Abstract
Cherrie Galletly, Department of Psychiatry, University of Adelaide, The Queen Elizabeth Hospital, Adelaide, Australia:
Recent articles in the Australian and New Zealand Journal of Psychiatry [1,2] have discussed changes in the prescribing of antidepressant and antipsychotic drugs. Beerworth and Tiller [1] noted the medico-legal advantages of initiating pharmacological therapy for depression with newer antidepressants, such as selective serotonin re-uptake inhibitors (SSRIs), selective serotonin/noradrenaline re-uptake inhibitors (SNRIs), reversible inhibitors of monoamine oxidase A (RIMAs) and 5HT2 receptor antagonists, rather than older antidepressants such as the tricyclics. Parker et al. [2] investigated changes in the use of antipsychotic drugs, reporting that 33% of a sample of psychiatrists surveyed in 1996 advocated the use of an atypical antipsychotic agent (risperidone) in preference to conventional antipsy-chotics in the treatment of first-episode psychosis. Parker et al. [2] also noted that the antipsychotic drug doses favoured by their sample of psychiatrists were about half those recommended by the Quality Assurance Project in 1984. Recently published treatment algorithms for depression and schizophrenia [3–7] vary in their recommendations regarding the place of the newer agents in the clinical pathway. This may reflect differences in the methods used to derive the algorithms, but also indicates a lack of consensus in defining best practice.
There has been little information published recently about the actual use of novel antipsychotic and antidepressant drugs in psychiatric practice in Australia. Such information would be helpful in gauging the extent to which the newer treatments have been adopted.
This letter reports on the medication prescribed on one day (13 August 1998) at Cramond Clinic, a 40-bed acute psychiatric inpatient unit serving the Western suburbs of Adelaide. Thirty-five medication sheets were available. The remaining patients were in the process of admission or discharge, or not on the ward.
Sixty-one percent (n = 17) of the 28 patients receiving antipsychotic medication were prescribed the atypical drugs olanzapine (n = 14) or risperidone (n = 3). The mean daily dose of olanzapine was 14 mg, and of risperidone was 1 mg. Typical antipsychotic drugs prescribed included thioridazine (seven patients, mean daily dose 168 mg) and haloperidol (six patients, mean daily dose 11 mg). Six patients received depot antipsychotics (flupenthixol, mean dose 46 mg/2 weeks; zuclopenthixol, mean dose 200 mg/2 weeks). Some patients received both depot and oral medication. It is perhaps a reflection of the use of atypical drugs, and moderate doses of typical drugs, that only two patients were prescribed regular anticholinergic medication.
The only antidepressants used were SSRIs (n = 9) and moclobemide (n = 3). Again, the mean daily doses were moderate (e.g. paroxetene 27 mg, fluoxe-tine 20 mg, moclobemide 450 mg).
Sodium valproate was the most popular mood stabiliser, being prescribed for 13 of the 14 patients taking mood-stabilising drugs. The mean daily dose of sodium valproate was 1538 m g (ra nge = 1000-3 000 mg/day). Only three patients were prescribed lithium and one carbamazepine.
About one-third of patients (n = 11) were prescribed regular benzodiazepines, again in moderate doses. Clonazepam was the most popular, in a mean daily dose of 1.4 mg.
This ‘snapshot’ is limited by the small sample size, and involves only one inpatient service. However, the results suggest that there have been major changes in the pharmacological treatment of acute psychiatric disorders, with most patients receiving the newer antipsychotic or antidepressant drugs, and a move from lithium to sodium valproate as the mood stabiliser of first choice. The doses of antipsychotic medication are considerably lower than those previously advocated [8] and prescribed [9] in Australian clinical practice.
These changes will hopefully result in a reduction in the burden of medication side effects and better treatment adherance, with the long-term benefits of improved outcome and a better quality of life for patients with psychiatric disorders.