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Previous hospital admissions and disease severity predict the use of antipsychotic combination treatment in patients with schizophrenia
Can findings be explained on the basis of brevity of inpatient hospitalizations?
James Dillon, Michigan Department of Community Health and University of Michigan Medical School Department of Psychiatry
17 August 2011
The circumstances described in this excellent and straightforward article mirror less rigorously formed impressions on this side of the Atlantic. In Michigan (USA) medical directors in the community (outpatient-based) mental health sector ascribe high rates of antipsychotic polypharmacy to hospitalization per se, as much as to treatment resistance or case complexity, though the latter may be contributing factors.
One view (I will call it the "brevity of hospitalization" hypothesis) is that very short inpatient hospitalizations, typically a week or less in duration, encourage polypharmacy. Cross-titration of drugs, adequate treatment trials, testing of adherence as a source of treatment failure, etc., cannot be accomplished in just a few days. Typically a patient arrives in a condition of impending violence, and the inpatient psychiatrist has a few days to render him or her fit for return to the community. Rather than take a chance that removing a drug already on board will make things worse, the psychiatrist is apt to add a second powerful drug, leaving the outpatient psychiatrist to sort out which of the multiple medications is really needed.
The "brevity of hospitalization" hypothesis is consistent with data presented in this paper, which show antipsychotic polypharmacy to be increasingly probable in second and subsequent hospitalizations. A patient with no hospitalizaton history is likely to present with no current medications or no prior treatment. S/he will show rapid improvement when one antipsychotic is prescribed, making polypharmacy unnecessary. Upon return to hospital, though, the patient may claim to have been taking the first medication while the family believes it was manna from heaven until a couple weeks prior to admission. Under cirucumstances such as these, the inpatient psychiatrist is apt to add a second antipsychotic without changing the first. One can imagine many such scenarios promoting addition of drugs in hospital.
Another observation from the current research favoring the "brevity of hospitalization" hypothesis is the difference in polypharmacy noted in outpatient versus inpatient groups. Inpatient status may be at the heart of the problem, while case complexity contributes indirectly by raising the risk of hospitalization.
This interpretation of the polypharmacy problem raises the question of whether psychiatric hospitalizations should be longer. In Michigan the costs of hospitalization are borne by the outpatient agency, the financial realities of which happen to be aligned with a philosophical commitment to deinstitutionalization and demedicalization of mental health care. If short hospitalizations routinely produce undesirable results, what payor will opt to authorize more of the same?
Can findings be explained on the basis of brevity of inpatient hospitalizations?
17 August 2011
The circumstances described in this excellent and straightforward article mirror less rigorously formed impressions on this side of the Atlantic. In Michigan (USA) medical directors in the community (outpatient-based) mental health sector ascribe high rates of antipsychotic polypharmacy to hospitalization per se, as much as to treatment resistance or case complexity, though the latter may be contributing factors.
One view (I will call it the "brevity of hospitalization" hypothesis) is that very short inpatient hospitalizations, typically a week or less in duration, encourage polypharmacy. Cross-titration of drugs, adequate treatment trials, testing of adherence as a source of treatment failure, etc., cannot be accomplished in just a few days. Typically a patient arrives in a condition of impending violence, and the inpatient psychiatrist has a few days to render him or her fit for return to the community. Rather than take a chance that removing a drug already on board will make things worse, the psychiatrist is apt to add a second powerful drug, leaving the outpatient psychiatrist to sort out which of the multiple medications is really needed.
The "brevity of hospitalization" hypothesis is consistent with data presented in this paper, which show antipsychotic polypharmacy to be increasingly probable in second and subsequent hospitalizations. A patient with no hospitalizaton history is likely to present with no current medications or no prior treatment. S/he will show rapid improvement when one antipsychotic is prescribed, making polypharmacy unnecessary. Upon return to hospital, though, the patient may claim to have been taking the first medication while the family believes it was manna from heaven until a couple weeks prior to admission. Under cirucumstances such as these, the inpatient psychiatrist is apt to add a second antipsychotic without changing the first. One can imagine many such scenarios promoting addition of drugs in hospital.
Another observation from the current research favoring the "brevity of hospitalization" hypothesis is the difference in polypharmacy noted in outpatient versus inpatient groups. Inpatient status may be at the heart of the problem, while case complexity contributes indirectly by raising the risk of hospitalization.
This interpretation of the polypharmacy problem raises the question of whether psychiatric hospitalizations should be longer. In Michigan the costs of hospitalization are borne by the outpatient agency, the financial realities of which happen to be aligned with a philosophical commitment to deinstitutionalization and demedicalization of mental health care. If short hospitalizations routinely produce undesirable results, what payor will opt to authorize more of the same?
Thank you for this interesting contribution.
Competing interests
None.