Maudsley Guidelines Research Articles

Hyperprolactinemia in patients taking antipsychotics: the importance of a shared approach between psychiatry and endocrinology

IntroductionHyperprolactinemia is a commonly encountered adverse effect of antipsychotic medication. Short and long-term repercussions of high prolactin, such as amenorrhea, sexual dysfunction, osteopenia and increased cardiovascular risk carry significant burden and may compromise therapeutic adherence. Despite its serious practical implications, hyperprolactinemia is still underscreened and its management neglected.ObjectivesTo review current clinical guidelines regarding the management of hyperprolactinemia associated with the use of antipsychotics, reflecting upon the importance and need to share the management of this risk with an endocrinology expert.MethodsWe performed a literature review to identify clinical guidelines containing specific recommendations for antipsychotic-induced hyperprolactinemia (British Association of Psychopharmacology [BAP], NICE, Maudsley Prescribing Guidelines, Royal Australian and New Zealand College of Psychiatrists), published over the last ten years, with a particular focus on its physical risks.ResultsMost guidelines do not recommend routine monitoring of prolactin levels in asymptomatic patients. NICE and BAP guidelines have suggested measuring the baseline prolactin level, but have not specified follow-up monitoring, while Maudsley guidelines have. Management strategies depend on factors such as sex, age, as well as the clinical manifestations that ensue. Different treatment strategies have been described, such as decreasing the dose of the antipsychotic, switching antipsychotics, adding aripiprazole or adding dopaminergic agonists. Referral to an endocrinology specialist should be made if the aetiology is unclear, prolactin levels continue to rise despite some intervention, the hyperprolactinaemia is severe (>3000 mIU/L) or there is suspected/confirmed pituitary adenoma. Further physical implications of having hyperprolactin are to be dressed by the endocrinology expert, namely those on bone metabolism, gonodal function and cancer risk.ConclusionsGiven the widespread use of antipsychotics and the need to have psychotic patients stabilized (sometimes with a lack of effective alternative), early detection and shared management of hyperprolactinemia are instrumental towards assisting both clinician’s and patients’ decision-making, be it towards lowering prolactin levels or managing its risk without compromising the antipsychotic’s efficacy.Disclosure of InterestNone Declared

Audit of Prolactin Levels Monitoring for Inpatients on Antipsychotics in SABP

AimsTo establish whether our practice is meeting NICE and Maudsley guidelines in establishing baseline prolactin levels in an inpatient set-up before starting treatment with antipsychotic medications with a medium or high-risk of causing hyperprolactinaemia.MethodsData were collected retrospectively from case notes of 127 patients from 9 wards at Surrey and Borders Partnership NHS Foundation Trust (SABP).We reviewed if the baseline prolactin was measured for inpatients before commencing on antipsychotics with medium or high risk of hyperprolactinemia.We reviewed if patients with elevated prolactin levels were assessed and managed appropriately.ResultsSABP is currently achieving 43% in recording serum prolactin levels for inpatients who are on antipsychotics with medium or high-risk of hyperprolactinemia respectively.Inpatient ward 76 patients out of total 127 were on antipsychotics with medium to high-risk of developing hyperprolactinemia.33 patients had their serum prolactin checked bringing the compliance to 43%,2 patients were excluded due to incomplete data bringing the sample size to 31.3 had elevated prolactin. Out of 3 patients,1 patient was managed appropriately with MRI brain, followed by change of antipsychotic medication and repeat prolactin levels. For 1 patient, prolactinlevel was rechecked. Unfortunately, no documentation of assessment of symptoms of hyperprolactinemia was found in all three patients case notes.ConclusionThe trust is falling short of meeting NICE and Maudsley guidelines of monitoring prolactin level. It is possible to introduce a robust system within the Trust so that we are complaint with a NICE and Maudsley prolactin monitoring guidelines.We need to local Trust guidelines for management of hyperprolactinaemia in line with NICE and Maudsley guideline of monitoring prolactin levels.Safety netting advice and leaflets explaining symptoms of hyperprolactinaemia should be provided to all the patients on antipsychotics with medium to high risk of developing hyperprolactinemia.

Pharmacological Treatment of Alcohol Withdrawal

Excessive chronic alcohol users, and particularly patients with alcohol use disorder, may present an alcohol withdrawal syndrome if they abruptly stop drinking. Alcohol withdrawal syndrome requires pharmacological treatment for the treatment of withdrawal symptoms and to prevent withdrawal complications. Medically assisted withdrawal treatment is used in alcohol treatment units, but it is also frequently required in patients admitted to hospital for other conditions. Review of major guidelines covering treatment of withdrawal syndrome with the aim to describe recent evidence and recommendations about the pharmacological treatment for alcohol withdrawal syndrome. Four major guidelines concerning treatment of withdrawal syndrome were selected (National Institute for Health and Care Excellence, American Society of Addiction Medicine, World Federation of Societies of Biological Psychiatry and American Psychiatric Association) and screened for the recommendations and level of evidence on drug prescribing for alcohol withdrawal syndrome. The Maudsley guidelines were also considered in this review. All the four reviewed guidelines recommended benzodiazepines as the first line treatment for alcohol withdrawal syndrome. The association of anticonvulsivants, adrenergic alpha-2 agonists, betablockers and antipsychotics with benzodiazepines is recommended for symptom reduction in severe alcohol withdrawal syndrome. Thiamine should be administered to all patients to prevent Wernicke-Korsakoff encephalopathy. If there is any electrolytic imbalance it should be corrected. Maintaining a high level of suspicion for alcohol withdrawal syndrome is important across all clinical settings, and it should be promptly treated.

Audit of physical health monitoring during initiation and ongoing treatment with antipsychotic medication in a tier 3 outpatient CAMHS service, Belfast

AimsTo evidence that physical health monitoring during antipsychotic initiation and continued treatment within the Child and Family Clinic is current, as per the agreed Antipsychotic Medication Monitoring Schedule for Belfast Trust CAMHS (2015), supporting Quality Network for Community CAMHS(QNCC) accreditation.BackgroundThe Antipsychotic Medication Monitoring Schedule CAMHS(2015) was agreed by a working group of consultant psychiatrists and pharmacists, based on evidence from The Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMSEA), NICE Guidelines CG 185(2014), CG155(2013) and Maudsley Guidelines, and was to be located on the electronic system (PARIS).MethodIn January 2019, a list of all children/young people on antipsychotic medication was collated (n = 12). Presence of the monitoring schedule in the clinical notes or PARIS was recorded. The Electronic Care Record was reviewed for blood results and PARIS letters for documentation of physical health parameters (heart rate, blood pressure, height, weight, BMI, extrapyramidal side effects, ECG) and to identify documentation of risk/benefit review where monitoring was declined. Re-audit January 2020 (n = 9). Criteria:All patients commenced on antipsychotic medication will have baseline blood investigations and other physical health parameters documented as per the monitoring schedule. If monitoring was declined, the reason for this and indications for prescribing must be documented as a risk/benefit analysis.All patients on antipsychotic medication will be current with their physical health Monitoring Schedule.All patients will have their Monitoring Schedule completed in clinical notes or on PARIS.ResultFirst cycle results (n = 12):Baseline bloods (or documented declined) = 92%, Baseline ECG (or documented declined) = 75%Complete monitoring bloods = 33%, Physical health monitoring parameters complete = 42%Monitoring schedule present in the notes and current = 42% (0% on PARIS).Initial Recommendations: Standardised recording of monitoring using PARIS clinic letters and the schedule in front of clinical notes; Baseline ECG mandatorySecond cycle results (n = 9):Baseline bloods (or declined) = 89%, Baseline ECG (or declined) = 67%Complete monitoring bloods = 44%, Physical health monitoring parameters complete = 56%Monitoring schedule present in notes and current = 38%, Present, not current = 50% (0% on PARIS).ConclusionLower numbers at re-audit limit interpretation.Further recommendations: Antipsychotic initiation checklist; Central bloods diary for clinicians; Antipsychotic care-pathway booklet, co-produced with young people, incorporating the monitoring schedule.

An audit into the physical health monitoring of patients who are prescribed antipsychotics in HMP Birmingham

AimsTo assess the compliance of physical health monitoring with NICE and Maudsley prescribing guidelines for those patients prescribed antipsychotics in HMP Birmingham. To assess secondary objectives including who prescribed the antipsychotics (GP vs psychiatrist), the indication and diagnosis they are prescribed for (licensed or otherwise) and which antipsychotics were usually prescribed.BackgroundPatients with psychosis or schizophrenia have a reduced life expectancy of 15-20 years when compared to the general population. The physical health effects of the medication prescribed for these conditions play a large role in this. Physical health monitoring and appropriate intervention is vital to reduce the discrepancy in life expectancy and improve the quality of life of these patients.MethodNotes of 105 patients in total at HMP Birmingham were reviewed to assess whether the primary outcomes of weight, waist circumference, physical observations, blood tests, medical systems review and education/lifestyle advice were done at the correct times. Secondary objectives of which antipsychotics were prescribed, the profession of the prescriber and the indication for the medications (or diagnosis) were also audited.ResultAntipsychotics were initiated by both GP's and psychiatrists. Appropriately, there were no prescriptions for clozapine. Olanzapine and quetiapine were the most common antipsychotics prescribed. Not all medications were prescribed for licensed indications and some lacked documentation of both a mental health diagnosis and indications in terms of symptoms. Average BMI of patients was overweight, with BMI ranging as high as 45. The pre-prescription, 12 weekly and annual physical health checks had poor compliance. Those that were completed in line with NICE and Maudsley guidelines were done so by coincidence at the time of diabetic reviews.ConclusionThe physical health monitoring of patients on antipsychotics in HMP Birmingham is not currently compliant with clinical guidelines. There needs to be improved systems in place for the monitoring of physical health both before prescriptions are initiated and after at the NICE recommended intervals. Amongst other actions, improved computer reminders and training of existing and new team members will be done. The monitoring requirements will be re-audited in 6 months following immediate implementation of the recommendations outlined below.

A quality improvement project to improve attendance to the physical health clinic at Southwark team for early psychosis

AimsThe aim of this project was to improve the booking and attendance of patients under Southwark Team for Early Psychosis (STEP) into the physical health clinic.BackgroundSTEP is an Early Intervention Service which provides treatment to 230 adults (18-65 years) with first episode psychosis in the community. In line with national and trust guidance, physical health checks are completed at baseline, 3 months, 6 months and annually, through a weekly physical health clinic run by the core trainee (CT). This is an essential opportunity to assess and monitor patients’ physical health and aid decisions regarding psychotropic medications, which is particularly important given the increased morbidity and mortality in this group and their reduced engagement with health services. It was noted that attendance to the clinic was poor and there was no guidance about how to communicate the results to the General Practitioner (GP).MethodData on the number of clinic appointments booked and attended were collected over 3 defined 9 week intervals between 17/09/18 and 29/07/19. The interventions were implemented prior to the third round of data collection and included an educational session to the STEP team and a protocol for booking and running the clinic to be used by the CT. We devised a physical health questionnaire to be completed by patients on arrival, which includes a summary of the Maudsley guidelines for antipsychotic monitoring. Finally, we created a template letter to communicate the results to the GP.ResultFollowing the interventions, the percentage of available clinic slots booked increased from an average of 27.8% to 100%. The proportion of slots attended reduced from an average of 80% to 50%. However, the absolute number of patients booked into clinic increased from an average of 10 patients over 9 weeks pre-intervention, of which an average of 8 patients attended, to 36 patients post-intervention, of which 18 attended.ConclusionWe observed full utilisation of available clinic slots post-intervention and an increase in the absolute number of patients attending. Given the ongoing use of the protocols developed, we expect these changes to be sustainable. The number of patients attending could be further increased by training additional staff to run the clinic more often and more flexibly. The number of Did-Not-Attends could be reduced by care-coordinators sending reminder texts prior to the appointments.

An audit into the monitoring of off-label antipsychotics in primary care

AimsTo ascertain whether patients prescribed second generation antipsychotics for off-label indications are being monitored and screened adequately for physical health side-effects.BackgroundThe prevalence of off-label antipsychotic use has increased significantly over recent decades. Common off-licence uses include dementia, post-traumatic stress disorder, adjunctive treatment for unipolar depression and personality disorders. Recent studies have demonstrated that up to 65% of antipsychotic prescriptions are now off-label. Since the metabolic side-effects of second-generation antipsychotics are well-established, guidelines have emphasised the need for active, routine physical health screening of all individuals taking these drugs. However, there have been few studies or reviews which have specifically investigated screening rates of individuals receiving antipsychotic medications for off-licence indications.MethodAn audit of patients taking second-generation antipsychotics for off-label indications, under the caseload of Neighbourhoods 1, 3 and 4 of Lewisham Assessment & Liaison team, was conducted. After isolating individual patients fulfilling inclusion criteria, patient investigation documents were requested from relevant GP practices. 40 patients were isolated in total, and data were successfully collected in 60% (n = 24). Data were collected via a proforma. This consisted of patient information, indications for antipsychotic use, and each variable to be monitored. The audit standard used was the recommendations of the 12th Maudsley guidelines. Data were then entered into SPSS and analysed.ResultThe most common reasons for off-label antipsychotic prescribing were Emotionally Unstable Personality disorder (42%, n = 10) and depression (29%, n = 7). Findings demonstrated that 54% (n = 13) of patients audited had ‘basic’ blood screening (FBC, U&E, LFTs), however glucose (38%, n = 9), Prolactin (13%, n = 3), and Creatine Kinase (0%, n = 0), and monitoring was less frequent. 0% (n = 0) were completely monitored as per audit standard.ConclusionPrimary care monitoring of off-label antipsychotics is unsatisfactory, with no patients having a complete set of investigations. Reasons for this are unclear at this stage, however based on initial discussion with GP surgeries, may be due to lack of education regarding screening investigations, patients lost between primary and secondary care services, and a lack of clarity regarding responsibility and designated roles. This audit will be expanded to also include patients from Neighbourhood 2 of the Lewisham Assessment & Liaison team. A more detailed investigation will be conducted into the barriers to physical health screening, such that a targeted intervention can be implanted.

Prescribed psychiatric interventions for children presented to a university psychiatric clinic in Egypt: a descriptive cross-sectional study

BackgroundThe number of children diagnosed with psychiatric disorders has significantly increased over the past two decades. This study examined the pattern of psychiatric interventions prescribed for a sample of children with mental health problems in Egypt. A descriptive cross-sectional study was conducted to examine the pattern of psychotropic drug prescribing and intervention (medication, doses, duration, side effects, and improvement) in children aged 2-12 years old in primary and secondary health settings, presented to Mansoura University Hospitals in Egypt over 1 year. The identified patterns were compared with the Maudsley guidelines to detect any significant deviations.ResultsAmong the 272 cases presented to the clinic, attention-deficit hyperactivity disorder (ADHD) and disruptive behavior disorders were the most prevalent diagnoses (85.3%) followed by intellectual disability (7.8%) and autism spectrum disorder (ASD; 5.1%). Antipsychotic drugs and ADHD medications (atomoxetine and methylphenidate) represented the most commonly prescribed medications (56.6% and 44.5% respectively), whereas behavioral therapy was among the least chosen (8.5%) treatment options. About 1/3 of the sample received multiple psychotropic medications. The prescribed intervention strategies did not match the Maudsley’s guidelines in 76% of the cases with the absence of psychotherapeutic interventions being the most frequently observed factor (95.7%). Although still inadequate, psychiatrists’ intervention strategies were more likely to follow the Maudsley’s guidelines (38.3%), whereas pediatricians and neurologists were almost oblivious to them.ConclusionsCurrent pattern of psychiatric interventions prescribed for a sample of children with mental health problems in Egypt are not in accordance with standard guidelines, such as “Maudsley’s,” rendering it imperative to provide relevant educational programs for health care providers.

Use of Benzodiazepines and Hypnotic Medications in Psychiatry Older Adult Outpatients

Benzodiazepines have anxiolytic, hypnotic, anticonvulsant, and muscle-relaxing properties, therefore, a widely prescribed treatment for anxiety and insomnia. They bind to gamma-aminobutyric acid type A (GABAA) receptors, which are responsible for most of the inhibitory neurotransmission in the central nervous system and these receptors are a major target of alcohol, barbiturates, muscle relaxants, and other medications with sedative effects, resulting in tolerance and dependence [1]. Benzodiazepines are categorized into short (15 to 30 minutes), intermediate (30 to 60 minutes), and long-acting agents (one hour or longer). Benzodiazepines are frequently prescribed for elderly patients living in the community and for those in hospitals and institutions. Prolonged use of benzodiazepines is particularly likely in old age for the treatment not only of insomnia and anxiety, but also of a wide range of nonspecific symptoms. Long term users are likely to have multiple concomitant physical and psychological health problems [2]. Benzodiazepines produce dependence, reduce attention, memory, and motor ability. They can cause disinhibition or aggressive behavior, facilitate the appearance of delirium, and increase accident and mortality rates in people older than 60 [3]. According to Maudsley guidelines, benzodiazepines use in elderly are poorly supported for their link to cognitive decline, increase risk of falls and hip fractures [4]. And, if indicated, short acting agents should be avoided. Long acting agents should be started in low doses and patients need to be followed and reassessed regularly. Zolpidem or melatonin are indicated for insomnia, clonazepam and diazepam for agitation and pregabalin for generalized anxiety disorder [5].

Standards of Lithium Treatment Monitoring In a Teaching Hospital in South India among Bipolar Affective Disorder

Background: Lithium is a commonly used drug with a narrow therapeutic index, it has significant adverse effects on kidney and thyroid, and is life threatening during intoxication. Maudsley guidelines on managing bipolar affective disorder patients (BPAD) with lithium recommends checking weight at baseline and every 3rd month, serum lithium after 7th day thereafter 3 months once, renal function test and serum thyroid stimulating hormone (TSH) at baseline and 6 months once. Aim: To evaluate whether Pre-Lithium workup and monitoring is done in Bipolar affective disorder (BPAD) patients initiated on Lithium as per Maudsley prescribing guidelines in psychiatry. Method: Retrospective audit conducted in a tertiary care hospital on lithium monitoring in BPAD patients treated with lithium atleast for six months compared against Maudsley prescribing guidelines. Results: Among medical records of 114 bipolar patients fulfilling study criteria, weight and serum lithium at baseline was checked in 100% of patients; serum creatinine and TSH at baseline along with lithium at 3rd month was done in 83.3%, 78.9% and 68.4% of patients respectively. Maudsley guidelines for serum creatinine, TSH and lithium level at 6th month were met only in 43.8%, 43.8% and 72.8% of patients respectively. Conclusion: The quality of lithium monitoring in bipolar patients falls well short of accepted standards; Hence addressing the issues in monitoring and following a standard protocol can improve the effectiveness of treatment and quality of life of patients.

Clozapine withdrawal syndrome.

There is no standardised protocol for the management of clozapine withdrawal syndrome following a red alert. This is one of the worst case scenarios with clozapine and it is not mentioned in the Maudsley guidelines[1][1] or any other reliable guide. We have had 3 patients with a red alert in the

Comparative study of the side-effect profile between clozapine and non-clozapine patients

IntroductionFor resistant schizophrenia, the only approved treatment is clozapine. However, clozapine is underused, mainly due to its wide range of side-effects. Secondary effects differ amongst antipsychotics (Leucht et al., 2009). Despite that there is no good evidence that combined antipsychotics offer any advantage over the use of a single antipsychotic, combination increases the frequency of adverse events (Maudsley guidelines).ObjectivesTo compare the side-effect profile between clozapine and non-clozapinepatients.AimsTo provide evidence that clozapine patients do not show a worse side-effects profile.MethodsWe cross-sectionally analysed all patients from a Spanish long-term mental care facility (n = 139). Schizophrenic/schizoaffective patients were selected (n = 118) and their treatment was assessed, 31 patients used clozapine. We paired clozapine and non-clozapine patients by sex and age and assessed antipsychotic side effects and possible confounder variables.ResultsOur sample was 27 clozapine patients and 29 non-clozapine patients. 67,9% were male with a mean age of 51.3 (SD 9.6) years. For continuous variables: age, BMI, waist/hip, cholesterol, TG, glucose, prolactin, heart-rate, blood pressure, sleeping hours, the only statistical differences found were lower heart-rate (P = 0.001) in clozapine group and higher salivation subscale of SAS (P = 0.002) in clozapine group. For discrete variables: monotherapy, obesity, overweight, metabolic syndrome or possible confounders as propranolol, laxative, diet, antiglycemiant or insulin, fibrates or statins, antihypertensive or anticholinergic, no statistical differences were found.ConclusionsWe did not find differences in cardiometabolic parameters, which are the main barrier to prescribing clozapine, probably due to the concomitant use of other drugs in both groups.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Audit of monitoring of the parameters of metabolic syndrome in patients on clozapine

Aims and MethodHigh rates of metabolic syndrome exist among patients on clozapine. Monitoring its parameters facilitates interventions which may alleviate negative health consequences. We completed an audit of the monitoring of the parameters of metabolic syndrome in patients on clozapine. The results were compared with the Maudsley Guidelines for monitoring in patients on any antipsychotic medication.ResultsInitial audit showed high overall rates of concordance with guidelines for the frequency of measurement of blood pressure (91.8%), but much lower rates for measuring fasting blood glucose (43.2%) and lipid profile (52.7%), and no record of analysis of waist circumference. This prompted development of a formal protocol for measuring parameters. Repeat audit after 1 year showed marked improvement in rates of measurement.Clinical implicationsImplementation of relatively straightforward measures, such as the introduction of a one-page form on which to record parameters, can lead to a much improved rate of monitoring for metabolic syndrome. This should in turn prompt therapeutic interventions, which are discussed.

P-1072 - Audit on the monitoring of physical health in primary and secondary care who are on antipsychotic medications

Introduction People with Schizophrenia have excess mortality due to physical illness. Guidelines recommend monitoring of physical health at least once a year with both primary and secondary Care having a role to play. Aim The aim was to improve the monitoring of the physical health of patients with severe mental illness on antipsychotic medications. Objectives The objectives were to look at the standards derived from NICE and Maudsley guidelines which included parameters like weight, blood pressure, ECG and blood tests and compare the current clinical practice and improve the annual monitoring of these in both primary and secondary care. Method Data was collected retrospectively from case notes and pathology laboratory results from August 2009 to August 2010. Inclusion criteria were patients between 18 and 65 years in the community who were on antipsychotics. Sample size obtained was 82. Results Weight, Blood Pressure and ECG were recorded in less than 10% of cases and blood parameters were recorded in less than 20% of cases in secondary care. Around 60% of patients had their blood parameters monitored in primary care. There was no communication of these results between primary and secondary care. In 60% of cases an annual physical health check was not recommended by Psychiatrists to General Practitioners. Conclusion Monitoring of Physical health needs to be more robust. We have devised a proforma to record results of the monitoring. We have developed a post for a Nurse Practitioner to facilitate liaison and more effective communication between the two services.

P-1120 - A study of an antipsychotic prescription pattern of patients with schizophrenia in a developing country

Though there are several recommended guidelines for treating schizophrenia, in routine clinical practice, these are not followed. To conduct an audit of the prescription pattern of antipsychotic drugs in patients with schizophrenia, in a tertiary care centre in India, during a period of 1 year and compare it with Maudsley guidelines and Clinical practice guidelines for Psychiatrists in India (IPS guidelines). Data were collected from the case records, compiled, and analyzed. The concordance or discordance with Maudsley and IPS guidelines were studied. The demographic variables of the patients and the prescription pattern of drugs were analyzed. The correlations between supramaximal and sub-threshold dosage of drugs to the gender, age, duration of illness, and combination of drugs were examined. Polypharmacy of antipsychotics is common. 31% of patients were on combination of typical and atypical antipsychotics. 4% of patients were receiving supramaximal dose of antipsychotics and all of them were on combination ( P = < 0.03, × 2 ). 24% of patients were on sub-threshold doses. 83% were not on anticholinergic drugs.

Antidepressant augmentation and combination in unipolar depression: strong guidance, weak foundations.

Depression will be the second leading contributor to the global burden of disease by 2020. In Ireland, in 2009, 6061 people were hospitalised with depressive disorders. This represents a significant economic and social burden. There is growing awareness of the difficulty in treating depression with medications alone. The likelihood that a patient will achieve remission with the first antidepressant tried is around 30%, and the rates are similar for the second antidepressant tried. This falls to around 15% after three trials. Many patients are exposed to pharmacotherapy for extended periods of time with little beneficial effect, but often with side-effects. Patients are therefore in great need of clear information with regard to their chance of success. Clinicians are in need of clear guidance on prescribing strategies which have proven efficacy. However, this guidance often discusses treatment strategies based on varying levels of evidence. Guiding bodies may approach the problem from varying perspectives. The UK National Institute for Health and Clinical Excellence (NICE) has a clear government mandate with regard to provision of not only effective but cost-effective treatments. The British Association of Psychopharmacology (BAP) is an independent body of interested researchers and therefore may discuss prescribing options from the point of view of tertiary care institutions, and university centres. The South London and Maudsley NHS Foundation Trust publish the popular Maudsley guidelines. These are perhaps more pragmatic in nature, but include very low levels of evidence, including case series. The American Psychiatric Association (APA) is an independent member association which also publishes guidelines. These are published in the American Journal of Psychiatry and the latest guidelines were published in October 2010. All these bodies attempt to weigh their advice according to the level of evidence available and aim to provide clinical guidance in difficult situations. The burden on guiding organisations is to provide some direction and clarity in areas that are often unclear or controversial. Clinical guidelines are one method of providing support and guidance to busy clinicians. However, this clinician-centered approach has limitations. The onus is on the authors of the guidance to provide ever-more treatment options. This may mean that conclusions about the efficacy of medications is overstated or the limitations of the literature not fully explored in explanatory notes.

P03-302 - Antpsychotics and CVD risk managment in rehabilitation inpatients - findings of an audit

IntroductionPatients with severe mental illness are at increased risk of cardiovascular disease because of lifestyle, co-morbidity and medication effects.Aim/objectivesThe aim of this audit is to ascertain the regularity of metabolic health checks, CVD risk assessment and adequate lipid modification therapy among patients on antipsychotic medication in 3 rehabilitation wards in county Durham and Darlington.MethodAccording to audit standards (based on NICE guidelines-Schizophrenia, Lipid Modification, Maudsley guidelines), All patients should have Blood Pressure, Body Mass Index (BMI), CVD risk assessment using appropriate calculator, Fasting blood glucose and Fasting Lipid profile done at least once a year. Lipid modification therapy has to be offered to those with 10 year CVD risk of 20% or greater. All 31 patients in 3 rehabilitation wards were included. We searched for these readings between 1/09/2010 to 30/08/2010 in patient records.ResultsOf 31 patients, 26(84%) had blood pressure, 29(94%) had BMI and 11(35%) had either fasting blood sugar or HbA1c recorded. CVD risk assessment using calculator was not done in any patients. 19(61%) lipid profile done. Of the 19 patients 16 (84%) had abnormal lipid profile. 9 (26%) patients were on lipid modifying drugs, 6 (19%) patients were on appropriate dose of lipid modifying drugs.ConclusionOur audit identified a need for systemic assessment of physical health with emphasis on cardiovascular risk management (lifestyle education, lipid modification therapy) which are critical to minimising risks and preventing long term adverse health consequences.

P03-103 - Physical health monitoring of patients on antipsychotic medication in community - findings of an audit

IntroductionPatients with severe mental illness are at increased risk of cardiovascular disease because of lifestyle, co-morbidity and medication effects.Aim/objectivesThe aim of this audit is to ascertain the regularity of blood tests (u&amp;e's, fasting blood glucose, lipid profile)among patients on Antipsychotic medication under North Durham Psychosis team.MethodAccording to audit standards (based on NICE guidelines-Schizophrenia and Maudsley guidelines), All patients on antipsychotic medication should have Urea &amp; Electorates, Fasting blood glucose and Fasting Lipid profile done at least once a year. All 67 patients in North Durham Psychosis Team were included. We searched for these readings between 1st September 2008 to 30th August 2009 in patient records. Of the 67 patients, notes were retrieved for 50. Of the 50, 46 were on antipsychotic medications.ResultsOf 46 patients, 58% had urea &amp; electorates, 58% had Fasting blood glucose and 46%had fasting lipid profile recorded.ConclusionBecause of lifestyle, co-morbidity and medication effects, patients with severe mental illness are at increased risk of cardiovascular disease. Our audit identified a need for systemic assessment of physical health with appropriate blood investigations and follow up with appropriate management plan (lifestyle education, lipid modification therapy) which are critical to minimising risks and preventing long term adverse health consequences. This results may also reflect a lack of communication between primary care and secondary care as the physical health for these clients are primarily managed by General Practitioners. It may be that these investigations are conducted but not communicated to secondary care.

A Study of an Antipsychotic Prescription Pattern of Patients with Schizophrenia in a Developing Country

Background:Though there are several recommended guidelines for treating schizophrenia, in routine clinical practice, these are not followed.Aim:To conduct an audit of the prescription pattern of antipsychotic drugs in patients with schizophrenia, in a tertiary care centre in India, during a period of 1 year and compare it with Maudsley guidelines and Clinical practice guidelines for Psychiatrists in India (IPS guidelines).Materials and Methods:Data were collected from the case records, compiled, and analyzed. The concordance or discordance with Maudsley and IPS guidelines were studied.Results:The demographic variables of the patients and the prescription pattern of drugs were analyzed. The correlations between supramaximal and sub-threshold dosage of drugs to the gender, age, duration of illness, and combination of drugs were examined.Conclusions:Polypharmacy of antipsychotics is common. 31% of patients were on combination of typical and atypical antipsychotics. 4% of patients were receiving supramaximal dose of antipsychotics and all of them were on combination (P =<0.03, x2). 24% of patients were on sub-threshold doses. 83% were not on anticholinergic drugs.

The Maudsley 2003 Prescribing Guidelines

The Maudsley 2003 Prescribing Guidelines, 7th edition D. Taylor, C. Paton & R. Kerwin Published by Martin Dunitz, 2003 ISBN 1 84184 176 5, 271 pages, Price £20.99 Psychiatric therapeutics originated with the advent of the barbiturates at the beginning of the twentieth century. With their broad spectrum of action these drugs dominated psychiatric and neurological therapeutics for over 50 years. The modern era of psychiatric therapeutics started in the 1950s with the serendipitous discovery of the first antidepressants (imipramine, iproniazide) and antipsychotics (chlorpromazine). For the next 30 years drugs available for prescribing by psychiatrists included mainly descendents of these early prototypes (tricyclic antidepressants, monoamine oxidase inhibitors, ‘classical’ antipsychotics), together with the later discovered benzodiazepines for the treatment of anxiety disorders. The differences between individual drugs in each class were relatively minor, and the clinician's choice was mainly guided by personal preference often based upon clinical habit. The situation has become more complex with the advent of some new classes of both antidepressants (selective inhibitors of either 5-hydroxytryptamine or noradrenaline re-uptake) and antipsychotics (‘atypical’ antipsychotics). Although the new drugs have some considerable clinical advantages, they also create a significant financial burden for the Health Service. Not surprisingly, the prescribing clinician has become quite bewildered when making choices between ‘old and cheap’ and ‘new and dear’ drugs. The prescriber's lot has been further complicated by the demise of the benzodiazepines as the treatment of choice for anxiety-related symptoms. Therefore, a real need has arisen to provide the prescriber with some guidelines. The Maudsley Guidelines have come about as a response to this need. They were initiated by the Drug and Therapeutics Committee of the Bethlem and Maudsley NHS Trust in the mid-1990s, and they were meant originally for internal use for prescribers within the Trust. The first formally published edition was the fifth edition in 1999. The present edition demonstrates that the Maudsley guidelines have come of age. This is a well constructed, thoughtful, up-to-date book, containing pertinent references to the literature. Following a short chapter on plasma concentration monitoring of psychotropics and anticonvulsants, the book covers the major clinical areas of schizophrenia, bipolar disorder (manic-depressive illness), depression/anxiety, and neuropsychiatric conditions (substance abuse, epilepsy). Separate sections are devoted to ‘special’ patient groups (e.g. children, the elderly, pregnant women, patients with renal or hepatic impairment, patients with dementia, violent patients). The guidance for drug choice is based, wherever possible, upon published literature, including mainly meta-analyses and reports of individual trials, Cochrane reviews, and also pertinent conference abstracts collected in 2002/2003. When available, reference is made to the guidelines of the National Institute of Clinical Excellence (NICE). This is an excellent book: the layout is pleasing and clear, it is easy to find almost any clinically important information on psychiatric drugs, and the information/guidance provided is usually based upon up-to-date evidence. I can recommend that every psychiatric prescriber has this book at his/her fingertips. However, the book should be used as intended and that is for guidance and not as a collection of prescriptive rules. It remains incumbent upon the prescribing clinician to use his/her judgement in the case of each individual patient.