Start low, go fast? Antipsychotic titration patterns at an inpatient psychiatric hospital

Abstract

Introduction Antipsychotics are commonly used to treat psychotic symptoms and severe mental illnesses. Treatment guidelines recommend antipsychotics be titrated quickly to therapeutic effect in the acute setting but acknowledge that determining the optimal dose is complicated by a delay between treatment initiation and therapeutic response. The purpose of this study was to evaluate antipsychotic titration patterns in an inpatient psychiatric hospital. Methods This study is a retrospective chart review of adult patients admitted to a teaching hospital and initiated on an antipsychotic for treatment of psychosis between January and December 2018. Patients were excluded if they had substance-induced psychosis, delirium, were prescribed >1 antipsychotic, or had no antipsychotic dose changes. The primary outcome was the average titration rate of the newly initiated antipsychotic. Secondary outcomes included differences in titration rate between involuntary and voluntary admissions and other antipsychotic characteristics. Results Of 149 patients included, the majority had a primary diagnosis of schizophrenia. Antipsychotics were titrated on average every 2 days regardless of admission type. Eighteen percent of patients were titrated to guideline-recommended maximum doses, and it took, on average, 3 days for patients to reach their final dose during hospitalization. Average length of stay was 9 days, and 43.6% of patients were readmitted within 1 year. Discussion Antipsychotics are titrated rapidly in the inpatient setting despite a lack of evidence regarding the impact of titration rate on clinical outcomes. Further studies comparing slow versus rapid titration strategies are needed to elucidate the impact of this on patient outcomes.

Healthcare Provider Engagement with a Novel Dashboard for Tracking Medication Ingestion: Impact on Treatment Decisions and Clinical Assessments for Adults with Schizophrenia

“… 13 Likewise, some antipsychotics that require weeks or months to reach maximal efficacy can reduce adherence because the patient believes the therapy does not work. 12 , 16 This may lead to unnecessary adjustments to the treatment regimen, such as increasing dosage, changing medications, or adding new medications. 13 The AS system can provide this key information to inform a patient’s care plan; as an example, when providers had access to patient drug adherence information, they made more informed treatment decisions for nonadherent or poorly controlled patients compared with providers who did not have that information.…”

“…3,8 While antipsychotics are the foundation of treatment for patients with schizophrenia, 9 many patients have a suboptimal response to these treatments, 10 particularly patients experiencing primary negative symptoms. 11 Achieving optimal pharmacotherapy for patients with schizophrenia is difficult 12 and is further complicated by medication nonadherence, 13,14 which is a common challenge in this patient population. 15 In a 2020 meta-analysis of 9 studies, 56% of 2643 patients with schizophrenia were nonadherent to their medications.…”