UK primary care physicians frequently prescribing antipsychotics for non-psychotic disorders

1. Almost half of UK primary care antipsychotic prescriptions were written for patients without a diagnosis of psychotic or bipolar disorder.

2. Anxiety, depression, sleep disorders, and dementia were the most common non-psychotic mental health conditions for which primary care physicians prescribed antipsychotics.

Evidence Rating Level: 2 (Good)

Study Rundown: Clinical guidelines in the United Kingdom (UK) recommend the use of antipsychotic drugs for the treatment of psychotic or bipolar disorders, but caution that antipsychotic use for other non-psychotic mental health conditions (e.g. depression, anxiety, or sleep disorders) be limited to treatment resistant cases. Antipsychotics are known to have several side effects, including movement disorders for first-generation drugs and metabolic effects such as weight gain for second-generation drugs. This study aimed to examine antipsychotic drug prescribing practices by UK physicians. It was found that more than half of UK patients who were prescribed antipsychotics did not have a formal diagnosis of psychotic or bipolar disorder. In fact, patients were frequently prescribed antipsychotics for non-psychotic disorders including anxiety, depression, and sleep disorders, though typically at lower doses and shorter durations than for psychotic disorders. Additionally, antipsychotics were commonly prescribed for patients with dementia, which is concerning given the known association between antipsychotics and increased stroke and mortality risk among dementia patients. Furthermore, elderly patients (in particular age 80 and greater) were twice as likely as younger patients to be prescribed an antipsychotic drug, despite the fact that elderly patients are more sensitive to their adverse effects.

This study had a strong study design as it used a large sample size of more than 40,000 patients from a nationally representative primary care database. One limitation is that authors determined the presence of mental health disorders using diagnostic coding, which is not always accurate (e.g. physicians may have forgotten to enter codes or may have purposely not entered codes to avoid a stigmatizing label). Overall, this study contributes to the literature by suggesting that UK primary care physicians frequently prescribed antipsychotics for uses other than those suggested by clinical guidelines. Efforts to increase safety of antipsychotic prescribing practices, such as avoiding antipsychotics for dementia patients or monitoring all patients on antipsychotics for side effects (current UK policy only recommends monitoring patients with psychosis or bipolar disorder), may be beneficial in the primary care setting.

Click to read the study in BMJ Open

Relevant Reading: Risk of death with atypical antipsychotic drug treatment for dementia

In-Depth [retrospective cohort]: 47,724 individuals who were prescribed first or second-generation antipsychotics in The Health Improvement Network (THIN), a UK primary care database, from 2007-2011 were identified. Demographic, diagnoses, and prescription claims data were examined for each patient. Older patients, females, and individuals living in deprived areas were more likely to be prescribed antipsychotics. Older individuals (age 80 and above) were twice as likely to be prescribed antipsychotics compared to those age 40-49 years (Incidence rate ratio 2.23, CI95% 2.22-2.25). The diagnosis of a psychotic or bipolar disorder was recorded for 27% to 35% of patients who were prescribed a first generation antipsychotic and for 36% to 62% of patients who were prescribed a second generation antipsychotic. Non-psychotic disorders that patients were most commonly prescribed antipsychotics for included anxiety, depression, sleep disorders, and dementia. Approximately one-third of patients who received haloperidol (a first generation antipsychotic) had a diagnosis of dementia. Additionally, 12 to 17% of patients who were prescribed an antipsychotic had no diagnostic record of a severe mental illness. Patients with a non-psychotic disorder were typically prescribed a lower median daily dose and shorter duration of an antipsychotic compared to those with psychoses or bipolar disorder, with the exception of patients with ADHD or dementia who were prescribed antipsychotics for a similar duration of treatment.

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