Utilization and Safety of Antipsychotic Medications in Special Populations
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CitationPark, Yoonyoung. 2017. Utilization and Safety of Antipsychotic Medications in Special Populations. Doctoral dissertation, Harvard T.H. Chan School of Public Health.
AbstractAntipsychotic medications are widely used in the United States (US). Understanding the extent of use and comparative safety of antipsychotics is especially important for certain groups of people such as pregnant women or hospitalized patients, for whom the evidence on safety and effectiveness is limited. Previous studies lacked power to detect difference in safety endpoints or suffered from potential confounding bias. In this dissertation, we used large administrative claims databases to provide evidence for antipsychotic use among vulnerable population subgroups.
In Chapter 1, we describe the pattern of antipsychotic utilization among publicly insured pregnant women in the US using a nationwide Medicaid claims database. We found that atypical antipsychotics are increasingly used in this population between 2001 and 2010, with a notable increase in the diagnosis of and antipsychotic use for bipolar spectrum disorders. More than 50% of women discontinue treatment after becoming pregnant and polytherapy with other psychoactive drugs was common. These findings require further attention with respect to safety of antipsychotic in this population.
In Chapter 2, we examine the association between the use of atypical antipsychotic and the risk of gestational diabetes (GDM) among pregnant women in Medicaid. Comparing women who continue treatment to those who discontinue among prevalent users of antipsychotic without pre-existing diabetes at the beginning of pregnancy, we observed a potentially increased risk of GDM among continuers of quetiapine and olanzapine but not for the continuers of aripiprazole, ziprasidone, or risperidone. Olanzapine showed the strongest evidence of increased risk of GDM across multiple analyses, but the variability in results was not large enough to comment on comparative safety of different antipsychotics.
In Chapter 3, we examine the comparative safety of antipsychotics in hospitalized patients with acute myocardial infarction, where antipsychotics are often used to manage delirium-related agitation. We found that the hazard ratio of 7-day mortality was greater for patients who received haloperidol compared to those who received atypical antipsychotics after adjusting for a large number of confounders. While residual confounding is a possible alternative explanation, our result is consistent with what has been reported from outpatient studies and in nursing home population.
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