the patients attending the psychiatry walk-in-clinic (Sample size = 10 214)

The most common major diagnostic group was that of neurotic, stress-related, and somatoform disorders (F4) of which other anxiety disorders (F41.0-41.9) were the most common, as shown in Table 2. Mood disorders formed the second largest diagnostic category, of which first episode depression was the most common clinical entity. Psychotic disorders constituted about 16% of the total study sample, with psychosis not otherwise specified (NOS) being the most common diagnosis in the psychotic disorder category.

Table 2.

Diagnostic break-up of the patients attending the psychiatry walkin clinic (Sample size = 10 214)

Antipsychotics

Almost all patients with a psychotic disorder received an antipsychotic medication and more than half of the patients with mania or bipolar disorder were receiving antipsychotic medications [Table 3]. Very few patients with unipolar depressive disorders and neurotic, stress-related, and somatoform disorders received antipsychotic medications. In all diagnostic groups, olanzapine was the most common antipsychotic medication. In psychotic disorders group, olanzapine was followed by risperidone, paliperidone, trifluoperazine, and quetiapine. In bipolar disorder group, olanzapine was followed by quetiapine and risperidone. Very few patients in all the diagnostic groups received typical antipsychotic medication (in total about 8% of the patients for whom antipsychotic prescription data were available). About two-fifth (41.2%; 609 of 1 477 patients for whom antipsychotic prescription data were available) of the prescription in the psychotic disorder group was that of olanzapine. In bipolar disorder/mania group, olanzapine was one of the antipsychotic medication in nearly half (303 of 633 patients for whom prescription data were available) of the patients. In the depression group, olanzapine formed 2.9% (80 of 2 750) of the total antipsychotic prescription. Risperidone and its congener paliperidone formed another one third (31.5%; 465 of 1 477) of the total antipsychotic prescription in the psychotic disorders group, 7% (44 of 633) of all prescriptions in the mania/bipolar group, and 2% (58 of 2 750) of all prescriptions in the depression group.

Table 3.

Prescription of psychotropic medications

Antidepressants

As shown in Table 3, selective serotonin reuptake inhibitors (SSRI) were the most commonly prescribed antidepressants, with escitalopram being the most commonly prescribed agent. In all diagnostic groups, escitalopram was the most commonly prescribed antidepressant medication followed by sertraline, except for the psychotic disorders group where paroxetine was the second most commonly prescribed antidepressant. In unipolar depressive disorder group, venlafaxine was the third most commonly prescribed antidepressant. In neurotic, stress-related, and somatoform disorders, paroxetine was the third most commonly prescribed medication. In the depression group, escitalopram formed one-third of all the antidepressant prescriptions (34.4%; 947 of 2 750) and a similar trend for escitalopram was seen in the group of neurotic, stress-related, and somatoform disorders (30.7%; 1 417 of 4 621).

Mood Stabilizers

Among the mood stabilizers, valproate was preferred over lithium.

Benzodiazepines and Other Hypnotic-sedative Medications

In all the groups, more than half of the patients were prescribed benzodiazepines or some other sedative. In all groups, clonazepam was the most commonly prescribed agent, followed by lorazepam and zolpidem.

Mean Number of Psychotropic Medications

The mean number of psychotropic medications was highest in the bipolar disorder group and least in the neurotic, stress-related, and somatoform disorders. Very few patients received the combination of same group of drugs, for example, two antipsychotic or antidepressant medications.

Discussion

Our literature review indicated that no study from India has evaluated psychotropic prescription patterns for such a large sample of patients. The present study aimed to study the pattern of first prescription of the patients visiting the walk-in-clinic of psychiatry outpatient clinic in North India.

The study suggests that at the beginning, most of the patients are prescribed a single medication from a particular group, i.e., only one antipsychotic or only one antidepressant, although most of the patients are prescribed more than one medication, with highest medication load in the bipolar disorder group and least in the neurotic, stress-related, and somatoform disorders group. This practice of prescribing a single agent from a particular group of drugs suggests that broadly the recommendations of treatment guidelines are followed, which discourage polypharmacy at the very outset of treatment.

Findings of the present study with respect to olanzapine and risperidone being the two most commonly prescribed antipsychotics in India for psychotic disorders are in keeping with the findings of the survey done among the Indian psychiatrists[9] and research reports from other centers in India.[8] Studies from many Western countries also suggest an increasing trend of prescription of atypical antipsychotic medications.[1,12,13] However, the percentage of atypical antipsychotic prescribed as noted in the present study is much higher than that reported in studies on patients with schizophrenia from other eastern countries.[14,15] Similarly, in the present study, the number of patients who received polypharmacy (i.e., more than one antipsychotic) is much less than that reported from other eastern countries.[13]

Very few psychotic patients were receiving mood stabilizers, which is significantly less than the figures of 19.5 to 23.7% reported in studies which have evaluated the usage of mood stabilizers from other part of the world.[15]

Less than 10% patients with psychotic disorders, for whom the prescription information was available, were receiving antidepressant, which is significantly less than that reported in other studies.[13] However, it is to be remembered that much of this difference could be due to the prevalence and clinical severity of depressive symptoms. Nonetheless, this finding of the present study is within the range of 4.1 to 48.6% reported for antidepressant usage in the multi-country study from East Asia.[16]

In the present study, more than half of the psychotic patients received adjunctive benzodiazepine, with clonazepam being the most common benzodiazepine. Findings of the present study are in the range (29.9% to 63%) reported for usage of benzodiazepine in schizophrenia from various developed and developing countries.[17–20]

In bipolar disorder/mania group, two-third of the sample was prescribed antipsychotic medications, which is much higher than the 11% to 43.3% reported in some of the studies from other countries.[5] Olanzapine was the most commonly prescribed antipsychotic in bipolar patients, followed by risperidone. The rate of olanzapine prescription in the bipolar group is much higher in the present study compared with some of the other reports.[20] This higher prescription rates of olanzapine may be reflection of the recent research in which olanzapine has been shown to be useful in both depressive and manic phase of the bipolar disorder.[20,21]

In the bipolar group, about one-sixth of the patients were also receiving antidepressant medications, much less than that reported from other countries like the USA.[7,19] Besides clinical differences which may explain some of the variability in prescription patterns, the lower use of antidepressants found in the present study possibly reflects concerns of a possible switch to mania with antidepressants in bipolar disorder patients.

More than half of the bipolar disorder patients for whom prescription data were available were receiving benzodiazepines. This figure is much higher than that reported from the West.[7,20] Higher rate of use of benzodiazepine may be reflection of its use in agitation and lower prescription of mood stabilizers in the present study at the first instance.

Nearly half of the bipolar patients for whom prescription data were available were receiving mood stabilizers and valproate was preferred over lithium. This pattern is similar to a study from the USA.[7] This may be due to the fact that valproate is considered to be rapidly effective in the management of acute mania.[22] Furthermore, valproate may have been preferred over lithium because of the fact that valproate is usually started after the basic investigations like liver function test and hemogram, in contrast to lithium where one requires more extensive investigations, which may not be at times feasible in acutely disturbed patients.

In the depression group, about three-fifth of the patients were prescribed SSRI and another one-sixth were prescribed serotonin norepinephrine reuptake inhibitors. These findings are similar to the ones reported from the West[1,13] and multi-country studies from East Asia.[16] Similar trends with respect to use of second generation antidepressants (i.e., newer antidepressants) as a group for initial prescriptions by psychiatrists (89.1% males and 88.6% females prescribed second generation antidepressant medications) has been reported in a study from Norway, although it did not specify the diagnostic group.[2] In terms of specific antidepressant, studies have shown that citalopram and escitalopram are prescribed in about 30 to 50%.[1,23] In a previous study from our center, which evaluated the prescription of antidepressants in patients of depression for the year 1996, imipramine was the most commonly prescribed antidepressant followed by fluoxetine.[11] The significant difference in the prescription of antidepressants in the present study from the earlier study reflects change in the trend which is heavily influenced by availability of newer antidepressants in the recent years.

Regarding the prescription of antipsychotics in the depression group, very few patients were prescribed an antipsychotic medication, which is less than that reported in previous studies from India, including one from our center.[8,11] This difference may be due to variation in the clinical profile of the patients studied (i.e., those with psychotic symptoms) or may be a true reflection of difference in the prescription patterns.

More than two-third of patients with depression were prescribed benzodiazepines, with clonazepam being the most common benzodiazepines in depression group. Another study from India had also reported that clonazepam is the most commonly co-prescribed benzodiazepine in patients with depression.[8] However, the percentage of patients prescribed benzodiazepine in the present study was significantly less than those reported in the previous study.[8] Prescription of benzodiazepines in more than two-third of the patients in the present study could be due to associated anxiety, insomnia, and agitation in depressed patients, which are common indications for prescribing benzodiazepines. It is also possible that benzodiazepine were prescribed in many patients because of the anticipated worsening of anxiety which is commonly seen with some of the SSRIs.

In the present study, nearly 90% of the patients suffering from neurotic, stress-related, and somatoform disorder group were prescribed antidepressants and about two-third were prescribed benzodiazepines. SSRIs as a class of antidepressant drug were the most commonly prescribed group of antidepressants, with escitalopram being the most common agent. As in depression group, clonazepam was the most common benzodiazepine. The antidepressant prescription rate in the present study is comparable, but the rate of benzodiazepine prescription rates are much higher in the present study as compared with a previous study from United Kingdom,[24] which has evaluated the prescription pattern in anxiety disorder patients.

To conclude, findings of the present study suggest that olanzapine, escitalopram, and clonazepam are the most commonly prescribed antipsychotic, antidepressants, and benzodiazepines, respectively. Valproate was preferred over lithium as a mood stabilizer. Polypharmacy is used infrequently. In general, the prescription trends are in accordance to the recommendations of various treatment guidelines, except for the use of benzodiazepines, which was higher.

Our study has several limitations. We focused only on the first prescription and this necessarily does not reflect the true clinical situation. Depending on the response in many patients, further medications may have been added and in many cases, certain medications like benzodiazepines may have been tapered off. Hence, in later stages, the number of medications may change. We did not document the dose and dosing schedule of the treatment given. Information with respect to the total number of medications including non-psychotropic medications was also not collected. Similarly, information with respect to trihexyphenidyl and other anticholinergic medications was not collected. We also did not evaluate factors like cost, treatment adherence, availability of supervision, concerns of the patients about side effects, and adherence to treatment guidelines while prescribing. Future studies should try to overcome these limitations. Moreover, our study was limited to a tertiary care, multi-specialty, postgraduate teaching center that may or may not reflect the national trends.