Eur J Clin Pharmacol (2004) 60: 29–35 DOI 10.1007/s00228-003-0719-7
P H A R M A C O E PI D E M I O L O G Y A N D PR E S C R I P T I O N
Len Bowers Æ Patrick Callaghan Æ Nicola Clark Catharine Evers
Comparisons of psychotropic drug prescribing patterns in acute psychiatric wards across Europe
Received: 23 July 2003 / Accepted: 28 November 2003 / Published online: 28 January 2004 Ó Springer-Verlag 2004
Abstract Objective: To compare prescribed daily doses (PDDs) of psychotropic drugs in several European centres. Method: A one-day census of psychotropic drug prescriptions to 613 patients in 39 acute psychiatric wards in ten countries. Results: Patients in Spain were on most drugs; patients in Germany were on the fewest. Chlorpromazine equivalents in Denmark, England, Germany and Spain were at high levels as were diazepam equivalents in Belgium, Finland, The Netherlands and Norway. Newer anti-psychotics were used in the majority of centres, although older anti-psychotics were used commonly in three centres. Conclusion: The high doses of psychotropic drugs patients receive in some centres may be having little additional therapeutic effect and could increase their risk of side effects. The use of older anti-psychotics in some centres may be causing side effects that could be reduced by using newer anti-psychotics. Keywords Drug Æ Treatment Æ Psychiatric
Introduction Psychotropic drugs play a central role in the treatment of most mental and behavioural disorders that require admission to hospital [1]. However, the appropriateness of drugs used and the prescribed daily doses (PDD) of L. Bowers (&) Æ P. Callaghan Æ N. Clark Æ C. Evers Department of Mental Health and Learning Disability, City University London, Philpot Street, London, E1 2EA, UK E-mail:
[email protected] Tel.: +44-20-70405824 Fax: +44-20-70405811 L. Bowers St. Bartholomew School of Nursing and Midwifery, City University, Philpot Street, London, E1 2EA, UK
these drugs have been challenged consistently [2, 3, 4]. Snowdon found that half the antidepressants prescribed to elderly patients were tricyclics likely to exacerbate cognitive deficits and delirium. Keks and Burrows [5] found that only 11% of patients were prescribed so-called new-generation anti-psychotics such as olanzapine, which they considered more effective than typical anti-psychotics and less likely to cause extrapyramidal side effects. Data from studies of prescribing practices within different European countries showed variation in prescribing patterns of psychotropic drugs with a particular tendency among psychiatrists to prescribe doses in excess of those recommended by recognised authorities [3]. There is also concern among the psychiatric community of the increasing number of deaths attributed to medication type and doses and unease that some patients are on drug doses that are above the recommended doses [6]. However, there is little evidence from studies of prescribing practices among different European countries showing the PDDs of patients on acute psychiatric wards. Psychotropic drugs may be used to contain disruptive, aggressive and disturbed behaviour in psychiatric inpatients. Their mode of action in this case seems likely to be a combination of the sedative effects of these drugs and their anti-psychotic action. A recent systematic review by the Royal College of Psychiatrists in the UK [7] concluded that the use of psychoactive drugs was an efficacious and safe method of treating patients with acute and disruptive symptoms, whilst pointing out that psychiatric symptomatology was not the only cause of violent behaviour by patients, and that other methods of control may also be effective. Research into drug prescribing patterns in Europe was pioneered by the work of Engels and Siderius at the European Regional Office of the World Health Organisation (WHO) in 1967 [8]. Engel and Siderius found wide variation in drugs used across six European countries. The WHO Collaborating Centre for Drug Statistics Methodology was established in 1982 to improve, among other things, drug prescribing patterns across Europe.
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There has been little comparative work of psychotropic drug prescribing patterns across Europe. The impetus for this study arose from discussion in the European Violence in Psychiatry Research Group (EViPRG), suggesting that aggressive behaviour by patients in some centres was a lesser problem because of high prescribing rates of psychotropic medication. Aim To compare the dosage of psychotropic drugs prescribed to patients in selected acute psychiatric wards in different European centres.
Methods Design The design was a 1-day census of drug prescribing on acute psychiatric wards in Europe. A comparative group design was employed in which prescribing patterns of psychotropic medications in acute psychiatric wards between ten different European centres were compared. In most centres, this data came from a single hospital site, but in Spain, Italy and The Netherlands, data were collected from two or more hospitals. As the study was unfunded, the size of the sample in each centre was dependent on the access and goodwill of the EViPRG member collecting the data. Collaborators were asked to collect details on the maximum number of patients whose current records were available to them when the census took place. Sample Data were collected on all patients in the selected wards in each country and Table 1 shows these patients’ characteristics. Wards were selected on the basis of their close contact with members of the EViPRG, using a common definition agreed in advance, namely: first line 24-h psychiatric facilities providing care to adult patients on a time-limited, acute basis. In the study, 613 patients participated: the majority were males, middle aged with a diagnosis of schizophrenia.
Table 1 Demographic characteristics of sample Number of patients and wards Centre Spain Italy England Ireland Norway Germany Finland Denmark The Netherlands Belgium
Patients 108 (17.6%) 87 (14.2) 79 (12.9) 74 (12.1) 65 (10.6) 62 (10.1) 49 (8.0) 37 (6.0) 35 (5.7) 17 (2.8)
Gender* Male Female Median age
357 (58.2%) 245 (40.0) 39 years
Diagnosis** Schizophrenia Mood disorders Adult personality disorder Substance abuse Organic disorder Neurotic Learning disabilities Developmental disorders
325 (53.5%) 142 (23.4) 45 (7.3) 41 (6.7) 19 (3.1) 10 (1.6) 8 (1.3) 3 (0.5)
Wards 3 6 4 3 5 3 6 3 3 1
*Excludes 11 (1.8%) missing cases **Excludes 6 (1.0%) missing cases collection instrument, instructions on its completion and a return envelope. Group members then contacted local clinicians for permission to collect data on their wards. In some cases (e.g. Italy), the clinicians collected the data themselves. Each Centre collected data on the total daily dosage in milligrams of each psychotropic drug taken by each patient in a 24-h period on the same day. The researchers did not record data on drugs prescribed, but refused by the patient. The completed data was sent to the main centre (London) for analysis. During data entry, each drug was identified, either from standard pharmaceutical handbooks (British National Formulary) or, where this was not possible, via inquiry with the participating centre submitting the data. Information on drugs being given for the treatment of non-psychiatric conditions was discarded.
Results Instrument Data were collected using a specially designed form in four sections. In section 1, demographic data about the country, region, hospital, unit and patients’ sex and year of birth were elicited. Section 2 recorded the patients’ primary diagnosis (from case notes) using the 10th edition of ICD-10 [9]. In section 3, the generic name, trade name and daily dosage in milligrams of each drug prescribed was recorded. Finally, in section 4, the compound name, trade name, dosage and frequency and dosage of each depot drug was recorded. A separate form was used for each patient. Each country except Norway—who used a Norwegian version—used the English language version of the form. Procedure A draft of the data collection instrument was sent to members of the EViPRG in each participating country for comment. Following this consultation exercise, section 4 was appended to the data collection instrument and, in June 1999, each EViPRG member in the participating country was sent a census pack, consisting of the data
Most of the patients in the sample were middle-aged males with a diagnosis of schizophrenia. Other than schizophrenia, some patients had a diagnosed mood disorder, and a small percentage had personality and behavioural disorders. This is fairly typical of the range of diagnoses one might expect to find in acute psychiatric wards. Of the 613 patients who were included in the drug census, 476 (78%) were on anti-psychotic drugs. The diagnostic patterns are shown in Table 2, and the drug prescribing patterns in each participating centre are shown in Table 3. Wide variations are displayed between centres on the proportion of patients on anti-psychotic drugs, and these patterns may be somewhat related to variations in diagnosis. For example, the top four centres in terms of numbers of patients prescribed anti-psychotic drugs
31 Table 2 Diagnosis by centre Country
Belgium Denmark England Finland Germany Ireland Italy Netherlands Norway Spain
Diagnosis (%) Schizophrenia
Mood Organic Substance Neurotic Behavioural Personality Learning Developmental Unspecified disorders disorder abuse disorder syndromes disorder disabilities disorders
7 (41.2) 24 (64.9) 46 (58.2) 27 (56.3) 26 (41.9) 57 (77.0) 44 (51.2) 17 (48.6) 25 (39.7) 52 (49.1)
2 (11.8) 8 (21.6) 23 (29.1) 14 (29.2) 13 (21.0) 8 (10.8) 13 (15.1) 12 (34.3) 22 (34.9) 27 (25.5)
2 0 2 0 4 3 5 1 0 2
(11.8) (0) (2.5) (0) (6.5) (4.1) (5.8) (2.9) (0) (1.9)
6 (35.3) 0 (0) 3 (3.8) 5 (10.4) 6 (9.7) 1 (1.4) 3 (3.5) 0 (0) 4 (6.3) 13 (12.3)
0 0 1 0 1 1 3 0 3 1
(0) (0) (1.3) (0) (1.6) (1.4) (3.5) (0) (4.8) (0.9)
0 0 0 0 0 0 0 0 1 0
(0) (0) (0) (0) (0) (0) (0) (0) (1.6) (0)
0 (0) 4 (10.8) 1 (1.3) 1 (2.1) 2 (3.2) 3 (4.1) 14 (16.3) 4 (11.4) 7 (8.5) 9 (8.5)
0 0 0 0 2 1 3 0 0 2
(0) (0) (0) (0) (3.2) (1.4) (3.5) (0) (0) (1.9)
0 0 0 0 2 0 1 0 0 0
(0) (0) (0) (0) (3.2) (0) (1.2) (0) (0) (0)
0 1 3 1 6 0 0 1 1 0
(0) (2.7) (3.8) (2.1) (9.7) (0) (0) (2.9) (1.6) (0)
Table 3 Drug prescribing patterns across centres Country
Percentage of patients on anti-psychotic drugs
Mean no. of psychotropic drugs prescribed per patient
Mean ±SD total chlorpromazine equivalents (mg)
Mean ±SD total diazepam equivalents (mg)
Belgium Denmark England Finland Germany Ireland Italy Netherlands Norway Spain
65% 86% 73% 92% 81% 88% 77% 63% 48% 77%
2.12 2.898 1.86 2.76 1.73 1.32* 2.89 2.89 2.45 3.21
498.09±443.17 685.13±420.61 776.13±434.57 550.67±459.38 714.30±481.17 555.37±394.43 474.18±414.59 550.50±370.77 554.56±375.66 668.19±478.73
47.97±30.39 31.39±20.74 7.20±5.01 37.64±38.90 15.11±7.12 21.73±12.16 29.51±24.92 49.06±33.74 38.65±21.98 27.97±18.47
*Ireland recorded only neuroleptic drug prescriptions
(England, Spain, Denmark and Germany) overlapped with the top four centres for numbers of patients with a diagnosis of schizophrenia (Ireland, Denmark, England and Finland). Despite this variation, schizophrenia was the most common diagnosis in all centres (39.7–77%), followed by mood disorders, although the proportions of the latter diagnosis were more variable, ranging from 10.8% to 34.9% of census patients. The centres showed wider variation in patient numbers being treated for substance use (0–35.3%) and personality disorder (0–16.3%). Up to eight psychoactive drugs were prescribed daily for each patient (median=2). The majority (n=188) of patients were on one drug, 142 patients were on two drugs and 141 patients were on three drugs. Seven of the patients were on a daily regime of seven drugs. Patients in Spain were on the highest number of drugs, patients in Germany were on fewest drugs. There were differences between males (mean=2.27±1.36) and females (mean=2.63±1.40) in the number of psychoactive drugs prescribed. However, there was little difference in doses of chlorpromazine or diazepam equivalents (see below) between males and females. Using PDDs to make useful comparisons across centres, the researchers converted all anti-psychotic drugs prescribed into chlorpromazine equivalents using guidelines published by the British Medical Association (BMA) and The Royal Pharmaceutical Society of Great
Britain (RPSGB) [10]. For example, 50 mg clozapine is the equivalent of 100 mg chlorpromazine. Where the chlorpromazine equivalent was not listed, it was calculated by computing how much above the recommended daily dose was the prescription and this was converted to a chlorpromazine equivalent. For example, 20 mg olanzapine is double the average daily recommended dose of 10 mg, and this would be equal to 1.3 g chlorpromazine—twice the recommended daily dose of 650 mg. Depot medications have different bioavailability and could not be converted to chlorpromazine equivalents in this way. They were therefore excluded from the analysis. The mean and SD total chlorpromazine equivalents for each centre are shown in Table 3. England had the highest mean total chlorpromazine equivalents, Italy had the lowest. Using the same PDD to make useful comparisons across centres, the researchers converted all benzodiazepine drugs prescribed into diazepam equivalents using the guidelines and methods described above. The mean and SD total diazepam equivalents for each centre are also shown in Table 3. Belgium had the highest mean total diazepam equivalents, England had the lowest. The researchers compared the most commonly prescribed drug in each of four categories across the different centres and these results are shown in Table 4. Olanzapine was the most commonly prescribed anti-psychotic drug; lithium was the mood stabiliser
Olanzapine (24.6%) Lithium (4.6%) Venlafaxin (10.8%) Oxazepam (18.5%) Biperiden (12.3%) Haloperidol (25.9%) Lithium (6.5%) Venlafaxin (7.4%) Diazepam (22.2%) Biperiden (26.8%)
prescribed in all centres, venlafaxin was the antidepressant prescribed in the majority of centres; diazepam was the most commonly prescribed anxiolytic and biperiden was the most commonly prescribed anti-Parkinson’s drug.
Discussion
Diazepam (13.5%) None*
None*
Trazodone (17.6%) Diazepam (29.4%) None *Ireland did not record anti-depressant or anti-Parkinson’s drug use
Anti-Parkinson
Anxiolytic
Anti-depressant
Mood stabiliser
Anti-psychotic
Haloperidol (16.4%) Lithium (12.7%) Mitazipine (7.4%) Diazepam (5.1%) Procyclidine (34.2%)
Olanzapine (35.1%) Lithium (13.5%) Citralopam (21.6%) Clonazepam (37.8%) Biperiden (8.1%)
Olanzapine (14.3%) Lithium (17.1%) Venlafaxin (5.7%) Oxazepam (14.3%) Biperiden (34.3%)
Pipamperon (22.6%) Lithium (3.2%) Amitryptaline (3.2%) Diazepam (11.3%) Biperiden (6.4%)
Haloperidol (23.5%) None
Haloperidol (31%) Lithium (5.7%) Setraline (6.9%) Cloddiazepam (28.7%) Orphenadrine (8%)
Olanzapine (24.3%) None
Olanzapine (28.6%) Lithium (4.1%) Mitazipine (12.2%) Oxazepam (22.4%) None
Norway Belgium Germany The Netherlands Denmark England
Country Drug category
Table 4 The most commonly prescribed drugs in each country (% of patients prescribed)
Italy
Ireland
Finland
Spain
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This small scale pilot study aimed to gather some data in an area where there is currently little or no information. The study was not funded and sampling of hospitals and wards was on the basis of proximity and access to EViPRG members. The centres participating in this exploratory study may not have been representative of the countries in which they were located, and it seems likely that there may be considerable within country variation in prescribing patterns, as well as the between country variation described. The lack of a statistical random sampling methodology meant that statistical tests could not be applied to our data. In addition, depot medications were not included in this one-day census, partly because of the complexity they would add to the already contentious issue of comparing prescribing levels using chlorpromazine equivalents as described above. Patients were, on average prescribed two drugs, females were prescribed slightly more drugs than males, but there was little difference in the dosages of chlorpromazine and diazepam equivalents prescribed among males and females. There was wide variation between and within participating in chlorpromazine and diazepam equivalents and number of psychoactive drugs prescribed. Four centres—Denmark, England, Germany and Spain—were prescribing chlorpromazine equivalents higher than the recommended daily dose. Three centres—Belgium, Finland and the Netherlands—were prescribing diazepam equivalents at very high levels. A consensus statement issued by the Royal College of Psychiatrists [6] states that doses above the recommended daily dose are considered ‘high doses’. The high levels of chlorpromazine equivalent doses in some centres concurs with data reported by previous research. Galletly and Tsourtis [11] reported daily average chlorpromazine equivalent doses of 635 mg in patients who were on a single drug, but average doses of 1157 mg in patients on several drugs. The use of higher than therapeutic dosages suggests that medication may be being used, in part, as a sedative to calm disturbed and disruptive patients. The violent incident rates in the three Danish wards in a 30-month period between June 1997 and December 1999 totalled 92, or 1 per month per ward. These rates are lower than acute psychiatric wards in The Netherlands where violent incidents were occurring almost daily [12]. The chlorpromazine equivalents prescribed in the Netherlands in our study were below the recommended daily dose, suggesting a link between low-level prescribing
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and disruptive behaviour. However, data from four studies in Germany conducted between 1991 and 1999 show on average two violent incidents per ward per week [13, 14, 15, 16], notwithstanding the fact that this study has shown higher than recommended doses of chlorpromazine equivalents in Germany. Further research is required to disentangle the relationship between prescribing rates and levels of aggressive behaviour, as there are likely to be many additional causes of variance between localities, for example admission and patient management policies. The doses of drugs may also be linked to staffing levels on acute psychiatric wards. In Norway, for example, where the chlorpromazine and diazepam equivalents are below recommended levels, the staffing levels in psychiatric wards are high: a staff–patient ratio of 5:1 has been reported [17]. A comprehensive survey of staffing levels has recently been carried out by the EViPRG and is being prepared for publication. The average number of psychotropic drugs prescribed (median=2) is similar to the number of psychotropic drugs prescribed in previous comparative research [1, 18]. Twenty-eight patients (4.6%) were on no drugs at all. However, in two cases, patients were prescribed seven different types of drugs and, in one case, a patient was prescribed eight different drugs. Linden et al. [1] reported that the number of drugs prescribed tends to increase with the severity of the patient’s illness. The diagnosis of the patients on large numbers of drugs did not suggest that they were suffering from multiple problems that may require such prescriptions. Of the two patients prescribed seven drugs, one was a 42-year-old female diagnosed with schizophrenia being treated in Spain. The other was a 52-year-old male with schizophrenia in Italy. The patient on eight drugs was a 31-year-old male in Norway whose diagnosis was not recorded. The characteristics of the patients on between five and eight drugs shows that most were male with personality disorder in Denmark, or Spain where they were mostly females with mood disorders, or males with personality disorders. However, the researchers had no data on the severity of the condition of patients on larger numbers of drugs. The large number of drugs prescribed to those with adult personality disorder may reflect uncertainty about the classification and treatment of such patients [19, 20]. The large number of drugs prescribed to patients with mood disorders may be due to severity of the patients’ symptoms or associated behavioural problems, co-morbidity, other complicating factors or simply psychiatrists’ preferences. It may be that these large doses are being used for sedative effect, although a previous review of multiple drug use in the treatment of mood disorders suggested that this may have an effective therapeutic effect [21]. It has been argued that the high rate of drug combinations in some countries is unsatisfactory for several reasons: little evidence that combinations of drugs are more effective than one-drug regimes, greater risk of
medication error in patients and serious cardiovascular and depressive side effects [22]. There is evidence, however, that combined drug regimes may improve clinical conditions, like refractory depression, that may be resistant to sole drug use [23]. The number of patients on anti-psychotic drugs ranged from 48% to 92% (median=77%). These figures are in excess of the percentage reported in a similar international comparison of prescription patterns in 15 different countries where 11.5% of patients were prescribed at least one psychotropic drug [1]. The differences in our results and those reported by Linden et al. [1] are very likely due to different levels of severity: this study is of acute in-patients, whereas Linden et al. studied community out-patients. Other factors that may contribute to variation in prescribing are: cultural differences in physician prescribing patterns and patients’ responses to psychotropic drugs [24]; differences in the educational preparation of prescribing professionals [25]. Variation in drug dosage patterns may also reflect the use of acute wards for different functions. Lower drug doses may be due to wards having a Psychiatric Intensive Care Unit (PICU) or rehabilitation unit to refer the most difficult clients. Some of the acute wards in the study may also have taken forensic patients. Many antipsychotics and antidepressants are substrates for a hepatic enzyme CYP2D6, the activity of which is largely genetically determined. Regarding ultrarapid metabolisers, there are differences across Europe; Mediterranean countries have the highest frequency, northern countries the lowest frequency. It is possible this (or other potential genetic differences) could explain some of the differences in prescribing patterns found in this study.1 The variation in diazepam equivalents may reflect differences in societal reactions to the use of these drugs. For example, in England there has been public criticism of the use of benzodiazepines [26]. Both England and Germany have relatively low levels of diazepam equivalents. Belgium and Finland have the highest levels of diazepam equivalents, and this may reflect more tolerance towards the use of these drugs in these societies, or the tendency among psychiatrists to over-prescribe benzodiazepines [3]. The Netherlands has a high level of diazepam equivalents, due partly to legal restrictions on compulsory medication in that country, necessitating the prescription of drugs that are acceptable to patients. Olanzapine is the anti-psychotic drug of choice in the majority of centres, being more favoured in Scandinavia than elsewhere on the continent. This is not surprising and reflects the growing popularity in the use of atypical anti-psychotics world-wide [27] and possibly the average age of the patients in our study. In an Australian study of adults in acute wards, Galletly [28] found that olanzapine was the drug prescribed in the majority 1 We are grateful to one of the reviewers of this manuscript for alerting us to these points during the review process.
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(61%) of cases. In an Australian study of older adults living in nursing homes, olanzapine was the least prescribed drug [4]. The older anti-psychotics such as haloperidol are favoured in England, Italy and Spain. Famuyiwa [22] found that haloperidol was used commonly in his study of psychotropic drug use in three hospitals in Nigeria. Tinsley et al. [29] found that haloperidol was the drug most often prescribed to adults by primary care physicians in the USA. Keks [30], however, criticised the use of the older anti-psychotics as less effective and more likely than the newer anti-psychotics to cause extra-pyramidal symptoms. However, olanzepine also has side effects, some potentially serious, as a result of consequent weight gain. There is variation in the type of anti-depressant prescribed across the different centres. Venlafaxin was the preferred anti-depressant choice in the majority of centres. Isacsson et al. [31] found that amitryptyline was the anti-depressant of choice of 228 physicians in Sweden. Snowdon [4], however, reported that tricylclics increased patients’ risks of cognitive deficits. Lithium is the preferred mood stabiliser in the majority of centres. This is surprising given the pattern of reduced use of lithium in many countries [32]; however, this may be due to the higher level of acuity in this inpatient sample. Benzodiazepines were the most commonly prescribed anxiolytic drugs across all centres. Diazepam is the most common and this finding concurs with previous studies of prescribing patterns of anxiolytic drugs [4, 33, 34]. Clonazepam, however, was the most prescribed anxiolytic in the data reported by Galletly [34]. There is little variation in the patterns of anti-Parkinson’s drugs used across centres. Finland has the highest percentage of patients on anti-psychotic drugs (Table 4) but no anti-Parkinson’s drugs were prescribed in this study. This may be due to the chlorpromazine equivalent doses in Finland being below the recommended daily dose, or because relatively more atypical drugs were used there. We found that females were on slightly more drugs than males, a finding supported by Linden et al. [1]. However, there were no significant differences between males and females in chlorpromazine and diazepam equivalents. This finding is similar to results reported previously [11]. Our results are less surprising in light of the variation in prescribing patterns shown in previous research comparing prescribing patterns across different continents [1]. Drug prescribing patterns are influenced by the skills and educational preparation of prescribers, the age, gender, educational, employment and family status of patients [1]. Psychological, social and cultural factors explain prescribing practices as much as medical and pharmacological variables [35, 36, 37]. The pricing structures and marketing strategies of pharmaceutical companies also seem likely to have an impact on the selection of drugs for prescription. The results of our study perhaps suggest a need for improved prescribing practices in the centres featured.
Work reported by Schmidt et al. [38] may be of use in this respect. Responding to increases in prescribing practices above recommended doses of psychoactive drugs in Swedish nursing homes Schmidt et al. found that regular multi-disciplinary team meetings to discuss prescribing patterns between doctors, nurses and pharmacists significantly improved prescribing patterns by reducing the number of prescriptions of various psychoactive drugs that were higher than the recommended daily doses. The emphasis of the intervention in this study was to improve teamwork among the key professionals involved in the prescription and administration of drugs. The sample in the reported study may not be fully representative of acute psychiatric wards across Europe. However, our study is significant in that we compared prescribing patterns across ten different European centres and it, therefore, provides data previously unavailable. Nevertheless, we did not compare the duration of drug prescribing nor did we investigate the factors that influenced the prescribing patterns of the psychiatrists in our sample. These issues are ripe for testing in future studies. The number of psychotropic drugs prescribed to acute psychiatric in-patients across Europe conforms to prescribing patterns from world-wide comparative studies. The high doses of psychotropic drugs patients receive in certain European centres may increase patients’ risk of harmful and unpleasant side effects. The use of more typical anti-psychotics in some centres may be causing patients to experience side effects that may be reduced by the use of newer, atypical anti-psychotics. Acknowledgements The authors thank the members of the EViPRG in each country for co-ordinating the data collection and the clinicians in each country for recording the prescribed daily doses.
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