scholarly journals High dose antipsychotic therapy (HDAT) in the Greater Manchester mental health adult psychiatric inpatient setting

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S105-S105
Author(s):  
Oli Sparasci ◽  
Emma Horrell ◽  
Gemma Buston ◽  
Oliver Edge ◽  
Tatiana Campo Celaya ◽  
...  
Keyword(s):  
Mental Health ◽  
Psychiatric Inpatient ◽  
Clinical Indication ◽  
Total Daily Dose ◽  
High Dose ◽  
Junior Doctors ◽  
Inpatient Setting ◽  
Antipsychotic Therapy ◽  
Daily Dose ◽  
Adult Inpatient

AimsTo identify the number of adult inpatients prescribed HDAT across GMMH.To establish whether guidelines for the prescribing and monitoring of HDAT are adhered to.To consider the initiation of HDAT, evaluating whether prescriptions of HDAT are intentionally made by consultant psychiatrists and the MDT, or by rotational junior doctors.BackgroundHigh Dose Antipsychotic Therapy (HDAT) is defined by the Royal College of Psychiatrists as either: a total daily dose of a single antipsychotic which exceeds the upper limit stated in the BNF or A total daily dose of two or more antipsychotics which exceeds the BNF maximum as calculated by percentage.The decision to prescribe HDAT should be made by a consultant psychiatrist and discussed with the patient and wider MDT. Clear documentation of this discussion, including the clinical indication, should be recorded within the case notes.The use of HDAT comes with greater risk of physical health complications and requires regular monitoring of ECG, BMI and blood biochemistry. For patients detained under the Mental Health Act, consent and appropriate consultation with a SOAD should be sought for HDAT where the patient lacks capacity.This audit investigates prescription of HDAT in the acute adult inpatient population within Greater Manchester Mental Health NHS Foundation Trust (GMMH).MethodSix junior doctors were recruited to collect data across the 5 sites covering general adult inpatients within GMMH. Data were collected week beginning 21st January 2020. Data were collected from all 20 general adult inpatient wards within the trust. Medication cards for each patient on the electronic bed-state at 9am on the day of the audit were checked for HDAT prescription. Subsequently, data were collected from electronic notes of patients identified as being on HDAT. Data were collated and submitted to the audit lead for analysis.Result31 patients were identified as being on HDAT, of those, 21 instances of HDAT were commenced during the patients MDT, although in only 2 of these cases was it noted that the medication prescribed would result in initiating HDAT. Of the remaining cases, 8 were prescribed by junior doctors and 2 were unclear. 15 out of 31 patients had an ECG within a month prior to commencing HDAT, of 24 patients on HDAT for longer than 3 months, only 5 had a repeat ECG within this time.ConclusionGuidelines are not closely adhered to, there is clear and necessary scope for improvement.

scholarly journals High dose antipsychotic therapy (HDAT) prescibing practice within the south trafford community mental health team

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S105-S106
Author(s):  
Oli Sparasci ◽  
Luis Rojo
Keyword(s):  
Mental Health ◽  
Physical Health ◽  
Good Practice ◽  
Total Daily Dose ◽  
High Dose ◽  
Inpatient Setting ◽  
Electronic Patient Records ◽  
The South ◽  
Antipsychotic Therapy ◽  
Daily Dose

AimsHigh Dose Antipsychotic Therapy (HDAT) is defined by the Royal College of Psychiatrists as either: “A total daily dose of a single antipsychotic which exceeds the upper limit stated in the BNF” or “A total daily dose of two or more antipsychotics which exceeds the BNF maximum as calculated by percentage.”The use of HDAT is associated with significant risks to physical health and as such requires regular monitoring of various physiological parameters such as ECG, bloods and an assessment of cardiometabolic risk.Following previous audits of HDAT prescribing practice in the inpatient setting within Greater Manchester Mental Health (GMMH) NHS FT, an audit of HDAT prescription in a general adult CMHT was conducted in Summer 2020, with the following aims:To identify patients in the South Trafford CMHT who are prescribed HDAT.To assess the prescription of HDAT against local guidance on the use of unlicensed medications.To highlight good practice and areas for improvement in the prescription of HDAT.MethodAll patients under the South Trafford CMHT in Summer 2020 were identified. Current prescriptions for antipsychotic medication were ascertained through review of electronic patient records. Those noted to be on HDAT were assessed against audit criteria derived from the GMMH Unlicensed Medicines Policy, previous audits of HDAT use and the RCPsych consensus report on HDAT prescription.Result11 of 252 patients (4%) were identified as being on HDAT, of which eight were due to polypharmacy and three to high dose of a single antipsychotic. For 1/11 patients target symptoms and a risk/benefit rationale were documented. The mean length of time on HDAT was 6 years. 7/11 patients had either tried or considered clozapine in the past. 8/11 patients had not had an ECG within the last year, 4/11 had not had yearly U&E. 8/11 had regular mental health reviews.ConclusionCompliance with the audit standards was found to be highly variable. This may reflect many factors, including the length of time since commencing HDAT and the complex shared care arrangements currently in place in Trafford. Thus, the following recommendations have been made:To start a register of all patients prescribed HDAT.To review local guidelines and documentation to ensure they are up to date and can be effectively implemented in routine clinical practice.To ensure that the responsibility for conducting yearly physical health checks for patients prescribed HDAT is communicated to the relevant parties.

scholarly journals Reducing the use of high dose antipsychotic medication in acute adult inpatient psychiatric units

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S341-S341
Author(s):  
Shay-Anne Pantall ◽  
Sarah Warwicker ◽  
Lisa Brownell
Keyword(s):  
Antipsychotic Medication ◽  
Psychiatric Inpatient ◽  
Electronic Prescribing ◽  
Antipsychotic Treatment ◽  
High Dose ◽  
Junior Doctors ◽  
List Type ◽  
Increased Risk ◽  
Adult Inpatient ◽  
Inpatient Units

AimsTo evaluate the use of antipsychotics, and high dose antipsychotic treatment (HDAT) in psychiatric inpatient unitsBackgroundThe Royal College of Psychiatrists published a consensus statement on high dose antipsychotic medication in October 1993. Such treatment carries an increased risk of adverse effects including towards ventricular tachycardia and sudden death.MethodA retrospective case note review of all male patients on acute adult inpatient units in a psychiatric hospital in South Birmingham on a date in June 2018 (n = 45) including review of electronic patient records and prescriptions. This was compared with the results of an earlier study, with identical methods, undertaken in June 2015.Result•In both 2015 and 2018, only a minority of patients (20% and 11% respectively) were informal.•In both 2015 and 2018, the majority of inpatients had a diagnosis of schizophrenia (54% and 67%)•In both 2015 and 2018, 93% inpatients were prescribed antipsychotic medication.•In 2015, 56% patients were prescribed HDAT. This reduced in 2018 to 16%.•This reduction in use of HDAT was almost entirely due to a reduction in the prescription of PRN antipsychotic medication.•In terms of regularly prescribed antipsychotic medication, in both years, the most commonly prescribed drug was flupentixol, with a range of other second generation oral and long acting medications being prescribed, usually at doses within BNF limits.Between the two years, there was a substantial change in the prescribing of PRN antipsychotics. In 2015, 59% individuals were prescribed at least one PRN antipsychotic (27% were prescribed two). In 2018, this reduced to 40% prescribed at least one, and only 2% being prescribed 2 PRN antipsychotics. In both years, oral quetiapine was a common choice (39% patients in 2015 prescribed oral quetiapine, and 34% in 2018). In 2015, 39% patients were prescribed oral or intramuscular aripiprazole, while this reduced to 7% in 2018.ConclusionThe vast majority of psychiatric inpatients were being prescribed antipsychotic medication. Prescription of high dose antipsychotic medication was common in 2015, and this was largely attributable to high levels of prescribing of PRN antipsychotics. Following an educational programme for junior doctors and ward nurses, and the introduction of electronic prescribing, we achieved a significant change in practice, particularly in the prescribing of PRN antipsychotics, which has reduced our patients’ risk of receiving high dose antipsychotic medication.

High-dose antipsychotic therapy and reflective prescribing: development of an online tool for rapid, easy calculation of antipsychotic total daily dose

2020 ◽  
Vol 28 (4) ◽  
pp. 410-413
Author(s):  
Korinne Northwood ◽  
Theo Theodoros ◽  
Nancy Wang ◽  
Dan Siskind
Keyword(s):  
Decision Making ◽  
Improve Patient Safety ◽  
Total Daily Dose ◽  
High Dose ◽  
Antipsychotic Therapy ◽  
Daily Dose ◽  
Prescribing Practice ◽  
Dosing Regimens ◽  
Antipsychotic Prescribing ◽  
The Impact

Objective: Safe and effective antipsychotic prescribing is a fundamental skill in psychiatric practice; however, antipsychotic medications are not without risk. These risks are increased when antipsychotics are prescribed in high doses, with or without polypharmacy. Decision-making regarding antipsychotic prescribing can be hampered by a lack of readily available or easily approachable tools for calculating and interpreting total daily doses, especially when antipsychotic polypharmacy is involved. Our objective was to create an accessible method for calculating antipsychotic total daily dosing. Methods: We have developed an online calculator for determining antipsychotic total daily dose using information on recommended maximum total daily dosing based on the British National Formulary. Results: This calculator is free, easy to implement and allows for users to input a large variety of possible antipsychotic dosing regimens. Conclusions: It is hoped that this tool will allow clinicians to readily review their prescribing practice, inform decision-making and improve patient safety outcomes. Further research may be appropriate to determine the impact of this tool on these intended goals.

Mania with Bupropion: A Dose-Related Phenomenon?

2000 ◽  
Vol 34 (5) ◽  
pp. 619-621 ◽  
Author(s):  
Jessica L Goren ◽  
Gary M Levin
Keyword(s):  
Affective Disorder ◽  
Bipolar Depression ◽  
Bipolar Affective Disorder ◽  
Antidepressant Drug ◽  
Manic Episode ◽  
Total Daily Dose ◽  
High Dose ◽  
Related Phenomenon ◽  
Increased Risk ◽  
Daily Dose

OBJECTIVE: To report a case in which bipolar depression was resistant to usual therapies, requiring dosages of bupropion >450 mg/d and to review the literature on mania associated with bupropion and propose a potential theory of a dose-related threshold associated with bupropion and mania. CASE SUMMARY: A 44-year-old white man with a 25-year history of bipolar affective disorder presented with depression resistant to usual therapies. Bupropion therapy was initiated and the dosage was titrated to 600 mg/d. After exceeding the maximum recommended daily dose (450 mg/d), he experienced a manic episode attrib uted to high-dose bupropion. DISCUSSION: Due to increased risk of seizures, current prescribing guidelines state that the total daily dose of bupropion is not to exceed 450 mg/d. Since bupropion is the agent least likely to cause a manic switch in bipolar disorder, this agent seemed a logical choice to treat the patient's depression. Due to a lack of response, the bupropion dosage was titrated to a maximum of 600 mg/d. Since the patient did not switch into mania until the dosage exceeded 450 mg/d, we speculate that this adverse reaction is a dose-related phenomenon. Scientific literature supports this theory. CONCLUSIONS: A switch into mania is a potential risk associated with antidepressant drug use in bipolar affective disorder. Bupropion is believed to be associated with a decreased risk compared with other antidepressant therapies. However, our case report as well as others support the theory that this decreased risk may be due to dosages not exceeding the recommended daily dose (450 mg/d). Doses of bupropion >450 mg/d should be used with caution in depressed patients with bipolar affective disorder.

scholarly journals Factors associated with use of psychiatric intensive care and seclusion in adult inpatient mental health services

2016 ◽  
Vol 27 (1) ◽  
pp. 51-61 ◽  
Author(s):  
A. E. Cullen ◽  
L. Bowers ◽  
M. Khondoker ◽  
S. Pettit ◽  
E. Achilla ◽  
...  
Keyword(s):  
Mental Health ◽  
Intensive Care ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Psychiatric Inpatient ◽  
Specific Patient ◽  
Female Sex ◽  
Admission Status ◽  
Adult Inpatient ◽  
Psychiatric Inpatient Services

Aims.Within acute psychiatric inpatient services, patients exhibiting severely disturbed behaviour can be transferred to a psychiatric intensive care unit (PICU) and/or secluded in order to manage the risks posed to the patient and others. However, whether specific patient groups are more likely to be subjected to these coercive measures is unclear. Using robust methodological and statistical techniques, we aimed to determine the demographic, clinical and behavioural predictors of both PICU and seclusion.Methods.Data were extracted from an anonymised database comprising the electronic medical records of patients within a large South London mental health trust. Two cohorts were derived, (1) a PICU cohort comprising all patients transferred from general adult acute wards to a non-forensic PICU ward between April 2008 and April 2013 (N = 986) and a randomly selected group of patients admitted to general adult wards within this period who were not transferred to PICU (N = 994), and (2) a seclusion cohort comprising all seclusion episodes occurring in non-forensic PICU wards within the study period (N = 990) and a randomly selected group of patients treated in these wards who were not secluded (N = 1032). Demographic and clinical factors (age, sex, ethnicity, diagnosis, admission status and time since admission) and behavioural precursors (potentially relevant behaviours occurring in the 3 days preceding PICU transfer/seclusion or random sample date) were extracted from electronic medical records. Mixed effects, multivariable logistic regression analyses were performed with all variables included as predictors.Results.PICU cases were significantly more likely to be younger in age, have a diagnosis of bipolar disorder and to be held on a formal section compared with patients who were not transferred to PICU; female sex and longer time since admission were associated with lower odds of transfer. With regard to behavioural precursors, the strongest predictors of PICU transfer were incidents of physical aggression towards others or objects and absconding or attempts to abscond. Secluded patients were also more likely to be younger and legally detained relative to non-secluded patients; however, female sex increased the odds of seclusion. Likelihood of seclusion also decreased with time since admission. Seclusion was significantly associated with a range of behavioural precursors with the strongest associations observed for incidents involving restraint or shouting.Conclusions.Whilst recent behaviour is an important determinant, patient age, sex, admission status and time since admission also contribute to risk of PICU transfer and seclusion. Alternative, less coercive strategies must meet the needs of patients with these characteristics.

Nature-based Group Therapy Reflections: A Grounded Theory Study

2020 ◽  
Vol 42 (12) ◽  
pp. 1129-1136
Author(s):  
Kelly Carlson ◽  
Jeanette Kingsley ◽  
Caroline Strimaitis ◽  
Shira Birnbaum ◽  
Theresa Quinn ◽  
...  
Keyword(s):  
Mental Health ◽  
Health Care ◽  
Grounded Theory ◽  
Mental Health Care ◽  
Therapy Group ◽  
Psychiatric Inpatient ◽  
Inpatient Setting ◽  
Grounded Theory Study ◽  
Beneficial Effects ◽  
Patient Responses

Nature-based therapies have a long history in mental health care. Beneficial effects have been documented for nature-based therapies in a variety of other health care settings. The aims of this grounded theory study were to understand the processes of maintaining nature-based therapeutic groups and the value of the activities to patients in a psychiatric inpatient setting. Over a nine-month period, semi-structured surveys of patient responses to nature-based activities were administered to patients in a pilot therapy group assessing the feasibility of a nature-based group program. Findings indicated that the group promoted use of the senses, social interaction, and care of self/others. Perceptions of benefits led to a nuanced understanding of the effects of being in contact with nature. Based on our findings we offer a preliminary theoretical model for patient engagement with nature-based programming in inpatient mental health care.

Metabolic screen and intervene: improving mental health inpatient metabolic monitoring

2020 ◽  
pp. 103985622093614
Author(s):  
Luke Viglione ◽  
Brooke L Short
Keyword(s):  
Mental Health ◽  
Plasma Lipids ◽  
Health Workers ◽  
Low Cost ◽  
Psychiatric Inpatient ◽  
Inpatient Setting ◽  
Inpatient Service ◽  
Metabolic Monitoring ◽  
Before And After ◽  
The Impact

Objective: To assess rates of metabolic monitoring in patients prescribed antipsychotic medications in the psychiatric inpatient setting and the impact education can have regarding monitoring compliance. Method: Two identical audits were undertaken at a NSW mental health inpatient service before and after a campaign designed to educate mental health workers about the importance of metabolic monitoring. Results from both audits were compared for statistically significant improvements in monitoring rates. Results: Rates of monitoring plasma lipids increased from 21.7% to 78.8% ( p < 0.01) and rates for plasma glucose increased from 20.8% to 73.7% ( p < 0.01). There were no statistically significant changes in rates of monitoring body mass index (83.0% and 77.1%, respectively), waist circumference (36.8% and 43.2%, respectively) and blood pressure (99.1% and 100%, respectively). Conclusion: This study has shown that rates of metabolic monitoring in the inpatient setting can be improved with a relatively low-cost education intervention. While absolute rates remain low, outcomes suggest that it may be worthwhile trialling further modes of education and repeating this education in cycles.

A review of ECG and QT interval measurement use in a public psychiatric inpatient setting

2017 ◽  
Vol 26 (1) ◽  
pp. 50-55 ◽  
Author(s):  
Ingrid Berling ◽  
Rahul Gupta ◽  
Cecilia Bjorksten ◽  
Felicity Prior ◽  
Ian M Whyte ◽  
...  
Keyword(s):  
Mental Health ◽  
Qt Interval ◽  
Psychiatric Inpatient ◽  
Torsades De Pointes ◽  
Qt Prolongation ◽  
Inpatient Unit ◽  
Inpatient Setting ◽  
Prolonged Qt Interval ◽  
Prolonged Qt ◽  
Clinically Significant

Objectives: There is an increased rate of sudden cardiac death (SCD) in mental health patients. Some antipsychotic medications are known to prolong the QT interval, thus increasing a patient’s risk of SCD via the arrhythmia, torsades de pointes (TdP). Our aim was to evaluate assessment for QT prolongation within a public inpatient mental health facility by auditing electrocardiograph (ECG) use. Methods: We reviewed records of all mental health inpatient admissions to a public emergency mental health inpatient unit between 1 January 2016 and 11 February 2016. ECG availability was noted and QT interval was manually measured and assessed for risk of TdP using the QT nomogram when present. Demographic information and medication use was collected. Results: Of 263 mental health inpatient admissions, 50 (19%) presentations had an ECG. A total of four (8%) had a prolonged QT interval. Of the 50 patients with an ECG, 12 (24%) were taking medication known to prolong the QT interval. Conclusions: There was very limited risk assessment for QT prolongation in a public hospital psychiatric inpatient unit, with less than 20% of patients having an ECG performed. Our study supports an association between QT-prolonging drugs and a clinically significant prolonged QT interval; however, a larger study with routine ECG screening is required.

scholarly journals Reducing high dose antipsychotic therapy (HDAT) in a community mental health team (CMHT)

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S110-S111
Author(s):  
Richard Walsh ◽  
Sonn Patel ◽  
Valentina Loddo ◽  
Rebecca Fahy ◽  
Elizabeth Walsh
Keyword(s):  
Antipsychotic Medication ◽  
Cumulative Dose ◽  
Best Practice ◽  
Baseline Survey ◽  
High Dose ◽  
Antipsychotic Therapy ◽  
Daily Dose ◽  
Prescribing Practice ◽  
Oral Antipsychotic ◽  
The Impact

AimsThe consensus statement (CR190) of The Royal College of Psychiatrists states that the benefit of prescribing HDAT does not outweigh the risk of the increased side effect burden. HDAT is defined as the “daily dose of a single antipsychotic exceeding the upper limit for that drug as stated in the Summary of Product Characteristic (SPC) or British National Formulary (BNF),” and as the cumulative daily dose of two or more antipsychotics (for combined prescription). The prevalence of HDAT has been shown to vary widely and protocols for monitoring poorly implemented. In 2018 we completed a baseline survey of the prevalence of HDAT within our CMHT. We assessed our prescribing practice as compared to seven best practice audit criteria, which were adopted. Our aim is to resurvey closing the audit loop to 1) establish the current prevalence of HDAT and 2) assess the impact the intervention on prescribing practice.MethodMulti-disciplinary case notes for all registered patients were studied. A database was created including sociodemographic details, chart diagnosis, and medication. The proportion of patients prescribed antipsychotic medication was identified. The dose of each medication was converted into a percentage of BNF maximum recommended dose for that drug. For combined antipsychotic prescription, the cumulative dose was obtained adding the single percentages together. Exceeding 100% was regarded as HDAT. All HDAT patients were assessed against identified audit criteria as outlined by the Humber NHS Foundation Trust.ResultOf a total of 246 patients, 177 (72%) were prescribed antipsychotic medication. Of these, 14 (8%) were in receipt of HDAT. This compared to 68% prescribed antipsychotics and 9% in receipt of HDAT in the baseline audit. The average cumulative dose for every category (oral medication, depot and both) was calculated with a range from 1% to 168% (mean = 70%) for oral antipsychotic (single/combined), 1% to 193% (mean = 50%) for depots and 20% to 257% (mean = 95%) for combination of oral and depot. This compares with ranges of 1.6% to 215% (mean = 44.3%) for oral antipsychotic (single/combined), 0.04% to 100% (mean = 25.8%) for depots and 21% to 425% (mean = 119.6%) for combination of oral and depot in the baseline audit. Similar to the baseline survey no patient met all seven audit criteria but there was better adherence overall with best practice guidance. Blood and ECG monitoring were the most consistent parameters measured.ConclusionLower HDAT was achieved post intervention. Results, whilst positive, indicate the need for ongoing audit to maintain best standards.

Evaluation of the EssenCES in a neurodevelopmental inpatient service for adolescents

2017 ◽  
Vol 22 (3) ◽  
pp. 233-245 ◽  
Author(s):  
Ciara Glennon ◽  
Marilyn A Sher
Keyword(s):  
Mental Health ◽  
Learning Disability ◽  
Normative Data ◽  
Psychiatric Inpatient ◽  
The Body ◽  
Inpatient Setting ◽  
Inpatient Service ◽  
Service Users ◽  
Inpatient Settings ◽  
Ward Climate

Ward climate is a key element within psychiatric settings, associated with positive clinical outcomes. The Essen Climate Evaluation Schema (EssenCES) is a ward climate measure, which is validated for use within UK forensic settings. It has been studied within neurodevelopmental psychiatric inpatient settings with mixed findings on its appropriateness, and there is a dearth of EssenCES research which has been conducted within an adolescent psychiatric inpatient setting. The present study piloted the EssenCES within an inpatient psychiatric neurodevelopmental setting for adolescents in the East of England, in order to explore its usefulness within this setting and to provide preliminary normative data for a child and adolescent mental health services inpatient learning disability population. Staff and service users from a locked ward ( N = 28) and low secure ward ( N = 31) participated in the pilot. Results are discussed in relation to the body of the literature on ward climate, including consideration of discrepancies in the results between wards and discrepancies between staff and service.

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