A prospective observational study on psychotropic drug use in non psychiatric wards.

BACKGROUND: Psychotropic medications are the first line for the management of psychiatric illnesses; in addition, they are also being used in an off-labeled manner. Inappropriate prescribing of psychotropic medications either can cause serious harm or may be of no benefit to the patients. However, there is a dearth of information on the pattern of psychotropic drug use in the nonpsychiatry wards. AIM: The aim of this study is to assess the use of psychotropic drugs in general medicine and surgical wards of a teaching hospital.
MATERIALS AND METHODS: An observational study was conducted in the general medicine and surgical wards of a university teaching hospital over 6 months. Patients admitted to the medicine and surgical ward were observed for a prescription of psychotropic medications. Once they were prescribed with a psychotropic medication, the patients were included in the study and were followed until discharge. All the necessary information such as dose, route, class of psychotropic and prescriber's status were documented and analyzed.
RESULTS: A total of 322 patients were prescribed with 452 psychotropic medications. The average number of psychotropic per patient was 1.40 ± 0.76 (range: 1-4). The rate of psychotropic medications prescription in the nonpsychiatric ward is 10.73%. Alcohol dependence syndrome (n = 90 [26.71%]) and pain (n = 43 [43.87%]) were the observed psychiatric and nonpsychiatric indications. The frequently prescribed psychotropic classes were benzodiazepines (n = 165 [36.50%]) and antidepressants (n = 144 [31.86%]). Nonpsychiatrists (n = 250 [55.3%]) were the common prescribers and benzodiazepines (n = 124 [27.43%]) were the preferred class for nonpsychiatrist, whereas psychiatrist prescribed different class of psychotropic drugs.
CONCLUSION: This study emphasizes that nonpsychiatrist irrespective of their specialty prescribed psychotropic medication for psychiatric and nonpsychiatric indications. Copyright:

INTRODUCTION

Physical health and mental health problems are often interwoven.[1] The coexistence of depression and anxiety with chronic illnesses is very common.[1234567] Despite the accepted psychiatric indications, psychotropic is also being used in an off-labeled manner.[2] Therefore, there is a likelihood of receiving psychotropic drugs by physically ill populations.[4] Globally, psychotropic drugs are available only on prescriptions. Studies reported that nonpsychiatrists were responsible for the majority of psychotropic drug prescriptions, and most of these prescriptions were without a psychiatric diagnosis.[368910] Inappropriate prescribing of psychotropic either does not provide any benefit to the patients or can cause serious harm. According to a study by the centers for disease control and prevention, psychotropic medications are often being received by the patients without prior evaluation by any mental health professional.[11] Patients receiving other medication along with psychotropic are at high risk for the occurrence of drug–drug interactions, toxicities, greater side effects, and may mitigate compliance with treatment.[381213]

Several studies have criticized the rationality of psychotropic prescriptions in psychiatric departments.[814] However, there is a dearth of information on the pattern of psychotropic drug use in the nonpsychiatry wards. To understand better about the pattern of prescription of psychotropic medications in the nonpsychiatric inpatient settings, we undertook a survey on the use of psychotropics in the general medicine and surgical wards. The main objective of the study was to assess the use of psychotropic drugs in these wards. In addition, the prevalence, nature, and extent of psychotropic drug use in general medicine and surgical wards were assessed. Furthermore, we assess the indications of these medications in the nonpsychiatric wards.

MATERIALS AND METHODS

A cross-sectional study using convenience sampling was conducted over 6 months from October 2016 to March 2017 in the general medicine and surgical wards of a university teaching hospital in South India. The study was approved by the Institutional Human Ethical Committee. An informed consent form both in English and Kannada has been obtained from the participants willing to participate in the study. All patients admitted to these wards with at least one psychotropic prescription were included in the study. Patients were excluded if they had a previous history of psychiatric illness and/or on regular treatment with the psychotropic or social history of psychotropic drug abuse and intentional/accidental poisoning with psychotropic. We also excluded the patients who are admitted in the neurology department as the psychotropic are widely used in neurology for the United States Food and Drug Administration-approved indications. Patients who are admitted in the surgical or medical intensive care unit were also excluded from the study. To this study, psychotropic drugs are referred as antidepressants, antipsychotics, mood stabilizers, benzodiazepines, drugs for ethanol dependency, and stimulants.

Three Pharm D Interns collected the data from medical and surgery wards from 9 a.m. to 5 p.m. Two of them spend their time in the medicine male and female wards, respectively. While the third person collects the data from both male and female units of surgery. Patients' treatment charts and medications were reviewed on a daily basis for the identification of psychotropic medications. On identification of a psychotropic prescription, all the study specifics such as patient demographics and details of each drug prescribed were collected and analyzed systematically. The enrolled patients were followed up until the day of discharge. The overall and individual drug prevalence in general medicine and surgical wards were calculated.

RESULTS

Of the total admissions in the general medicine and surgical wards, 1800 (24.32%) and 1200 (16.21%) patients were reviewed. Of which, n = 322 (10.73%) patients were prescribed with at least one psychotropic medication. The median duration of the hospital stay of patients was 7 days (range of 1–32 days). Of the total 2140 drugs, 452 were psychotropic medication. The rate of psychotropic drug consumption in the general medicine and surgical wards was 21.38% (n = 344) and 20.34% (n = 108), respectively. Importantly, we found a statistically significant difference between sociodemographic characters and this practice (P > 0.05). We observe a statistically significant association between the practice of psychotropics in male genders and patients who are > 40 years age (P > 0.05). Demographic details of the patients are given in Table 1.

Table 1

Demographic details of study patients

Patient characteristics	Patients with psychotropic (n=322)	Patients without psychotropic (n=2678)	Total (n=3000)	χ2	P
Gender
Male	204 (63.36)	1875 (70.0)	2079 (69.3)	5.99	0.01
Female	118 (36.64)	803 (29.9)	921 (30.7)
Surgery	82 (25.46)	1118 (41.7)	1200 (40)	31.7	<0.001
General medicine	240 (74.53)	1560 (58.25)	1800 (60.)
Age
≤40	145 (45.3)	1362 (50.85)	1507 (50.23)	3.905	0.04
>40	177 (54.9)	1316 (49.14)	1493 (49.76)
Education
Literate	169 (52.4)	1513 (56.4)	1682 (56.6)	1.87	0.170
Illiterate	153 (47.52)	1165 (43.5)	1318 (49.21)
Marital status
Married	250 (77.6)	1988 (74.23)	2238 (74.6)	5.33	0.02
Single	58 (18.)	655 (24.4)	713 (23.7)
Others	14 (4.3)	35 (1.3)	49 (1.6)
Residential area
Urban	141 (43.7)	908 (33.9)	1049 (34.9)	12.34	<0.001
Rural	181 (56.21)	1770 (66.1)	1951 (65.3)
Number of drugs				0.019	0.890
<5	66 (20.4)	418 (15.6)	484 (16.13)
≥5	257 (79.8)	2260 (84.3)	2517 (83.9)

Details of psychotropics

A total of 452 psychotropic drugs were prescribed to 322 patients at an average of 1.40 psychotropic per prescription. Of the 86.96% (n = 280) who received psychotropic during a hospital stay, 59% continued to receive it after discharge also. However, 12.1% (n = 39) received the psychotropic only as a discharge medication. Benzodiazepines and antidepressant (n = 165 [36.50%]), (n = 144 [31.86%]) were the frequently prescribed class of drug in our patients. Details are given in Figure 1.

Figure 1

Distribution of psychotropic drug classes in medical and surgical wards

Escitalopram (n = 55 [15.99%]) and clonazepam (n = 41 [11.92%]) were commonly prescribed in the general medicine, whereas amitriptyline (n = 22 [20.37%]) and levosulpiride (n = 21 [19.44%]) were preferred in surgical wards.

Indication of the psychotropic drugs

A total of n = 452 indications were identified for 322 patients, of which n = 337 (74.56%) and n = 98 (21.68%) were psychiatric and nonpsychiatric indications. Alcohol dependence syndrome (ADS) (n = 90 [26.71%]) and insomnia (n = 78 [23.15%]) were the common psychiatric diagnosis in both units. However, pain (n = 43 [43.87%]) and gastrointestinal (GI) irritation (n = 24 [24.49%]) were common nonpsychiatric indications. The details of indications are presented in Tables 2 and 3.

Table 2

Psychiatric indications of psychotropic

Indications	General medicine (%)	Surgical wards (%)	Total (%)
Alcohol dependence	60 (21.81)	30 (48.39)	90 (26.71)
Insomnia	67 (24.36)	11 (17.74)	78 (23.15)
ISH	61 (22.18)	-	61 (18.10)
Depression	41 (14.91)	12 (19.35)	53 (15.73)
Irritability	16 (5.81)	2 (3.22)	18 (5.34)
Anxiety	9 (3.27)	5 (8.06)	14 (4.15)
Adjustment disorder	8 (2.91)	-	8 (2.37)
Nicotine dependence	5 (1.81)	-	5 (1.48)
Delirium	3 (1.09)	2 (3.22)	5 (1.48)
Bipolar disorders	2 (0.73)	-	2 (0.59)
Panic attack	1 (0.36)	-	1 (0.29)
Psychotic symptoms	1 (0.36)	-	1 (0.29)
Schizoaffective disorder	1 (0.36)	-	1 (0.29)

ISH – Intentional self-harm

Table 3

Nonpsychiatric indications of psychotropic

Indication	General medicine (%)	Surgical wards (%)	Total (%)
Pain	24 (44.44)	19 (43.18)	43 (43.87)
GI irritation	3 (5.55)	21 (47.73)	24 (24.49)
Seizure	15 (27.77)	2 (4.54)	17 (17.37)
Nausea and vomiting	6 (11.11)	1 (2.27)	7 (7.14)
Migraine	4 (7.41)	1 (2.27)	5 (5.10)
Hemichorea	1 (1.85)	-	1 (1.02)
Pseudoseizure	1 (1.85)	-	1 (1.02)

GI – Gastrointestinal

Prescribers versus psychotropic drug class

Nonpsychiatrists (n = 250 [55.3%]) were the common prescribers in our study and benzodiazepines (n = 124 [27.43%]) were the preferred class for nonpsychiatrist, whereas psychiatrist prescribed a different class of psychotropic drugs. A total of n = 19 patients were prescribed with psychotropic fixed drug combinations. Antidepressants with benzodiazepines were the only one fixed drug combinations used in our population, and psychiatrist were the major prescriber. Table 4 gives the details of prescribers.

Table 4

Prescribers versus classes of psychotropic

Psychotropic drug classes	General medicine (n=344), n (%)		Surgery (n=108), n (%)		Total (n=452), n (%)
	Nonpsychiatrist	Psychiatrist	Nonpsychiatrist	Psychiatrist	Nonpsychiatrist	Psychiatrist
Benzodiazepines	110 (31.98)	25 (7.27)	14 (12.96)	16 (14.81)	124 (27.43)	41 (4.07)
Antidepressants	39 (11.34)	75 (21.80)	26 (24.07)	4 (3.70)	65 (14.38)	79 (17.48)
Antipsychotics	27 (7.85)	42 (12.21)	24 (22.22)	13 (12.04)	51 (11.28)	55 (12.17)
Drugs for ethanol dependency	2 (0.58)	9 (2.62)	-	7 (6.48)	2 (0.44)	16 (3.54)
Fixed combination	6 (1.74.)	9 (2.62)	2 (1.85)	2 (1.85)	8 (1.77)	11 (2.43)
Total	184 (53.49)	160 (46.51)	66 (61.11)	42 (38.88)	250 (55.31)	202 (44.69)

DISCUSSION

Psychiatric drugs are the cornerstone for the treatment of psychiatric disorders. However, there is a great world prevalence of consumption of psychiatric drugs by the general population. Monitoring and analyzing the prescribing pattern is a useful tool to improve the clinical practice, saves the drug expenditure, and reduces the medication-related problems. The overall prevalence of psychotropic drug use in the study population was 10.73%. This was considerably lower compared to other studies, wherein it ranged from 35% to 50%.[2358] One of the possible reason could be that, the study site is a mutispecilaity hospital, therefore patients with psychiatric symptoms tend to visit the psychiatry speciality. We observe a statistically significant association between the practice of psychotropics in male genders and patients who are >40 years of age. This probably could be due to the reason that one of the indications of psychotropics in both these units is ADS and it is common in male.

Majority (86.96%) of the patients received psychotropic drugs during hospital stay only. One of the reasons is that in hospital settings, there is a strong emphasis of symptom-based treatment. More than half of the patients continued to receive the hospital-initiated psychotropic even on discharge. We also observed that in limited cases though the psychiatrists had prescribed the drug, the treating clinicians tentatively ceased it. Drug-drug intraction, Adverse drug reactions, marginal psychitaric symptoms, affordability by patients and increased pill burden were the reasons for the cessassation of psychotropices by the treating physcians. This pattern of use of psychotropic drugs must be monitored with care, as it could bring negative repercussions to both individual and group health. Especially, when there is a high risk of occurrence of interaction between medication, possibility of side effects, dependence on use, and causing additional health problems for the individual.

Of the 322 patients on psychotropic, 141 patients were in consultation liaison with the psychiatric department. Patients transferred to the psychiatric ward from medical and surgery were excluded from the study because they were taken the direct care from the psychiatric team. An appreciable number of studies documented that nonpsychiatrist were the common prescribers of psychotropics in general medicine and surgical wards.[38] A similar trend was observed in our study. This would lead to merely symptomatic treatment, delaying the correct treatment and recovery of the patient. Psychiatrists prescribed a wide variety of psychotropic, whereas the nonpsychiatrists prescribed benzodiazepines (31.98%) and antidepressants (11.34%). A study conducted by Oyewumi and Kazarian found a similar trend in the psychiatrist's prescriptions, whereas it was reported that the nonpsychiatrists prescribed mainly antipsychotics and benzodiazepines.[8]

Like other studies,[3] the most extensively used class of drug in general medicine was benzodiazepines. Insomnia, delirium, and irritability were the everyday symptoms observed in our medical inpatients that tip into increased use of benzodiazepine. In addition to the above, the use of benzodiazepines for a wide variety of indications may have led to its high use in general medicine. The high rate of antipsychotics prescription in surgical wards may be due to the use of levosulpiride for GI disturbances and amisulpride for ADS. Interestingly, mood stabilizers and stimulants were not observed in our study populations. Psychotropic medications in the non psychiatrice wards may increases the risk of falls, leads to reduction of independence and quality of life of the patient. This may overload of care responsibilities for family members, as well as costs for the public health care system.

In our study, psychotropic drugs were used mainly for psychiatric indications rather than nonpsychiatric indications. Researchers have confirmed the indication of each prescription by direct contact with the prescriber or the member of the team. If we are not able to find members of the consultation team, nursing care team was our concerned person. We also confirmed the indications by asking the patients for similar complaints. In both wards, psychotropic has been predominantly used for psychiatric indications such as ADS, insomnia, depression, and irritability. It is a routine practice in our settings that patients with a social history of alcohol dependence or abuse were referred for psychiatry opinion irrespective of their reason for admission. This explains ADS being the most common psychiatric indication. The second-most common indication observed in our study was insomnia, and it could be supported with the well-documented evidence that altered sleeping patterns of patients during hospitalization.[15] Several nonpsychiatric conditions are also being treated with a wide variety of psychotropic drugs.[4] For example, antidepressants mainly amitriptyline are the widely accepted treatment for neuropathic pain. GI disturbances being the most common indication in the surgical wards could be due to the high use of antibacterial, anesthetics, and analgesics.

Escitalopram was frequently prescribed in general medicine wards while its use in surgical wards was limited because it was the treatment of choice for three-fourth of the patients with intentional self-harm (ISH) in the medical wards. Patients with suicide attempts are considered ISH if they do not meet the ICD 10 criteria for the diagnosis of depression irrespective of the wards; amitriptyline was preferred choice for prescribers, due to its availability and affordability and approved indications such as pain and insomnia.

Antidepressants with benzodiazepines fixed drug combination was repeatedly used in our settings. Psychiatrists prescribed different combinations, whereas nonpsychiatrists limited their prescriptions to amitriptyline and chlordiazepoxide. This could be obvious with the more expertise of psychiatrists with the use of psychotropic.

This single centred hospital based study was carried out in two nonpsychiatrice departments only. This may restrict the generalization of the data in to other departments. The present research has shown that there is a high prevalence of the use of psychiatric drugs in the medical and surgical clinics under study. This may lead to difficulty in the identification of mental disorders in the early stage by a psychiatrist. We observe a high rate of prescription of benzodiazapines by the nonpsychitrist, that may eventualy lead to the risk of abuse and dependence.

CONCLUSION

Non psychiatrist prescribed a considerable number of psychitropice medications for psychiatric and non psychiatric indiactions. Their prescriptions are resricted to a narrow range of psychotropice medications. Currently, an array of more effective and less side effects psychotropic is available; hence, consultation liaison with psychiatry or continuous medical education for nonpsychiatrist should be highly emphasized for better patient care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.