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Accuracy of Clinician Assessments of Medication Status in the Emergency Setting: A Comparison of Clinician Assessment of Antipsychotic Usage and Plasma Level Determination

Lopez, Leonardo V. MD*†; Shaikh, Atef DO*; Merson, Jonathan MD*†; Greenberg, Jessica MS*; Suckow, Raymond F. PhD; Kane, John M. MD*†§

Journal of Clinical Psychopharmacology: June 2017 - Volume 37 - Issue 3 - p 310–314
doi: 10.1097/JCP.0000000000000697
Original Contributions

Purpose The present study aimed to assess the level of agreement between clinicians’ routine assessments of medication status and plasma levels of commonly prescribed antipsychotic medications in patients presenting to an emergency room with an exacerbation of psychosis.

Methods We studied 105 patients presenting to an emergency room and admitted to an inpatient psychiatric unit with a diagnosis of schizophrenia, schizoaffective disorder, bipolar I disorder, or psychotic disorder not otherwise specified and a prior outpatient medication regimen including risperidone, olanzapine, quetiapine, aripiprazole, or paliperidone. Plasma levels of antipsychotics were drawn and sent to a specialty laboratory for testing.

Findings Of the 97 patients with usable samples, 33 (34%) were found to have therapeutic antipsychotic levels. Of these, 22 were judged by emergency room staff to be taking their medications at the appropriately prescribed doses, whereas 11 were judged not to be taking medication at all. Sixty-four patients were found to have subtherapeutic antipsychotic levels, 31 of whom had been assessed to be taking medication as prescribed. Emergency assessment of medication status predicted therapeutic and nontherapeutic antipsychotic levels at rates of 41.5% and 75%, respectively. Emergency staff assessment was statistically independent from the likelihood of having a therapeutic antipsychotic level.

Implications In patients presenting to emergency rooms with exacerbations of psychosis who are subsequently admitted to an inpatient facility, common assessments of medication status are frequently misleading. Readily available methods for rapidly measuring antipsychotic plasma levels in clinical settings are needed for clinicians to make reliable assessments.

From the *Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks; †Department of Psychiatry, The Hofstra Northwell School of Medicine, Hempstead; ‡New York State Psychiatric Institute, Columbia University College of Physicians & Surgeons, New York; and §Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY.

Received April 22, 2016; accepted after revision February 16, 2017.

Reprints: Leonardo V. Lopez, MD, The Zucker Hillside Hospital, 75-59 263rd St, Glen Oaks, NY 11004 (e-mail:

Investigator-Initiated Study grant support was provided by Janssen Pharmaceuticals (Raritan, NJ).

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