Dr. Joe Parks works through pharmacological trends.

1. Best Practices for Best Outcomes April 13, 2010

2. Psychotropic Medication Utilization

3. Antipsychotic Patterns

4. Portion of Prescriptions Potentially Questionable CMHC’s 6.3% - 17.5% CPS Special Housing 18.0% - 22.6% Hab Centers 16.6% - 36.3%

6. Outlier Prescribing and Psychiatry Time

8. Incorrect Diagnosis

9. Failed Tapers

10. Over reliance on medication as the sole treatment

13. Increased Medication Errors

14. Increasing Difficulty Assessing Effect of Individual Medications

15. Increased Side Effects

16. Increased Mortality

17. Additional Medications for Side Effects

19. Treatment Resistant (15 studies)

20. Non-Treatment Resistant (15 studies)

21. Included:

22. Randomized Controlled Trials, (9 trials)

23. Non- Randomized Controlled Trials (6 trials)

24. Non-Controlled Observational studies (15 studies)

25. Excluded:

26. Series without statistical analysis

28. Treatment Resistant Studies

29. Treatment Resistant Studies by Medications Utilized

31. Retrospective Chart Review of 26 patients

32. Second antipsychotic added after 4 months on mono-therapy

33. Outcomes

34. 26% reduction on BPRS and decreased PRN use

35. Increased side effects

37. Non-Treatment Resistant Studies by Medications Utilized

39. Non-Randomized Controlled Trial

40. Compared pimozide/thioridazine polypharmacy with both as mono-therapy

41. Outcomes

42. Poly was superior to low dose mono

43. Poly was no better than higher dose mono

45. All had Metabolic Syndrome reduction as Primary Outcome

46. One Non-Controlled Observational Study

47. CLZ vs CLZ/quetiapine: poly did better

48. Two Non-Controlled Random Studies

49. Mono-SGA vs poly-SGA : no difference

51. 10 year prospective inpatient schizophrenia study

52. RR associated with AP polypharmacy = 2.46

53. Adjusted for cumulative AP dose and years on APs

54. Joukamaa, et. Al. 2006

55. 17 year retrospective schizophrenia study

56. RR associated with AP polypharmacy = 2.50

58. Limitations- What We Don’t Know Efficacy of non-Clozapine SGA Polypharmacy in treatment resistant psychosis Efficacy of Clozapine polypharmacy in non-treatment resistant psychosis

59. Aripiprazole augmentation of Risperidone or Quetiapine Correll, Kane, Goff et.al. June , 2008 Poster 16 week, double blind, placebo controlled RTC 323 patients on risperidone or quetiapine given aripiprazole or placebo No improvement in symptoms with SGA polypharmacy Mixed changes in side effects

61. Published Practice GuidelinesRegarding Antipsychotic Polypharmacy Published Guide lines include American Psychiatric Association Expert Consensus Guideline Series Texas Medication Algorithmns PORT All recommend use of more than one AP only: After multiple trials of monotherapy After trial of clozapine

62. Justifications for Antipsychotic Polypharmacy Clozapine Augmentation A History of 3 or more failed Trials of monotherapy Recommended Plan to taper to monotherapy

63. §483.450(e) Standard: Drug Usage (e)(1) The facility must not use drugs in doses that interfere with the individual client’s daily living activities. (e)(2) Drugs used for control of inappropriate behavior must be approved by the interdisciplinary team andbe used only as an integral part of the client’s individual program plan that is directed specifically towards the reduction of and eventual elimination of the behaviors for which the drugs are employed. http://www.cms.gov/manuals/downloads/som107ap_j_intermcare.pdf accessed 4.09.10

64. §483.450(e) Standard: Drug Usage (e)(3) Drugs used for control of inappropriate behavior must not be used until it can be justified that the harmful effects of the behavior clearly outweigh the potentially harmful effects of the drugs. (e) (4)(i) Drugs used for control of inappropriate behavior must bemonitored closely,in conjunction with the physician and the drug regimen review requirementfor desired responses and adverse consequences by facility staff; and http://www.cms.gov/manuals/downloads/som107ap_j_intermcare.pdf accessed 4.09.10

65. §483.450(e) Standard: Drug Usage (e)(4)(ii) Gradually withdrawn at least annually in a carefully monitored program conducted in conjunction with the interdisciplinary team, unless clinical evidence justifies that this is contraindicated http://www.cms.gov/manuals/downloads/som107ap_j_intermcare.pdf accessed 4.09.10

66. Spectrum of AP Side Effects NMS EPS Prolactin WBC Weight Gain ANTIPSYCHOTIC AGENTS Diabetes/DKA Sedation Lipids Seizures Anticholinergic Orthostasis NMS = Neuroleptic Malignant Syndrome

67. Relative Risk of Side Effects Among Agents Professional Resources & Business Development +++ substantial risk, ++ moderate risk, + mild risk, +/- minimal risk or insufficient data Mueser KT, Jeste DV. in Clinical Handbook of Schizophrenia, 2008, Fuller M, Sajatovic M, in Psychotropic Drug Information Handbook 2009, Drug PIs

68. Meaningful Medication Tapers Polypharmacy – 2 or more in same class 25% dose reduction per month Completely off in 6 – 9 months Monotherapy – only one of that class 10% dose reduction per month Completely off in 12 – 18 months

69. But Our Patients are Sicker