# Antipsychotic prescribing patterns in a state psychiatric hospital with predominantly forensic admissions

## TL;DR

This study examines how antipsychotics are prescribed in a U.S. state psychiatric hospital, finding high-dose use and multiple medications are common.

## Contribution

The study is the first to analyze antipsychotic prescribing patterns in U.S. state hospitals, highlighting potential overuse and the need for stewardship programs.

## Key findings

- Nearly two-thirds of patients were prescribed antipsychotics at or above the maximum recommended dose.
- About 35.8% of patients received antipsychotic polypharmacy (two or more antipsychotics).
- High rates of long-acting injectable antipsychotics and first-generation antipsychotics were observed.

## Abstract

There are currently no published studies evaluating antipsychotic prescribing patterns in state hospital settings in the United States. This data is important to review since state hospitals involuntarily commit patients with serious mental illness (SMI) to receive treatment with antipsychotic medications, which are associated with a multitude of dose-dependent adverse effects.

This cross-sectional study describes antipsychotic prescribing patterns at a single state psychiatric hospital with predominantly forensic admissions. Data was collected via chart review at a single point in time, including demographic data and clinical characteristics such as admission type, neuropsychiatric diagnoses, length of stay, antipsychotic selection and dosing, and total number of scheduled antipsychotics. If the total daily dose of the scheduled antipsychotic was greater than the recommended typical maximum dose, it was considered ‘high-dose’ antipsychotic use.

Among 212 state hospital admissions, nearly two-thirds of patients were prescribed ≥ 1 antipsychotic at either the recommended typical maximum dose (N=76; 35.8%) or above the typical maximum dose (N=62; 29.2%). Several patients were prescribed antipsychotic polypharmacy (APP) (two scheduled antipsychotics [N = 76; 35.8%]; three scheduled antipsychotics [N = 13; 6.1%]). About one-third of patients were prescribed olanzapine (N = 76; 35.8%), and about a quarter of patients were prescribed clozapine (N = 51; 24.1%) and/or paliperidone (including Invega Sustenna) (N = 49; 23.1%). One-fifth of patients were prescribed a first-generation antipsychotic (N = 43; 20.3%). Nearly one-third of patients were prescribed a long-acting injectable antipsychotic (LAIA) (N = 69; 32.5%).

High-dose antipsychotic use and APP was common in this U.S. state psychiatric hospital. Larger, multicenter studies are needed to determine how antipsychotic prescribing patterns vary between U.S. state hospitals. Testing the development and implementation of antipsychotic stewardship programs in state hospital settings is recommended to establish best practices for monitoring antipsychotic use patterns and associated health outcomes.