Prescribing practice

David Taylor is Chief Pharmacist at the South London and Maudsley NHS Trust. Honorary Senior Lecturer at the Institute of Psychiatry and Foundation President of the College of Mental Health Pharmacists. His main areas of research are pharmacokinetics and prescribing practice in mental health. His team at the Maudsley is widely involved in systemic reviews and meta-analyses of psychotropic drug therapy. David is lead author of the Maudsley 2001 Prescribing Guidelines (Martin Dunitz, 2001) and co-editor of Case Studies in Psychopharmacology (Martin Dunitz, 1998). 

Prescribing practice is the least widely regulated activity. It is regulated in six of the 10 countries, namely Australia, Cuba, Estonia, Malaysia, Venezuela and Zimbabwe. 

Long-term use of hormone-replacement therapy and concurrent use of progestins appear to contribute to breast cancer risk.7 The use of postmenopausal estrogen-replacement therapy in women with a history of breast cancer generally is considered contraindicated. However, most experts believe that the safety and benefits of low-dose oral contraceptives currently outweigh the potential risks and that changes in the prescribing practice for the use of oral contraceptives are not warranted. Oral contraceptives are known to reduce the risk of ovarian cancer by about 40% and the risk of endometrial cancer by about 60%. 

This volume covers topics including cultural perspectives in psychiatric diagnosis and psychopharmacotherapy, differences in pharmacokinetics and pharmacodynamics of psychotropics, pharmacogenetics of ethnic populations, ethnic variations in psychotropic responses, complementary medicines in mental disorders, attitudes towards psychotropic medications, prescribing practices in Asia-Pacific countries, pharmaco-economic implications, integrating theory and practice, and... 

Segal, S. R, Bola, J. R. 8c Watson, M. A. (1996). Race, quality of care, and antipsychotic prescribing practices in psychiatric emergency services. Psychiatr. Serv., 47, 282-6. 

Compared to antipsychotics, there are even fewer studies on the prescribing patterns of antidepressants done in Asian countries. Pi etal. (1985) conducted a survey of psychotropic prescribing practices reported by psychiatrists in 29 medical schools in 9 Asian countries. Daily dose range of tricyclic antidepressants (TCAs) such as amitriptyline, imipramine, and nortriptyline in Asian countries was comparable to the practice in USA. This is despite differences found between Asian and non-Asian populations in the pharmacokinetics of TCAs (Pi et al, 1993). A questionnaire on the practical prescribing approaches in mood disorders administered to 298 Japanese psychiatrists was reported by Oshima et al. (1999). As first-line treatment, the majority of respondents chose newer TCAs or non-TCAs for moderate depression and older TCAs for severe depression. Combination of antidepressants and anxiolytics was preferred in moderate depression, while an antidepressant and antipsychotic combination was common in severe psychotic depression. Surprisingly, sulpiride was the most favored drug for dysthymia. In a naturalistic, prospective follow-up of 95 patients with major depression in Japan, the proportion of patients receiving 125 mg/day or less of imipramine was 69% at one month and 67% at six months (Furukawa et al., 2000). 

Oshima, A., Higuchi, T., Fujiwara, Y. et al. (1999). Questionnaire survey on the prescribing practice of Japanese psychiatrists for mood disorders. Psychiatry Clin. Neurosci., 53(suppl), S67-S72. 

Coveil, N.H., Jackson, C.T., Evans, A.C. Essock, S. M. (2002). Antipsychotic prescribing practices in Connecticut s public mental health system rates of changing medications and prescribing styles. Schizophr. Bull., 28( 1), 17-29. 

It is not often that researchers find their work leading to such widespread changes of behaviour. Still, the 44 per cent figure reveals a split opinion. Most physicians did not intend to alter their prescribing practices. Our analysis has provoked a vociferous and continuing debate on the effectiveness of antidepressants and the circumstances under which they should be prescribed. In this chapter I consider and respond to the various criticisms that have been levelled at our data-based conclusions about the efficacy of antidepressants. 

A large and growing number of older people across the world suffer from schizophrenia. Recommendations for their treatment are largely based on data extrapolated from studies of the use of antipsychotic medications in younger populations. In addition most manufacturers of such medications recommend prescription of reduced doses to the elderly. The evidence base for these assumptions is unclear and raises obvious questions regarding the appropriateness of such prescribing practice. 

Pharmacists receive prescriptions by telephone, fax, as written prescriptions from individual prescribers, practicing in a group, or hospitals and other institutions. Telephone orders are reduced to a written prescription (hard copy) by pharmacists. Generally, prescriptions include printed forms called prescription blanks which include the name, address, and telephone number of the prescriber a provision to write the name, address, age or date of birth of the patient and the I symbol. Medication orders are prescription equivalents which are written by practitioners (prescribers) in a hospital or a similar institution. Components of medication orders with appropriate examples are presented in the subsequent section. 

In the 24 years since it was first published in the current format, editions have appeared every 6 months and it has become generally regarded as the most influential guide to good prescribing practice. 

Jensen, P.S., Bhatara, V.S., Vitiello, B., Hoagwood, K., Feil, M., and Burke, L.B. (1999) Psychoactive medication prescribing practices for U.S. children gaps between research and clinical practice. J Am Acad Child Adolesc Psychiatry 38 557-565. 

Kaplan, S.L. and Busner, J. (1997) Prescribing practices of inpatient child psychiatrists under three auspices of care. / Child Adolesc Psychopharmacol 7 275-286. 

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