Reviewing the safe and appropriate prescribing of antipsychotic depots

Antipsychotic medicine is prescribed to treat many mental health conditions, alleviate suffering and improve daily functioning[1]
.

However, a significant barrier to the successful treatment of psychotic illnesses is medication adherence. Antipsychotic medication in the form of an intramuscular depot is one way to overcome this[2]
. Depots have been shown to improve patient adherence and have contributed to better global outcomes compared with oral antipsychotics[3]
, as well as a reduced risk of hospitalisation[4]
,[5]
.

As with all medicines, antipsychotics have their downsides. Side effects include extrapyramidal side effects, QT-prolongation, weight gain and sedation. Not only can these contribute to patient non-adherence, but some also have the potential to be dangerous and even fatal[2]
. It is, therefore, vital that these treatments are monitored appropriately.

Patients within four community teams based in the Cambridgeshire and Peterborough NHS Foundation Trust were retrospectively audited in December 2017 to identify whether their antipsychotic depot was prescribed correctly and safely, and to see if they were being monitored appropriately according to guidance from the National Institute for Health and Care Excellence (NICE)[6]
. A total of 17 standards were set and divided into two groups: prescribing quality and monitoring quality. Data were collected from prescription charts and available electronic medical records.

Overall, 51 patients were reviewed. Some 96% of the charts clearly stated the dose; 92% of the charts stated the frequency; 98% of the charts stated the next administration date; and only 27% of the charts clearly stated the site of the intramuscular injection. Interestingly, 29% of the prescription charts were screened by a pharmacist. As a result of this work, we are considering a routine intervention — a pharmacist to screen every chart — to ensure that all standards are completely adhered to.

The physical health monitoring for this group of patients was not well adhered to. Simple monitoring parameters, such as weight and blood pressure, were adhered to in less than 50% of patients over the past 12 months. This is disappointing given the simplicity of the tests. Other important checks recommended by NICE guidance were equally poorly adhered to, including blood glucose (37%), blood lipids (45%) and prolactin (35%). A lack of monitoring consistency was apparent during data collection, and there was an observed pattern of positive testing — mostly in patients who had been admitted to general hospitals in the previous 12 months. This may indicate even worse adherence for the trust’s wider population.

A concerning issue was identified regarding the monitoring parameter standards; there does not appear to be a single comprehensive record in which patients’ monitoring is recorded. It did not appear as though there was a clear nominated person taking responsibility of the patients’ monitoring requirements. As healthcare professionals initiating patients on significant long-term medication with known serious side effects, it is vital that we monitor these patients for the appropriate parameters, as specified by local and national guidelines. Options for improving these results could include patient-held monitoring records, centralised recording of test results or coordinated planning for when and where such monitoring is carried out. This is not, of course, without its own difficulties.

People living with serious chronic mental illnesses live 15–20 fewer years, on average, than the general population[7]
. This is not just a result of suicide; it is also a result of physical health conditions which may contribute to physical health decline, owing to the side effects of antipsychotic medication. The physical health of people with severe mental health disorders is often ignored, not only by the person themselves, but also by people around them — including the NHS[8]
. Physical health must not be ignored.

 

Annabel Lane, pharmacist, South London and Maudsley NHS Foundation Trust;

Christopher Jenkins, pharmacist team manager, Fulbourn Hospital, Cambridgeshire and Peterborough NHS Foundation Trust

References

[1] Joint Formulary Committee. British National Formulary. 73rd edn. 2017. London: BMJ Group and Pharmaceutical Press

[2] Barnes TR, Shingleton-Smith A & Paton C. Antipsychotic long-acting injections: prescribing practice in the UK. Br J Psychiatry Suppl 2009;195(52):S37–42. doi: 10.1192/bjp.195.52.s37

[3] Adams CE, Fenton MKP, Quraishi S et al. Systemic meta-review of depot antipsychotic drugs for people with schizophrenia. Br J Psychiatry. 2001;179(4):290–299. doi: 10.1192/bjp.179.4.290

[4] Schooler NR. Relapse and rehospilization: comparing oral and depot antipsychotics. J Clin Psychiatry 2003;64(Suppl 16):14–17. PMID: 14680414

[5] Tiihonen J, Wahlbeck K, Lonnqvist J et al. Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitilisation due to schizophrenia and schizoaffective disorder: observational follow-up study. BMJ 2006;333(7561):224. doi: 10.1136/bmj.38881.382755.2F

[6] National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. Clinical guideline [CG178]. 2014. Available at: https://www.nice.org.uk/guidance/cg178 (accessed September 2019)

[7] World Health Organization. Management of physical health conditions in adults with severe mental disorders. 2018. Available at: https://www.who.int/mental_health/evidence/guidelines_physical_health_and_severe_mental_disorders/en/ (accessed September 2019)

[8] Saxena S & Maj M. Physical health of people with severe mental disorders: leave no one behind. World Psychiatry 2017;16(1):1–2. doi: 10.1002/wps.20403

Last updated
Citation
The Pharmaceutical Journal, September 2019;Online:DOI:10.1211/PJ.2019.20206885