Abstract
Previous studies have shown significant ethnic differences in prescribing patterns of two or more antipsychotics. This study examined changes in atypical and typical antipsychotic prescriptions among Asian Americans and Pacific Islanders. Five hundred consecutive charts were reviewed for antipsychotics at the time of admission and discharge from each of two inpatient psychiatric facilities in Hawai‘i. Multiple antipsychotic prescription rates were 9% at intake and 6% at discharge. For the ethnic groups studied, there were no statistically significant differences by patient ethnicity regarding antipsychotics at intake (χ2 = 29.2, df = 21, P = .110) or discharge (χ2 = 20.5, df = 24, P = .667). There were no significant differences in prescription and polypharmacy patterns among Asian Americans and Pacific Islanders ethnic groups in this study.
Keywords: ethnicity, atypical antipsychotics, polypharmacy
Introduction
Antipsychotics have been prescribed for schizophrenia for over fifty years. Typical or first generation antipsychotics refer to older antipsychotics such as chlorpromazine and haloperidol which primarily affect the dopamine system. Newer atypical antipsychotic medications (also called second generation antipsychotics) include medications such as risperidone and olanzapine which affect both the dopamine and serotonin system. The effectiveness of atypical and typical antipsychotics appears to be similar.1 While tardive dyskinesia occurs less frequently with atypical antipsychotics, the cost of those agents, compared to typical antipsychotics, is considerable as many are still under patent. Additionally, recent concerns of metabolic syndrome have been raised, which may be a greater problem with atypical antipsychotics.2 However, pharmacoeconomics may justify the use of atypical antipsychotics over older medications.3
While some studies have shown ethnic differences in use of atypical antipsychotics with lower prescription rates for African Americans and Hispanic Americans;4,5,6 others note no differences.7 Recent articles from the United Kingdom do not show any differences.8,9 Among children with schizophrenia, African Americans, received comparable rates of antipsychotic prescriptions as Caucasians, but were less likely to be adherent.10 In New Zealand, Asian patients were less likely to be prescribed clozapine.11 A Canadian study from 2011 showed lower usage of antipsychotics among Chinese and higher among mixed ethnicity compared with Caucasian patients.12
Antipsychotic polypharmacy (hereafter referred to as “polypharmacy”) is the concurrent use of two or more antipsychotics and this has increased in frequency. In the United States polypharmacy ranged from 4.1%–41%.13,14 Studies comparing African Americans with Caucasians did not show clear differences in polypharmacy15,16 However, none included Asian Americans or Pacific Islanders. Polypharmacy across East Asia ranged from 12.0% to 78.6%17 consistent with the rate of 46% reported by Chong, et al.18 Unlike the US mainland, Asian Americans and Pacific Islanders(including Hawaiians) are the predominant ethnic groups in Hawai‘i.19 Our team considered whether the race and ethnicity of patients are associated with patterns of polypharmacy with atypical antipsychotics. We sought to study these patterns among patients receiving treatment in Hawai‘i, both at intake and discharge from an inpatient psychiatric facility. We assumed that intake patterns reflected community practice, whereas discharge patterns reflected inpatient treatment practices. We hypothesized that antipsychotic prescriptions and polypharmacy among Asian Americans and Pacific Islanders in Hawai‘i would be higher than the US Mainland but lower than in Asia.
Methods
An arbitrary date was chosen (April 30, 2002 at one facility and December 5, 2003 at the other facility). Five hundred consecutive charts were reviewed at two inpatient psychiatric facilities in Hawai‘i with catchment areas of similar socioeconomic status. Records from January 14, 1997 to December 5, 2003 were included to reach the sample size. Information included demographics, medications on intake and discharge, discharge information, legal status, marital status, educational achievement, and the patient's diagnoses on intake and discharge based upon the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) which is used for classifying psychiatric disorders. Missing data was recorded as such. Only patients with psychotic disorders, listed either among primary or secondary diagnostic codes, were included (schizophrenia [295.xx], schizoaffective [295.70], and psychosis not otherwise specified {psychosis not otherwise specified (NOS) [298.9]}). The resulting sample size for this study was 485.
Ethnicity was collected from multiple sources including the history and physical, admission form, and discharge summary. Ethnicity chosen at admission was based on dropdown list with greater than 20 choices. Ethnicity was coded individually with up to ten ethnicities available to be chosen by each person. Ethnicities or combinations of ethnicities were then classified into more inclusive categories. For the purpose of this study, the final and most inclusive categories were Caucasian (European American), Pacific Islander (primarily, but not exclusively, indigenous Hawaiian), Asian American, and other. If the patient indicated a primary ethnicity then it was coded into one of the four groups. However, if the patient did not indicate a primary ethnicity, this field was coded as mixed and categorized as “Other.”
Only antipsychotic medications were included for coding in this study. Intake medications were based on nursing documentation and the unit medication administration log. Discharge medications were listed on the discharge summary. Previous outpatient medications not on the discharge summary were excluded.
Intake and discharge medications were classified into mutually exclusive categories—single atypical oral, no other antipsychotic; single typical oral, no other antipsychotic; single intramuscular (IM) injection of an antipsychotic, no other antipsychotic (most injections administered were of typical antipsychotics, since IM injections of atypical antipsychotics were introduced in 2001, just prior to study commencement in 2002); clozapine, no other antipsychotic; clozapine plus other (one atypical only or one typical); other polypharmacy among antipsychotics; antipsychotics with pro re nata (prn) medications; and no antipsychotics. Other polypharmacy included using more than one atypical or typical antipsychotic with or without clozapine; IM injection plus atypical, typical, or clozapine; and more than one IM injection. Although classified as an atypical antipsychotic, clozapine was categorized separately due to usage primarily for refractory psychosis. Two categories were included at discharge regarding tapering—tapering antipsychotics, and tapering multiple antipsychotics. Tapering antipsychotics, defined here as the transient use of multiple antipsychotics when switching a single antipsychotic, was not considered polypharmacy. The university and hospital institutional review boards (IRB) approved the study. SAS, version 9.2 (Cary, NC) was used to examine frequency distribution and comparative statistics including χ2 and ANOVA. Multivariate methods were not needed, as most potential confounders were insignificantly associated with the outcome.
Results
Table 1 displays sample characteristics. Missing or discrepant data for sample characteristic was less than 2% for age, gender, and marital status, and 8% for educational level. The ethnically diverse sample was 33% Asian American, 30% Caucasian, 21% Pacific Islander and 16% other. Sixty-nine percent of patients were male. Twenty-three percent had less than a high school education, 44% received a high school diploma or general educational development (GED), and 33% had some college. Sixty-nine percent of patients were single and 10% were married. The mean age was 40.1 years. Forty-nine percent were diagnosed with schizophrenia, 36% with schizoaffective disorder, and 15% with psychosis not otherwise specified. There were no statistically significant differences in gender, marital status, and psychotic diagnoses by ethnicity. Pacific Islanders were significantly younger and less educated than Caucasians and Asian Americans.
Table 1.
Sample Characteristics of Inpatients with Psychotic Disorders (N=485)
| Asian American | Caucasian | Pacific Islander | Other | Total | Significance | |
| Total (row %) | 159 (33%) | 148 (30 %) | 101 (21%) | 77 (16%) | 485 | Ethnicity χ2 = 37.2, df = 3, P = .001 |
| Gender | Gender* Ethnicity χ2 = 3.5, df = 3, P = .326 |
|||||
| Male | 100 (64%) | 107 (73%) | 71 (72%) | 53 (71%) | 331 (69%) | |
| Female | 57 (36%) | 40 (27%) | 28 (28%) | 22 (29%) | 147 (31%) | |
| Education | Education* Ethnicity χ2 = 25.2, df = 9, P = .003 |
|||||
| Less than High School | 27 (19%) | 26 (19%) | 30 (31%) | 20 (30%) | 103 (23%) | |
| Completed High School /GED | 62 (43%) | 57 (41%) | 51 (53%) | 24 (36%) | 194 (44%) | |
| Some College/2-year College | 45 (31%) | 45 (33%) | 15 (15%) | 16 (24%) | 121 (27%) | |
| 4-year College Degree or Higher | 10 (7%) | 10 (7%) | 0 | 7 (10%) | 27 (6%) | |
| Marital Status | Marital Status* Ethnicity χ2 = 11.6, df = 12, P = .476 |
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| Single | 99 (63%) | 109 (75%) | 70 (69%) | 50 (68%) | 328 (69%) | |
| Married | 18 (11%) | 11 (8%) | 13 (13%) | 6 (8%) | 48 (10%) | |
| Separated | 10 (6%) | 7 (5%) | 5 (5%) | 4 (5%) | 26 (5%) | |
| Divorced | 25 (16%) | 17 (12%) | 13 (13%) | 11 (15%) | 66 (14%) | |
| Widowed | 5 (3%) | 1 (<1%) | 0 | 3 (4%) | 9 (2%) | |
| Age | Age* Ethnicity F = 3.85 , df = 3,477, P = .010 |
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| Mean (sd) | 41.7 (10.8) | 40.8 (11.8) | 37.1 (10.5) | 39.7 (10.7) | 40.1 (11.1) | |
| Psychotic Diagnosis | Diagnosis* Ethnicity χ2 = 4.6, df = 6, P = .595 |
|||||
| Schizophrenia | 83 (52%) | 71 (48%) | 38 (49%) | 45 (46%) | 237 (49%) | |
| Schizoaffective | 57 (36%) | 49 (35%) | 27 (33%) | 42 (42%) | 175 (36%) | |
| Psychosis NOS | 19 (12%) | 28 (19%) | 12 (16%) | 14 (14%) | 73 (15%) | |
Note: Totals may not equal 100% due to missing or discrepant data in some of the demographic characteristics. * = interaction effect.
The frequency of antipsychotic medications at intake by ethnicity is provided in Table 2. There was no statistically significant difference in the category of antipsychotic medications at intake by ethnicity (χ2 = 29.2, df = 21, P = .110). Fifty two percent of patients were prescribed a single antipsychotic at intake which included 36% atypical antipsychotic, 14% typical antipsychotic, 1% single intramuscular injection of antipsychotic, and 1% clozapine. Nine percent of patients were prescribed multiple antipsychotics. On admission, one percent of the patients received both a standing dose and prn dosing of antipsychotic, and 0.8% received clozapine with another antipsychotic. Thirty-seven percent of patients did not receive any antipsychotic medications.
Table 2.
Frequency of Antipsychotic Medications at Intake by Ethnicity (N=485)
| Antipsychotic Medications | Asian American | Caucasian | Pacific Islander | Other | Total |
| Single Oral Atypical, no other antipsychotic | 45 (28%) | 54 (36%) | 36 (35%) | 39 (51%) | 174 (36%) |
| Single Oral Typical, no other antipsychotic | 26 (16%) | 19 (13%) | 15 (15%) | 6 (8%) | 66 (14%) |
| Single IM Injection, no other antipsychotic | 0 | 2 (1%) | 3 (3%) | 0 | 5 (1%) |
| Clozapine, no other antipsychotic | 3 (2%) | 1 (.7%) | 3 (3%) | 0 | 7 (1%) |
| Clozapine plus Other Antipsychiotcs | 3 (2%) | 1 (.7%) | 0 | 0 | 4 (.8%) |
| Other Polypharmacy (or multiple antipsychotics) | 14 (9%) | 12 (8%) | 12 (12%) | 5 (6%) | 43 (9%) |
| Antipsychotics with prn | 3 (2%) | 2 (1%) | 2 (2%) | 0 | 7 (1%) |
| No Antipsychotics | 65 (41%) | 57 (39%) | 30 (30%) | 27 (35%) | 179 (37%) |
Table 3 displays the frequencies of prescribed antipsychotic medications by ethnicity at discharge. There was no statistically significant difference in antipsychotic medications at discharge by ethnicity (χ2 = 20.5, df=24, P=0.667). Patients receiving a single antipsychotic increased from 52% to 74% of whom 58% received an atypical antipsychotic, 6% received a typical antipsychotic, 4% received a single intramuscular injection of antipsychotic and 6% received clozapine; 0.2% were prescribed both a standing dose and prn dose of antipsychotics, and 1% received clozapine with another antipsychotic. At discharge, 4% were tapering to a single antipsychotic. Multiple antipsychotic usage was reduced to 6% from 9%. Thirteen percent of patients did not receive antipsychotics at discharge.
Table 3.
Frequency of Antipsychotic Medication at Discharge by Ethnicity (N=485)
| Antipsychotic Medications | Asian American | Caucasian | Pacific Islander | Other | Total |
| Single Oral Atypical, no other antipsychotic | 95 (60%) | 89 (60%) | 58 (58%) | 41 (54%) | 283 (58%) |
| Single Typical, no other antipsychotic | 13 (8%) | 7 (5%) | 5 (5%) | 5 (6%) | 30 (6%) |
| Single IM injection, no other antipsychotic | 4 (3%) | 5 (3%) | 6 (6%) | 2 (3%) | 17 (4%) |
| Clozapine, no other antipsychotic | 10 (6%) | 7 (5%) | 10 (10%) | 4 (5%) | 31 (6%) |
| Clozapine plus Other Antipsychotic | 2 (1%) | 0 | 1 (1%) | 0 | 3 (1%) |
| Other Polypharmacy (or multiple antipsychotics) | 11 (7%) | 11(7%) | 5 (5%) | 4 (5%) | 31 (6%) |
| Antipsychotics with prn | 0 | 0 | 1 (1%) | 0 | 1 (0.2%) |
| Tapering Antipsychotics | 7 (4%) | 5 (3%) | 5 (5%) | 3 (4%) | 20 (4%) |
| Tapering Multiple Antipsychotics | 3 (2%) | 2 (1%) | 1 (1%) | 1 (1%) | 7 (1%) |
| No Antipsychotics | 14 (9%) | 22 (15%) | 9 (9%) | 17 (22%) | 62 (13%) |
Discussion
This is the first study to examine atypical antipsychotic use and prescription changes in an inpatient setting among Asian Americans and Pacific Islanders. We did not find ethnic differences in atypical prescription practices at intake or discharge. In our study, atypical antipsychotics were widely prescribed to all groups with higher rates at time of discharge. Overall, the percentage receiving antipsychotics increased from 63% at admission to 87% by discharge. Furthermore, multiple antipsychotics (excluding the use of clozapine) was uncommon, decreasing from 9% at admission to 6% at discharge. The low clozapine usage is concerning given the indication for refractory illness but consistent with other studies.20 Discharges without any antipsychotics likely reflect refusal of medications. The rate of prn antipsychotic, a common practice to manage acute agitation or insomnia without a strong evidence base, was reassuringly low.21
There are a number of possible explanations for our findings. First, atypical antipsychotics have been widely accessible in Hawai‘i without restriction since 1997.22 Second, Hawai‘i has few uninsured individuals and a comprehensive Medicaid program. Most patients have access to antipsychotic medications.19 Copeland and colleagues noted only slightly less use of atypical antipsychotics in African American and Hispanic American veterans where access is equal.3 Third, Hawai‘i lacks a majority ethnic group which may minimize racial disparities. At the time of this study, there was less emphasis on metabolic syndrome and diabetes which is now a significant concern for atypical antipsychotics. Selection of the antipsychotics was likely not based on body size, typically larger for a Pacific Islander compared with an Asian American.23
The main limitation of this study is the sample size. Ethnicity was based on self-report so participants with multiple ethnicities may have arbitrarily made only a single choice as evidenced by only 16% of patients being categorized as Other. Ethnically mixed individuals comprise 44% of individuals in Hawai‘i.19 For example, indigenous Hawaiians are virtually all of mixed ethnicity. It is not clear whether such patients would be coded differently if blood quantum were analyzed (ie, patient ethnicity based on highest percentage). Additionally, states or counties with formulary restrictions will likely have different utilization patterns. The use of two inpatient institutions is another limitation as community outpatients are not represented, and hospitalized patients may not be representative of all patients prescribed antipsychotic medications.
Polypharmacy and antipsychotic treatment are complex issues involving health care systems, nonpharmacological treatment, differing reasons for admission, and variations in prescriptions. While this study was not designed to address all of those issues, it is the first study to document antipsychotic prescription use among Asian Americans and Pacific Islanders with psychotic disorders in Hawai‘i.
Conclusion
Our data shows no racial differences in antipsychotic prescriptions for Asian Americans and Pacific Islanders that may reflect equality in antipsychotic treatment of public sector patients in Hawai‘i. A multi-site study comparing Hawai‘i with other states with large Asian American and Pacific Islander populations is needed to determine whether the findings are replicated in other health systems.
Acknowledgement
This article was supported by the National Center for Indigenous Hawaiian Behavioral Health (National Institute of Mental Health R24MH057079 and National Institute of Mental Health R24MH050151), the Queen Emma Foundation, The Queen's Medical Center, and the John A. Burns Foundation, the Asian/Pacific Islander Youth Violence Prevention Center (Centers for Disease Control and Prevention; R49/CCR918619-05; 1 U49/CE000749-01), and National Center on Minority Health and Health Disparities. The authors would also like to express their appreciation to Naleen Andrade MD, for mentorship and editorial comments, Anand Samtani MA, for statistical assistance and Davis Rehuher, Assistant Program Manager for assistance with the submission.
Conflict of Interest
None of the authors identify a conflict of interest.
References
- 1.Lieberman JA. Comparative effectiveness of antipsychotic drugs. A commentary on: Cost Utility Of The Latest Antipsychotic Drugs In Schizophrenia Study (CUtLASS 1) and Clinical Antipsychotic Trials Of Intervention Effectiveness (CATIE) Archives of General Psychiatry. 2006;63:1069–1072. doi: 10.1001/archpsyc.63.10.1069. [DOI] [PubMed] [Google Scholar]
- 2.Hartling L, Abou-Setta AM, Dursun S, Mousavi SS, Pasichnyk D, Newton AS. Antipsychotics in adults with schizophrenia: comparative effectiveness of first-generation versus second-generation medications. Annals of Internal Medicine. 2012;157:498–511. doi: 10.7326/0003-4819-157-7-201210020-00525. [DOI] [PubMed] [Google Scholar]
- 3.Bounthavong M, Okamoto M. Decision analysis model evaluating the cost-effectiveness of risperidone, olanzapine and haloperidol in the treatment of schizophrenia. Journal of Evaluation in Clinical Practice. 2007;13:453–460. doi: 10.1111/j.1365-2753.2006.00782.x. [DOI] [PubMed] [Google Scholar]
- 4.Copeland A, Zeber JE, Valenstein M, Blow FC. Racial disparity in the use of atypical antipsychotic medications among veterans. American Journal of Psychiatry. 2003;160:1817–1822. doi: 10.1176/appi.ajp.160.10.1817. [DOI] [PubMed] [Google Scholar]
- 5.Daumit GL, Crum RM, Guallar E, et al. Outpatient prescriptions for atypical antipsychotics for African Americans, Hispanics, and whites in the United States. Archives of General Psychiatry. 2003;60:121–128. doi: 10.1001/archpsyc.60.2.121. [DOI] [PubMed] [Google Scholar]
- 6.Kuno E, Rothbard AB. Racial disparities in antipsychotic prescription patterns for patients with schizophrenia. American Journal of Psychiatry. 2002;159:567–572. doi: 10.1176/appi.ajp.159.4.567. [DOI] [PubMed] [Google Scholar]
- 7.Woods SW, Sullivan MC, Neuse, et al. Best practices: racial and ethnic effects on antipsychotic prescribing practices in a community mental health center. Psychiatric Services. 2003;54:177–179. doi: 10.1176/appi.ps.54.2.177. [DOI] [PubMed] [Google Scholar]
- 8.Hashmi A, Rahim A, Sharif MS. Antipsychotic prescription trends according to ethnicity. The Psychiatrist. 2009;33:313–314. [Google Scholar]
- 9.Connolly A, Taylor D, Sparshatt A, Cornelius V. Antipsychotic prescribing in Black and White hospitalized patients. Journal of Psychopharmacology. 2010;25:704–709. doi: 10.1177/0269881109387841. [DOI] [PubMed] [Google Scholar]
- 10.Sleath B, Domino ME, Wiley-Exley E, Martin B, Richards S, Carey T. Antidepressant and antipsychotic use and adherence among Medicaid youths: differences by race. Community Mental Health Journal. 2010;46:265–272. doi: 10.1007/s10597-009-9277-5. [DOI] [PubMed] [Google Scholar]
- 11.Wheeler A, Humberstone V, Robinson E. Ethnic comparisons of antipsychotic use in schizophrenia. Australian and New Zealand Journal of Psychiatry. 2008;42:863–873. doi: 10.1080/00048670802345482. [DOI] [PubMed] [Google Scholar]
- 12.Puyat JH, Hanley GE, Cunningham, et al. Ethnic disparities in antipsychotic drug use in British Columbia: a cross-sectional retrospective study. Psychiatric Services. 2011;62:1026–1031. doi: 10.1176/ps.62.9.pss6209_1026. [DOI] [PubMed] [Google Scholar]
- 13.Stahl SM, Grady MM. High-cost use of second-generation antipsychotics under California's Medicaid program. Psychiatric Services. 2006;57:127–129. doi: 10.1176/appi.ps.57.1.127. [DOI] [PubMed] [Google Scholar]
- 14.Ganguly R, Kotzan JA, Miller LS, Kennedy K, Martin BC. Prevalence, trends, and factors associated with antipsychotic polypharmacy among Medicaid-eligible schizophrenia patients, 1998-2000. Journal of Clinical Psychiatry. 2004;65:1377–1388. doi: 10.4088/jcp.v65n1013. [DOI] [PubMed] [Google Scholar]
- 15.Kreyenbuhl JA, Valenstein M, McCarthy JF, Ganoczy D, Blow FC. Long-term antipsychotic polypharmacy in the VA health system: patient characteristics and treatment patterns. Psychiatric Services. 2007;58:489–495. doi: 10.1176/appi.ps.58.4.489. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Garver D, Lazarus A, Rajagopalan, et al. Racial differences in medication switching and concomitant prescriptions in the treatment of bipolar disorder. Psychiatric Services. 2006;57:666–672. doi: 10.1176/ps.2006.57.5.666. [DOI] [PubMed] [Google Scholar]
- 17.Sim K, Su A, Fujii S, et al. Antipsychotic polypharmacy in patients with schizophrenia: a multicentre comparative study in East Asia. British Journal Clinical Pharmacology. 2004;58:178–183. doi: 10.1111/j.1365-2125.2004.02102.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Chong MY, Tan CH, Fujii S, et al. Antipsychotic drug prescription for schizophrenia in East Asia: rationale for change. Psychiatry and Clinical Neurosciences. 2004;58:61–67. doi: 10.1111/j.1440-1819.2004.01194.x. [DOI] [PubMed] [Google Scholar]
- 19.Hawaii Department of Business, Economic Development and Tourism, Research and Economic Analysis Division, Statistics and Data Support Branch, author. Ethnic Distribution, State of Hawaii: 2007. State of Hawaii Data Book: A Statistical Abstract. Retrieved June 8, 2009, from http://hawaii.gov/dbedt/info/economic/databook/db2007/db2007.pdf.
- 20.Conley RR, Kelly DL, Lambert TJ, Love RC. Comparison of clozapine use in Maryland and in Victoria, Australia. Psychiatric Services. 2005;56:320–323. doi: 10.1176/appi.ps.56.3.320. [DOI] [PubMed] [Google Scholar]
- 21.Geffen J, Sorenson L, Stokes J, et al. Pro re nata medication for psychoses: an audit of practice in two metropolitan hospitals. Australian and New Zealand Journal of Psychiatry. 2002;36:649–656. doi: 10.1046/j.1440-1614.2002.01069.x. [DOI] [PubMed] [Google Scholar]
- 22.Orimoto E. Changes to DSS formulary. Honolulu, HI: Queen's Development Corporation; 1997. [Google Scholar]
- 23.Baruffi G, Hardy CJ, Waslien CI, Uyehara SJ, Krupitsky D. Ethnic differences in the prevalence of overweight among young children in Hawaii. Journal of the American Dietetic Association. 2004;104:1701–1707. doi: 10.1016/j.jada.2004.08.027. [DOI] [PubMed] [Google Scholar]