A survey of prescribing psychotropic drugs in two psychiatric hospitals K Michel and T Kolakowska The British Journal of Psychiatry 1981 138: 217-221 Access the most recent version at doi:10.1192/bjp.138.3.217
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EDWARD HARE
Mania before Kraepelin In their authoritative textbook, Bucknill and Tuke refer to “¿the constant tendency of mania, and other forms of mental derangement, to pass into dementia― (1879, p. 304). This observation sums up the nine teenth century concept of mania as a condition commonly leading to mental (i.e. intellectual) deter ioration. Clouston (1892, p. 205), discussing the prognosis of mania, says there is complete recovery in about half the cases, death in 5 per cent, partial re covery (that is, chronic mania) in 15 per cent; and in the remaining 30 percent, dementia—adding that “¿the bulk of chronic patients in asylums are of this class―. Melancholia had a similar outcome, and it is evident that the concepts of mania and melancholia in the nineteenth century included cases of what we would now call schizophrenia and which Kraepelin called dementia praecox; indeed, Kraepelin specifically makes this point (1913, p. 193). The question may then be asked, did Kraepelin's concepts of manic-depressive insanity and dementia praecox spring fully armed, as it were, from the head of Jove, so that he saw in a sudden flash of inspiration what had been there all the time but which no one else had seen; or had a gradual change been taking place in the understanding, or in the clinical manifestations, of mental disorders, such that a distinction between these two groups must soon have become obvious to many observers? It is this question which I am going to consider. The attempt to answer it will involve a search among the complex and changing patterns of nineteenth century classifications for the emergence of the idea that there were some types of insanity, characterized by excitement or depression or both, which did not progress to “¿dementia―. I propose to examine four strands from this vast pattern: the ideas related to (1) periodicity, (2) partial insanity, (3) simple mania, and (4) recoverability. Periodic insanity
Because we are apt to think of affective disorder (in its modern sense) as typified by a tendency to re currence, an examination of the concept of periodic insanity might seem a promising one for our purpose. But Pinel was only recalling what had been recog nized for centuries when he wrote in 1801 (p. 5) about insanity in general that, “¿intermittent or periodical insanity is the most common form of the disease―; and this is why, he says, he begins his Treatise with the subject of periodical insanity. It was of course this general tendency to periodicity which gave rise to the mediaeval English word “¿lunatic―, meaning a person affected with intermittent insanity—the intermittency being attributed to changes in the moon. A claim is sometimes made that Jean Pierre Falret, a pupil of
91
Esquirol, “¿discovered― manic-depressive insanity in his delineation of circular insanity, which he called “¿folie circulaire―(1854). Thus in Hinsie and Camp bell's Psychiatric Dictionary(1970), “¿folie circulaire―is described as “¿Falret's term for the condition known today as manic-depressive psychosis, circular or alternating―. Falret indeed described a disorder characterized by alternating attacks of mania and melancholia, in which there were lucid intervals between each attack. The attacks were of the simple form of mania and melancholia—that is to say, without incoherence or intellectual disturbance. And yet, he says, although the simple forms are more curable than most insanities when occurring in isolation, it is a remarkable fact that when they were united to form folie circulaire he had never known a case with complete cure or even a lasting remission; and that, even in the lucid intervals, the patient only seemed recovered and tried to conceal his intellectual loss and delusions. The prognosis of folie circulaire, he said, was particularly grave, indeed it was désesperant—hopeless. This view was generally accepted. Bucknil and Tuke (1879, p. 304), in observing that mania may pass into melancholia, add that “¿if the two conditions alternate, it assumes the very unfavourable form of circular insanity―.Mauds Icy (1895, p. 279) says that the prognosis of alternating recurrent insanity is always bad: it causes “¿the mind eventually to become weaker and the disease to last for life―. Clearly, Falret's folie circulaire cannot be simply equated with our modern affective disorder. On the other hand, Falret say@of his folie circulaire that it is strongly hereditary and that it affects females much more than males. And in spite of Falret's explicit statement about the bad prognosis, Kraepelin in cluded “¿the so-called periodic or circular insanity― within his category of manic-depressive insanity. However, Kraepelin did not use periodicity as a distinguishing feature of the manic-depressive in sanities because (he said) periodicity is also char acteristic of epileptic insanity, hysterical insanity, and certain forms of dementia praecox (1913, p. 189). Thus the original concept of periodic or alternating insanity does not seem to lead us directly to the reason for the Kraepelinian divide. Partial insanity The nineteenth century inherited two opposing views on the nature of the mind and, in consequence, on the nature of mental disease. One view—ofwhich John Locke was a proponent—saw the mind as an indivisible unity, like the soul. On this unitarian view, the mind was incapable of suffering any partial derangement: if diseased, it would be diseased
A SURVEY OF PRESCRIBING PSYCHOTROPIC DRUGS IN TWO PSYCHIATRIC HOSPITALS
218
TABLE II
TABLE I
Characteristics ofthepatient population 511n%Day
Hospitals N =A
Prescriptions
for psychotropic
drugs and their combinations
&B (N = 511) DrugsPatients
n
(%)%
patients19939Women26752Age:17—39981940—591432860
of all on
neuroleptics (294 =
100%)Neuroleptics
over26852Diagnosis:Schizophrenia20741Affective and
178 41 19 71
only* with antidepressants with minor tranquilizers with hypnotics294
(58) (35) 14 (8) 7 (4) (14)61 24%
of all on
disorder12024Dementia organicdisorder10120Neuroses245Personality and other
anti depressants (97 =
100%)Antidepressants disorder286Other317
receiving other psychotropic drugs, viz hypnotics (71), antidepressants (41) and/or minor tranquillizers (19). Anti-parkinsonian medication was prescribed to half. Chlorpromazine was the favourite oral neuroleptic (77 patients), followed by fluphenazine decanoate and flupenthixol decanoate in about equal proportions, then by thioridazine. In 32 patients, prescriptions for neuroleptics included two different drugs. Among the highest dosages recorded was chlorpromazine 900 mg/day with clopenthixol 300 mg/week. Depot preparations were given to less than half of patients treated with neuroleptics (Table Ill) but, even among day-patients, one-fifth of those receiving long-acting injections also had oral preparations. Antidepressants were prescribed to one-fifth of the population (Table II) and in the majority of this group (78 of 97) they were combined with other psychotropic drugs, mainly neuroleptics (41) and/or hypnotics (33). The most commonly prescribed antidepressant was amitriptyline (68 patients), followed by imipramine (16)and mianserin(8).Monoamine oxidaseinhibitors were used for two patients and other antidepressants in single cases only. The doses did not exceed ami triptyline 200 mg/day or its equivalent, and in nearly one-third of patients doses were lower than 100 mg/ day. These lower doses were prescribed mainly for the elderly and for those with diagnoses other than ‘¿affective disorder, depression'. Over one-quarter of patients received hypnotics.
The drugs used were mainly benzodiazepines, with a small proportion of prescriptions for chloral hydrate (mainly in the elderly) or chlormethiazole. Only one
19 41 19 33
only with neuroleptics with minor tranquilizers 34Minor with hypnotics97
(19) (4) (8) (4) (6)20
42 20
(10)Hypnotics143 tranquilizers51 (28)Lithium39 (8) * No
other
psychotropic
drugs.
TABLE III
Treatment
with neuroleptic
drugs: prescriptions
for oral and
depot preparations by type of care neurolepticsIn-patients with 294)N (N = 115)Total (N = (N = 179)Day-patients PreparationPatientstreated (%)Oral (%)N
(%)N
(58)Depot only132
(74)38
(33)170
(32)Depot only33
(18)62
(54)95
(8)15
(13)29
-oral17
(10)
was for a barbiturate. Nearly three-quarters of these patients were treated with neuroleptics or anti depressants. Minor tranquillizers were given during the day to 10 per cent of the population, mostly in combination
KONRAD MICHEL AND TAMARA KOLAKOWSKA
219
TABLE IV
Number of psychotropic drugs per patient Numberof drugsper patient01234ormoren%n%n%n%n%AveragePsychotropicdrugsonly110222144214729377311.2Includinglithium103201953816332469411.3Including
lithium and anti-parkinsonian drugs9719143281533092182651.9 with neuroleptics and/or antidepressants. Nearly all prescriptions were for diazepam. The highest dose
Table VI relates type of psychotropic drug to diag nosis. Among patients treated with neuroleptics, 40
recorded was 40mg/day. Table IV shows, when lithium and anti-parkin
per cent had diagnoses other than schizophrenia.
sonian agents were excluded, that about one-fifth of the entire population had no psychotropic drugs,
while for one-third (nearly half of those receiving medication) prescribed. medication appeared as
a combination of two or more drugs was When lithium and anti-parkinsonian were included, 19 per cent of patients drug free and 5 per cent as receiving four
Neuroleptics were prescribed to one-third of depressed patients, to 40 per cent of those with dementia or other organic disorder and to almost half of those diagnosed as personality disorder. Similarly, over one-third of prescriptions for anti
depressants were made for patients with diagnoses other than affective schizophrenia.
illness,
mainly
neurosis
and
or more different drugs. Frequency of administration and number of tablets per day Prescriptions for three or more than three doses per
day were common with minor tranquillizers (26 and 6 of 51 patients respectively) and neuroleptics (one fourth and one-fifth respectively). Antidepressants were given mainly once or twice a day (three-quarters of prescriptions); only three patients had 4 doses a day. Prescriptions for 3 or more doses a day resulted in a
high number of tablets or capsules given to some patients. The maximum of 22 tablets per day was found in the middle-aged group (average 6.0); in the groups aged under 40 and over 60 it was 14 and 19 tablets respectively (average 3.8 and 4.4 respectively). Psychotropic drugs and diagnosis The proportion of patients with no psychotropic drugs
(Table
V) was
highest
in the
diagnostic
group
of
dementia (43 of 101), followed by those with person ality disorder (one-third), and neuroses (4 of 24). Polypharmacy was common in all the diagnostic groups. Combinations of two or more psychotropic drugs were prescribed to nearly two-thirds of both manic and depressed patients, to 40 per cent of schizophrenics, to half the patients diagnosed as neurotic and over one-third of those with personality disorder.
Discussion The survey shows that from each class of psycho tropic drugs only a small number of compounds has been used. In particular, the ‘¿new antidepressants'
were seldom used and diazepam had a monopoly position as a minor tranquillizer. Over one-third of all patients, i.e. almost half of those receiving psycho tropic medication, had more than one psychotropic drug (when lithium was excluded), and about 10 per cent had at least three different drugs. This frequency of polypharmacy is lower than that reported from some hospitals in Israel and Finland (Yosselson Superstine, 1979—up to 67 per cent; Hemminki, 1977—69 per cent), but is close to the average in the surveyed US hospitals (Prien et a!, 1978) and to the high 37 per cent found in prescriptions by general practitioners (Tyrer, 1978). Polypharmacy is generally not recommended because of increased risk of adverse reactions, and the lack of evidence for therapeutic advantage from using several psychotropic drugs instead of a properly chosen one (see reviews by Hollister, 1975 and Hemminki, 1977). In particular, the sedative and anxiolytic properties of some antidepressants and neuroleptics make it hard to justify the common concurrent administration of minor tranquillizers
and/or hypnotics. It seems doubtful also whether
220
A SURVEY
OF PRESCRIBING
PSYCHOTROPIC
DRUGS
IN TWO PSYCHIATRIC
HOSPITALS
TABLE V
Number of psychotropic drugs per patient by diagnosis patient0
Number of drugs per
34ormoreDiagnosis
1
2
n(%)n(%)Schizophrenic N
n
(%)
n
(%)
n
(%)
16(8)2(1)Affective
207
21
(10)
104
(50)
64
(31)
disorders
120
19
(16)
43
(36)
43
(36)
14
5 27
(38) (37)
7 31
(54) (43)
1 13
hypomania depression (1)Dementia inremission
13 72
—¿ —¿
36
19
(53)
11
(30)
6
(17)
101
43
(43)
38
(38)
20
(20)
4(17)—Personality
24
4
(17)
8
(33)
8
(33)
3(10)—Other disorder
28
9
(32)
9
(32)
7
(25)
31
14
(45)
12 —¿â€”TABLE (39) 5
(16)
(8) (18)1 —¿(12)
—¿
1 —¿(1)
and other —¿â€”Neurosis organic disorder
VI
diagnosisDiagnosisPrescriptions for neuroleptics, antidepressants and lithium by N
Neuroleptics
N=39Schizophrenia
185Affective disorder:
N=294
207
177
Antidepressants
N=97Lithium
120
51
63
hypomania depression
13 72
13 29
—¿ 61
9Dementia in remission
35
9
233
101
43
101Personality
24
2
5—Other disorder
28
12
31
9
—¿â€”Neurosis and other organic disorder
one-fifth of day-patients treated with depot prepara tions needed an additional oral neuroleptic. The next questionable pattern concerns prescribing drugs to be taken three or more times a day, as was the casewithtwo-thirds ofminor tranquillizers and nearly
half of oral neuroleptics. The pharmacokinetics
of
most of these drugs make it possible, except in the initial phase of treatment, to administer the entire daily amount at bed-time or at the most in two doses. Less frequent administration could improve compliance, save the time of nursing staff, and reduce the number of tablets taken per day.
5 18
—¿â€”
The clinical data collected are insufficient to allow us to comment any further on these and certain other aspectsof drug prescribing. Thus, the specificity of drug choice cannot be discussed, although the pres cription of neuroleptics for a high proportion of patients in the diagnostic groups of personality dis order (12 of 28) or depression (over a half) raises this
question. Similarly, without information on the side effects and duration of treatment, it is impossible to assess whether the use of anti-parkinsonian medication
was excessive among those treated with neuroleptics.
221
KONRAD MICHEL AND TAMARA KOLAKOWSKA This question is of clinical importance since in a proportion of patients, anticholinergics can be safely withdrawn after a few months of treatment (McClel
KLETr, C. J. & CAFFEY, E. (1972) Evaluating the long term need for antiparkinson drugs by chronic schizo
land et a!, 1974; Klett and Caffey, 1972; Orlov et a!,
LASKA, E., VARGA, E., WANDERLING, J., SIMPSON, G., LOGEMANN, G. W. & Siwi, B. K. (1973) Patterns of
1971) and there is evidence that these drugs promote development of tardive dyskinesia (Perris et a!, 1979). In addition, from our unsystematic observations, we
believe that some patients become dependent on the stimulating effects of orphenadrine or benzhexol and tend to abuse them. To answer these questions, more detailed clinical information will have to be collected on the selected groups of patients. It would also be of interest to
compare these findings with the use of psychotropic drugs in other British psychiatric
hospitals.
It has been
shown that such surveys are helpful in improving prescribing habits (Diamond eta!, 1976) and we report our findings partly in the hope that others will be encouraged to carry out enquiries into the use of drugs in the hospitals in which they work. Acknowledgements
We would like to thank Mr Leslie Hall, Mrs E. Green and Mrs I. E. Kuht for their help in recording patients' medication. We are grateful to all the consultant psych iatrists who gave permission to collect information
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H.,
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T.
& Ricicns,
K.
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(1977)
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psychiatric
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Konrad Michel, M.D., M.R.C.Psych.,Research Psychiatrist, more Hospital, Oxford, 0X4 4XN
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University of Oxford, Department
Tamara Kolakowska, M.D., M.R.C.Psych.,Senior Research Psychiatrist, iatry, Littlemore Hospital, Oxford, 0X4 4XN (Received8 September; revised 14 November1980)
patients.
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