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

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.