Psychotropic Pro Re Nata Research Articles

Influence of Psychotropic Pro Re Nata Drug Use on Outcomes in Hospitalized Patients with Schizophrenia.

In the treatment of patients with schizophrenia, pro re nata (PRN) drugs are commonly prescribed for medical indications such as agitation, acute psychiatric symptoms, insomnia, and anxiety. However, high-quality evidence supporting the use of PRN medications is lacking, and these drugs are administered on the basis of clinical experience and habits. Therefore, the actual use of psychotropic PRN drugs and its influence on the patients' outcomes need to be investigated. This study included 205 patients who underwent inpatient treatment for schizophrenia. We investigated the prescription of psychotropic drugs before admission and at discharge, as well as the dosing frequency of PRN drugs during hospitalization. We also examined the influence of psychotropic PRN drug use on hospitalization days, antipsychotic polypharmacy, and readmission rates. Patients who used psychotropic PRN drugs during hospitalization had significantly longer hospitalization days (p = 7.5 × 10-4) and significantly higher rates of antipsychotic polypharmacy (p = 2.4 × 10-4) at discharge than those who did not use psychotropic PRN drugs. Moreover, a higher number of psychotropic PRN drugs used per day was associated with higher readmission rates within 3 months of discharge (p = 4.4 × 10-3). Psychotropic PRN drug use is associated with prolonged hospitalization, antipsychotic polypharmacy, and increased readmission rates in inpatients with schizophrenia. Therefore, psychiatric symptoms should be stabilized with regularly prescribed medications without the extensive use of psychotropic PRN drugs. Moreover, a system for monitoring and reexamining PRN drug use needs to be established.

The characteristics of patients receiving psychotropic pro re nata medication at discharge for the treatment of schizophrenia and major depressive disorder: A nationwide survey from the EGUIDE project.

Although several guidelines indicate that daily pharmacotherapy is an important part of the treatment of schizophrenia and major depressive disorder, there are few reports regarding pro re nata (PRN) prescriptions. The purpose of this study is to clarify the characteristics of patients receiving psychotropic PRN prescription for the treatment of schizophrenia and major depressive disorder. We used data from 'the effectiveness of guideline for dissemination and education in psychiatric treatment' (EGUIDE) project to evaluate the presence or absence of psychotropic PRN prescription at the time of discharge, the age and sex of patients receiving PRN prescription for each diagnosis, and the association between PRN prescription and regular daily psychotropics. The psychotropic PRN prescription ratio was 29.9% among 2617 patients with schizophrenia and 31.1% among 1248 patients with major depressive disorder at discharge. In schizophrenia, the psychotropic PRN prescription ratio was 21.6% for patients aged 65 years or older, which was lower than that of all other age groups. In major depressive disorder, the psychotropic PRN prescription ratio was 34.2% for female patients, which was significantly higher than that for male patients (25.5%). In schizophrenia, there was an association between psychotropic PRN prescription and regular use of multiple psychotropic medications. Psychotropic PRN prescription was less common in elderly patients with schizophrenia and more common in female patients with major depressive disorder. In schizophrenia, psychotropic PRN prescription led to polypharmacy of psychotropics. Further studies are needed to accumulate evidence and to provide education on appropriate PRN prescriptions.

Use of Psychotropic "Pro Re Nata" Medications by Patients Attending the Outpatient Clinic in a Hospital: A Qualitative Exploration.

Introduction: Administration of psychotropic pro re nata (PRN) medications is influenced by diverse factors such as legal use of PRN medications, the attitude of patients, personal bias, and stigma toward such medication use. While PRN prescriptions increase the efficiency of care and encourage patients to participate in self-care, the use of psychotropic PRN medications by outpatients has raised concerns about its risks of harm, especially for the outpatients. This study explored the use of psychotropic PRN medications by patients attending the outpatient clinic in a hospital.Methods: Qualitative in-depth interviews were conducted. Purposeful sampling was done to achieve cases with enriched information. Participants were chosen regardless of their ethnicity and were selected using the database and patient records in the clinic. Patients 18 years of age prescribed PRN psychotropic medications attending outpatient clinics in a hospital were included. Vulnerable patients (e.g., pregnant ladies, prisoners, cognitively impaired individual, AIDS/HIV subjects, and terminally ill subjects) were excluded.Results: This study revealed the patients' perspectives and experiences on self-management of psychotropic PRN medications. The themes that emerged were clustered as education and background, knowledge on psychotropic medications, frequency of medication intake, underuse of medication, the overdose of medication, side effects concern, source of information, and personal experience.Conclusions: Patients' understanding of medication, inappropriate medication use, cues to action, and use of alternatives are the factors that affected the self-management of psychotropic PRN medications by the patients.

Characterization of Psychotropic PRN Medications in a Canadian Psychiatric Intensive Care Unit.

Pro re nata (PRN) antipsychotics and benzodiazepines are routinely used for the rapid stabilization of acutely agitated patients. Despite the popular use of PRN medications in mental health units, primary literature supporting efficacy and safety is poor, and there is no single universally accepted practice guideline. PRN psychotropic medications have the potential to cause adverse effects when used inappropriately. Our objective was to characterize the prescribing, administration, and documentation practices of PRN psychotropic medications in a psychiatric intensive care unit. We conducted a retrospective chart review of patients admitted to a 12-bed psychiatric intensive care unit between June and September 2018. All PRN antipsychotic and benzodiazepine orders, administrations, documentation practices, and attempted nonpharmacological strategies were assessed for each order and patient. Descriptive statistics were used to analyze data. Thirty-two patients with a total of 123 physicians' orders and 1,179 PRN administrations of antipsychotics and benzodiazepines were reviewed. Of the total administrations, 720 (61%) were combinations with at least two psychotropic agents. Forty-one (33%) physicians' orders had a prescribed indication, and 559 (47%) administrations had an attempted nonpharmacological method prior to PRN administration. Eight patients (25%) had antipsychotic PRN orders, which exceeded the total daily maximum dose. Three adverse drug effects were attributed to PRN administration. Areas of improvement that we identified included documentation practices of effectiveness of administered PRNs, prescriptions to include clear indications and dosage within the 24-hour maximum limits, and documentation of nonpharmacological methods utilized.

The monitoring and use of Pro re nata (PRN) psychotropic medication for people with learning disabilities on an inpatient ward

AimsThis project was designed to evaluate the use of PRN medication and PRN monitoring charts on an adult learning disability ward. These charts had been designed by the trust to provide us with a way of monitoring the use of psychotropic PRN medication to ensure monitoring of treatment response, physical health and side effects.MethodThe data were collected from PRN monitoring charts, electronic case notes and electronic prescribing chart records for all patients on an adult learning disability inpatient unit. The sample consisted of 7 patients who had been prescribed and/or received PRN psychotropic medication over a five week period. Quantitative data were derived by simple calculation for the total amount of PRN medication used and number of PRN monitoring charts completed. Qualitative data were collected of prescription charts and PRN protocols which is supposed to guide treatment.ResultOut of all the incidences where PRN medication was administered, only 64% of monitoring charts were completed. Out of the 7 patients on the ward, 6 had PRN protocol charts and for only 5 patients these were followed.ConclusionClinical practice must be improved. The results were presented to ward staff and doctors to discuss the implications for patient care and ways to improve clinical practice by ensuring full monitoring of the use of PRN medication to help reduce the overmedication of people with learning disability by improving the use of the PRN charts. NICE guidelines and The Royal College of Psychiatrists have published guidelines on the prescription of psychotropic drugs for people with learning disabilities. NHS England have also published an article to discourage over-medication of people with learning disabilities. There is a risk that doctors are prescribing medication to treat behaviour that is an expression of distress or a mode of communication rather than a mental disorder. Doctors have a responsibility to ensure they have fully assessed the person's potential to benefit from medication before they prescribe. The audit would serve to provide a baseline for this team prior to any audits in the future.

Patient participation in pro re nata medication in forensic psychiatric care: A nursing document analysis.

As-needed medication is commonly used for psychiatric inpatients' acute psychiatric and physical symptoms. Both patients and staff can initiate such medication. Earlier studies have focused on what and how as-needed medication has been used for psychiatric reasons. Little is known about how patients participate in planning, administration and evaluation of as-needed medication and its alternatives. Nursing documentation provides an insight into these practices. Long-term inpatients have an active role in initiating as-needed medication. However, patients and staff may have divergent opinions on the need for medication. Alternatives to medication are mostly proposed by staff, and the feedback on as-needed medication events is usually provided from nurses' point of view. Patients' views on decision-making and evaluation should be noticed and documented more. Patient participation can be promoted by planning as-needed medication and its alternatives beforehand. INTRODUCTION: Pro re nata (PRN) medication is unscheduled and used for acute physical and psychiatric symptoms. Previous studies have focused on the what and how of psychotropic PRN administration. Initiators of PRN events and occasions in which PRN was denied have rarely been studied. Thus, knowledge of patient participation in PRN is fragmented. We aimed to describe and explain long-term psychiatric inpatients' participation in relation to planning and initiation of, as well as decisions and feedback on their PRN medication treatment. We retrieved data from patients' (n=67) nursing documentation in a Finnish forensic psychiatric hospital in 2018. Data were analysed using statistical methods. All patients were prescribed PRN, and they initiated half of the 8,626 PRN events identified, in a 1-year period. Non-pharmacological strategies were rarely (6%) documented, and most of them were initiated by staff (76%). Feedback on PRN was usually from a nurse's viewpoint (71%). Nurses' feedback was positive (80%) more often than patients' (50%). Patient participation needs to be recognized throughout the PRN process. Future research could continue to explore patient participation in planning and evaluating their PRN medication. Patients participate in PRN by requesting medication. Their participation can be developed by supporting patients to communicate their choice of non-pharmacological methods, take the initiative for medication when needed and disclose their viewpoint on the effects of PRN.

Pro Re Nata Medication Use in Acute Care Adolescent Psychiatric Unit.

Objective: Evidence to support the use of pro re nata (PRN) medication is limited, and the details of PRN use (indication, frequency of administration, patient characteristics) are rarely reported, particularly in youth populations. The goal of this study was to report on the pattern of PRN use over 6 years in an acute care psychiatric unit for adolescents. Methods: A retrospective chart review of patients' records from November 2012 to October 2018 was conducted. Variables extracted from electronic medical records included age, gender, race/ethnicity, clinical rating scores at admission (on a subset of patients), length of stay, psychotropic and nonpsychotropic PRN medication administration, timing of administration, discharge diagnosis, and discharge medication. Results: Records from 2961 individuals with a total 3937 admissions were analyzed. A total of 62% of admissions had at least one PRN medication administration. Severity of symptoms, as indicated by higher scores on clinical rating scales at admission, longer length of stay, and readmission were related to high PRN use. Patients with bipolar spectrum disorders received more psychotropic and nonpsychotropic PRN medications than other patients. Patients who were high psychotropic PRN users were also high nonpsychotropic PRN users. Conclusion: Despite the lack of clear evidence in support of the efficacy of PRN medications, they commonly used to control symptoms in acute care inpatient settings. Youth with severe symptoms utilized not only psychotropic PRN medication but also nonpsychotropic PRN more frequently, suggesting a possible role of systemic disorder among youth with serious mental illness. More research is necessary to examine the efficacy of PRN medications for managing targeted symptoms.

Staff perceptions of PRN medication in a residential care setting

Purpose The purpose of this paper is to explore the perceptions of staff towards psychotropic Pro Re Nata (PRN) medication in a residential care setting. Design/methodology/approach Three male and seven female participants were interviewed using a semi-structured interview. Transcripts were analysed using thematic analysis. Findings Four themes pertaining to PRN medication emerged from the data: behaviour change, calming effect, importance of timing and perceived uniqueness. Research limitations/implications The participant group was not homogenous and findings may have been different in a more qualified cohort. This care setting may not be representative of other environments where PRN medication is administered. The findings do, however, highlight some of the challenges facing the administration of PRN medication in mental health and care settings. Practical implications The awareness of these themes is significant for improving staff knowledge, training practices and policies towards the use and administration of psychotropic PRN medication. Originality/value This is the first study to engage in a thematic analysis of staff views towards the administration of PRN medication.

Analysis of non-pharmacological interventions attempted prior to pro re nata medication use.

The aim of the present study was to elucidate what non-pharmacological interventions are applied by nursing staff prior to the administration of psychotropic pro re nata (PRN) medication. Best practices would instruct clinical staff to provide non-pharmacological strategies, such as de-escalation and skills coaching, as the first response to patient distress, anxiety, or agitation. Non-pharmacological strategies might be safer for patients, promote more collaborative relationships, and facilitate greater skills development for managing symptoms. The literature has highlighted that poor documentation of pre-PRN administration interventions has limited our understanding of this practice, but evidence suggests that when this information is available, non-pharmaceutical approaches are not being attempted in the majority of cases. This is troubling given that, while clinically appropriate in some instances, PRN have been subject to criticism and lack critical evidence to support their use. The current study is a continuation of our previous work, which examined the reason, frequency, documentation, and outcome (e.g. effectiveness, side-effects) of PRN medication use at our facility. A chart review was conducted to understand what happens prior to the administration of PRN medication at our facility across all inpatient units over the course of 3months. Results support previous findings that non-pharmacological interventions are poorly documented by front-line staff and are seemingly used infrequently. The use of these interventions differs by patient presentation (e.g. agitation, insomnia), and most often include supportive measures. The findings suggest that both documentation and intervention practices of nursing staff require further investigation and adjustment to align with best practices.

The use and effectiveness of pro re nata psychotropic medications in children and adolescents: A systematic review

Background:Published studies have not demonstrated the benefits of the practice of psychotropic PRN administration.Aim:The goal of this study is to perform a systematic review on pro re nata (PRN) psychotropic medications administration in children and adolescents and examine the safety and effectiveness of this practice in child and adolescent psychiatric care units.Settings and Design:This is a systematic review.Materials and Methods:Several databases were searched till date. One hundred and sixty-five titles and abstracts were found and a total of 14 studies, for which most were retrospective, met the absolute criteria. The patients studied were children, adolescents and patients that presented to the emergency room or admitted as inpatient.Results:Indications for admission included aggression and agitation for all the studies. Most the medications used include haloperidol, olanzapine, diazepam, and risperidone. Commonly reported adverse effects following the administration of the PRN medications were sleepiness, acute dystonia, and drowsiness. The effectiveness of PRN medications, which was reported in four of reviewed studies, ranged from 30% to 50%.Conclusion:Different effectiveness/outcome measures were used for all the studies; therefore, we could not generalize effectiveness across all the studies. Findings of the reviewed articles show the imperativeness of more research to evaluate the safety and effectiveness of PRN medications among child and adolescent populations.

Descriptive analysis of pro re nata medication use at a Canadian psychiatric hospital.

Pro re nata (PRN), a Latin phrase meaning 'as needed', is used to describe medications that might be used in specific situations, in addition to regularly-scheduled medications, such as when a patient is particularly anxious, experiencing insomnia, or suffering pain. While helpful in some circumstances, PRN are associated with an increased risk of morbidity, overuse, dependence, and polypharmacy. There is also a dearth of medical literature describing current practices and trends of PRN administration in mental health facilities, especially in Canada, and the literature that does exist is limited by poor documentation practices. Therefore, the primary objective of the current study was to understand the reason (purpose), frequency, use, documentation practices, and outcome (i.e. effectiveness, side-effects) of PRN medication use on inpatient units. Data were pulled to capture a snapshot of PRN administrations over a 3-month period, and included information related to the administration of the PRN medication, such as time of administration, type and dose of PRN medication, and prescribed indication, as well as patient-specific information. Results indicated that approximately 8200 psychotropic PRN medications were administered during the designated 3-month time period, and over 90% of patients received at least one PRN. Most of these were benzodiazepines, followed by antipsychotics. Further analyses were conducted to determine other characteristics of PRN use patterns and to provide a baseline of understanding that will inform future research to investigate the practice of PRN administration to psychiatric inpatients.

The experiences of mental health professionals' and patients' use of pro re nata (PRN) medication in acute adult mental health care settings: a systematic review protocol of qualitative evidence

The experiences of mental health professionals' and patients' use of pro re nata (PRN) medication in acute adult mental health care settings: a systematic review protocol of qualitative evidence

Psychotropic PRN use among older people's inpatient mental health services

Concerns have been expressed about the use of antipsychotics with older people, particularly in those who have dementia. Pro re nata (PRN) psychotropic medications including antipsychotics are commonly used to manage disturbed and distressed behaviour. This audit aimed to understand the use of PRN psychotropic medications in older people's inpatient mental health services and the quality of prescriptions and nursing documentation associated with this. A retrospective audit was undertaken on 154 patients on 11 wards in three Mental Health Trusts in the North West of England. A proforma adapted from previous research was used to collect data. Eighty-seven patients were prescribed combinations of 14 psychotropic drugs in 145 different prescriptions as PRN. Seventy-six doses of PRN were administered to 26 patients (range 1-17 doses). The most commonly administered drug was Lorazepam (n = 28, 36.8%). Drugs were most frequently administered during the night (n = 33, 43.4%). The majority of administrations of PRN were not documented (n = 45, 59.2%). PRN appeared to be used differently (smaller doses and less frequently) in this study compared to previous research of those aged under 65. Further work needs to examine the use of the use of PRN psychotropic medicines and the older person, and focus on developing alternative nonpharmacological interventions.

A best‐evidence synthesis review of the administration of psychotropic pro re nata (PRN) medication in in‐patient mental health settings

This paper aims to synthesise published literature of drug use/administration studies of pro re nata psychotropic medications in mental health wards. The study employed a best-evidence synthesis review design. The administration of psychotropic pro re nata medications is a frequently used clinical intervention in mental health wards. Pro re nata contributes to exposing patients to high doses of antipsychotic medication. Despite the frequent use of pro re nata, there is limited evidence of their effectiveness. A best-evidence synthesis review. Six major themes emerged from the literature: (i) frequency of administration; (ii) administration during the 24-hour day; (iii) administration associated with length and stage of admission; (iv) rationales for administration; (v) medicines administered (including route of administration); and (vi) effects and side effects of the medicines administered. Overall findings indicate that the administration of psychotropic pro re nata varies radically and appears to be influenced by many variables. Relevance to clinical practice. Patients are most likely to receive a benzodiazepine or typical antipsychotic as pro re nata. Pro re nata is an important and under-researched clinical intervention used in mental health wards.

The impact of a good practice manual on professional practice associated with psychotropic PRN in acute mental health wards: An exploratory study

Background As required or pro re nata (PRN) psychotropic medicines are frequently used in acute mental health wards. PRN is known to contribute to polypharmacy and high doses of antipsychotic medication. Few studies have attempted to improve clinician's use of these potentially harmful drugs. Aims The objectives of the study were to determine the impact and acceptability of a good practice manual on prescribing and administration practices of PRN psychotropic medication in acute mental health wards. Design The study used a pre–post exploratory design with two acute mental health wards in the NW of England. Results Over the total trial period of 10 weeks, 28 of 35 patients received 484 doses of PRN. Patients had a mean of 3.6 prescriptions of 14 different PRN medications in 34 different dose combinations prescribed. Medication errors beyond poor quality of prescribing occurred in 23 of the 35 patients (65.7%). Prescription quality improved following the introduction of the intervention but quality of nursing notes reduced. Acceptability of the manual to both nursing and medical staff was high. Conclusion The introduction of the manual appeared to influence some of the practices associated with the prescribing and administration of PRN psychotropic medications. Further, larger, more robust studies are required in this area. In particular research is required to identify the reasons why professionals continue to rely so heavily on using PRN medication.

Multidisciplinary consensus of best practice for pro re nata (PRN) psychotropic medications within acute mental health settings: a Delphi study

There is a limited evidence base for the use of pro re nata (PRN) 'as required' psychotropic medication within acute mental health settings. This study aimed to explore expert opinion concerning issues and best practice for the prescribing and administration of psychotropic PRN medications within acute inpatient mental health settings. Eighteen experts participated in three Delphi rounds of a modified Delphi panel to establish consensus. A total of 271 items were initially generated from four questions. As a result of the consensus process the number of items retained reduced to 78, then 34 items and finally 13 items. Clinicians' practice could be informed by the 13 recommendations established by the Delphi panel. Further research is required to establish the clinical effectiveness of these recommendations.