MWD-75-47 Controls on Use of Psychotherapeutic Drugs And

‘ REPORT TO THE CONGRESS Controls On Use Of Psychotherapeutic Drugs And Improved Psychiatrist Staffing Are Needed In Veterans Administration Hospitals b BY THE COMPTROLLER GENERAL OF THE UNITED STATES MWDJ5-47 APRIL18,19?'5 t COMPTROLLER GENERAL OF THE UNITED STAlES WASHINGTON. D.C. 21XI48 B-i33044 .To the Presid-ent of the Senate and the Speaker of the House of Representatives We reviewed psychiatric treatment at Veterans Adminis- tration hospitals and found a need for (1) controls to insure appropria-te use of psychotherapeuticdrugs and (2) improved psychiatrist staffing. Our review was made pursuant to the Budget and Accounting Act, 1921 (31 U.S.C. 53), and the Accounting and Auditing Act 0.f 1950 (31 U.S.C. 67). We are sending copies of this report to the Director, Office of Management and Budget, and to the Secretary of Health, Education, and Welfare. Comptroller General of the United States . I” n Contents -- Page DIGEST i CHAPTER 1 INTRODUCTION 1 Use of psychotherapeutic drugs 1 Side effects of psychotherapeutic drugs 2 Scope of review 3 CLOSERMONITORING NEEDED TO PRECLUDE OVERUSEOF PSYCHOTHERAPEUTICDRUGS 4 Drugs used in excess of recommended maximum doses 5 Simultaneous use of more than one psychotherapeutic drug 7 Possible overuse of drugs to treat Parkinson's disease symptoms 10 Frequency of administering psychotherapeutic drugs 13 Inadequate use of drug holidays 16 Actions taken by hospital officials as a result of our findings 18 Conclusions 18 Recommendations 19 Agency comments and our evaluation 19 3 STAFFING OF PSYCHIATRIC WARDSIN VA HOSPITALS 23 Conclusions 25 Agency comments 25 APPENDIX I Letter dated February 7, 1975, from the Deputy Administrator of Veterans Affairs 27 II Drugs and recommended maximum daily dosages ,36 III Letters da,ted February 5, 1974; Febru- ary 20, 1974; and April 23, 1974, from three VA hospital officials 39 and in some cases delusions and hallucina- , tions. Mood changes include inappropriate emotional responses and loss of empathy. Withdrawn, regressive, and bizarre behavior may be noted. /’ . ,; ,’ ,. * I, ‘. ‘, ,, COMPTROLLER GENERAL'S CONTROLS ON USE OF REPORT TO THE CONGRESS PSYCHOTHERAPEUTIC DRUGS AND IMPROVED PSYCHIATRIST STAFFING ARE NEEDED IN VETERANS ADMINISTRATION HOSPITALS -------DIGEST WHY THE REVIEW WAS MADE results and implications of current medical research on Because of the important role these drugs. drugs have in the care of the Veterans Administration's GAO prepared drug profiles on (VA's) psychiatric patients, 6,171 psychiatric patients. GAO souQht to determine if VA The profiles included infor- had established proper con- mation on the type of drug trols over the use of psycho- or drugs being taken, length therapeutic drugs and whether of time they had been taken, other improvements might be dosages, and frequency with needed. which they were being administered. (See p. 4.) VA estimated that during fis- cal year 1976 the average Using the drug profiles, GAO daily number of mentally ill found that in many instances patients in its hospitals psychotherapeutic drugs were will total about 26,000 and not being used as recommended the cost of providing care by authoritative medical ref- will be about $518 million. erences. VA officials were generally un- FINDINGS AND CONCLUSIONS aware that the drugs were not being administered in accord- i ante with these references. Medical authorities agree that psychotherapeutic drugs Officials of three hospitals are beneficial in treating advised GAO that actions would certain psychiatric patients. be taken to monitor the pre- They have cautioned, however, scribing of drugs so that ad- that prolonged or improper justments could be made when use of these drugs can be conditions warranted. ( See detrimental. p. 18.) VA should establish a system VA has had problems recruiting to inform its officials about enough physicians to treat psy- $ whether psychotherapeutic chiatric patients, many of the j drugs are being properly physicians assigned to treat used. VA also needs an ef- such patients had no formal fective system for dissemi- psychiatric training, and the nating to its physicians number of patients for which JSheet. Upon removal, the report MWD-75-47 cover date should be noted hereon. i a physician was responsible Simultaneous *--use of varied widely. (See p. 23.) Ke than-- one drug Numerous studies, including Drugs used in excess of some by VA, have concluded -Zazurn recommended - dosage that little evidence exists to support simultaneous use The proper dosage of a psy- of more than one psychother- chotherapeutic drug varies apeutic drug on the same pa- with the individual patient. tient--a practice commonly A physician must consider referred to as polypharmacy. several factors, including the patient’s weight, sever- These studies have shown that ity and type of illness, and polypharmacy increases the tolerance level, in deter- possibility of adverse reac- mining the proper dosage. tions and have suggested that Medical authorites generally it be avoided if possible. agree that dosages above the (See p. 7.) recommended maximum may cre- ate an unacceptable risk of The drug profiles for the 6,171 toxicity and may fail to pro- patients showed that 2,002, or vide a substantial additional about 32 percent, were being therapeutic effect. (See given more than one psychother- P* 5.1 apeutic drug simultaneously. Many were taking more than two A comparison of drug profiles drugs simultaneously. ( See with maximum recommended dos- pp. 7 and 8.) ages showed that 631 of the 6,171 patients, or about 10 A disparity also existed in percent, were receiving dos- the use of polypharmacy among ages in excess of the recom- wards of the same hospital 0 mended daily maximums. Some wards at almost every hospital had no patients receiving The average percentage of more than one psychotherapeutic patients taking more than the drug; however, every hospital recommended dosage in the 13 had at least one ward in which hospitals visited by GAO polypharmacy was practiced to ranged from 4 to 23. ( See a considerable extent, ( See P* 5.1 PO 9.1 GAO also noted a wide dispar- Use of drugs to treat ity in the number of patients Parkinson’s dzgexe svmntoms receiving more than the maximum recommended dosage among One possible side effect of wards of the same hospital. the class of psychotherapeutic In some wards more than 40 drugs known as antipsychotic percent of the patients were is the inducement of Parkin- receiving dosages in excess son’s disease symptoms--but not of the recommended maximums. the disease itself. Drugs used ii to treat these symptoms are A wide disparity also existed commonly referred to as anti- in the number of drugs admin- Parkinson drugs. istered three or more times daily for more than 6 months Studies conducted of antipar- among hospitals and among kinson drugs have concluded wards within a hospital. that they (1) should not be used preventively or routine- --Use of drug ----_-holidays ly and (2) can usually be c discontinued after about 3 According to studies, includ- months because the symptoms ing some by VA, a majority of usually disappear by then. chronic schizophrenics--con- stituting a large portion of Of the 1,645 patients taking psychiatric patients in VA antiparkinson drugs: hospital s-- who are stabilized on doses of antipsychotic --42 percent appeared to be drugs can receive no medica- taking them routinely. tion for 2 or 3 days a week (drug holidays) without sub- --37 percent had been taking stantial clinical change, them for longer than 3 months. (See p. 10.) Drug holidays are feasible because these psychotherapeutic A wide disparity also existed drugs are stored in various among hospitals in the use of body tissues and released over antipar kinson drugs. Routine a period of days or weeks. use of antiparkinson drugs (See pe 16.) ranged from 28 percent at one hospital to 54 percent at GAO’s analysis of the drug data another. suggested that drug holidays were not being used to the extent possible. In 6 of the 13 Frequency of administering ---- . -- hospitals, no patients were on ----cychotherapeutic -----drugs drug holiday schedules. About 90 percent of all the patients VA studies state that VA ad- on drug holidays were from ministers many psychothera- three hospitals. (See p. 17.) peutic drugs to patients three or more times daily. Staffing problems----- These studies recommend I however, that,. after some VA has had problems recruiting degree of control over the enough physicians to provide patient’s condition has care to psychiatric patients. been obtained (one noted VA Many of its physicians assigned psychopharmacologist has to provide psychiatric care suggested that this may take have had no formal psychiatric 3 to 6 months), the drug be training, and the number of pa- administered only once or tients for which a physician twice daily. (See p. 13.) was responsible varied widely. iii One hospital had 1 physician --Establish a uniform drug for every 21 patients.; anoth- utilization review system er had 1 physician for every to provide management with 100 patient,s. The overall information on whether psy- ratio was 1 for 53. chotherapeutic drugs are being used in accordance Considering only the psychia- with the guidelines. trists who were certified or eligible to become certified --Require hospitals using (physicians who specialize in psychotherapeutic drugs to psychiatry) by the American implement the drug utiliza- Board of Psychiatry and Neu- tion review system. rology, GAO found that the ratio ranged from 1 psychia- --Design an effective, ongoing trist for every 24 patients educational program to dis- to 1 for 399. (See p. 23.) seminate to hospital person- nel the results and implica- VA officials and hospital tions of current medical psychiatrists identified the research on psychotherapeutic following problems as ones drugs.

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