Nonmedical influences on the use of cholinesterase inhibitors in dementia care

We examined primary care physicians' (PCPs) attitudes toward cholinesterase inhibitors (ChEI) to better understand nonmedical factors influencing prescribing decisions in dementia care. In a cross-sectional, qualitative study, 40 PCPs were interviewed concerning their general approach to managing patients with dementia, and their care for a particular dementia case. Three readers independently identified and categorized themes associated with prescribing ChEI. Physicians' attitudes toward ChEI were also coded. Physicians were predominantly ambivalent (51%) or negative (31%) about prescribing ChEI for their patients with dementia. Nonmedical factors affecting prescribing included lack of knowledge, dependence on specialists, influence of family wishes and involvement, and physicians' values. PCPs reported that lack of knowledge and experience made prescribing decisions for ChEI challenging. Physicians reported feeling pressured by families to prescribe ChEI. Under these ambiguous conditions, some physicians prescribed medications simply to be able to offer "something" to patients.     

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

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 sociocultural biases toward the medical profession appeared to significantly 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.     

Factors in choosing atypical antipsychotics: toward understanding the bases of physicians' prescribing decisions

OBJECTIVE: Off-label prescribing of medications, polypharmacy, and other questionable prescribing practices have led investigators to examine a large VA pharmacy database to determine if physician prescribing decisions appear reasonable. METHOD: The current study addresses the question of physician prescribing of atypical antipsychotics in 34,925 veterans with schizophrenia, using a series of signal detection analyses. RESULTS: These results suggest that only three factors (hospital size, age, and secondary diagnosis) allow classification of patients prescribed atypicals into three groups with frequencies of use of atypicals ranging from 43% to 79%, and that these results are consistent with reasonable clinical practice. CONCLUSIONS: Results of two-stage signal detection analyses are readily interpretable by clinicians and administrators who are faced with the task of evaluating how physicians prescribe medications in clinical practice. Physicians' decisions to prescribe atypical antipsychotics are based on both patient and fiscal considerations. This likely reflects a combination of clinical judgment and institutional guidelines.     

Bipolar II or unipolar depression: pharmacologic considerations

This column offers a question-and-answer forum to help nurses maintain their knowledge of advances in prescribing and psychopharmacology, and implications for safe psychiatric care. Send your questions related to prescribing psychotropic medications to the Editor, Mary Paquette, at mary@artwindows.com .     

Treatment considerations for the client with interferon-alpha-induced depression

This column offers a question‐and‐answer forum to help nurses maintain their knowledge of advances in prescribing and psychopharmacology, and implications for safe psychiatric care. Do you have a question related to prescribing psychotropic medications? Send it to the Editor, Mary Paquette, at: mary@artwindows.com .     

Antidepressant discontinuation syndrome

The Art of Prescribing is a question-and-answer forum that can help nurses maintain their knowledge of advances in prescribing, psychopharmacology, and implications for safe psychiatric care.
Send your questions related to prescribing psychotropic medications to the Editor, Mary Paquette, at mary@artwin-dows.com.     

Attention to body mass index by child psychiatry providers when prescribing second-generation antipsychotic medication to children: a survey study using a clinical vignette

Aim: We sought to determine whether weight and body mass index measurement were taken into consideration when prescribing second‐generation antipsychotic (SGA) medication to a child. Methods: Two hundred clinicians were surveyed using a hypothetical clinical case vignette at a child psychopharmacology, postgraduate medical education course. The vignette described an overweight 10‐year‐old boy who was about to be prescribed an SGA medication to control psychotic symptoms. The reference to the patient's being ‘overweight’ was purposefully included to determine if providers would assess the patient's risk of morbidity from the metabolic side effects of the SGAs at the time of prescribing. Results: Only 7.0% of prescribers listed either ‘body mass index’ or a combination of ‘height’ and ‘weight’ as part of their next treatment steps for an overweight child before prescribing an SGA. Conclusions: These results suggest the need for education as to the importance of body mass index monitoring when prescribing second‐generation antipsychotic medications to children.     

Changes in the prescription of anticholinergic drugs (1970-1977) in a state hospital

A study of the prescribing patterns of physicians in a state hospital during 1970-1977 revealed a four-fold drop in the use of combinations of drugs with strong anticholinergic properties. This dramatic shift to more rational practices stands in contrast to reports of persistent inappropriate prescribing in other settings. The time pattern of the changes suggests that an active ongoing educational program combined with a drug monitoring system providing feedback to physicians was primarily responsible for the findings. This study clearly documents the fact that physicians' prescribing patterns are amenable to change in the direction of more appropriate practices.     

The art of pharmacotherapy in depressed outpatients

There is an art to prescribing medications to depressed patients. Both patient and therapist factors are important to a successful outcome with appropriate timing and prescribing of treatment. Two case reports are provided as examples. Specific strategies used by experienced clinicians are presented in the discussion.     

Antidepressant prescribing in nursing homes: is there a place for tricyclics?

OBJECTIVE: To deduce a model describing physicians' choice of antidepressants for treating elderly nursing home patients. METHODS: Subjects were geriatric residents of 137 skilled nursing facilities who regularly received an antidepressant medication for at least one month (n = 3,440, 28% of all residents). Reasons for prescribing antidepressants and physicians' diagnoses of depression and dementia were identified by medical record audit. Residents were grouped by dementia and antidepressant target symptoms (depression, or one or more non-psychiatric symptoms, i.e. insomnia, pain, incontinence, itching). RESULTS: Selective serotonin reuptake inhibitors (SSRIs) were prescribed preferentially over tricyclic antidepressants (TCAs) for treating depression in both demented and non-demented residents, but TCAs were nine times more likely to be prescribed for treating non-psychiatric target symptoms alone. When non-psychiatric target symptoms were present without depression or dementia, both amitriptyline and nortriptyline prescribing was increased, but amitriptyline appeared to be the antidepressant of choice. In all subgroups examined, its use was two to five times more prevalent when such symptoms were present. In patients with dementia, amitriptyline prescribing declined whether or not non-psychiatric target symptoms were present, but nortriptyline prescribing did not; nortriptyline was three times more likely than amitriptyline to be prescribed in the presence of dementia. CONCLUSIONS: Physicians prescribe anticholinergic TCAs principally to treat common non-depressive symptoms in nursing home residents, preferring SSRIs for uncomplicated depression and depression with dementia. They tend to avoid prescribing anticholinergic TCAs other than nortriptyline when they recognize a patient as demented. The data suggest that physicians employ a decision model for antidepressant prescribing that simultaneously recognizes the utility of TCAs in treating non-psychiatric symptoms and the anticholinergic vulnerability of older, especially demented, patients. Whether or not this model leads to optimal patient management requires further study.     

Antidepressant prescribing and suicide rate in Northern Ireland.

PURPOSE: Although antidepressants are the most commonly used treatment for depressive illness, there is uncertainty if their use is associated with a reduction in suicide rate. Antidepressant prescribing in Northern Ireland has increased over fivefold in the decade 1989-1999. The authors sought to explore whether this increase was associated with a reduction in suicide rate taking into account social and political factors thought also to have an influence on suicide. MATERIALS AND METHODS: Factors that have been suggested to influence suicide were entered into a linear regression with frequency of suicide and undetermined deaths (referred to as suicide rate) as the dependent variable. The above factors were antidepressant prescribing, unemployment rate, household alcohol expenditure and persons charged with terrorist offences. The rise in younger suicides, in recent decades, suggests this analysis should be carried out separately for younger (less than 30 years) and older (30 years and above) suicides separately. The predictors in the two models are based on aggregate data for the total group. RESULT: In the younger group there was no association between antidepressant prescribing and suicide. For the older group increased antidepressant prescribing was associated with a reduction in suicide rate over the 10 years of the study. CONCLUSION: Increasing antidepressant prescribing appears to be an effective strategy for reducing suicide. This has been demonstrated in older individuals.