The South London and Maudsley NHS Foundation Trust and Oxleas NHS Foundation Trust Prescribing Guidelines, 9th Edition

Abstract

This new edition of the Maudsley NHS prescribing guidelines may very well contribute to safer, more rational and more responsible current psychopharmacotherapy if applied correctly. It is authored by the chief pharmacist at the Institute of Psychiatry at the Maudsley and King's College London, the chief pharmacist at Imperial College London, and the late Robert Kerwin Professor of Clinical Neuropharmacology and consultant psychiatrist at the Institute of Psychiatry (obituary: BJCP 2007; 63: 765–6). Consisting of eight chapters, it offers the reader practical guidance on the most frequently prescribed drugs in the pharmacological treatment of the major psychiatric disorders. Utilizing the taxonomy of the DSM-IV, the psychoses (including schizophrenia and catatonia), bipolar disorder, depression (including psychotic depression), anxiety, children and adolescent psychopharmacotherapy, substance abuse and so-called ‘special patient groups’ are covered. Also, ample prescription guidelines are provided based on those of the British NICE guidelines. Many recent literature references refer to research by experts, with selected ones singled out for further reading. The guide devotes its first chapter to plasma concentration monitoring of psychotropic drugs. Generally its interpretation leads to confusion in clinical practice. However, this chapter provides a conceptual introduction to its practice and increases awareness that the relationship between plasma drug concentrations and clinical efficacy in psychiatry remains to be established in some cases. Sound overviews are provided on antipsychotics, antidepressants, lithium and anticonvulsants. Also many concise tables for quick reference are provided per group of drugs. Many of these are pretty much standard, including names, indications, maximal dosages and most common side-effects. However, by having added information on less well known but potentially important side-effects and information on potential drug–drug and CYP450 interactions, these tables are rendered up-to-date and relevant, without obscuring clarity. Additionally, advice is provided on switching of drugs (including antidepressants and antipsychotics), focusing primarily on the process of switching rather than the guidelines dictating when and to which drug to switch. Although the latter may seem useful, the underlying rationale of switching these drugs based on PD and PK characteristics is not sufficiently clarified. Useful information is provided on the effects of alcohol, nicotine and caffeine which can influence the pharmacology of psychotropics in many psychiatric patients. Unexpectedly, the stagnation in innovative drug development for the treatment of depressive disorders again becomes apparent from these chapters. Importantly, the authors give side-effects of all featured drugs a prominent role. Not only the traditional side-effects associated with most commonly prescribed drugs (e.g. QT-interval prolongation with antipsychotics and sexual dysfunction with SSRIs) but also potentially dangerous ones of which the impact is increasingly being recognized. These include weight gain and features of the metabolic syndrome which have been acknowledged since the advent of atypical antipsychotics. Also, chapters on SSRI-induced hyponatraemia and SIADH, SSRIs and bleeding, and the effects of antidepressants on cardiac function (including their effects on heart rate, blood pressure, arrhythmias and the myocardium) are informative. These may increase physicians' awareness of lesser well-known adverse effects when prescribing antidepressants. Additionally a chapter is devoted to the interaction between electro-convulsive therapy (ECT) and antidepressants, focusing mainly on their pharmacodynamic effects on ECT. The special patient groups remain to be mentioned. These are patients with psychiatric disorders who more often than not pose problems to the application of psychopharmacological treatment guidelines. They encompass patients who are pregnant and lactating, patients with epilepsy, renal and hepatic impairment, HIV and AIDS and patients using psychotropics during the peri-operative period. Providing relevant information on clinical management, it pays attention to both altered dynamic and kinetic characteristics. The addition of potential drug–drug and CYP450 interactions, combined with basic pharmacodynamic and pharmacokinetic characteristics of psychiatric drugs, make this book relevant. However, it is a pity that no overviews of known CYP450 and SERT polymorphisms are provided. This may be important for future individualized drug therapy since their role is increasingly being recognized in inadequate drug response and therapy resistance in psychiatry. Although the most current information on psychiatric drugs can always be found electronically, this text is excellent for scenarios in which this might not be possible. Generally speaking, this 9th edition is concise and clinically relevant. However, it is quite bulky and not the kind of reference to carry around on ward rounds. It is intended as a reference guide but may also contribute to the consolidation of previously attained knowledge of clinical psychopharmacology. As a prescription guide it can be useful combined with existing (but not only NICE) guidelines, in both pharmacological treatment of major mental disorders and in consultation-liaison psychiatry.