Psychotropic prescription in non-psychiatric hospital settings

Eur Psychiatry 2002; 17: 414-8 © 2002 Éditions scientifiques et médicales Elsevier SAS. All rights reserved S0924933802006958/SCO

SHORT COMMUNICATION

Psychotropic prescription in non-psychiatric hospital settings Isabelle Gasquet1,2*, J. Medioni3, J. Lellouch1,3, J.D. Guelfi2;4 1

Department of Public Health, Paul Brousse Hospital (Assistance Publique–Hôpitaux de Paris), 12, avenue Paul Vaillant-Couturier, Villejuif 94804 cedex, France; 2 Department of Psychiatry, Paul Brousse Hospital (Assistance Publique–Hôpitaux de Paris), 12, avenue Paul Vaillant-Couturier, Villejuif 94804 cedex, France; 3 INSERM U 472 (Epidemiology and Biostatistic), Villejuif, France; 4 Clinique des maladies mentales et de l’encéphale, Paris, France (Received 25 August 2001; accepted 26 April 2002)

Summary – A study was conducted to assess differences in psychotropic prescription (PP) in various non-psychiatric hospital settings. After adjustment for demographic, medical and psychological status, rates of PP were significantly lower for surgical, intensive care and outpatients and higher for geriatric patients than for patients in other settings, suggesting inadequate consideration of psychiatric problems in certain contexts, in particular intensive care units. © 2002 Éditions scientifiques et médicales Elsevier SAS

INTRODUCTION The risk of anxiety and depressive disorders is high among patients with severe, painful, and/or chronic somatic conditions. [8,19,21,26]. The association of psychiatric and somatic conditions leads to worse prognosis for physical recovery and quality of life [19,20]. Hospital physicians are reluctant to refer their patients to mental health professionals for assessment, even within their hospital [12], yet they often initiate, modify or stop psychotropic treatment [6,14,29]. A large proportion of patients hospitalised in non-psychiatric wards and who need psychotropic treatment are either not treated, or have inadequate prescriptions [4,15,24]. Studies have shown that practice on the part of physicians regarding psychotropics varied with hospital setting, with lower rates of treatment in surgical and obstetrical wards than in medical wards [5,10,18,22,32]. A positive correlation has also been demonstrated between PP and duration of hospital stay [4,11,28,30,32].

*Corresponding author. E-mail address: [email protected] (I. Gasquet).

These relationships may be explained by factors like demographic, psychological and medical characteristics of the patients, which may well influence recourse to psychotropic medication [5,6,11,27,28]. It is also possible that a part of the overall variation of PP rates from one hospital setting to another is merely related to differences in medical practice on the part of individual physicians with respect to psychotropics. The aim of this study was to identify the influence of types of hospital setting on PP, independently from patient profile (i.e. psychological distress, medical and demographic characteristics). MATERIALS AND METHODS Study population A cross-sectional study was carried out in an 800-bed teaching hospital located in the Paris area. All adults admitted as inpatients or day-care outpatients in medical departments (internal medicine, infectious disease,

Psychotropic prescription in non-psychiatric settings

and oncology), surgical department (abdominal surgery) or geriatric wards were enrolled. Patients hospitalised in long-term geriatric care or in the psychiatric unit, inpatients admitted less than 3 days and day-care outpatients hospitalised less than three times in the hospital were not included. Data collection Data were collected prospectively over a 3-week period via two questionnaires. Demographic data and the Hospital Anxiety and Depression Scale (HADS) [31] were self-completed by the patient. The HADS has been widely used for studies in non-psychiatric clinical populations, and is considered reliable for measuring severity of emotional distress in medical patients [7,13]. The French version has been validated [16]. The second questionnaire, completed by the physician in charge of the patient explored (i) medical characteristics of the patient (ICD-10 somatic diagnosis, co-morbidity, disease duration since diagnosis, severity and probable outcome of current pathology); (ii) type of hospital setting (which department, whether an operation was performed, inpatient or outpatient hospitalisation, any time in intensive care unit, number of previous hospitalisations in the hospital); (iii) name(s) of psychotropic drug(s) prescribed, whether or not treatment was initiated during hospital stay. Psychotropics prescribed for conditions other than psychological were excluded.

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RESULTS Patient participation Three hundred and sixty-four patients were included. Completion rate for the patient questionnaire was 70% (n = 254). Among the non-respondents (n = 109), 68 were medically unable, 20 did not read French, 11 refused, and for 10 reasons for non-response were unknown. Compared to respondents, non-respondents were older (56.9 ± 19.8 versus 71.2 ± 16.7, P ≤ 0.001), had less favourable somatic prognosis (44.2% versus 57.1%, P ≤ 0.05) and were more often inpatients (30.4% versus 8.7%, P ≤ 0.001). Psychotropic prescription rates did not differ between these two groups (37.6% versus 40.2%, P = 0.65). Description of population and frequency of psychotropic treatments Descriptions of patient profiles, of types of hospital setting and of PP are shown in table I. More than one-third of the population was treated with psychotropic drugs. The prescriptions included at least one benzodiazepine, one antidepressant and one neuroleptic in respectively, 76.2%, 49.7% and 18.2% of the cases. The average number of psychotropics per prescription was 1.7 (±0.9). Polypharmacy (i.e. prescription of several psychotropics) was observed in 46.9% of cases where there was psychotropic treatment. Patients’ profile and psychotropic treatment

Statistical analysis Univariate analyses were first performed to assess the association between psychotropic treatment and patient profile. To assess the specific role of the type of hospital setting (dependent variable) in PP, four logistic regressions were performed. In each model, PP was included as a dependent and one of the items defining type of hospital setting (i.e. department; operation; intensive care; inpatient vs. outpatient) as an independent variable. All other patient profile variables statistically associated with both psychotropic prescribing and hospital setting was also included in each model. Data analyses were performed using SAS and BMDP statistical software. Eur Psychiatry 2002; 17: 414–8

Psychotropic drugs were significantly more frequently prescribed for females, elderly people and patients living alone (P ≤ 0.001 for the three instances) (table II). Patients suffering from infectious or cardiological diseases were significantly more likely to be treated with psychotropics than other patients. Patients with severe disease and multiple somatic disorders had a non-significant likelihood of being treated more frequently with psychotropic medication (P = 0.06 for both). Overall scores on the HADS scale were higher in the PP group than in the group without treatment (17.5 ± 7.5 versus 13.5 ± 7.3, P ≤ 0.001). The same was true both for the anxiety subscale (9.0 ± 4.4 versus 7.4 ± 4.4, P ≤ 0.01) and for the depression subscale (8.2 ± 4.5 versus 6.1 ± 4.3, P ≤ 0.001).

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I. Gasquet et al. Table II. Patient profiles and psychotropic prescription

Table I. Description of the population a

Demographic characteristics Female (%) Age (mean (SD)) Marital status (%) Married or living with a partner Single Separated Widow French nationality (%) Medical characteristicsb CIM 10 physical diagnosis (%) Infectious disease Tumour Non-malignant digestive disorders Cardiological diseases and other Less than 6 month since diagnosis (%) Severity of the physical disease (%) Comorbidity with other physical disease (%) Probable outcome (%) Recovery or improvement Stabilisation Deterioration Emotional distress (HADS)a HADS score mean (SD) Score ≥ 11 for anxiety sub-scale (%) Score ≥ 11 for depression sub-scale (%) Score ≥ 11 for anxiety or depression sub-scale (%) Hospital settingb Department (%) Internal medicine Infectious diseases Oncology Abdominal surgery Geriatric medicine Previous hospitalisation in the hospital (%) Stay in the intensive care unit (%) Inpatient care (%) Psychotropic prescriptionsb Anxiolytics and hypnoticsc (%) Antidepressants (%) Neuroleptics (%) At least one psychotropic (%)

49.3 63.1 (19.2) 50.0 20.6 10.7 18.7 86.0 16.2 50.6 17.8 15.6 32.4 63.7 41.6 33.7 18.7 47.6 15.0 (7.2) 30.7 21.4 39.3 14.3 12.1 19.0 20.7 33.9 66.3 9.4 86.9 30.0 19.5 7.1 39.4

Demography Gender Female Male Age <50 years 50–70 years >70 years French nationality Yes No Matrimonial status Married or living with a partner Single Divorced Widow Emotional distress No (HADS score < 11) Yes (HADS score ≥ 11) Medical characteristics CIM-10 physical diagnosis Infectious disease Tumour Cardiological disorder Digestive disorder Comorbidity No Yes Duration of physical pathology Duration < 6 months Duration ≥ 6 months Severity of the physical disease Mild Severe Probable outcome Recovery or improvement Stabilisation Deterioration a

Prescription of psychotropicsa (n = 363) %

P-valueb

48.3 31.1

0.001

35.3 26.9 26.9 42.2 27.7 27.4 38.8 57.1 67.3 34.6 47.5 46.1 31.1 45.9 18.6

0.001 ns

0.001

0.04

0.02

38.2 48.5

0.06

44.3 42.0

Ns

39.2 49.5

0.06

43.3 37.0 40.0

ns

Including anxiolytics, hypnotics, antidepressants and neuroleptics. Chi-square tests.

a

Data from patient questionnaire (n = 254). b Data from physician questionnaire (n = 363). c Including benzodiazepines and benzodiazepine-like drugs.

b

Hospital setting and psychotropic prescription (table III)

related to both PP and hospital setting variables (see footnote of table III). There was a significant relationship between ward speciality and PP. Compared to patients hospitalised in medical wards, those hospitalised in geriatric wards were more frequently treated (adjusted OR = 3.1) and those hospitalised in the surgical ward much less frequently (adjusted OR = 0.2).

In order to identify any specific effect of hospital setting (independent variable) on PP (dependent variable) independently from patient characteristics (independent variables), four logistic regressions were performed. Patient characteristic variables (including HAD scores) selected for each model were those significantly

Eur Psychiatry 2002; 17: 414–8

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Psychotropic prescription in non-psychiatric settings Table III. Hospital settings and psychotropic prescription (logistic regressions)

Department Internal medicine Infectious diseases Surgery Geriatric medicine Oncology Past hospitalisation in the hospital 0 ≥1 Surgical intervention No Yes Stay in an intensive care unit No Yes Hospitalisation type Day-care Inpatient

Prescription of psychotropicsa (n = 363) %

Univariate analysis

Odds-ratiob

34.6 45.4 13.3 60.1 30.4

P < 0.001

1 1.7 [0.6–4.2] 0.2 [0.1–0.7] 3.1 [1.5–6.5] 0.7 [0.3–1.7]

c

d

43.6 38.0

P = 0.38

1 0.7 [0.4–1.3]

44.4 26.3

P < 0.05

1 0.4 [0.2–0.9]

44.6 25.8

P < 0.05

1 0.1 [0.02–0.9]

e

e

f

10.8 44.9

P < 0.001

1 10 [2.0–14.2]

a

Including anxiolytics, hypnotics, antidepressants and neuroleptics. Logistic regression. c OR adjusted for gender, age and physical comorbidity. d Non-adjusted OR. e OR adjusted for age, HADS score and severity of physical pathology. f OR adjusted for age and physical comorbidity. b

Psychotropic prescription rate was higher for inpatients than for day-care outpatients (OR = 10.0). Surgical intervention and stay in an intensive care unit were associated with a lower rate of prescription (respectively, OR = 0.4 and OR = 0.1). DISCUSSION The frequency of anxiolytic and hypnotic prescription (30%) found in this study was similar to data in the general French population [23]. These results are also comparable to studies conducted on non-psychiatric inpatient populations in France [1,27] and in other countries such as the USA [32], New Zealand [9,14], Australia [22] and Great Britain [25]. As in other hospital-based studies [5,24], rates of antidepressant and neuroleptic prescriptions in this study (20% and 7%, respectively) were higher than in the French general population [3,23]. Neuroleptic prescription in this study was lower than in previous studies conducted among elderly patients living in long-term geriatric wards and nursing homes (13–39%) [2,18]. It was also noted (data not shown) that neuroleptic prescription rates were higher in geriatric wards in comparison to other departments. However, when taking into account all the patients included Eur Psychiatry 2002; 17: 414–8

no influence of patients’ age was observed on neuroleptic prescription. This suggests that geriatric ward physicians are more prone to prescribe neuroleptics than other non-psychiatric physicians, independently of patients’ age. Examination of the demographic factors influencing psychotropic treatment showed that females, elderly patients and those living alone are more frequently treated than other patients. This corroborates data from several studies on hospital prescription of hypnotics and anxiolytics [6,11,27] and neuroleptics [28]. Whatever the patients’ demographic, somatic and psychological profiles, PP by hospital physicians was influenced by the setting in which they were involved. Inpatient hospitalisation increased the probability of PP. It could be suggested that full time hospitalisation allows more time for the appearance or diagnosis of psychological problems. Patients hospitalised in surgery are prescribed treatment less often than those hospitalised in other wards. This confirms other studies [5,10,22]. Surgeons and to a lesser extent physicians in other wards may be more tolerant than geriatricians towards psychological symptoms, and/or may not consider these problems but focus their attention on organic symptoms instead.

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Patients in intensive care were prescribed less psychotropic medication, although emotional problems are more frequent among patients hospitalised in intensive care units [17]. No data was found in the literature on this point. It might be concluded that the psychological trauma linked to intensive care is not sufficiently taken into account by hospital physicians. CONCLUSION Psychotropic prescription rate during hospitalisation was relatively high in this study but close to those found in previous studies conducted in other countries. Medical practices regarding PP varied from one hospital setting to another and prescription was more frequent in inpatient care, independently of the demographic, medical and psychological profiles of patients. In particular, it appears that psychological problems of hospitalised patients in intensive care probably received inadequate consideration. REFERENCES 1 Alran C, Damaze-Michel C, Celotto N, Durand MC, Montastruc JL. Consumption of benzodiazepines in a French university hospital between 1980 and 1991. Fundam Clin Pharmacol 1993;7:319–23. 2 Avorn J, Dreyer P, Connelly K, Soumerai SB. Use of psychoactive medication and the quality of care in rest homes. Findings and policy implications of a state wide study. N Engl J Med 1989;320:227–32. 3 Bouhassira M, Allicar MP, Blachier C, Nouveau A, Rouillon F. Which patients receive antidepressants? A ‘real world’ telephone study. J Affect Dis 1998;49:19–26. 4 Callies AL, Popkin MK. Antidepressant treatment of medical surgical inpatients by nonpsychiatric physicians. 44:157–60.. Arch Gen Psychiatr 1987;44. 5 Davidson JRT, Raft D, Lewis BF, Gebhardt M. Psychotropic drugs on general medical and surgical wards of a teaching hospital. Arch Gen Psychiatr 1975;32:507–11. 6 Edwards C, Buschnelle JL, et al. Hospital prescribing and usage of hypnotics and anxiolytics. Br J Clin Pharmacol 1991;31: 190–2. 7 Elliot D. Comparison of three instruments for measuring patient anxiety in a coronary care unit. Intens Crit Care Nurs 1993;9:195–200. 8 Evans DL, McCartney CF, Nemeroff CB, Raft D, Quade D, Golden RN, et al. Depression in women treated for gynecological cancer: clinical and neuroendocrine assessment. Am J Psychiatr 1986;143:447–52. 9 Fleischhacker WW, Barnas C, Stuppäck C. Benzodiazepines: utilization and patterns of use in a university hospital. Pharmacopsychiatry 1989;22:111–4. 10 Haggerty JJ, Evans DL, McCartney CF, Raft D. Psychotropic prescribing patterns of nonpsychiatric residents in a general hospital in 1973 and 1982. Hosp Commun Psychiatr 1986: 357–61. 11 Halfens RJ, Lendfers ML, Cox K. Sleep medication in Dutch hospitals. J Adv Nurs 1991;16:1422–7.

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