Exploring psychiatric prescribing practices: The relationship between the role of the provider and the appropriateness of prescribing

Exploring Psychiatric Prescribing Practices: The Relationship Between the Role of the Provider and the Appropriateness of Prescribing John J. Seaman, Pharm.D. Clinical Research Department,

Ciba-Geigy

Pharmaceuticals,

Summit, New Jersey

Richard M. Cornfield, M.D. Institute of Pennsylvania

Hospital,

Doyle M. Cummings, Clinical Assistant

Professor,

Philadelphia,

Pennsylvania

Pharm.D.

Jefferson Medical College of Thomas Iefferson

University,

Philadelphia,

Pennsylvania

Carl W. Peterson, Pharm.D. Department

of Pharmacy

Practice,

University of lllinois College of Pharmacy,

Chicago, lllinois

James Lyon, Pharm.D. Pharmakinetics,

Inc., Pittsburgh,

Pennsylvania

Abstract: The prescribing habits of psychiatrists and neurologists in a large, urban Veterans Administration medical center were surveyed. It was determined that these physicians prescribed a large amount of nonpsychotropic medication, and the rationale for this practice was explored and is presented. Patient expectations in this population derived from certain established so&cultural biases toward the medical profession appeared to signi&antly influence prescribing practices. Such prescribing behavior suggests that the psychiatrist in this setting is often required to assume the role of primary care provider as part of a larger patient therapist relationship.

Introduction Since their introduction into clinical practice, psychotherapeutic agents have become a vital part of the overall treatment of many psychiatric disorders. Clinical expertise in prescribing of psychotropics has contributed significantly to the shift in emphasis from inpatient to outpatient care and to the development of community-based treatment programs. In an attempt to evaluate psychotropic prescrib220 ISSN 0X3-8343/87&X50

ing practices and to improve patient care, several authors have described drug utilization review projects for this class of agents [l-7]. A report by Schroeder et al. [l] based on data collected from 42 Veterans Administration (VA) hospitals compared prescribing practices to current recommendations outlined in a report entitled “Guidelines for Antipsychotic Drug Use” by Prien and Caffey [8]. The results demonstrated moderate differences between actual practices and those recommended in the guidelines. Significant differences were observed in polypharmacy, use of antiparkinson drugs, dosage levels, and drug holidays. However, this and a majority of studies have been undertaken using inpatients and may inadequately reflect current trends in the area of outpatient psychiatric practice. Diamond et al. 191 have examined certain parameters of outpatient psychotropic prescribing in an extensive community mental health center network and have shown a reduction in polypharmacy and in multiple daily dose prescribing through peer review mechanisms and education. To date, however, outpatient comGeneral Hospital Psychintry 9, 22C-224, 1987 0 1987 Elsevier Science Publishing Co., Inc. 52 Vanderbilt Ave., New York, NY 10017

Psychiatric Prescribing Practices

and education, To date, however, outpatient community mental health resources have been insufficiently scrutinized for the demands upon their psychiatrists’ services and for the prescribing practices that reflect a response to these demands. As a result, the following study was undertaken.

Objectives The objectives of the investigation

were as follows:

1. Systematically evaluate outpatient psychotropic and nonpsychotropic drug prescribing practices for an urban veteran population during a defined 6-week time period. 2. Determine if prescribing practices are consistent with established guidelines for optimal usage. rationale, 3. Explore and document physicians’ systematically and patient by patient, for prescribing habits that deviate from the recommended norms. 4. Identify patterns of drug prescribing that may require an intervention such as inservice education to improve prescribing practices.

Patient Population and Setting The patients (n = 320) whom this study addressed consisted of veterans attending a large, urban VA Ambulatory Care Center. The majority of patients received a pension from the government for a psychiatric disability. A preponderant number of the patients were unemployed, many for decades, and would fall in the socioeconomic grades III or IV of the Hollingshead and Redlich scale [lo]. The authors feel that the relationship between the psychiatry/neurology outpatient service (as well as the entire Ambulatory Care Center) and the patient population more closely resembled that of a social welfare center in terms of patient need and expectation toward the clinic and its health care providers. Thus, a significant proportion of patients viewed the center from a crisis orientation and had frequent missed appointments, while a large number also tended to see the clinic psychiatrist or neurologist regularly as their primary care provider. A substantial percentage of chronic patients followed by clinic psychiatrists and neurologists, especially those with a compensation for psychiatric disability, sought regular renewal of a variety of psychotropic and nonpsychotropic medications. Many of these patients had “missed’ medical clinic

follow-up appointments for long time periods, instead relying upon the psychiatrist for a11 medications. It was this behavior that the investigators sought to document and explore. The physicians involved in this study included ten psychiatrists and two neurologists, the majority of whom were board-certified in their respective field.

Methods A daily review of all new prescriptions received in the pharmacy and written by the psychiatry/neurology staff was undertaken during a six-week period. The following information was gathered, logged on computer data forms, transferred to computer cards, and analyzed using the Statistical Analysis (SAS)/79, a computerized data analysis program: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Physician identification Patient identification Date Drug name Dose of drug Dosing interval of drug Quantity of drug Schedule of drug (e.g., controlled Type of drug

The following specific computer analysis:

issues

substance)

were evaluated

via

1. The total number of prescriptions of all classes of medications written by psychiatrists and neurologists at the Ambulatory Care Center during the 6-week study period. 2. The number of prescriptions written by psychiatrists and neurologists for psychotropic versus nonpsychotropic medications. of psychotropic versus non3. The breakdown individual psychotropic prescribing by physicians. 4. The classes of drugs prescribed most frequently. 5. The frequency with which each drug was prescribed and the breakdown by individual physician. Prescribing practices for each physician were carefully documented. Prescribing practices considered unusual by the investigators were noted and the rationale behind these practices explored. Physicians responsible were asked to complete a brief questionnaire related to their prescribing habits. Each questionnaire contained a list of possible 221

J. J. Seaman et al.

14 UNCOOED

AGENTS

c

PSYCHOTROPICS

NON-PSYCHOTROPICS 1034

Figure 2. Breakdown of psychotropics and non-psychotropics by physician (*neurologist; **psychiatrist).

Rx’s

Figure 1. Number of psychotropic (1040) and nonpsychotropic (1034) prescriptions written for by clinical physicians (n = 2099 total prescriptions).

guidelines

for a particular

class of drugs.

The pres-

criber was asked to rank in order each of the avail-

able reasons as to how well the response described his or her reason for prescribing the drug in question. If available choices were insufficient, the prescriber was asked to state his or her rationale. Responses for each instance of evaluated prescribing were then combined by drug class and analyzed.

Results Overall, physicians in the department of psychiatry/neurology wrote approximately an equal number of prescriptions for nonpsychotropic and psychotropic medications: 1040 prescriptions for psychotropics vs. 1034 for nonpsychotropic drugs (Figure 1). Figure 2 shows this information broken down by individual physician and his or her specialty. Each patient was therefore taking an average of 6.5 medications concurrently. The 15 most commonly prescribed drugs are shown in Table 1 with the number and percentage of all prescriptions for each agent. Of interest is the fact that a multiple vitamin and mineral product 222

was the most commonly prescribed agent by the psychiatry/neurology service. This was followed closely by diazepam, a commonly prescribed anxiolytic. The three most widely prescribed drugs combined to account for only 20.7% of all prescriptions written. No other drug accounted for more than 5% of the remainder of prescriptions. Thus, a great diversity of medication was prescribed during the 6-week period of evaluation. Table 2 illustrates the frequency with which each class of drugs was prescribed. Vitamins were the most commonly prescribed class of agents (27.5% of all prescriptions), followed by neuroleptics and

Table 1. The 15 most common

1. Multiple vitamin and mineral 2. Diazepam 3. Thioridazine 4. Chlorpromazine 5. Phenytoin 6. Amitriptyline 7. Benztropine 8. Multiple Vitamin 9. Chlordiazepoxide 10. Doxepin 11. Haloperidol 12. Flurazepam 13. Acetaminophen 14. Phenobarbital 15. Trifluoperazine

prescriptions

No. of Rxs

% of All Rxs

190 138 105 102 77 74 63 63 57 56 55 51 51 49 45

9.1 6.6 5.0 4.9 3.7 3.4 3.0 3.0 2.7 2.7 2.6 2.4 2.4 2.3 2.2

Psychiatric Prescribing Practices

Table 2. Percentage

of prescriptions

in each class

Table 3. Rational for prescribing

medically

related drugs Class Vitamins Neuroleptics Medical Anxiolytic Tricyclics Anticonvulsant Nonnarcotic analgesics Anticholinergic Sedative Antacid Laxative Topical Narcotic analgesics

Percentage of Total Prescriptions 27.4 17.3 11.0 10.0 7.4 7.0 4.5 4.3 3.7 3.0 2.2 1.9 0.2

Rank*” 1 2

3 4 5 6 7 8

medical drugs (nonpsychotropics). The use of vitamins to this extent in this population was felt to be a significant issue not highlighted in previous reviews and an analysis of the rationale behind such prescribing was completed. The results demonstrated three major reasons (in order of ranking): 1) the patient is a suspected alcoholic and needs vitamin supplementation; 2) placebo purposesthe patient is more comfortable emotionally when taking vitamins; and 3) patient seen by me on a “walk-in” basis and needed refilling of medication including vitamins. Fifty percent of all prescriptions were for nonpsychotropic drugs. Focusing only on psychiatrist prescribers, 45% of the total prescriptions were for medical drugs and vitamins (medical = 27%, vitamins = 18%). Although no specific guidelines exto the prescribing of isted with respect nonpsychotropic medications by psychiatry/neurology staff, it was deemed important to pursue the rationale for this practice in light of the availability of a medical department in the Ambulatory Care Center. Physicians’ reasons for prescribing nonpsychotropic drugs clustered around two categories: 1) the patient’s need for medication refill, and 2) the physician’s concern about inconsistent treatment or lag in treatment time after the patient is referred to the appropriate medical department. Noteworthy, were staff members’ concerns over potentially inconsistent medical attention if the patient were referred to the medical clinic.

Reason Medical condition diagnosed previously; patient requests/requires medication refill. Feel that patients may not have rapid or consistent treatment after referral to medical department. Patient seen by me on “walk-in” basis and needed refilling prescriptions. Medical condition diagnosed and treated by me. Drugs prescribed have very high margin of safety. Feel that patients may be inconvenienced by referral medical department. Holistic medicine should be practiced by psychiatrists. Patient pressure very strong to refill all medications.

“Scale 1 = most appropriate rational; 8 = least appropriate rationale.

Discussion This study documents seemingly unusual prescribing practices among psychiatrists and neurologists involving nonpsychotropic medications. A survey of physician prescribers was completed to explore the rationale for this prescribing behavior. Responses by the physicians suggest three main areas of concern: 1) irregular scheduling of outpatient medical treatment, often seen as insufficient to meet the patient’s needs; 2) insufficient medication to last the interim between medical clinic appointments; and 3) patient failure to keep medical appointments on a consistent basis. In addition, the desire to help an indigent patient with costly medication was mentioned. The above areas of conem, when considered in conjunction with patient expectation, tended to cast the physician in the psychiatry/neurology department in the role of general health care provider. This was particularly likely after the initial “medical” diagnosis and medication regimen had been previously established. Of interest, when questioned in the rationale assessment regarding their practice of more wholistic medicine, most psychiatrists did not perceive this as their role. However, as illustrated above, their prescribing practices suggest that they do, in fact, assume a more primary care role. A minority of psychiatry/neurology staff, however, seemed to

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J. J. Seaman et al.

view their role differently, prescribing mainly psychotropic medication and rarely nonpsychotropics . The etiology of this assumption of more of a primary care role by the psychiatrist or neurologist remains unclear. The environmental influences peculiar to this outpatient government setting of subsidized health care and compensation undoubtedly play a role and serve to reinforce the patient’s global perception of the clinician as part of a larger social wefare center. Other possible considerations include the demand by patients in the context of an established patient-therapist relationship and an altered role perception on the part of the prescribing physician. Interestingly, most psychiatrists who participated in the rationale assessment rated patient demand as the least important reason for prescribing “medical” drugs. Depsite this perception, prescribing practices suggest that patient demand probably does play a significant role. More than one third of all nonpsychotropic prescriptions were for vitamins. It is of particular interest that dietary supplementation of vitamins because of suspicion of alcoholism was regarded as important by 73% of physicians. However, placebo purposes (related to feeling of psychologic well-being in the patients) also had a high priority among 63% of physicians, suggesting that patient expectations influenced the prescribing of vitamins. In general, staff psychiatrists and neurologists appeared to have few reservations in prescribing vitamins related or unrelated to suspicions of dietary insufficiency. In the majority of cases the patient’s feeling of comfort with vitamins seemed to play a strong role in their prescribing by the psychiatry/neurology staff, as most prescriptions were not accompanied by referral for medical consultations. This prescribing behavior supports the suggestion above that these prescribers are assuming more of a primary care role, perhaps as a result of patient demand. In addition, two physicians regarded the use of vitamins as potentially therapeutic in the treatment of certain psychiatric conditions.

ularly in the group of patients discussed here. When the psychiatrist is regarded in a poorly differentiated manner as “the doctor” rather than as a highly specialized physician who practices psychiatry, within the medical field, confidence and feelings of well-being may pivot upon gratification of many perceived medical needs as a prelude to more specific psychiatric intervention. The characterization of the psychiatrist as a primary care provider and sustainer that was identified in this investigation should be pursued in further studies in similar outpatient settings.

References

Conclusion

1. Schroeder NH, Caffey EM, Lorei TW: Antipsychotic drug use: Physician prescribing practices in relation to current recommendations. Dis Nerv Syst 38:114116, 1977 2. Gee S, Nesard L: Psychiatric Drug Study, Part IPsychiatric Ward/Unit Survey and Specialized Inpatient Alcohol Dependence Treatment Unit Survey (RCS 11-191-S). Reports and Statistics Service, Office of Controller, Veterans Administration, 1979 3. Gee S: Psychiatric Drug Study, Part II-Mental Hygiene Clinic Survey Day Treatment Center Survey, Day Hospital, Survey (RCS 11-191-S). Reports and Statistics Service, Office of Controller, Veterans Administration, 1980 4. Gee S: Psychiatric Drug Study, Part III-Domiciliary Survey, Nursing Home Care Unit survey (RCS ll191-S). Reports and Statistics Service. Office of the Controller, Veterans Administration, 1981 5. Greenblatt DJ, Shader RI, Koch-Weser J: Psychotropic drug use in the Boston area. Arch Gen Psychiatry 32:518-521, 1975 6. Salzman C: Psychotropic drug use and polypharmacy in a general hospital. Gen Hosp Psychiatry 3:19, 1981 7. Holt RJ, Gaskins JD: Neuroleptic drug use in a family practice center Am. J. Hosp Pharm 38:1716-1719, 1981 8. Prien R, Caffey E: Guidelines for Antipsychotic Drug Use. Veterans Administration Central Neuropsychiatric Research Laboratory. Research Report No. 95. Ferry Point, M.D., Veterans Administration, 1974 9. Diamond H. et al: Peer review of prescribing patterns in a community mental health center. Am J Psychiatry 133:697-699, 1976 10. Hollingshead, Redlich: Social Classes and Mental Illness. New York, Wiley, 1958

The evaluation procedures discussed in this article suggest an important interplay of nonpharmacologic factors and physician prescribing practices. Patient expectations derived from certain established sociocultural biases toward the medical profession cannot be overlooked or dismissed easily, partic-

Direct reprint requests to: Doyle M. Cummings, Pharm.D. Jefferson Medical College of Thomas Jefferson University 1015 Walnut Street No. 402 Philadelphia, PA 19107

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