M.Sc. (Med), Faculty of Health Sciences,University of the Witwatersrand, 2011 / Background: Many factors affect the prescribing of medication to patients with
schizophrenia including variables that relate to physicians and may result in marked
variance in the choice of drugs, dosages, drug combinations, route of administration and
the use of antipsychotic, anticholinergic, sedative and other adjuvant drugs.
Clinical practice guidelines were developed to address this variance and for other reasons,
including the management of side-effects, drug innovation, rising costs, information
overload, changes in treatment goals and the management of medication non-adherence.
There are advantages and disadvantages to using clinical practice guidelines including
those pertaining to context and cultural norms, but they remain the best method of
assessing prescribing quality.
Many guidelines are based on the results of randomised clinical trials (with a single drug)
or are the consensus of experts in the field. Despite the development and publication of
these guidelines over the past two decades, they are frequently not adhered to resulting in
much variance in treatment.
Aims and objectives: The aim of the study was to determine to what extent the
prescribing of psychotropic drugs in the treatment of schizophrenia was consistent with the
most recent version of each of five guidelines that originate outside South Africa (two from
the United States and one each from Canada, the United Kingdom, and Australia and New
Zealand); and one that was developed locally.
Methodology: A retrospective, cross-sectional prescription chart review with data
sampling at three time points (on hospital admission, at fourteen days thereafter and on
hospital discharge) was undertaken. A sample population was drawn over a three year
period during which the patients’ physician had access to the same drug formulary.
Seventy patients met the study selection criteria in terms of age, diagnosis and receipt of
antipsychotic medication during hospital stay and on discharge. Seventy patients met the
study selection criteria, and their prescriptions for psychotropic medication (exclusively)
were examined for a number of parameters including: drug class, drug name, dose, route
of administration and whether the medication was to be administered routinely or ‘as
needed’.
Findings and discussion: As compared with the recommendations made in some or all
of the guidelines, first generation antipsychotic agents were over-prescribed especially
early on in the patients’ hospital stay, whereas second generation antipsychotics were
under-prescribed. The profile changed after fourteen days and on discharge there were
more patients on second generation drugs than on the older drugs. More patients were
discharged on depot antipsychotic treatment than were admitted which is considered a
favourable finding, however, many patients receiving the depot form continued to be
prescribed the oral drug on a routine basis and for an indefinite period, resulting in
antipsychotic polypharmacy.
Anticholinergic drugs were prescribed as prophylaxis for the extra-pyramidal side-effects
of the first generation antipsychotic drugs and more than a quarter of the sample received
these drugs on discharge, after which they were to be taken routinely and indefinitely.
A similar finding was made with the use of benzodiazepine sedatives, where nearly a
quarter of patients received these drugs on discharge - again to be taken routinely and for
an unspecified period.
Sodium valproate was given increasingly to many patients in the sample and was
prescribed to over a quarter of those upon discharge, without an indication of duration.
Limitations: The study was retrospective in design, without the benefit of the patients’
clinical histories and treatment progress, and the findings were compared with guidelines
whose age spanned more than a decade and some of which had become redundant.
Conclusions: The study demonstrated some prescribing habits that were not in accord
with the guidelines used for comparison in the study. The extent of the disagreement
reveals the need for a prospective pilot study that will include the patients’ clinical progress
in the study design which will provide greater insight into why specific medication
parameters were chosen by the physician for the individual patient. If the findings justify it,
then a programme promoting better adherence to the most current guidelines should be commenced.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:wits/oai:wiredspace.wits.ac.za:10539/10515 |
| Date | 10 October 2011 |
| Creators | King, Russell Wayne |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Thesis |
| Format | application/pdf |
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