|Year : 2020 | Volume
| Issue : 2 | Page : 175-180
A drug utilization study of psychotropic drugs in indoor patients of psychiatry department in a tertiary care hospital
Sunita Jaiprakash Ramanand1, Pawan Vilas Khot2, Jaiprakash Bharama Ramanand3, Smita Laxman Gaidhankar1
1 Department of Pharmacology, R.C.S.M. Government Medical College, Kolhapur, Maharashtra, India
2 Department of Psychiatry, R.C.S.M. Government Medical College, Kolhapur, Maharashtra, India
3 Department of Pharmacology, Shri Bhausaheb Hire Government Medical College, Dhule, Maharashtra, India
|Date of Submission||07-Apr-2020|
|Date of Decision||12-Jul-2020|
|Date of Acceptance||20-Jul-2020|
|Date of Web Publication||25-Nov-2020|
Dr. Smita Laxman Gaidhankar
Flat No. A-103, Bluebell Apartment, New Tarabai Park, Karande Mala, Kolhapur - 416 003, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: The rapidly expanding field of psychopharmacology is challenging the traditional concepts of treatment and constantly seeking new drugs to treat psychiatric disorders. There is a sparse work on the utilization of psychotropic drugs in indoor patients. Hence, the present study was planned to add to the existing knowledge of the utilization of psychotropic drugs. Aims: The aims of were to study the drug utilization of psychotropic drugs in the indoor patients of psychiatry department and to evaluate it according to the World Health Organization core drug use prescribing indicators. Settings and Design: This was an observational study in indoor patients of psychiatry department in a medical college. Materials and Methods: In this study, patients of all age groups diagnosed with psychiatric disorder admitted to the psychiatry department were included. The data were collected from 300 prescriptions over 6 months. Data were analyzed using descriptive statistics. Results: In 300 prescriptions, 61.98% were psychotropic drugs and average number of drugs per prescription was five. The percentage of drugs prescribed by generic name and from the essential drug list was 52.93% and 60.9%, respectively. The most common diagnosis was schizophrenia (55.6%), followed by mood disorders (26.6%). The most commonly prescribed drugs for schizophrenia, bipolar disorders, and depression were olanzapine (71.85%), sodium valproate (71.4%), and escitalopram (51.6%), respectively. Conclusion: Most of the drugs were used in accordance with standard guidelines given by the Indian Psychiatric Society. The percentage of drugs prescribed by generic names and from the National List of Essential Medicines (NLEM) needs to be increased. Olanzapine, which is not included in NLEM, was commonly prescribed psychotropic drug
Keywords: Drug utilization, indoor patients, psychotropic drugs
|How to cite this article:|
Ramanand SJ, Khot PV, Ramanand JB, Gaidhankar SL. A drug utilization study of psychotropic drugs in indoor patients of psychiatry department in a tertiary care hospital. Ann Indian Psychiatry 2020;4:175-80
|How to cite this URL:|
Ramanand SJ, Khot PV, Ramanand JB, Gaidhankar SL. A drug utilization study of psychotropic drugs in indoor patients of psychiatry department in a tertiary care hospital. Ann Indian Psychiatry [serial online] 2020 [cited 2021 Apr 20];4:175-80. Available from: https://www.anip.co.in/text.asp?2020/4/2/175/301430
| Introduction|| |
The World Health Organization (WHO) defines drug utilization as “the marketing distribution, prescription, and use of drugs in society, with special emphasis on the resulting medical, social, and economic consequences. Drug utilization studies aim to evaluate factors related to the prescribing, dispensing, administering, and its associated events either beneficial or adverse. The scope of drug utilization studies is to evaluate the present state and trends of drug usage to estimate the drug expenditure, appropriateness of prescriptions, and adherence to evidence-based recommendations.
Indiscriminate use of drugs may result in unwanted side effects and drug interactions along with increase in economic burden. The principle aim of the drug utilization research is to facilitate the rational use of drugs. Knowledge of how drugs are being prescribed helps to improve prescribing habits. Drug utilization studies are a prerequisite for the formulation of drug policy.
Psychotropic drugs have had a remarkable impact in psychiatric practice. However, their utilization in clinical practice, effectiveness, and safety in real-life situation need continuous study. The rapidly expanding field of psychopharmacology is challenging the traditional concepts of psychiatric treatment and research and is constantly seeking new and improved drugs to treat psychiatric disorders. It is likely that patients in psychiatry ward may have comorbid ailments and are exposed to drugs other than psychotropics rendering to drug interactions.
But very very few studies are available in indoor patients of psychiatry. Most of the studies have been conducted in outdoor patients. Hence the present study was planned to add to the existing knowledge of utilization of psychotropic drugs in indoor patients.
| Materials and Methods|| |
The present work was an observational study. Patients of all age groups diagnosed with psychiatric disorder admitted to the psychiatry department in a medical college attached to the tertiary care hospital were included in the study. Approval from the Institutional Ethics Committee and written informed consent from patients were obtained. In patients who lacked the mental capacity to give consent, the consent was obtained from legally acceptable representative. Confidentiality was maintained throughout the study. The objectives were to study the drug utilization of psychotropic and other drugs in the indoor patients of psychiatry ward and to evaluate the drug utilization according to the WHO core drug use prescribing indicators. Data of prescriptions were collected from patient case paper over 6-month period. A prescription or an encounter was considered as written order for drugs in the patient's case paper, given by the doctor for 1 day. Prescriptions were collected daily from admission to discharge from each patient. Hence, the number of prescriptions from each patient equals to number of days the patient was admitted in the ward. Data of 59 patients (male – 35 and female – 24) including 300 prescription orders were recorded and analyzed. The number of prescribed drugs was 1515.
The detailed information about drugs prescribed during the entire hospital stay such as number of drugs prescribed per prescription, number of antibiotics prescribed, number of injections prescribed, use of generic/brand names, and duration of treatment was retrieved from medical and nursing charts. Data of patients who died or sought discharge against medical advice within 24 h of admission were excluded.
Drug utilization data were analyzed with respect to the WHO core indicators. Classification of disease was as per the International Classification of Diseases-10 given by the WHO.
Data were recorded in predesigned Microsoft Excel and analyzed using descriptive statistics. The sum total of percentage exceeds hundred as some patients received >1 drug.
| Results|| |
Characteristics of the study participants
The relative distribution of different psychiatric disorders in different age groups is shown in [Table 1]. The percentage of male and female patients was 59.3% and 40.67%, respectively.
|Table 1: Distribution of psychiatric disorders across different age groups (n=59)|
Click here to view
Pattern of psychiatric disorders
[Table 2] shows the pattern of psychiatric disorders. Fifty-five percent of prescriptions were of schizophrenia, 26.6% of mood disorders, 17.7% of depression, and 16.8% of anxiety.
|Table 2: Percentage of prescriptions in different psychiatric disorders (n=300)|
Click here to view
[Table 3] shows the analysis of prescription patterns according to the WHO drug use indicators.
The percentage of different drugs used in different psychiatric disorders is shown in [Table 4], [Table 5], [Table 6], [Table 7] and [Graph 1].
|Table 5: Percentage of drugs used in schizophrenia, schizotypal and delusional disorders (n=167)|
Click here to view
|Table 7: Percentage of drugs used in mental and behavioral disorders due to psychoactive substance use (n=35)|
Click here to view
| Discussion|| |
In the present study, prescription data of 59 patients admitted to the psychiatry ward were analyzed. The maximum number of patients belonged to the age group of 20–40 years [Table 1]. The percentage of male and female patients was 59.3% and 40.67%, respectively.
Pattern of psychiatric disorders
[Table 2] shows the pattern of psychiatric disorders. The frequencies of disorders in descending order were schizophrenia, schizotypal, and delusional disorders (55.6%), followed by mood disorders (26.6%); mental and behavioral disorders due to psychoactive substance use (11.6%) and neurotic, and stress-rapid or somatoform disorders (5%).
Analysis of prescription patterns according to various who drug use indicators
[Table 3] shows analysis of prescription patterns according to the WHO drug use indicators. In the present study, the number of drugs in 300 prescriptions was 1515. Of these, 939 (61.98%) were psychotropic drugs. The other co-prescribed drugs were multivitamins, ranitidine, antimicrobials, intravenous fluids, antihypertensives, antitussives, and antihistaminics prescribed for the treatment of associated conditions. The average number of drugs per prescription in the present study was five. On excluding drugs other than psychotropic drugs, the average number per prescription was three. Previous studies on psychotropic drugs in the outpatient department have reported an average number of drugs per prescription ranging from 2.3 to 3.,, Restricting average number of drugs per prescription as low as possible is always preferable to reduce the risk of drug-drug interactions, development of drugs resistance, poor patient compliance, and adverse drug events.
In the present study, the percentage of drugs prescribed by generic name was lesser (52.93%) as compared to the study reported (76%) by Thakkar et al. Greater tendency to prescribe by generic name rather than brand name has various benefits like low cost of drug therapy, increased patient adherence, and equivalent therapeutic benefits. This finding substantiates the need for intervention to improve prescribing practices of physicians.
The percentage of encounters with antibiotic was 11% and with an injection was 30%. Previous outpatient department study on psychotropic drugs has reported 2.2% encounters with injections. The high percentage of injectables in the present study may be attributed to the possibility that admitted patients had acute conditions. The injections prescribed were haloperidol in schizophrenics and lorazepam to treat alcohol withdrawal seizures. The present study shows that 60.9% of drugs prescribed were from the National list of Essential Medicines (NLEM). In a study of psychotropic drugs in the outpatient department, Chawla et al. have reported that 87% of drugs were prescribed from NLEM. The most commonly prescribed antipsychotic drug in the present study was olanzapine, followed by trifluoperazine both of which are not included in NLEM. The findings propose inclusion of olanzapine in NLEM giving due consideration to its adverse reactions. Another way to deal with this finding is to increase the awareness about NLEM in prescribers.
Observed drug use pattern in schizophrenia
The most commonly prescribed drugs were second-generation antipsychotics (SGAs)/atypical antipsychotics, namely olanzapine (71.85%), risperidone (5.9%), and clozapine (4.7%), followed by first-generation antipsychotics (FGAs)/conventional antipsychotics, namely trifluoperazine (17.9%) and haloperidol (12.5%]. SGAs were preferred by the prescribers in this center as they are associated with lesser extrapyramidal side effects. Thakkar et al. report more use of FGAs/conventional antipsychotics such as trifluoperazine, haloperidol, and chlorpromazine. The treatment guidelines on schizophrenia by the Indian Psychiatric Society (IPS) state that there is very little difference in terms of efficacy, adherence, and other subjective aspects between the FGA and the SGA group or between individual antipsychotics belonging to either group. The only exception to this trend is clozapine, which appears to be more efficacious than any other antipsychotic in patients with treatment resistance. The choice of the antipsychotic depends on factors other than efficacy such as past treatment response, cost of treatment, psychiatric comorbidity, medical comorbidity, side effects, and treatment resistance.
The treatment guidelines on schizophrenia by the IPS state that there is limited evidence for the efficacy of combination of antipsychotics. In the present study, the percentage of monotherapy was 45.5%, combination of two drugs was 20.35%, and combination of three drugs was 17.35%. Kim et al. have reported that majority (79.7%) of patients were treated with a single antipsychotic drug, while 19.2% were prescribed two antipsychotic drugs and 1.2% were prescribed three antipsychotic drugs. Guidelines recommend that combinations should be used on as required basis and for the shortest possible time. Combinations of antipsychotics for prolonged periods should be avoided, except in patients not responding to clozapine.
The treatment guidelines on schizophrenia by the IPS state that although antipsychotic agents are the mainstay of treatment of schizophrenia, management may involve use of adjunctive treatments with antidepressants, mood stabilizers, or benzodiazepines. However, these can be used with proper rationale and for the shortest possible duration. In the present study, sodium valproate was prescribed as mood stabilizers in 31.73% patients in agitated, overactive patients or those with affective symptoms responding poorly to their current drug. Benzodiazepines such as clonazepam (43.11%) and lorazepam (14.9%) were co-prescribed for managing agitation and sleep disturbance. Antidepressants such as escitalopram (22.15%) and sertraline (21.55%) were co-prescribed for managing postpsychotic depression. Prophylactic use of anticholinergics is not recommended by the IPS. Treatment with anticholinergics should be practiced when the patient actually develops extrapyramidal side effects. In the present study, central anticholinergic trihexyphenidyl was prescribed in 33.5% of patients who developed extrapyramidal side effects. It was not used prophylactically. The fixed-dose combination (FDC) of trifluoperazine and benztropine was used in 17.9% of prescriptions. This FDC was used, as extrapyramidal side effects may be associated with trifluoperazine, and this FDC is available in government supply in our institute.
Observed drug use pattern in mood disorders
Among the Mood disorders, 31 patients were suffering from major depressive disorder. The antidepressants prescribed most commonly were selective serotonin reuptake inhibitors (SSRIs), namely escitalopram (51.61%), followed by sertraline (41.9%). A study done in indoor patients suffering from major depression also reports SSRIs as the most commonly prescribed antidepressants in 68.62%, followed by tricyclic antidepressants in 19.60%. According to the current recommendations of the American Psychiatric Association and National Institute for Health and Clinical Excellence (NICE) in the management of mood disorders, SSRIs are preferred because of safer adverse-effect profile and better compliance., Monoamine oxidase inhibitors were not prescribed. This could be because of cardiovascular risk and drug interactions. In this study, antipsychotics were prescribed for associated psychotic symptoms in patients suffering from major depressive disorder, and the most commonly prescribed antipsychotic was olanzapine in 16 (51.61%) prescriptions. Benzodiazepines (clonazepam) were co-prescribed in 25 (80.64%) prescriptions.
The treatment guidelines on bipolar mood disorders by the IPS recommend that the mainstay of management of bipolar mood disorders is mood stabilizers such as lithium, valproate, lamotrigine, and carbamazepine/oxcarbazepine. In the present study, among the drugs used in bipolar mood disorders, valproate (71.4%) was the most commonly prescribed mood stabilizer followed by carbamazepine (11.9%). Lithium was not used in any patient of bipolar disorder. Although lithium is the best mood stabilizer and has antisuicidal effects, it was not prescribed because this is a government setup where drugs available in hospital pharmacy are prescribed. Tablet lithium is not available in this hospital pharmacy and it does not have facility to monitor serum lithium levels. In contrast to this, in a study conducted by Piparva et al., in Gujarat in 2011, it was found that lithium was used extensively in about 54% of patients diagnosed with bipolar disorders.
Observed drug use pattern in mental and behavioral disorders due to psychoactive substance use
The most common mental and behavioral disorders due to psychoactive substance use were due to alcohol use. The most commonly prescribed drug was antipsychotic was olanzapine (91.4%), followed by haloperidol (40%) which were used to treat alcohol-induced psychosis followed by benzodiazepine (lorazepam – 80%) which was used to treat alcohol withdrawal seizures. A systematic review suggests that there is adequate evidence that patients with alcohol-induced psychosis show a favorable response to antipsychotic medication. Both first- and second-generation drugs appear to be effective.
Observed drug use pattern in anxiety disorders
SSRIs namely fluoxetine (66.6%) and escitalopram (33.3%) were the most commonly prescribed drugs for anxiety disorders, followed by benzodiazepines such as Clonazepam (80%) and lorazepam (20%). This is in accordance with the NICE guidelines for the management of anxiety disorders which state that SSRIs or serotonin norepinephrine reuptake inhibitors should be offered to the patient first. Benzodiazepines can be reasonably used as an adjunct in the initial stage, while SSRIs are titrated to an effective dose, and they can then be tapered over 4–12 weeks, while the SSRI is continued.
| Conclusion|| |
In the present study on the utilization of psychotropic drugs in indoor patients of the psychiatric ward, schizophrenia was the most common diagnosis followed by mood disorders. There is a need to increase the percentage of drugs prescribed by generic names. The percentage of drugs prescribed from NLEM is less. Olanzapine, which is not included in NLEM, was commonly prescribed psychotropic drugs. Olanzapine should be included in NLEM.
This study was approved by the Institutional Ethics Committee with reference number RCSMGMCK/Pharmac/ethics Comm/1072/2019 obtained on April 4, 2019.
Declaration of patient consent
Patient consent statement was obtained from each patient as per the institutional ethics committee approval along with consent obtained for participation in the study and publication of the scientific results/clinical information/image without revealing their identity, name, or initials. The patient is aware that confidentiality would be maintained.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Baldessarini RJ, Tarazi FI. Pharmacotherapy of psychosis and mania. In: Hardman JG, Limbird LE, Gilman AG, editors. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 11th
ed.. New York: McGraw-Hill; 2006. p. 429-54.
How to Investigate Drug use in Health Facilities: Selected Drug use Indicators-EDM Research Series No. 007. Geneva: World Health Organization; 1993. Available from: http://apps.who.int/medicinedocs/en/d/Js2289e/
. [Last accessed on 2019 Oct 15].
Piparva KG, Parmar DM, Singh AP, Gajera MV, Trivedi HR. Drug utilization study of psychotropic drugs in outdoor patients in a teaching hospital. Indian J Psychol Med 2011;33:54-8.
] [Full text]
Dutta SB, Dhasmana DC, Bhardwaj R. Psychotropic drug utilization pattern among patients with schizophrenia. Indian J Psychiatry 2005;47:243-4.
] [Full text]
Lahon K, Shetty H, Paramel A, Sharma G. Retrospective drug utilization study of antidepressants in the psychiatric unit of a tertiary care hospital. J Clin Diagnostic Res 2011;5:1069-75.
Thakkar KB, Jain MM, Billa G, Joshi A, Khobragade AA. A drug utilization study of psychotropic drugs prescribed in the psychiatry outpatient department of a tertiary care hospital. J Clin Diagn Res 2013;7:2759-64.
Haas DM, Imperiale TF, Kirkpatrick PR, Klein RW, Zollinger TW, Golichowski AM. Tocolytic therapy: A meta-analysis and decision analysis. Obstet Gynecol 2009;113:585-94.
Chawla S, Agarwal M, Sharma S, Jiloha R. A Drug utilization study of psychotropic drugs among the psychiatric outpatients in a tertiary care hospital. Indian J Pharm Sci 2017;79:112-20.
Grover S, Chakrabarti S, Kulhara P, Avasthi A. Clinical practice guidelines for management of schizophrenia. Indian J Psychiatry 2017;59:S19-33.
Kim HY, Lee HW, Jung SH, Kang MH, Bae JN, Lee JS, et al
. Prescription patterns for patients with schizophrenia in Korea: A focus on antipsychotic polypharmacy. Clin Psychopharmacol Neurosci 2014;12:128-36.
Thakare V, Dubey L. Observational study of drug use pattern in indoor patients suffering from major depression admitted in psychiatry department of tertiary care teaching hospital. Int J Basic Clin Pharmacol 2018;7:1808-11.
NICE. Depression in Adults (update) (CG90). National Institute for Health and Clinical Excellence. National Collaborating Centre for Mental Health; 2009. Available from: http://guidance.nice.org.uk/CG90
. [Last accessed on 2012 Nov 03].
Balon R, Mufti R, Arfken CL. A survey of prescribing practices for monoamine oxidase inhibitors. Psychiatr Serv 1999;50:945-7.
Shah N, Grover S, Rao GP. Clinical practice guidelines for management of bipolar disorder. Indian J Psychiatry 2017;59:S51-66.
Masood B, Lepping P, Romanov D, Poole R. Treatment of alcohol-induced psychotic disorder (Alcoholic Hallucinosis)-a systematic review. Alcohol Alcohol 2018;53:259-67.
NICE. Anxiety (CG22). National Institute for Health and Clinical Excellence. National Collaborating Centre for Mental Health; 2011. Available from: http://guidance.nice.org.uk/CG113
. [Last accessed on 2020 Jan 03].
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]