Study on the prescribing patterns of antipsychotic medication in a rural England Community Mental Health Team.

INTRODUCTION: Providing comprehensive services for about 400 patients in the South Herefordshire area, the community mental health team manages cases of varying severity and complexity, ranging from Schizophrenia, to neuroses and disorders of adult personality. Antipsychotic medication remains a mainstay of treatment and management for patients under the team case load; hence a need exists for a detailed look into the prescription patterns of such medications.

AIM: The aim of this study was to look into the prescribing patterns of antipsychotics for a sample of 50 patients in the South Herefordshire community team during the year of 2016 (from Jan 2016 to Dec 2016), as well as investigate whether these antipsychotics were licensed to be used for the corresponding diagnoses of these patients. We also looked into whether patients were prescribed antipsychotics within BNF limits. As a part of this audit we looked into whether patients were made aware that they were on unlicensed antipsychotics or on above the BNF maximum doses of antipsychotics.

METHODOLOGY: A random sample of 50 patients was taken from the case load of the South community team as is documented on RIO. The mean age of the patients in the sample was 46.1 (SD= ±14.6) Sample selection was done by selecting every seventh patient in the patient case load (if not using antipsychotics the next patient was chosen). Patients studied involved those with F1-F19 Mental and behavioural disorders due to psychoactive substance use, F20-F29 Schizophrenia/Schizotypal/Delusional disorder, F31 Bipolar affective disorders, F32 Depression, F40-F48 Anxiety Neurotic and stress related disorders and somatoform disorders, F50-F59 Behaviour syndromes associated with physiological disturbances and physical factors, F60-F69 Disorders of adult personality and behaviour. The patients selected had to be followed up by the recovery team during the year 2016 and they had to be on an antipsychotic medication at any point during that time period. A scale was utilized to help the orderly collection of information as dose, patient diagnoses, comorbid substance use etc. SPC was relied upon for investigating the licensing of the different antipsychotics.

RESULTS: It was found that the most commonly prescribed antipsychotic was Quetiapine (28.07%) followed by Olanzapine (24.56%), Aripiprazole (14.04%) and Depot drugs (12.28%). It was found that the most commonly used depot drugs were Modecate and Depixol. It was also found that 14% of our patients were prescribed two antipsychotics at the same time. Unlicensed antipsychotics made up 17.54% of all prescribed antipsychotics. It was also found that no documentation on the system evidenced that patients were told about the use of unlicensed antipsychotics. Quetiapine and olanzapine made up 60 % of the unlicensed antipsychotics followed by risperidone and aripiprazole 40%. The conditions that were found to be given unlicensed medications were anxiety neurotic and stress related disorders and somatoform disorders (F40-48), disorders of adult personality and behaviour (F60-F69) and multiple conditions. The most common daily doses prescribed for Aripiprazole were found to be 5, 10 and 15 mg doses. For Quetiapine, it was the 300mg dose and for Olanzapine it was found to be the 10mg dose. In all but one patient antipsychotics were prescribed within BNF limits. One patient was prescribed Olanzapine 25 mg (BNF maximum dose 20 mg). Polypharmacy was found to be used more in the multiple diagnosis and schizophrenia conditions. Patients with schizophrenia and adult personality disorders were found to be the most patients who abused alcohol, cannabis and prescription opioid analgesic medications.

CONCLUSION: Antipsychotics have a range of central nervous system effects and there are situations where it becomes necessary to use them off-license. However, it is essential to explain to the patient about the unlicensed use of antipsychotics and document this on the system. The effects of unlicensed antipsychotics need to be carefully monitored and their benefits regularly assessed and recorded. Antipsychotics interact with physical health medication and could adversely affect the physical health condition. Hence it is necessary to look into healthier means of pain management and review the long term prescription of opioid analgesics. It is important to investigate more into how to manage comorbidities such as substance misuse of alcohol and cannabis and whether cross referral between services is the best way to address this issue. Further audits can look into the follow up of patients on polypharmacy, and on the general effect on disease prognosis, and physical health side effects of such regimens.