High-dose antipsychotic medication

Sub-optimal prescribing in an adult community mental health service: prevalence and determinants

Aims and Method

To compare prescribing practice in a community mental health service with evidence-based guidelines and identify factors related to sub-optimal prescribing. All current patients (n=640) were assessed regarding six key aspects of prescribing (polypharmacy, high-dose treatment, use of thioridazine/maintenance benzodiazepine/maintenance hypnotic or routine anticholinergic treatment). The relationship of quality of prescribing practice to demographic, illness and service variables was examined by regression analysis.

Results

Five-hundred and five (79%) patients were receiving psychotropic medication. Of these, 232 (46%) had evidence of sub-optimal prescribing practice. Mean prescribing practice quality score was 0.75 ± 0.99. Maintenance benzodiazepine/ hypnotic (31%) and anticholinergic (30%) use were particularly common. Prescribing practice quality score was higher in those receiving depot antipsychotic treatment (P < 0.01) and in older patients (P < 0.01). Scores were significantly lower in patients whose principal medical contacts were with a consultant rather than a junior doctor (P < 0.001).

Clinical Implications

Prescribing practices in real-world settings frequently deviate from evidence-based guidelines. The quality of prescribing is related to patient, illness and service variables. In particular, greater contact with consultant staff is linked to better practices. Patients receiving depot antipsychotics are especially liable to less judicious prescribing practice.

Sub-optimal prescribing in an adult community mental health service: prevalence and determinants

Aims and Method

To compare prescribing practice in a community mental health service with evidence-based guidelines and identify factors related to sub-optimal prescribing. All current patients (n=640) were assessed regarding six key aspects of prescribing (polypharmacy, high-dose treatment, use of thioridazine/maintenance benzodiazepine/maintenance hypnotic or routine anticholinergic treatment). The relationship of quality of prescribing practice to demographic, illness and service variables was examined by regression analysis.

Results

Five-hundred and five (79%) patients were receiving psychotropic medication. Of these, 232 (46%) had evidence of sub-optimal prescribing practice. Mean prescribing practice quality score was 0.75 ± 0.99. Maintenance benzodiazepine/ hypnotic (31%) and anticholinergic (30%) use were particularly common. Prescribing practice quality score was higher in those receiving depot antipsychotic treatment (P < 0.01) and in older patients (P < 0.01). Scores were significantly lower in patients whose principal medical contacts were with a consultant rather than a junior doctor (P < 0.001).

Clinical Implications

Prescribing practices in real-world settings frequently deviate from evidence-based guidelines. The quality of prescribing is related to patient, illness and service variables. In particular, greater contact with consultant staff is linked to better practices. Patients receiving depot antipsychotics are especially liable to less judicious prescribing practice.

Achieving evidence-based prescribing practice in an adult community mental health service

Aims and Method

Prescribing in everyday practice frequently deviates from evidence-based guidelines. Previous work compared practice in a community mental health service with evidence-based guidelines and identified factors related to suboptimal prescribing. This study reports the impact of a multifaceted intervention on prescribing practice. A Prescribing Practice Quality (PPQ) score was generated from six key aspects of prescribing at initial assessment and again 1 year later after an intervention to reduce suboptimal prescribing practices.

Results

A total of 264 patients were attending the service at both the initial and follow-up phase and were thus exposed to the prescribing intervention. In this population, PPQ scores were significantly lower at follow-up (0.96v.0.67,P<0.001). Improved prescribing practice was predicted by receipt of adjunctive supportive inputs, such as anxiety management (P=0.003).

Similarly, mean PPQ scores substantially decreased when the total patient population was considered at each time point (0.75 in 2001 and 0.52 in 2002). These results suggest a reduction in both the initiation and continuation of suboptimal practices.

Clinical Implications

Prescribing in real-world settings can be improved by interventions that target multiple aspects of service activity. The provision of supportive inputs is a key factor in improving practice.

A rational approach to employing high plasma levels of antipsychotics for violence associated with schizophrenia: case vignettes

Forensic psychiatric settings contain a high prevalence of treatment-resistant violent schizophrenia patients. Clozapine therapy has the most robust data for the management of violence in patients with schizophrenia, but for those who cannot tolerate or refuse clozapine, high-dose antipsychotic treatment to high achieve high plasma levels remains a viable option despite limited evidence for efficacy in controlled trials. This article enumerates rational guidelines for employing high plasma level strategies, emphasizing the appropriate interpretation of, and reaction to high plasma antipsychotic levels in these treatment resistant patients, and the need to push treatment to the limits of tolerability or clinical response.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: recommendations from the British Association for Psychopharmacology

These guidelines from the British Association for Psychopharmacology address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting, involving experts in schizophrenia and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from the participants and interested parties, and cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. The practice recommendations presented are based on the available evidence to date, and seek to clarify which interventions are of proven benefit. It is hoped that the recommendations will help to inform clinical decision making for practitioners, and perhaps also serve as a source of information for patients and carers. They are accompanied by a more detailed qualitative review of the available evidence. The strength of supporting evidence for each recommendation is rated.

Trends in antipsychotic prescribing in schizophrenia in Auckland

OBJECTIVE

This study describes antipsychotic prescribing practices for outpatients with schizophrenia over a 3 year period in two large mental health catchment areas of Auckland.

METHODS

All community files were reviewed at three time points. Patient characteristics, diagnosis and antipsychotic treatment information were recorded and analysed.

RESULTS

Over the three time periods, the number of outpatients with a diagnosis of schizophrenia or schizoaffective disorder was stable. There was a marked change in the type of antipsychotic prescribed, with an 18.6% increase in atypical antipsychotics and a decrease in both intramuscular and oral typical antipsychotics. Clozapine was the most commonly prescribed antipsychotic in 2003 (35%). Despite the fact that polypharmacy was relatively low (14.6% in 2003), those receiving more than one antipsychotic had a greater likelihood of being prescribed a higher total daily dose.

CONCLUSIONS

This study describes a change in antipsychotic prescribing towards recommended practice guidelines for the treatment of schizophrenia over a 3 year period.

Use of high-dose depot neuroleptics

Aims and methods

To identify and reduce the number of patients receiving depot neuroleptics above the British National Formulary maximum. The medical records were scrutinised and individual consultants were informed of the results.

Results

For the team involved in this audit there was a significant reduction in the prescription of high-dose depot medication, but this did not generalise to other teams.

Clinical implications

Different teams should repeat the audit and a new depot card has been developed.