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 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.

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.

Physical health in schizophrenia: a challenge for antipsychotic therapy

2010 ◽  
Vol 25 (S2) ◽  
pp. S6-S11 ◽  
Author(s):  
A. Heald
Keyword(s):  
Mental Health ◽  
Physical Health ◽  
Health Risks ◽  
Self Esteem ◽  
Psychotic Symptoms ◽  
Antipsychotic Therapy ◽  
Metabolic Monitoring ◽  
Increased Risk ◽  
Physical Health Problems

AbstractIn the management of schizophrenia, mental health outcomes are the principal focus of treatment. The objective is to control the psychotic symptoms while minimising negative features of the illness, to achieve an overall improvement in the societal functioning of patients. Physical health is also important because if it is compromised, many of the benefits of improved mental health will be offset. Compared with the general population, schizophrenia patients are at increased risk of weight gain, abdominal obesity, diabetes, metabolic syndrome, and cardiovascular disease. These physical health problems can contribute to the decreased quality of life, lowered self-esteem and reduced life expectancy commonly reported in schizophrenia. For these reasons there is a pressing need to improve both the monitoring and the management of physical health in patients with schizophrenia as a part of their overall care. A consensus for metabolic monitoring of patients receiving treatment with antipsychotic drugs is available. However, the practicing clinician requires guidance about management of physical health in routine clinical practice. This should include recommendations for measurements that have strong predictive value about physical health risks yet are easy to make, and about the use of medications that have the least effect on physical health parameters. This article will review the gravity of the physical health risks facing schizophrenia patients.

The successful impact of adapting CBT in IAPT for people with complex long-term physical health conditions

2020 ◽  
Vol 13 ◽  
Author(s):  
Rupal Panchal ◽  
Brian Rich ◽  
Carly Rowland ◽  
Tessa Ryan ◽  
Sarah Watts
Keyword(s):  
Mental Health ◽  
Physical Health ◽  
Clinical Supervision ◽  
Healthcare Professionals ◽  
Medical Condition ◽  
Good Practice ◽  
List Type ◽  
Physical And Mental Health ◽  
Medical Healthcare

Abstract It is widely recognised that a diagnosis of a long-term physical health condition (LTC) is likely to have a significant impact on a person’s mental health. This is highlighted in the Five Year Forward View for Mental Health (NHS England, 2016) where significant numbers of patients projected to be seen through the expansion of Improving Access to Psychological Therapies (IAPT) services are to come from within the LTC community. IAPT services offer evidence-based therapeutic interventions for common mental health issues – anxiety disorders and depression. The South East Staffordshire IAPT services have developed an integrated pathway as a Wave 2 site for the delivery of cognitive behavioural therapy (CBT) adaptations for LTC. The main themes outlined in this paper focus on the innovations and service developments of IAPT-LTC including: the importance of engagement between mental health and medical healthcare professionals, identifying the key professionals in medical healthcare to enhance engagement, extended training for clinicians with in-house continued professional development, as an extension to the National IAPT-approved top-up training for LTC, and developments in clinical supervision structures and practice, along with future developments in the field of IAPT-LTC. These themes have direct relevance to CBT practitioners working within the LTC community in IAPT services. The four contrasting case studies demonstrate how the application of CBT can successfully be adapted to condition related beliefs and behaviours, despite the complexity of the medical condition. Findings show how integrated services and engaging with medical healthcare professionals had profound benefits for the patients, IAPT therapists and medical healthcare professionals. Key learning aims (1) The good practice points in the development of the IAPT-LTC pathway within South East Staffordshire IAPT services. (2) The successful design and implementation of the IAPT-LTC pathway within South East Staffordshire IAPT services. (3) The key considerations of the interaction for patients between their physical and mental health symptoms. (4) The application of CBT adaptations for people with complex LTCs can be effective in improving psychological wellbeing and physical condition management.

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.

scholarly journals COVID-19: A daily dose of yoga to cope with anxiety

Coronaviruses ◽  
2020 ◽  
Vol 01 ◽  
Author(s):  
Surabhi Gautam ◽  
Rima Dada
Keyword(s):  
Mental Health ◽  
Physical Health ◽  
Coping Strategy ◽  
Health Conditions ◽  
Eating Patterns ◽  
Sleep Patterns ◽  
Mental Health Conditions ◽  
Daily Dose ◽  
Psychological Pressure ◽  
Mental And Physical Health

: The coronavirus disease (COVID-19) pandemic has undoubtedly created an unbearable psychological pressure on our minds ranging from anxiety, fear, worry, changing sleep patterns, changing eating patterns, worsening of existing chronic or mental health conditions. There is an urgent need for the adoption of an effective coping strategy. We propose that yoga-based intervention may aid in improving mental and physical health with its multi-faceted dimensions.

scholarly journals Physical health monitoring after rapid tranquillisation: clinical practice in UK mental health services

2019 ◽  
Vol 9 ◽  
pp. 204512531989583 ◽  
Author(s):  
Carol Paton ◽  
Clive E. Adams ◽  
Stephen Dye ◽  
Oriana Delgado ◽  
Chike Okocha ◽  
...  
Keyword(s):  
Mental Health ◽  
Clinical Practice ◽  
Mental Health Services ◽  
Health Services ◽  
Physical Health ◽  
Health Monitoring ◽  
High Dose ◽  
Behavioural Disturbance ◽  
Falling Asleep ◽  
Recommended Level

Background: We aimed to assess the quality of physical health monitoring following rapid tranquillisation (RT) for acute behavioural disturbance in UK mental health services. Methods: The Prescribing Observatory for Mental Health (POMH-UK) initiated an audit-based quality improvement programme addressing the pharmacological treatment of acute behavioural disturbance in mental health services in the UK. Results: Data relating to a total of 2454 episodes of RT were submitted by 66 mental health services. Post-RT physical health monitoring did not reach the minimum recommended level in 1933 (79%) episodes. Patients were more likely to be monitored (OR 1.78, 95% CI 1.39–2.29, p < 0.001) if there was actual or threatened self-harm, and less likely to be monitored if the episode occurred in the evening (OR 0.79, 95% CI 0.62–1.0, p < 0.001) or overnight (OR 0.57, 95% CI 0.44–0.75, p < 0.001). Risk factors such as recent substance use, RT resulting in the patient falling asleep, or receiving high-dose antipsychotic medication on the day of the episode, did not predict whether or not the minimum recommended level of post-RT monitoring was documented. Conclusions: The minimum recommended level of physical health monitoring was reported for only one in five RT episodes. The findings also suggest a lack of targeting of at-risk patients for post-RT monitoring. Possible explanations are that clinicians consider such monitoring too demanding to implement in routine clinical practice or not appropriate in every clinical situation. For example, physical health measures requiring direct contact with a patient may be difficult to undertake, or counter-productive, if RT has failed. These findings prompt speculation that post-RT monitoring practice would be improved by the implementation of guidance that integrated and refined the currently separate systems for undertaking and recording physical health observations post-RT, determining nursing observation schedules and detecting acute deterioration in physical health. The effectiveness and clinical utility of such an approach would be worth testing.

scholarly journals Falling between the cracks. Invited commentary on … Service innovation: the first year of lifestyle clinics for psychiatric outpatients

2009 ◽  
Vol 33 (12) ◽  
pp. 448-450
Author(s):  
Fiona Gaughran
Keyword(s):  
Mental Health ◽  
Physical Health ◽  
Good Practice ◽  
Service Innovation ◽  
First Year ◽  
Service Users ◽  
Pragmatic Approach ◽  
Health Checks ◽  
Positive Experiences ◽  
Political Priority

SummaryHamilton's paper describes a thorough and pragmatic approach to the introduction of physical health checks in people registered with mental health services. This is a moral and political priority, but translating this into day-to-day practice in already stretched community mental health teams requires leadership and vision. Pivotal in Hamilton's success was the establishment of good channels of communication between the mental and physical healthcare teams. Hearing about good practice and positive experiences in other teams should help in the widespread introduction of reliable systems to improve physical health in mental health service users.

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