Hostname: page-component-586b7cd67f-tf8b9 Total loading time: 0 Render date: 2024-11-23T14:18:32.010Z Has data issue: false hasContentIssue false
  • English
  • Français

The DEBIT trial: an intervention to reduce antipsychotic polypharmacy prescribing in adult psychiatry wards – a cluster randomized controlled trial

Published online by Cambridge University Press:  10 September 2007

A. Thompson ,
S. A. Sullivan ,
M. Barley ,
S. O. Strange ,
L. Moore ,
P. Rogers ,
A. Sipos  and
G. Harrison
A. Thompson
Affiliation:
Academic Unit of Psychiatry, University of Bristol, Bristol, UK
S. A. Sullivan*
Affiliation:
Academic Unit of Psychiatry, University of Bristol, Bristol, UK
M. Barley
Affiliation:
Academic Unit of Psychiatry, University of Bristol, Bristol, UK
S. O. Strange
Affiliation:
Academic Unit of Psychiatry, University of Bristol, Bristol, UK
L. Moore
Affiliation:
Cardiff Institute of Society, Health and Ethics, Cardiff University, Cardiff, UK
P. Rogers
Affiliation:
School of Care Sciences, University of Glamorgan, Pontypridd, UK
A. Sipos
Affiliation:
Academic Unit of Psychiatry, University of Bristol, Bristol, UK
G. Harrison
Affiliation:
Academic Unit of Psychiatry, University of Bristol, Bristol, UK
*
*Address for correspondence: Ms S. Sullivan, Academic Unit of Psychiatry, University of Bristol, Bristol BS6 6JL, UK. (Email: [email protected])
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Clinical guidelines advise against prescribing more than one antipsychotic with limited exceptions. Despite this, surveys continue to report high antipsychotic polypharmacy rates. The aim of the study was to investigate the effectiveness of a multi-faceted intervention in reducing prescribing of antipsychotic polypharmacy on general adult psychiatry wards, compared with guidelines alone.

Method

A pragmatic cluster randomized controlled trial recruited 19 adult psychiatric units (clusters) from the South West of England. Participants were all ward doctors and nurses. The multi-faceted intervention comprised: an educational/CBT workbook; an educational visit to consultants; and a reminder system on medication charts.

Results

The odds of being prescribed antipsychotic polypharmacy in those patients prescribed antipsychotic medication was significantly lower in the intervention than control group when adjusted for confounders (OR 0.43, 95% CI 0.21–0.90, p=0.028). There was considerable between-unit variation in polypharmacy rates and in the change in rates between baseline and follow-up (5 months after baseline).

Conclusion

The intervention reduced levels of polypharmacy prescribing compared to guidelines alone although the effect size was relatively modest. Further work is needed to elicit the factors that were active in changing prescribing behaviour.

Keywords

Antipsychoticsevidence-based guidelinespolypharmacyrandomized controlled trial
Type
Original Articles
Information
Psychological Medicine , Volume 38 , Issue 5 , May 2008 , pp. 705 - 715
Copyright
Copyright © Cambridge University Press 2007

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

APA (2004). Practice Guideline for the Treatment of Patients with Schizophrenia. American Psychiatric Association: Washington, DC.Google Scholar
Avorn, J, Soumerai, SB, Everitt, DE, Ross-Degnan, D, Beers, MH, Sherman, D, Salem-Schatz, SR, Fields, D (1992). A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes. New England Journal of Medicine 327, 168–173.CrossRefGoogle ScholarPubMed
Barley, M, Pope, C, Chilvers, R, Sipos, A, Harrison, G (in press). Psychiatrists' attitudes to clinical practice guidelines for the pharmacological treatment of schizophrenia: a qualitative study. Journal of Mental Health.Google Scholar
Berings, D, Blondeel, L, Habraken, H (1994). The effect of industry-independent drug information on the prescribing of benzodiazepines in general practice. European Journal of Clinical Pharmacology 46, 501–505.CrossRefGoogle ScholarPubMed
Bero, LA, Grilli, R, Grimshaw, JM, Harvey, E, Oxman, AD, Thomson, MA (1998). Getting research findings into practice: closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. British Medical Journal 317, 465–468.CrossRefGoogle Scholar
Canadian Psychiatric Association (1998). Canadian Clinical Practice Guidelines for the Treatment of Schizophrenia. Canadian Journal of Psychiatry 43 (Suppl. 2), S25–S40.CrossRefGoogle Scholar
Centorrino, F, Eakin, M, Bahk, W-M, Kelleher, JP, Goren, J, Salvatore, P, Egli, S, Baldessarini, RJ (2002). Inpatient antipsychotic drug use in 1998, 1993 and 1989. American Journal of Psychiatry 159, 1932–1935.CrossRefGoogle ScholarPubMed
Chilvers, R, Harrison, G, Sipos, A, Barley, M (2002). Evidence into practice: application of psychological models of change in evidence-based implementation. British Journal of Psychiatry 181, 99–101.Google ScholarPubMed
Donner, A, Klar, N (2000). Analysis of binary outcomes. In Design and Analysis of Cluster Randomised Trials in Health Research, pp. 79–110. Arnold: London.Google Scholar
Ereshefsky, L (1999). Pharmacologic and pharmacokinetic considerations in choosing an antipsychotic. Journal of Clinical Psychiatry 60 (Suppl. 10), 20–30.Google ScholarPubMed
Forensic Psychology Practice Ltd (1999). Working with Sex Offenders. Forensic Psychology Practice Ltd: London.Google Scholar
Freemantle, N, Nazareth, I, Eccles, M, Wood, J, Haines, A (2002). A randomised controlled trial of the effect of educational outreach by community pharmacists on prescribing in UK general practice. British Journal of General Practice 52, 290–295.Google ScholarPubMed
Freudenreich, O, Goff, DC (2002). Antipsychotic combination therapy in schizophrenia. A review of efficacy and risks of current combinations. Acta Psychiatrica Scandinavica 106, 323–330.CrossRefGoogle ScholarPubMed
Gill, PS, Makela, M, Vermeulen, KM, Freemantle, N, Ryan, G, Bond, C, Thorsen, T, Haaifer-Ruskamp, FM (1999). Changing doctor prescribing behaviour. Pharmacy World and Science 21, 158–167.CrossRefGoogle ScholarPubMed
Grimshaw, JM, Eccles, MP, Walker, AE, Thomas, RE (2002). Changing physicians' behavior: what works and thoughts on getting more things to work. Journal of Continuing Education in the Health Professions 22, 237–243.CrossRefGoogle ScholarPubMed
Harrington, M, Lelliott, P, Paton, C, Okacha, C, Duffett, R, Sensky, T (2002). The results of a multi-centre audit of the prescribing of antipsychotic drugs for in-patients in the UK. Psychiatric Bulletin 26, 414–418.CrossRefGoogle Scholar
Hogman, G, Sandamas, G (2000). A Question of Choice. NSF: London.Google Scholar
Ito, H, Koyama, A, Higuchi, T (2005). Polypharmacy and excessive dosing: psychiatrists' perceptions of antipsychotic drug prescription. British Journal of Psychiatry 187, 243–247.CrossRefGoogle ScholarPubMed
Joint Formulary Committee (2003). British National Formulary, 46th edn. British Medical Association and Royal Pharmaceutical Society of Great Britain: London.Google Scholar
Joint Formulary Committee (2004). British National Formulary, 47th edn. British Medical Association and Royal Pharmaceutical Society of Great Britain: London.Google Scholar
McGorry, P, Killackey, E, Elkins, K, Lambert, M, Lambert, T (2003). Summary Australian and New Zealand clinical practice guideline for the treatment of schizophrenia. Australian Psychiatry 11, 136–158.CrossRefGoogle Scholar
MRC (2000). A Framework for Development and Evaluation of RCTs for Complex Interventions to Improve Health. Medical Research Council: London.Google Scholar
NICE (2002). Guidance on the Use of Newer (Atypical) Antipsychotic Drugs for the Treatment of Schizophrenia. Technology appraisal Guidance No. 43. National Institute for Clinical Excellence: London.Google Scholar
Oxman, AD, Thomson, MA, Davis, DA, Haynes, RB (1995). No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. Canadian Medical Association Journal 153, 1423–1431.Google ScholarPubMed
Prochaska, JO, DiClemente, CC (1986). Towards a Comprehensive Model of Change. In Treating Addictive Behaviours: Processes of Change (ed. Miller, W. R. and Heather, N.), pp. 3–27. Plenum Press: New York.CrossRefGoogle Scholar
Rawson, RA (1999). Treatment for Stimulant Use Disorders: Treatment Improvement Protocol (TIP) Series 33. Rockville, MD: U.S. Department of Health and Human Services.Google Scholar
Ray, WA, Blazer, DG, Schaffner, W, Federspiel, CF (1987). Reducing antipsychotic drug prescribing for nursing home patients: a controlled trial of the effect of an educational visit. American Journal of Public Health 77, 1448–1450.CrossRefGoogle ScholarPubMed
Sipos, A (2004). Preparing the way for evidence based implementation: A pharmacoepidemiological study of antipsychotic prescribing practice informing the design of a cluster randomised trial (Thesis). University of Bristol.Google Scholar
Soumerai, SB, Avorn, J (1990). Principles of educational outreach (‘academic detailing’) to improve clinical decision making. Journal of the American Medical Association 263, 549–556.CrossRefGoogle ScholarPubMed
Stahl, SM (2002). Antipsychotic polypharmacy: evidence based or eminence based? Acta Psychiatrica Scandinavica 106, 321–322.CrossRefGoogle ScholarPubMed
Taylor, D, Mace, S, Mir, S, Kerwin, R (2000). A prescription survey of the use of atypical antipsychiotics for hospital inpatients in the United Kingdom. International Journal of Psychiatry in Clinical Practice 4, 41–46.Google Scholar
Thomson O'Brien, MA, Oxman, AD, Davis, DA, Haynes, RB, Freemantle, N, Harvey, EL (1997). Educational outreach visits: effects on professional practice and health care outcomes. The Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD000409. doi: 10.1002/14651858.CrossRefGoogle Scholar
Van Eijk, EC, Avorn, J, Porsius, AJ, de Boer, A (2001). Reducing prescribing of highly anticholingeric antidepressants for elderly people: randomised trial of group versus individual academic detailing. British Medical Journal 322, 654–657.CrossRefGoogle Scholar
Wensing, M, Van Der Weijden, T, Grol, R (1998). Implementing guidelines and innovations in general practice: which interventions are effective? British Journal of General Practice 48, 991–997.Google ScholarPubMed