Analysis of the prescription pattern of psychotropics in an outpatient department of a general hospital psychiatry unit

Abstract

Background

World Health Organization has prescribed drug use indicators for evaluating rational prescribing. Very few studies have been conducted on rational prescriptions for psychotropic drugs; hence, this study was undertaken at a tertiary care center of North India.

Methods

After obtaining approval of the Institutional Ethics Committee, all prescriptions deposited with the dispensary of the psychiatry department of the hospital between 01 October 2017 and 31 December 2017 were included in the study. The prescriptions were analyzed for drug use indicators, namely the average number of drugs per encounter, percentage of prescriptions with generic name, percentage of prescriptions from the essential drug list, percentage of prescriptions with antibiotics, and percentage of prescriptions with an injection. In addition, the prescriptions were analyzed for patterns of psychotropics prescribed.

Results

A total of 3770 prescriptions were analyzed. On an average, 2.35 medicines were prescribed per prescription. Injectable comprised 2.39% of prescriptions and fixed drug combinations were 0.16% of the total. Of all prescriptions, 91.3% were by generic name, while 55.02% of prescriptions were from the essential drug list. Polypharmacy constituted 4.53% of prescriptions. Risperidone, escitalopram, sodium valproate, and clonazepam were the most commonly prescribed drugs.

Conclusion

While we fared well with respect to the percentage of prescriptions with injections and those with an antibiotic, we have not been able to achieve the prescribed standards in prescription with generic names, number of drugs per prescription, and prescriptions from the essential drug list. The study emphasizes that there is scope for improvement.

Introduction

Rational use of medicines as defined by the World Health Organization (WHO) states that “Patient receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community”.^1,2 According to WHO estimates, more than half of the medicines prescribed are irrational in nature, leading to an increase in issues such as drug interactions, development of resistance, and non-compliance.³ WHO estimates suggest that up to 5% of country's health expenditure can be saved with practice of rational prescribing, price control, and improving medicine quality.⁴

Psychiatric disorders form an important public health priority. Mental illness is associated with high level of health service utilization and associated costs.⁵ The arena of psychopharmacology is changing rapidly, challenging the traditional concepts in the research and treatment of psychiatric disorders. This rapid growth exposes the psychiatrists continuously to the onslaught of new drugs which claim to be safer and efficacious.⁶ Few studies have been carried out in India, which have evaluated the prescription pattern of psychotropic medications.

Study of prescriptions is considered as part of ‘drug utilization’, which encompasses the study of marketing, distribution, and prescription of various drugs in society, along with evaluation of its medical, social, and economic consequences.⁷ The aim of drug utilization studies is to encourage and facilitate rational use of medicines.⁸ A number of studies have been conducted in India covering different aspects of health care over the last decade using WHO drug use indicators.9, 10, 11, 12 However, drug utilization studies involving psychotropic use for psychiatry patients are lacking.⁸

Hence, this study was undertaken in the context of a developing country such as India to study the drug utilization pattern of various psychotropic drugs. The study was also undertaken as an audit of prescriptions for the hospital in particular and psychiatry practice in general. The study aimed to analyze the prescriptions of a psychiatry unit in a tertiary care hospital, based on the WHO drug use indicators. A secondary objective was to assess prescription patterns of various psychotropic drugs.

Materials and methods

This retrospective, prescription-based, descriptive study was carried out in the dispensary of the psychiatry unit of a tertiary care hospital (general hospital psychiatry unit). The department of psychiatry runs its dispensary which dispenses psychotropic medication, separate from the central dispensary of the hospital. This psychiatry unit consisted of four psychiatrists having MD in psychiatry and five residents in psychiatry who were working under the supervision of the psychiatrists. None of the clinicians were exposed to any program/lecture/seminar on rational drug use or any other similar topic in the recent past.

Patients were attended as usual by all the clinicians, and the prescriptions were based on the clinicians’ understanding of the illness, as per existing literature. After obtaining approval of the Institutional Ethics Committee, all the prescriptions deposited in the dispensary of the psychiatric department of the hospital between 01 October 2017 and 31 December 2017 were included in the study. According to the WHO recommendations, a minimum of 600 prescribing encounters should be included to evaluate prescribing indicators.¹³ We included 3770 prescriptions, spread over a period of 3 months.

Because it was a retrospective study, none of the clinicians prescribing the medicines were aware about the study being carried out or planned and hence the prescription pattern was not affected by the study. Data from the prescriptions were collated in Microsoft Excel sheet and was analyzed using functions in the excel software.

All the prescriptions were analyzed for the following parameters: (1) average number of the drugs per prescription, (2) average number of the psychotropic drugs per prescription, (3) percentage of the psychotropic drugs prescribed by generic name, (4) percentage of injectable drugs prescribed, (5) percentage of prescriptions containing psychotropic fixed dose combinations (FDCs), (6) percentage of the psychotropic drugs prescribed from the essential drug list, and (7) percentage of polypharmacy (prescribing 4 or more drugs).9, 10, 11, 12 In addition, the psychotropic drugs in the prescription were classified into various groups based on classification. The demographic information available on the prescription (age and sex) was also recorded.

Results

A total of 3770 prescriptions were analyzed, with a total of 8883 medicines prescribed. The prescription pattern of psychotropics as per age and gender is as per Table 1. The age group of 30–50 years constituted the maximum users of psychotropic drugs. On an average, 2.35 medicines were prescribed per prescription, and psychotropic drugs constituted an average of 1.86 per prescription. A small percentage of medicines was prescribed as injectable (2.39%) and as FDCs (0.16%). A significant percentage (91.3%) of medicine was prescribed by generic name. More than 50% of the psychotropic drugs (55.02%) prescribed were from the essential drug list. A small percentage (4.53%) of prescriptions constituted polypharmacy (Table 2).

Table 1.

Prescription patterns based on age and gender.

Male:females	1690:2080 (44.82%:55.17%)
Age group (in yrs)	No. of prescriptions
1 to 10	61
11 to 20	300
21 to 30	593
31 to 40	810 (21.48%)
41 to 50	836 (22.17%)
51 to 60	602
61 to 70	394
71 to 80	156
81 to 90	15
91 to 100	03

The age group with maximum prescription of psychotropic drugs represented as bold.

Table 2.

Analysis of prescriptions based on WHO drug use indicators.

S.No	Drug use indicators	Result of analysis
1	Total no. of prescriptions	3770
2	Total no. of drugs	8883
3	Total no. of psychotropic drugs	7030
4	Average no. of drugs per prescription	2.356
5	Average no. of the psychotropic drugs per prescription	1.864
6	Percentage of the psychotropic drugs prescribed by generic name	91.30
7	Percentage of injectable drugs prescribed	2.39
8	Percentage of prescriptions containing fixed drug combinations	0.16
9	Percentage of the psychotropic drugs prescribed from essential drug list (National List of Essential Medicines -–2015, India)	55.02
10	Percentage of polypharmacy	4.53

WHO, World Health Organization.

The second-generation antipsychotics dominated the prescription of antipsychotics (90.45%) with risperidone being the most commonly prescribed (26.04%) followed closely by olanzapine (23.35%) (Table 3). Among the antidepressants prescribed, selective serotonin reuptake inhibitors (SSRIs) constitute the most with 61.59% prescriptions (Table 4). Escitalopram was the most commonly prescribed SSRI.

Table 3.

Prescription patterns of Antipsychotic drugs.

S.No	Antipsychotic drugs	No. of prescriptions (%age of total prescriptions)
(a)	First-generation antipsychotics (9.54%)
	i. Chlorpromazine	03
	ii. Trifluperazine	15
	iii. Haloperidol	165 (Injectables – 72)
	iv. Pimozide	02
	v. Loxapine	01
	vi. Levosulpiride	13
(b)	Second-generation antipsychotics (90.45%)
	i. Clozapine	68
	ii. Risperidone	543 (26.04%) (Injectables – 33)
	iii. Quetiapine	400
	iv. Aripiprazole	265
	v. Ziprasidone	11
	vi. Amisulpiride	92
	vii. Olanzapine	487 (23.35%) (Injectables – 32)
	viii. Paliperidone	20 (Injectables)
	Total	2085

Table 4.

Prescription patterns of antidepressant drugs.

S.No	Antidepressant drugs	No. of prescriptions (%age of total prescriptions)
(a)	Selective serotonin reuptake inhibitors (SSRIs) (61.59%)
	i. Fluoxetine	300
	ii. Fluvoxamine	97
	iii. Paroxetine	370
	iv. Sertraline	360
	v. Escitalopram	573
(b)	Tricyclic antidepressants (16.66%)
	i. Imipramine	21
	ii. Amitriptyline	152
	iii. Doxepin	94
	iv. Dothiepin	02
	v. Clomipramine	115
	vi. Nortryptyline	76
(c)	Serotonin and noradrenaline reuptake inhibitors (SNRIs) (5.90%)
	i. Venlafaxine	57
	ii. Desvenlafaxine	18
	iii. Duloxetine	88
(d)	Other antidepressants (15.65%)
	i. Trazodone	05
	ii. Mirtazapine	370
	iii. Bupropion	27
	iv. Tianeptine	30
	Total	2760

Mood stabilizers constitute an important category of drugs with sodium valproate topping the chart with more than 70% prescriptions. Clonazepam with 72.17% prescriptions was the most commonly prescribed sedative hypnotic drug. Anxiolytic drugs include benzodiazepines, sedative antihistaminics, beta blockers, and azapirones. Clonazepam was the most prescribed benzodiazepine, and propranolol was the most commonly prescribed drugs for anxiety (Table 5).

Table 5.

Prescription patterns of mood stabilizers, sedative hypnotics, and anxiolytics drugs.

S.No	Mood stabilizers	No. of prescriptions (%age of total prescriptions)
(a)	Lithium carbonate	100
(b)	Sodium valproate (including divalproex sodium)	578 (71.80%)
(c)	Carbamazepine	89
(d)	Lamotrigine	38
Total		805
S.No	Sedative-hypnotic drugs
(a)	Diazepam	02
(b)	Alprazolam	08
(c)	Lorazepam	74
(d)	Zolpidem	153
(e)	Etizolam	10
(f)	Clonazepam	695 (72.17%)
(g)	Chlordiazepoxide	21
	Total	963
S.No	Anxiolytics
(a)	Buspirone	95
Miscellaneous
(a)	Propranolol	259
(b)	Trihexyphenidyl	524
(c)	Promethazine	52
(d)	Atomoxetine	68
	Total	903

Discussion

Our results suggest that there is polypharmacy, use of FDCs, and suboptimal use of medicines from the essential drug list at this center. Although polypharmacy reflects the individual clinicians’ preferences and attitudes, availability of medicines in the hospital may affect other two aspects found wanting at this center.

In our study, an average of 2.35 drugs was prescribed per prescription which is higher than the WHO standard of less than 2 (1.6–1.8) drugs per prescription.^12,14 Sisay et al. in their study to evaluate rational drug use using WHO core drug use indicators in public health hospital reported an average of 2.34 drugs prescribed per prescription.¹² Ofori-Asenso et al. in their systemic analysis of WHO prescribing indicators at primary health centers of African region from 2006 to 2015 showed that the average number of medicines prescribed per patient was 2.6 or public centers which was higher than that in private centers (2.5).¹⁴ In the Indian context, Jhanjee et al. in their study on psychotropic prescriptions conducted at a tertiary care center at Delhi had reported the figure as 6.24.¹⁵ While a more recent study by Kumar et al. again from Delhi had reported the figure as 3.12.¹⁶ It may be noted that in the current scenario, this center appears to be doing better though improvement is still warranted.

Generally more number of drugs per prescription points toward, the practice of polypharmacy, which is a global phenomenon and associated with undesirable consequences. Polypharmacy is measured numerically, which often fails to indicate the appropriateness of prescribed medications. Specific indicators such as Beer's criteria and Medication Appropriateness Index may be more suitable.¹⁶In our study, although the number of drugs prescribed per prescription was higher, the same is concordant with other similar studies. Moreover, the use of greater than four medications was encountered in less than 5% of prescriptions in our study. Here, it may be noted that the average number of psychotropics per prescription was only 1.864, but the average number of medicines per prescription was higher, which shows significant use of medicines other than psychotropics (e.g., levothyroxine, promethazine, trihexyphenidyl, thiamine, and so on) which are often used to augment treatment or to counter/prevent side effects of psychotropics. Given the high rate of adverse effects with psychotropics, these drugs are prescribed as per indications. Possibly a closer look at the prescription pattern of these drugs may be warranted, which calls for further research.

Medical Council of India emphasizes the use of generic names of drugs (vide Indian Medical Council Regulations related to ethics, professional conduct, and etiquettes).^17,18 In our study, 91.30% of psychotropic drugs was prescribed by generic name, which is again less than the WHO standard of 100% but similar to the results in a study by Sisay et al.^12,14 This result was significantly different from Kumar et al. ¹⁶ who brought out in their study that only 16.22% antipsychotic prescription was by generic name. Another study from Delhi by Jhanjee et al. ¹⁵ had reported this figure as a mere 25.12%, while a similar study from West Bengal by Kumar et al. ¹⁹ had reported that 92.66% of the drugs were being prescribed by generic names. Our results are similar to those reported by Kumar et al. indicating that there is still scope for improvement.¹⁶ Kumar et al. have argued that marketing pressures from the pharmaceutical industry drive the writing of brand names.¹⁶ While there is no pressure of the pharmaceutical industry at our center, some drugs are manufactured by one company which has a monopoly over it. Writing those names has become so automatic that often the clinicians do not realize the folly while writing brand names, possibly explaining 8.7% prescriptions containing brand names. Examples are Inderal (propranolol) and Pacitane (Trihexyphenidyl). Because it has become a habit, a conscious effort is required to break it by actively spreading this message among the clinicians to use generic names instead of brand names.

In our study, injectable medicines were prescribed in just 2.39% prescriptions, well within the WHO recommended value of <20%.¹⁴ This result was in contrast to result of Ofori-Asenso R, et al. ¹⁴ who in their analysis reported a proportion of 25% for overall encounter with injectables. Kumar et al., ¹⁹ reported 4.59% injectable use in their study, while Kumar et al, ¹⁶ reported 0.44% prescriptions with injectables. Among psychotropics, injectables are used either in emergencies or as long acting injectables for maintenance. Their use at various centers depends on the type of patients, availability of injectables, and local policies. Considering the recent evidence of better tolerability and efficacy of newer long acting injectables, their use indicates better patient care. Although the data are insufficient to indicate such a pattern of use, the authors assume that to be the case.

The use of FDCs in our study was just 0.16%, which points toward rationality in prescriptions. Solanki et al. reported that more than 50% of the antipsychotic FDCs sales internationally include formulations with banned drugs.²⁰ A relook at the data revealed that these FDCs were mainly multivitamin, iron with folic acid, and calcium plus vitamin D3 tablets often prescribed along with the psychotropics for various reasons. As a policy of the center, FDCs are discouraged and seldom written by the psychiatrists. However, there are some instances when the hospital supply consists of such combinations and the clinicians use them as per availability.

The medicine expenses constitute 72% in rural and 68% in urban areas’ health expenses.⁴ Essential medicines as defined by the WHO are those that satisfy the priority healthcare needs of majority of the population and are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness.^4,21 To provide guidance to its member countries, the WHO brought out the first list of essential medicines in 1977, amended from time to time. Following the footsteps of the WHO, the Indian National List of Essential Medicines (NLEM) was introduced in 1996 with latest amendments in 2015.^4,21

In our study, the compliance of psychotropics prescription to the NLEM 2015 was 55.02% and was similar to the study by Dutta et al. who reported 55.39% psychotropic drugs prescribed from the NLEM.²² Pugazhenthan et al. in their study of drug use pattern in dermatology reported 95% drugs prescribed were from the NLEM. the NLEM 2015 consists of only four antipsychotics and three antidepressants.²³ While this list of medicines may be adequate for smaller peripheral centers, it becomes inadequate for providing standard of care at a tertiary care center such as ours where we attempt to offer the best medicines in terms of tolerability and efficacy. There appears to be a need to enhance psychotropic prescriptions from the NLEM at this center; however, it would be prudent to consider inclusion of more psychotropics in the next revision of the NLEM.

Kumar et al. in their study of prescription pattern of antipsychotics reported that maximum antipsychotics were prescribed in the age group of 31–40 yrs (31.4%), followed by 41–50 yrs (27.5%), and 18-30 yrs (28.6%).¹⁶ Our study results show maximum psychotropic drugs prescription to the age group of 41–50 yrs (22.17%) followed closely by the age group of 31–40 yrs (21.48%). Our results closely match the National Mental Health Survey of India, 2015–2016 report which states that individuals in the age group between 40 and 49 yrs are affected predominantly by psychotic, bipolar, neurotic, and stress-related disorders.²⁴

Roberts et al. in their study of antipsychotic prescription trends reported that atypical antipsychotics constitute 79.9% of antipsychotic prescriptions.²⁵ In line with this trend, our study results reveal that atypical antipsychotics constitute 90.45% of the prescriptions. Similar to our results, Kumar et al. in their study have demonstrated risperidone to be the most prescribed antipsychotic (44.71%) followed by olanzapine (34.81%).¹⁶

Yoon et al. in their study of antidepressant prescription pattern have reported escitalopram to be the most commonly prescribed antidepressant.²⁶ Tripathi et al. in their study of antidepressant prescription pattern in India report 62.2% patients on SSRIs and escitalopram to be the most commonly prescribed SSRI.²⁷ We have similarly reported SSRIs as the most commonly prescribed antidepressants (61.59%) and escitalopram as the most commonly prescribed SSRI.

About 25% of the prescriptions contained a benzodiazepine. This may be because benzodiazepines are used in therapeutic doses in a variety of illnesses for short-term symptom relief. A community pharmacy-based Swiss study reported that 9.1% of all prescriptions contained a benzodiazepine.²⁸ Dutta et al. reported in their study on depression that 72% of the prescriptions included a benzodiazepine.²⁹ Although there is no available data for direct comparison, a likelihood of overuse and misuse of benzodiazepines at this center cannot be ruled out and calls for research. In our study, clonazepam was the most commonly prescribed benzodiazepine with 72.17% prescriptions.

It can be noted that, on the one hand, there are some encouraging results, whereas there are areas for improvement as noted ante. The purpose of drug utilization studies is to assess the pattern of prescription of a center or a group of centers for correctness viz a viz standards laid down and to compare with other centers/organizations/countries. We have noted that there is a need to increase prescription by generic names, discourage polypharmacy, and to increase prescription from the NLEM. We also noted that we have been faring well as compared with other centers in India and abroad. With respect to classes of drugs, our results are similar to studies conducted in India and abroad. Although the ideal pattern of prescription is difficult to achieve in a real-world scenario, a scrutiny into the same paves way for a gradual process of improvement, which we think will continue in the future.

There were certain limitations in the study. Not being a prospective study, we missed out on the illness-related data which could have given further insight into rational drug use. In addition, we may have missed some data for patients who did not collect medicines from the dispensary because of non-availability, or other reasons. Because the study was carried out at one center only, the prescription pattern was guided by local policies and reflected the knowledge and attitudes of a few clinicians practicing at this center. This is a possible source of bias. Using WHO indicators, we were able to collect data which could be compared directly with other studies worldwide. Very few studies in the past have conducted a scrutiny of prescription pattern using drug use indicators, which makes for strength for this study. We suggest similar multicentric studies with prospective design in future to assess the prescription patterns for the whole organization. Such a study is likely to bring uniformity and standardization in the prescription patterns of various psychiatry centres across the country, in addition to improving the practice of individual clinicians.

Conclusion

Our prescriptions were not as per the ideal standards with respect to average number of drugs per prescription, percentage of prescriptions with generic names, and prescriptions from the essential drug list. We fared well in prescriptions with injections and prescriptions with antibiotics. Although we have not been able to meet the ideal scenario, compared with other studies, the results point toward a practice of rational prescription in line with the national and international trends for psychotropics. There is a scope for improvement in prescription of drugs by generic name, prescription from the NLEM and reducing polypharmacy. This study provides a baseline data on psychotropic drugs and can be used to carry out further studies on individual psychotropics. Further, multicentric prospective studies in similar lines can be conducted to achieve better results.

Acknowledgements

The authors acknowledge the support and guidance of the Head of the hospital where the study was carried out because of which a detailed audit could be performed.

Disclosure of competing interest

The authors have none to declare.