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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 67-73

Prescription Pattern, follow-up pattern, and medication adherence in psychiatric outpatients


1 Department of Psychiatry, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Department of Statistics, Pondicherry University, Puducherry, India

Date of Submission28-Dec-2020
Date of Decision11-Feb-2021
Date of Acceptance12-Feb-2021
Date of Web Publication18-Jun-2021

Correspondence Address:
Dr. Parthasarathy Ramamurthy
Department of Psychiatry, Pondicherry Institute of Medical Sciences (A Unit of Madras Medical Mission), Kalathumettupathai, Ganapathichettikulam, Village No. 20, Kalapet, Puducherry - 605 014
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_146_20

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  Abstract 


Background: Drug utilization research on psychotropic drug use facilitates rational prescriptions in psychiatric patients. Low follow-up rates and nonadherence to psychotropic medications are key challenges in psychiatry. The objective of this study was to determine the prescription pattern of psychotropic medications, the follow-up pattern, and medication adherence in psychiatric outpatients. Materials and Methods: In this retrospective observational study, the prescription pattern and number of follow-ups were abstracted for each new psychiatric outpatient for a period of 6 months from the time of the first assessment. In addition, medication adherence was assessed using a secondary database analysis. A continuous measure of medication acquisition (CMA) was calculated and those patients with CMA of 0.8 or more were considered adherent. Results: A total of 317 patients were included in the study. At the first visit, 198 patients (62.46%) were prescribed two psychotropic medications. Out of the total sample, 157 (49.53%) were prescribed once-daily medication and 151 (47.63%) received twice-daily medication. During the follow-up visits, the primary medication was changed in 40 (12.62%) patients and polypharmacy was used in 23 (7.26%) patients. After the initial visit, 138 (43.53%) patients did not come for even a single follow-up visit. Only 50 (15.77%) patients had a medication prescription for at least 80% of the study period. Conclusion: Olanzapine, escitalopram, sertraline, and clonazepam were the most commonly prescribed psychotropic medications. Most patients were prescribed two psychotropic medications which included one benzodiazepine. However, polypharmacy was an uncommon practice. Follow-up rate and medication adherence were poor across different diagnostic categories.

Keywords: Anxiety disorder, depressive disorder, drug prescription, medication persistence, psychotic disorder


How to cite this article:
Ramamurthy P, Alexander A, Solomon S, Thilakan P, Rudravaram VV. Prescription Pattern, follow-up pattern, and medication adherence in psychiatric outpatients. Ann Indian Psychiatry 2021;5:67-73

How to cite this URL:
Ramamurthy P, Alexander A, Solomon S, Thilakan P, Rudravaram VV. Prescription Pattern, follow-up pattern, and medication adherence in psychiatric outpatients. Ann Indian Psychiatry [serial online] 2021 [cited 2021 Aug 5];5:67-73. Available from: https://www.anip.co.in/text.asp?2021/5/1/74/318677




  Introduction Top


Drug utilization research provides insights into the pattern of drug use and facilitates the rational use of drugs in psychiatric patients.[1] The prescription pattern of psychotropic medication has been studied extensively in India.[2],[3],[4] Olanzapine, escitalopram, and clonazepam are the most commonly prescribed antipsychotic, antidepressant and benzodiazepine respectively.[2] These and other studies[5],[6] that studied the prescription pattern of psychotropic drugs in the Indian context used a cross-sectional design and did not analyze longitudinal prescription data at an individual patient level. Such longitudinal data can inform clinicians and researchers regarding changes in therapy, duration of treatment, concordance with treatment, coprescribing, and health outcomes.[1]

Low follow-up rates and nonadherence to psychotropic medications are key challenges in psychiatry. Various markers of poor outcomes including higher hospital admissions, higher rates of aggression, suicide, and premature mortality are associated with nonadherence to psychotropic medications.[7] More than half the psychiatric outpatients drop out after the first visit[8],[9] and about half of major psychiatric disorder patients are nonadherent to their psychotropic medication.[10] The studies on nonadherence to psychotropic medications used subjective measures such as self-reported rating scales.[11],[12] Although self-reported scales on adherence provide valuable information, they have certain disadvantages including underreporting, and their use should be complemented with objective measures of adherence.[13]

In the above context, the present study was conducted with the objectives of determining the prescription pattern of psychotropic medications, the follow-up pattern, and medication adherence in psychiatric outpatients.


  Materials and Methods Top


This was a retrospective observational study conducted in a tertiary care teaching hospital in South India. In this setup, patients who visit the psychiatric outpatient department for the first time undergo a detailed assessment by a team of postgraduate and consultant. At the end of the assessment, the clinical details and the prescription are entered in the Hospital Information Management System (HIMS). Thereafter, the follow-up assessment notes and the corresponding prescriptions are periodically updated in the HIMS. The study was approved by Institute Ethics Committee IEC: RC/19/122.

The outpatient records of all patients who underwent detailed assessment in the psychiatry outpatient department from January 1, 2019 to August 31, 2019 were screened for eligibility. Psychiatric outpatients of both genders with an International Classification of Diseases-10 diagnosis of psychotic disorders (F20 to F29), depressive disorders (F32, F33, and F34.1), or anxiety disorders (F40 to F42) were considered eligible for the study. Patients from rehabilitation homes and those with grossly incomplete records were excluded. Longitudinal data of eligible participants were collected for 6 months from the time of the first assessment. The data collection was done during April and May 2020. The study period was planned so that the follow-up period of the participants did not fall under the national lockdown imposed due to COVID-19. The follow-up period for the last included patient ended on February 29, 2020 much before the lockdown was imposed.

The data collection was done by the first three investigators after a period of initial training to ensure inter-rater reliability. The investigators had full access to the assessment notes and the prescriptions of all participants.

The relevant sociodemographic and clinical characteristics were recorded in a semi-structured pro forma. The following data were abstracted from the first prescription issued to the patient: number of psychotropic medications, drug name, frequency of use of drug, and duration of treatment. From the follow-up prescriptions, information on primary medication change (i.e., change of antipsychotic in psychotic disorders, change of antidepressants in depressive disorders, and change of anti-anxiety medication in anxiety disorders), polypharmacy use (i.e., two antipsychotics in psychotic disorders, two antidepressants in depressive disorders, and two antianxiety medications in anxiety disorders), and benzodiazepine use were obtained. The number of follow-up visits for each patient during the study period was counted.

A continuous measure of medication acquisition (CMA) was used as an indirect indicator of adherence. For each patient, all the prescriptions issued during the study period were reviewed and the cumulative duration for which the patient would have had a supply of psychotropic medication (s) was computed and this number was divided by 180 (follow-up period for each patient) to give CMA. The value could range from zero to one. The patients who had CMA of 0.8 or more were considered to have an acceptable level of medication adherence.

In addition to adherence, medication persistence was assessed as a continuous measure using the refill sequence model (RSM). The interval between the first prescription and the point at which an unacceptable gap between prescriptions occurred was considered a measure of persistence. A gap for 30 days without any psychotropic medication supply was considered unacceptable. Thus, the number of days between the first prescription and the late date of medication supply before an unacceptable gap of 30 days was calculated for each patient by reviewing the prescriptions issued.

The sample size was calculated based on the following assumptions. Assuming the proportion of patients with at least one follow-up to be 50% (estimate based on a study from Ludhiana, India[9]) and the proportion of nonadherence to be 50% (estimate based on previous studies on nonadherence to psychotropic medications[10],[11]), the sample size was calculated to be 97 for each group to detect similar proportions with a 10% precision and 95% confidence interval. Hence, the data collection was carried out till a sample size of at least 97 patients in each diagnostic category was achieved.

Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) software version 19 (IBM Corp., Armonk, NY, USA). Frequencies and percentages were used to summarize categorical data. Continuous variables were represented as means and standard deviations. Nonnormal data were summarized as medians and interquartile ranges. An exploratory data analysis was conducted to compare the follow-up pattern and measures of adherence between the three diagnostic groups. The number of follow-ups, adherence as measured by CMA and persistence as measured by RSM were compared between the three diagnostic groups using Kruskal–Wallis H test as the data were nonnormally distributed. The proportion of patients with acceptable adherence was compared between the three diagnostic groups using the Chi-square test of independence.


  Results Top


A total of 880 outpatient records were screened and 317 (36%) were found to be eligible for the study. The flowchart of participant selection and the reasons for exclusion are summarized in [Figure 1]. The mean age of the participants was 38.82 (standard deviation [SD] – 13.68) years. More than half of them were female. About one-fourth had a graduate-level education or higher. A substantial proportion (42%) was unemployed. Two-thirds of the participants were married. Hypertension and diabetes mellitus were the most common medical comorbidities and were present in one-third of the participants. Out of the 39 patients who required admission, 27 were diagnosed with a psychotic disorder [Table 1].
Table 1: Sociodemographic and clinical characteristics of the psychiatric outpatients

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Figure 1: Flowchart of selection of participants

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Of the 98 patients with psychotic disorders, 69 (70.41%) had a diagnosis of schizophrenia. A diagnosis of moderate depressive episodes accounted for about half (63/122) of the patients with depressive disorders. Among the 97 patients with anxiety disorders, panic disorder (31/97), and obsessive-compulsive disorder (25/97) were the most common diagnoses together accounting for more than half the patients in the anxiety disorders group.

In the first visit, most patients were prescribed two psychotropic medications to be taken once or twice daily for an average of about 12 days. Only 3/317 (0.01%) patients were not prescribed any medications during the first visit [Table 2]. A benzodiazepine was the second medication in most patients who were prescribed two psychotropic drugs at the first visit.
Table 2: Characteristics of the first prescription issued in psychiatric outpatients

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Olanzapine was the antipsychotic prescribed in more than half the patients with psychotic disorders. Escitalopram, sertraline, and mirtazapine together accounted for 83.6% of antidepressant prescriptions in patients with depressive disorders. Similarly, 83.5% of patients with anxiety disorders were initiated on sertraline, escitalopram, or fluoxetine. Clonazepam was the most commonly prescribed benzodiazepine in depressive and anxiety disorders. Lorazepam and clonazepam were both commonly prescribed in patients with psychotic disorders [Table 3].
Table 3: Psychotropic medications prescribed at the first visit among psychiatric outpatients

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An analysis of the follow-up prescriptions revealed that the primary medication was changed in 40 (12.62%) patients and polypharmacy was used in 23 (7.26%) patients [Table 4]. The common reasons documented for primary medication change were side effects (15/40) and lack of efficacy (9/40). Change of diagnosis and multiple reasons were documented in six and five patients, respectively. The reason for the change of primary medication was not documented in five patients. In the 212 (66.88%) patients who were prescribed benzodiazepines, the mean duration of benzodiazepine use was found to be 22.94 (SD – 22.17) days.
Table 4: Follow-up prescriptions in psychiatric outpatients with psychotic, depressive, and anxiety disorders

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A review of the number of follow-up visits showed that 138 (43.53%) patients never came for a follow-up visit after the initial assessment. An additional 109 (34.28%) had one to three follow-up visits. Only 70 (22.08%) patients had four or more follow-up visits. The patients with depressive disorders were found to have significantly less number of follow-up visits when compared to those in the other two diagnostic categories [Table 5].
Table 5: Follow-up pattern in psychiatric outpatients with psychotic, depressive, and anxiety disorders (summary statistics are presented using median (interquartile range))

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The median CMA was found to be 0.15(interquartile range [IQR] 0.42) in the overall sample. Only 16% of the patients had a CMA value of 0.8 or more, that is, had psychotropic medication supply for at least 80% of the study period. In the total sample, the median duration of medication persistence was 25 (IQR 64) days. The measures of medication adherence and persistence were not significantly different among the three diagnostic groups [Table 6].
Table 6: Comparison medication adherence and persistence in psychiatric outpatients with psychotic, depressive, and anxiety disorders (summary statistics are presented using median (interquartile range))

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  Discussion Top


The present study found that most patients were prescribed two psychotropic medications in the first visit and this involved a benzodiazepine in addition to the primary drug. During follow-up visits, the primary medication was changed in 13% of the patients, and polypharmacy was used in about 7% of the patients. About 44% of patients dropped out after the first visit and only 16% of patients had psychotropic medication prescriptions for at least 80% of the study period.

The findings from the analysis of first prescriptions were broadly concordant with the findings of the Indian Psychiatric Society (IPS) multicentric study[2] which reported that 41% of the patients were prescribed two drugs. Olanzapine was the most commonly prescribed antipsychotic in the multicentric study as well. However, aripiprazole, amisulpride, and quetiapine were found to be at least as commonly prescribed as risperidone in the present study. Increasing use of these antipsychotic drugs may reflect the easy availability and preferential use in patients with preexisting metabolic abnormalities. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly prescribed psychotropic drug in depressive and anxiety disorders in this study. Several previous studies also report that SSRIs were the most widely prescribed antidepressant.[3],[4],[14]

In the present study, clonazepam was essentially the only benzodiazepine prescribed in depressive and anxiety disorders. On the other hand, lorazepam and clonazepam were both commonly prescribed in patients with psychotic disorders. These patterns are comparable to the findings of the IPS multicentric study[2] which found that clonazepam was the most widely prescribed benzodiazepine in unipolar depression and neurotic, stress related, and somatoform disorders, whereas clonazepam and lorazepam were both commonly prescribed in the psychosis group.

The analysis of follow-up prescriptions revealed that a change of primary psychotropic medication was done in about 13% of patients. The proportion was found to be similar in all the diagnostic groups. More than 40% of the participants continued on the same medication during the follow-up visits. This finding has to be interpreted with caution as the calculated proportion included patients who came for even one follow-up. This proportion is likely to be higher among patients under regular follow-up. The use of polypharmacy was found in 7.26% of patients in the present study. This is relatively lower than the rates previously reported by Grover et al. in the IPS multicentric study in which the rate of antidepressant polypharmacy 13.64% in the unipolar depression group and antipsychotic polypharmacy was 20.9% of patients with psychotic disorders group.[2]

In this study, it was found that benzodiazepines were prescribed in about 67% of the patients during the study period. This finding is in concordance with the findings of the IPS multicentric study which reported that no benzodiazepine was prescribed in 28%–34% across various diagnostic categories.[2] An earlier study at a tertiary care center in North India also revealed that no benzodiazepine was prescribed in 30%–40% of patients across different diagnostic groups.[3] An additional important finding of the present study is that the average duration of benzodiazepine use was 23 days. This is encouraging as generally benzodiazepine use should be restricted to <2–4 weeks.[15] Even though benzodiazepine use is discouraged in anxiety disorders, psychiatrists prescribe them commonly as they rapidly and reliably relieve anxiety and improve sleep.[16]

In this study, about 44% of the patients dropped out of treatment after the initial visit. Similar disappointingly low follow-up rates have been reported in two Indian studies in the last decade. Earlier, a study conducted in a private psychiatric clinic reported that 50% of the patients dropped out after the first visit.[8] More recently, a study conducted in a tertiary care medical college and hospital found that 53.1% of psychiatric outpatients dropped out after the first visit and 29.4% of patients had 1–3 follow-up visits before dropping out.[9] In contrast, a relatively low missed follow-up appointment of 16% was reported in a publicly funded mental health setup in the United Kingdom.[17]

Only 15.77% of patients had a prescription for psychotropic medication for at least 80% of the 6 months after initiation of treatment. Secondary database analysis was used as an indirect indicator of adherence in this study. It has the advantage of being an objective measure of adherence and thus not influenced by underreporting due to social pressure. However, this method does not identify the barriers to adherence in individual patients.[13] Previously, a study conducted on 400 psychiatric outpatients found that 43% were nonadherent to the prescribed medication.[11] Other studies have reported nonadherence as 73% in depressive disorders[18] and 52% in psychotic disorders.[12] A recent systematic review reported that 49% of major psychiatric disorder patients were nonadherent to psychotropic medication.[10] The divergent findings can be explained by the differences in methods adopted to assess adherence and the cutoffs used to define nonadherence. Nevertheless, the indisputable fact is that nonadherence is common among psychiatric outpatients and a case can be made for routine implementation of adherence-enhancing strategies.

Strengths

Assessment of prescription pattern using longitudinal patient-level data in this study adds to the existing knowledge regarding the prescription pattern of psychotropic medications. The use of objective measures to assess medication adherence is also an important strength of this study.

Limitations

In the absence of a centralized patient registry, a small proportion of participants is likely to have continued treatment at other clinics/hospitals and that could have resulted in underestimation of the follow-up rate and adherence. Since the study was conducted at a single tertiary care setting in a general hospital psychiatry unit, the findings may not be generalizable to primary care settings or more specialized psychiatric hospital settings.

Future directions

Similar studies in other settings such as government hospitals, psychiatric hospitals, and primary care settings will facilitate comprehensive understanding and help in planning remedial measures in each setting. Assessment of adherence using both subjective and objective measures in the same patient population will provide critical inputs regarding the various aspects of adherence. The development of low-cost interventions to improve the follow-up rates and adherence in psychiatric outpatients should become a research priority.


  Conclusion Top


Olanzapine, escitalopram, sertraline, and clonazepam were the most commonly prescribed psychotropic medications. Most patients were prescribed two psychotropic medications which included one benzodiazepine. However, polypharmacy was an uncommon practice. Follow-up rate and medication adherence were poor across different diagnostic categories.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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World Health Organisation. Introduction to Drug Utilisation Research. Oslo, Norway: World Health Organisation; 2003.  Back to cited text no. 1
    
2.
Grover S, Avasthi A, Sinha V, Lakdawala B, Bathla M, Sethi S, et al. Indian psychiatric society multicentric study: Prescription patterns of psychotropics in India. Indian J Psychiatry 2014;56:253-64.  Back to cited text no. 2
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Grover S, Kumar V, Avasthi A, Kulhara P. An audit of first prescription of new patients attending a psychiatry walk-in-clinic in north India. Indian J Pharmacol 2012;44:319-25.  Back to cited text no. 3
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Tripathi A, Avasthi A, Desousa A, Bhagabati D, Shah N, Kallivayalil RA, et al. Prescription pattern of antidepressants in five tertiary care psychiatric centres of India. Indian J Med Res 2016;143:507-13.  Back to cited text no. 4
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Lahon K, Shetty HM, Paramel A, Sharma G. Pharmacoepidemiological study of antipsychotics in the psychiatry unit of a tertiary care hospital: A retrospective descriptive analysis. Int J Nutr Pharmacol Neurol Dis 2012;2:135.  Back to cited text no. 5
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Chapman SC, Horne R. Medication nonadherence and psychiatry. Curr Opin Psychiatry 2013;26:446-52.  Back to cited text no. 7
    
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Singla. Profile and Pattern of Follow-ups of Psychiatry Outpatients at Christian Medical College, Ludhiana. Available from: http://www.jmhhb.org/article.asp?issn=0971-8990;year=2015;volume=20;issue=2;spage=76;epage=79; aulast=Singla. [Last accessed on 2019 Oct 19].  Back to cited text no. 9
    
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Semahegn A, Torpey K, Manu A, Assefa N, Tesfaye G, Ankomah A. Psychotropic medication non-adherence and its associated factors among patients with major psychiatric disorders: a systematic review and meta-analysis. Syst Rev 2020;9:Syst Rev 2020;9:17. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6966860/. [Last accessed on 2020 Jun 26].  Back to cited text no. 10
    
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