Florida State University Libraries Electronic Theses, Treatises and Dissertations The Graduate School 2008 Patient-Level Demographic and Clinical Variables Associated with Sustained Antipsychotic Polypharmacy: A Naturalistic Study of State Hospital Inpatients Jeffrey Raymond Lacasse Follow this and additional works at the FSU Digital Library. For more information, please contact [email protected] FLORIDA STATE UNIVERSITY COLLEGE OF SOCIAL WORK PATIENT-LEVEL DEMOGRAPHIC AND CLINICAL VARIABLES ASSOCIATED WITH SUSTAINED ANTIPSYCHOTIC POLYPHARMACY: A NATURALISTIC STUDY OF STATE HOSPITAL INPATIENTS By JEFFREY RAYMOND LACASSE A Dissertation submitted to the College of Social Work in partial fulfillment of the requirements for the degree of Doctor of Philosophy Degree Awarded: Summer Semester, 2008 Copyright © 2008 Jeffrey Raymond Lacasse All Rights Reserved The members of the Committee approved the Dissertation of Jeffrey Raymond Lacasse, defended on June 2, 2008. __________________________________________ Tomi Gomory Professor Directing Dissertation __________________________________________ Bruce Bullington Outside Committee Member __________________________________________ C. Aaron McNeece Committee Member Approved: __________________________________________________ Darcy Siebert, Doctoral Program Director __________________________________________________ C. Aaron McNeece, Dean, College of Social Work The Office of Graduate Studies has verified and approved the above named committee members. ii This dissertation is dedicated to my parents, E. Raymond Lacasse and Tresha Souders-Lacasse iii ACKNOWLEDGEMENTS First, I would like to acknowledge my dissertation committee. Drs. Aaron McNeece and Dr. Bruce Bullington provided thoughtful feedback and were a pleasure to work with. Dr. Tomi Gomory not only served as dissertation chair, but was my mentor throughout my doctoral education. Dr. Gomory, you have demonstrated what it means to be both a rigorous scholar and an engaged and caring colleague. I have learned so much from your teaching and guidance, as well as from our collaborative projects. I look forward to our continuing collaboration and friendship. I want to thank the entire faculty and staff of the FSU College of Social Work. They have been friendly and supportive colleagues. In particular, I would like to acknowledge those faculty who directly supported the completion of this dissertation by providing guidance, funding, moral support, methodological advice, or all of the above: Fran Gomory, MSW, and Drs. Neil Abell, Jim Hinterlong, Aaron McNeece, Scott Ryan, Darcy Siebert, Martell Teasley, Stephen Tripodi, and Linda Vinton. Special thanks are due to Dr. David Cohen for stimulating my initial interest in psychiatric medications and social work academia. Thanks to Dr. Jonathan Leo for his consistent encouragement, and also for his enthusiastic participation in our collaborative work. I am also deeply indebted to Dr. Joshua Gross and the Friday afternoon group. I am grateful to the many extramural academics who took the time to answer questions about their research and otherwise correspond with me. It made for an intellectually enriching experience. In particular, I want to acknowledge Drs. David Altman, Richard Berk, Gerd Gigerenzer, Julie Kreyenbuhl, Deidre McCloskey, Ric Procyshyn, David Taylor, and Stephen Zilliak. I appreciate my friends in my doctoral cohort and their families: Lisa, Clint, Lynn, Butch, Steve, Rose, Julie, Jennifer, Machelle, and Blace. To my friends Jon and B. Klaus, I deeply value your friendship, support, and our many hours of laughter in anxious times. Also, thanks to Rachel, Dave, and Gary. iv Many thanks to Beth for her support and understanding throughout the dissertation process. Beth, we made the best of a chaotic and work-intensive semester! Special thanks for spending our Friday night ‘date nights’ in my office while I analyzed data, and for bringing me delicious meals when I was facing deadlines. Finally, I want to acknowledge my family. Thanks to my grandmother, Louise Waters, for supporting me and reading my published work religiously. Deepest thanks are due to my wonderful parents. Since I was very young, they have emphasized the value of education, the need for compassion towards the less fortunate, and the importance of critical thinking. Mom and Dad, I am thankful for you love, encouragement, and tireless support of my efforts. v TABLE OF CONTENTS List of Tables .................................................................................................................... vii List of Figures.................................................................................................................... ix Abstract................................................................................................................................x 1. HISTORICAL BACKGROUND AND STATEMENT OF THE PROBLEM ..............1 2. LITERATURE REVIEW ..............................................................................................44 3. RESEARCH QUESTIONS ...........................................................................................68 4. METHODOLOGY AND DESCRIPTION OF STUDY POPULATION .....................75 5. FINDINGS.....................................................................................................................93 6. DISCUSSION..............................................................................................................105 APPENDIX A – SYSTEMATIC RESEARCH SYNTHESIS ........................................114 APPENDIX B – DISCHARGE PANNS BY POLYPHARMACY STATUS ................124 APPENDIX C – INSTITUTIONAL REVIEW BOARD APPROVAL LETTER ..........126 REFERENCES ................................................................................................................128 BIOGRAPHICAL SKETCH ..........................................................................................155 vi LIST OF TABLES Table 1. Evaluation Criteria for Naturalistic Studies ........................................................46 Table 2. Sample Contingency Table..................................................................................72 Table 3. Demographics of State Hospital Inpatients. ........................................................78 Table 4. Axis I and II Diagnoses of Study Population. .....................................................80 Table 5. Axis III Diagnoses of Study Population. .............................................................82 Table 6. Overall Health Status of Study Population..........................................................85 Table 7: Potentially Iatrogenic Symptoms, Syndromes, and Diseases..............................86 Table 8: PANSS Mean Scores by Administration............................................................86 Table 9. Mean PANSS for Admission and Mid-Hospitalization Combined.....................87 Table 10. Seclusion and Restraint Data. ............................................................................89 Table 11. Chronicity and Length of Stay...........................................................................90 Table 12. Antipsychotics Prescribed for Routine Use.......................................................91 Table 13. Total Number of Antipsychotics Prescribed During Hospitalization................92 Table 14. Non-Routine Antipsychotic Prescriptions. ........................................................92 Table 15. Sensitivity Analysis of Operational Definitions ................................................93 Table 16. All Antipsychotic Polypharmacy Regimens Prescribed ≥ 60 Patient-Days......95 Table 17. Summary of Antipsychotic Polypharmacy Combinations.................................96 Table 18. Patterns of Antipsychotic Polypharmacy...........................................................96 Table 19. Differences in Demographics by Polypharmacy Status ....................................98 Table 20. Differences in Clinical Diagnoses by Polypharmacy Status ............................99 Table 21. Differences on Continuous Measures According to Polypharmacy Status ....100 Table 22. Career Seclusion and Restraint According to Polypharmacy Status ..............101 vii Table 23. Seclusion and Restraint During Hospitalization According to Polypharmacy Status.................................................................................................102 Table 24. Systematic Research Synthesis........................................................................115 Table 25. Discharge PANSS According to Polypharmacy Status...................................125 viii LIST OF FIGURES Figure 1. Prevalence of Antipsychotic Polypharmacy.......................................................50 Figure 2. Clinical Significance of Demographic Variables...............................................56 Figure 3. Clinical Significance of Psychopathology and Service Utilization Variables ...60 Figure 4. Clinical Significance of Co-Diagnosed Conditions ...........................................63 Figure 5. Clinical Significance of All Patient-Level Variables ........................................66 ix ABSTRACT In the pharmacological treatment of psychotic disorders, evidence-based treatment recommendations suggest the prescription of one antipsychotic (monotherapy) where possible. The simultaneous co-prescription of multiple antipsychotics, known as antipsychotic polypharmacy (APP) has recently been the subject of much discussion and research in the scholarly