Antipsychotic and Anticholinergic Drug Prescribing Pattern in Psychiatry: Extent of Evidence-Based Practice in Bahrain


The aim of this study is to determine the antipsychotic prescribing pattern and the prevalence of concurrent anticholinergic prescribing in a psychiatric referral hospital. A retrospective audit of prescriptions issued for outpatients was carried out at the Psychiatric Hospital, the only facility that provides psychiatric services for both inpatients and outpatients in the Kingdom of Bahrain. Antipsychotic monotherapy was prescribed for 89.2% patients, whereas polytherapy with two- and three-drugs in 10.4 and 0.4%, respectively. Atypical antipsychotics were prescribed more often (67.7%) than typical antipsychotics. Risperidone and haloperidol were the most frequently prescribed antipsychotics. Long-acting risperidone injection was the only depot preparation prescribed. The mean antipsychotic dose expressed as chlorpromazine equivalent (CPZeq; mg/day) was 242 (220 for monotherapy and 414 for polytherapy). The prevalence of high dose antipsychotic (mean CPZeq > 1000 mg/day) was 1.8%, prescribed at a mean CPZeq dose of 1531 (1925 for monotherapy and 1137 for polytherapy), mainly attributed to haloperidol. Anticholinergics were co-prescribed for almost two third of patients receiving antipsychotics, particularly for those on polytherapy (monotherapy 57.3%; poly-therapy 87.5%). Antipsychotic polytherapy, high dose and co-prescription of an oral with a depot antipsychotic preparation were strongly associated with concurrent prescription of anticholinergics. Procyclidine and orphenadrine were the most often prescribed anticholinergics. In Bahrain, antipsychotic monotherapy is a common practice for outpatients with psychotic disorders. Some of the antipsychotic polytherapies, dosage strategies, and high prevalence of anticholinergic use are therapeutic issues that need to be addressed to foster evidence-based prescribing practice.

Share and Cite:

Khaja, K. , Al-Haddad, M. , Sequeira, R. and Al-Offi, A. (2012) Antipsychotic and Anticholinergic Drug Prescribing Pattern in Psychiatry: Extent of Evidence-Based Practice in Bahrain. Pharmacology & Pharmacy, 3, 409-416. doi: 10.4236/pp.2012.34055.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] K. Sim, H. C. Su, S. Y. Fujii, M. Y. Chong, G. Ungvari, T. Si, Y. L. He, E. K. Chung, Y. H. Chan, N. Shinfuku, E. H. Kua, C. H. Tan and N. Sartorius, “High-Dose Antipsychotic Use in Schizophrenia: A Comparison between the 2001 and 2004. Research on East Asia Psychotropic Prescription (REAP) Studies,” British Journal of Clinical Pharmacology, Vol. 67, No. 1, 2009, pp. 110-117. doi:10.1111/j.1365-2125.2008.03304.x
[2] W. J. Broe-kema, I. W. de Groot and P. N. van Harten, “Simultaneous Prescribing of Atypical Antipsychotics, Conventional Antipsychotics and Anticholinergics—A European Study,” Pharmacy World Sciences, Vol. 29, No. 3, 2007, pp. 126-130. doi:10.1007/s11096-006-9063-1
[3] M. Y. Chang, C. H. Tan, S. Fujii, S. Y. Yang, G. S. Ungvari, T. Si, E. K. Chung, K. Sim, H. Y. Tsang and N. Shinfuku, “Antipsychotic Drug Prescription for Schizo- phrenia in East Asia: Rationale for Change,” Psychiatry and Clinical Neurosciences, Vol. 58, No. 1, 2004, pp. 61- 67. doi:10.1111/j.1440-1819.2004.01194.x
[4] I. Bitter, J. C. Chou, G. S. Ungvari, W. K. Tang, Z. Xiang, A. Iwanami and P. Gaszner, “Prescribing for Inpatients with Schizophrenia: An International Multi-Center Comparative Study,” Pharmacopsychiatry, Vol. 36, No. 4, 2003, pp. 143-149. doi:10.1055/s-2003-41199
[5] A. Wheeler, “Atypical Antipsychotic Use for Adult Out-patients in New Zealand’s Auckland and Northland Regions,” New Zealand Medical Journal, Vol. 119, No. 1237, 2006, pp. U2055.
[6] L. Koen, P. Magni, D. J. H. Niehaus and A. le Roux, “Antipsychotic Prescription Patterns in Xhosa Patients with Schizophrenia or Schizoaffective Disorders,” African Journal of Psychiatry, Vol. 11, No. 4, 2008, pp. 287- 290.
[7] S. Leucht, “Psychiatric Treatment Guidelines: Doctors’ Non-Compliance or Insufficient Evidence?” Acta Psychiatrica Scandinavica, Vol. 115, No. 6, 2007, pp. 417- 419. doi:10.1111/j.1600-0447.2007.01030.x
[8] W. Gaebel, S. Weinman, N. Sartorius, W. Kutz and J. S. McIntyre, “Schizophrenia Practice Guidelines: International Survey and Comparison,” British Journal of Psychiatry, Vol. 189, 2005, pp. 248-255. doi:10.1192/bjp.187.3.248
[9] S. Mace and D. Taylor, “A Prescription Survey of Antipsychotic Use in England and Wales Following the Introduction of NICE Guidance,” International Journal of Psychiatry in Clinical Practice, Vol. 9, No. 2, 2005, pp. 124-129. doi:10.1080/13651500510028995
[10] I. Cancelli, G. L. Gigli, A. Piani, B. Zanchettin, F. Janes, A. Rinaldi and M. Valante, “Drugs with Anticholinergic Properties as a Risk Factor for Cognitive Impairment in Elderly People: A Population-Based Study,” Journal of Clinical Psycho-pharmacology, Vol. 28, No. 6, 2008, pp. 654-659. doi:10.1097/JCP.0b013e31818ce849
[11] I. Carriere, A. Fourrier-Reglat, J. F. Dartigues, O. Rouaud, F. Pasquier, K. Ritchie and M. L. Ancelin, “Drugs with Anticholinergic Properties, Cognitive Decline, and Dementia in an Elderly General Population: The 3-City Study,” Archives of Internal Medicine, Vol. 169, No. 14, 2009, pp. 1317-1324. doi:10.1001/archinternmed.2009.229
[12] Y. T. Xiang, C. Y. Wang, T. M. Si, E. H. Lee, Y. L. He, G. S. Ungvari, H. F. Chiu, S. Y. Yang, M. Y. Chong, C. H. Tan, E. H. Kua, S. Fujii, K. Sim, K. H. Yong, J. K. Trivedi, E. K. Chung, P. Udomratn, K. Y. Chee, N. Sartorius and N. Shinfuku, “Use of Anticholinergic Drugs in Patients with Schi-zophrenia in Asia from 2001 to 2009,” Pharmacopsy-chiatry, Vol. 44, No. 3, 2011, pp. 114-118. doi:10.1055/s-0031-1275658
[13] S. Leucht, W. Kissling and J. M. Davis, “Second-Generation Antipsychotics for Schizophrenia: Can We Resolve the Conflicts,” Psychological Medicine, Vol. 39, No. 10, 2009, pp. 1591-1602. doi:10.1017/S0033291709005455
[14] G. Foussias and G. Remington, “Antipsychotics and Schizophrenia: From Efficacy and Effectiveness to Clinical Decision Making,” Canadian Journal of Psychiatry, Vol. 55, No. 3, 2010, pp. 117-125.
[15] R. J. Baldessarini, “Drug Therapy of Depression and Anxiety Disorders,” In: L. L. Brunton, J. S. Lazo and K. L. Parker, Eds., The Pharmacological Basis of Therapeutics, McGraw-Hill, New York, 2006, pp. 429-459.
[16] “British National Formulary (BNF) March 2010,” BMJ Group and RPS Publishing, London, 2010.
[17] R. A. Endow-Eyer, M. M. Michell and J. P. Lacro, “Schizophrenia,” In: M. A. Koda-Kimble, L. Y. Young, B. K. Aldredge, R. L. Corelli, B. J. Guglielmo, W. A. Kradjan and B. R. Williams, Eds., Applied Therapeutics—The Clinical Use of Drugs, Lippincott Williams and Wilkins, Philadelphia, 2009, pp. 78.1-78.34.
[18] A. F. Lehman and D. M. Steinwachs, “Translating Research into Practice: The Schizophrenia Patient Outcomes Research Team (PORT) Treatment Recommendations,” Schizophrenia Bulletin, Vol. 24, No. 1, 1998, pp. 1-10. doi:10.1093/oxfordjournals.schbul.a033302
[19] N. A. Keks, K. Altson, J. Hope, N. Krapivensky, C. Culhane, A. Tanaghow, P. Doherty and A. Bootle, “Use of Antipsychotic and Adjunctive Medications by an Inner Urban Community Psychiatric Service,” The Australian and New Zealand Journal of Psychiatry, Vol. 33, No. 6, 1999, pp. 896-901. doi:10.1046/j.1440-1614.1999.00639.x
[20] R. R. Aparasu, E. Jano and V. Bhatara, “Concomitant Antipsychotic Prescription in US Outpatient Settings,” Research in Social and Administrative Pharmacy, Vol. 5, No. 3, 2009, pp. 234-241. doi:10.1016/j.sapharm.2008.08.005
[21] A. Tapp, A. E. Wood, L. Secrest, J. Erdmann, L. Cubberley and N. Kil-zieh, “Combination Antipsychotic Therapy in Clinical Practice,” Psychiatric Services, Vol. 54, No. 4, 2003, pp. 55-59. doi:10.1176/
[22] N. Ranceva, W. Ashraf and D. Odelola, “Antipsychotic Polypharmacy in Outpatients at Birch Hill Hospital: Incidence and Adherence to Guidelines,” Journal of Clinical Pharmacology, Vol. 50, No. 6, 2010, pp. 699-704. doi:10.1177/0091270009350625
[23] R. J. Baldessarini, B. M. Cohen and M. H. Teicher, “Significance of Neuroleptic Dose and Plasma Level in Pharmacological Treatment of Psychoses,” Archives of General Psychiatry, Vol. 45, No. 1, 1988, pp. 79-90. doi:10.1001/archpsyc.1988.01800250095013
[24] A. Essali, N. Al-Haj Hassan, C. Li and J. Rathbone, “Clozapine versus Typical Neuroleptic Medication for Schizophrenia,” Cochrane Database System Review, Vol. 21, No. 1, 2009, CD 000059.
[25] Y. L. Tang, P. X. Mao, F. Jiang, Q. Chen, C. Y. Wang, Z. J. Cai and P. B. Michell, “Clozapine in China,” Pharmacopsychiatry, Vol. 41, No. 1, 2008, pp. 1-9. doi:10.1055/s-2007-993224
[26] A. Wheeler, V. Hum-berstone, E. Robinson, J. Sheridan and P. Joyce, “Impact of Audit and Feed-Back on Antipsychotic Prescription in Schizophrenia,” Journal of Evaluation in Clinical Practice, Vol. 15, No. 3, 2009, pp. 441- 450. doi:10.1111/j.1365-2753.2008.01032.x
[27] S. Miyamoto, G. E. Duncan, C. E. Marx and J. A. Lieberman, “Treatments for Schizophrenia: A Critical Review of Pharmacology and Mechanisms of Action of Antipsychotic Drugs,” Molecular Psychiatry, Vol. 10, No. 1, 2005, pp. 79-104. doi:10.1038/
[28] S. M. Stahl, “Antipsychotic Polypharmacy. Part 1: Therapeutic Option or Dirty Little Secret?” Journal of Clinical Psychiatry, Vol. 60, No. 7, 1999, pp. 425-426. doi:10.4088/JCP.v60n0701
[29] G. B. Hung and H. K. Cheung, “Predictors of High-Dose Antipsychotic Prescription in Psychiatric Patients in Hong Kong,” Hong Kong Medical Journal, Vol. 14, No. 1, 2008, pp. 35-39.
[30] Y. T. Xiang, Y. Z. Weng, C. M. Leung, W. K. Tang and U. G. Sandor, “Exploring the Clinical and Social Determinants of Prescribing Anticholinergic Medication for Chinese Patients with Schizophrenia,” Human Psycho-pharmacology, Vol. 22, No. 3, 2007, pp. 173-180. doi:10.1002/hup.830
[31] P. Gjerden, L. Slordal and J. G. Bramness, “The Use of Antipsychotic and Anticholinergic Antiparkinson Drugs in Norway After the Withdrawal of Orphenadrine,” British Journal of Clinical Pharmacology, Vol. 68, No. 2, 2009, pp. 238-242. doi:10.1111/j.1365-2125.2009.03446.x
[32] I. S. Hong and J. R. Bishop, “Anticholinergic Use in Children and Adolescence after Initiation of Antipsychotic Therapy,” Annals of Pharmacotherapy, Vol. 44, No. 7, 2010, pp. 1171-1180. doi:10.1345/aph.1M643
[33] American Psychiatric Association, “American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders, Compendium 2006,” American Psychiatric Publishing Inc., Arlington, 2006.
[34] A. J. Wheeler, “Treatment Pathway and Patterns of Clozapine Prescribing for Schizophrenia in New Zealand,” Annals of Pharmacotherapy, Vol. 42, No. 6, 2008, pp. 852-860. doi:10.1345/aph.1K662
[35] P. Seeman, “Atypical Antipsychotics: Mechanism of Action,” Canadian Journal of Psychiatry, Vol. 47, No. 1, 2002, pp. 27-38.
[36] S. Leucht, G. Pitschell-Walz, D. Abraham and W. Kissling, “Efficacy and Extrapyramidal Side-Effects of the New Antipsychotic Olanzapine, Quetiapine, Risperidone, and Sertindole Compared to Conventional Antipsychotics and Placebo: A Meta-Analysis of Randomized Controlled Trials,” Schizophrenia Research, Vol. 35, No. 1, 1999, pp. 51-68. doi:10.1016/S0920-9964(98)00105-4
[37] I. R. de Olivera, A. M. Mirand-Scippa, E. P. de Sena, E. L. Pereira, M. G. Ribeiro, E. de Castro-e-Silva and J. Bacaltchuk, “Risperidone versus Haloperidol in the Treatment of Schizophrenia: A Meta-Analysis Comparing Their Efficacy and Safety,” Journal of Clinical Pharmacology & Therapeutics, Vol. 21, No. 5, 1996, pp. 349-358. doi:10.1111/j.1365-2710.1996.tb00030.x
[38] R. Tandon, R. H. Belmaker, W. F. Gattaz, J. J. Lopez-Iber Jr., A. Okasha, B. Singh, D. J. Stein, J. P. Olie, W. W. Fleisch-hacker and H. J. Moeller, “World Psychiatric Association Pharmacopsychiatry Section Statement on Comparative Effect of Antipsychotic in the Treatment of Schizophrenia,” Schizophrenia Research, Vol. 100, No. 1-3, 2008, pp. 20-38. doi:10.1016/j.schres.2007.11.033
[39] M. O. Bakare, “Effective Therapeutic Dosage of Antipsychotic Medications in Patients with Psychotic Symptoms: Is There a Racial Difference?” BMC Research Notes, Vol. 1, No. 1, 2008, pp. 1-25.
[40] M. L. Chen, “Ethnic or Racial Differences Revisited: Impact of Dosage Regimen and Dosage form on Pharma-cokinetics and Pharmacodynamics,” Clinical Pharma-cokinetics, Vol. 45, No. 10, 2006, pp. 957-964. doi:10.2165/00003088-200645100-00001

Copyright © 2024 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.