THE STATE HOSPITALS BOARD FOR SCOTLAND 12 MONTHLY REPORT. Medicines Committee. Reference Number Item 7 Issue:

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1 THE STATE HOSPITALS BOARD FOR SCOTLAND 12 MONTHLY REPORT Medicines Committee Reference Number Item 7 Issue: Lead Author Lead Pharmacist Contributing Authors Clinical Effectiveness Co-Ordinator Medicines Committee members Approval Group Medicines Committee Effective Date October 2017 Review Date October 2018 Responsible Officer Professor Lindsay Thomson (eg SMT lead) Medicines Committee 12 Monthly Report

2 Table of Contents Page 1. Chairperson s Foreword 3 2. Governance Arrangements 3 3. Key Pieces of Work Key Performance Indicators Comparison with Last Annual Report Areas of Good Practice The Patients Voice Future Areas of Work Next review date 12 Appendix Medicines Committee 12 Monthly Report

3 1 Chairperson s Foreword Items of particular note from The Medicines Committee this year are the ongoing use of MaPPs (Medicines: A Patient Profile Summary) which give patients an individualized summary of their medication regime, coordinated with pharmacists meeting with patients directly to discuss their medication. These steps are likely to have been responsible for an increase in the number of patients being confident they have been well informed regarding side effects of medication. Regarding increased efficiency, our first Pharmacist Independent Prescriber began practice this year, with a measurable improvement in the time taken for medications to be updated on kardexs. Specific pieces of work undertaken include guidance on the unlicensed use of short term intramuscular clozapine, a difficult issue especially given the likelihood of concurrent blood taking under restraint. National and local audits highlight areas of good practice within the hospital such as a comparably low number of IM emergency medication episodes with appropriate monitoring in place around such episodes, and, the prescription of one IM agent rather than two. The committee continues to raise awareness of issues highlighted by audit for improving areas of practice via the Medical Advisory Committee, nursing practice development staff and Awareness Bulletins. Dr Natasha Billcliff Please note this 12 month report covers data up to the end of September Governance Arrangements 2.1 Committee membership Dr N Billcliff, Consultant Psychiatrist (Chair) Dr S Howitt, Consultant Psychiatrist - new Dr B Prasad, Speciality Doctor Mr I Rodger, Practice Development Mrs S Smith, Clinical Effectiveness Mrs C Topping, Practice Nurse Mrs J McWilliam, Clinical Pharmacist Mrs M Wright, Lead Pharmacist Minute Secretary: David McCafferty - new Dr P Apurva, Consultant Psychiatrist stepped down after a short while due to other commitments on the regular committee meeting day. Dr J Murie, General Practitioner stepped down following a review of primary care services time commitments. Alternative communication meeting in place. Mrs Avril Adamson, Medical Secretary stepped down as minute secretary following a hospital wide RMO/administration remit review. The committee would like to thank all of these for their time and participation. 2.2 Role of the committee The role of the committee is to help improve the quality and cost effectiveness of prescribing. This along with the objectives below is in line with the 14 Health Board Area Drug and Therapeutic Committees (ADTCs). In relation to formulary choices and for new medicine guidance the State Hospital as a Special Health Board (out with ADTC network) links in with NHS Lothian ADTC decisions. The Medicines Committee has now better links to the ADTC Consortium with regards Scottish Government workplan and priority developments. This includes the hospital being cited on work towards a national single formulary. Medicines Committee 12 Monthly Report

4 2.3 Main objectives of the Committee To promote safe, effective and economic use of medicines To advise, monitor and co-ordinate the production of policies and procedures relating to drug prescribing and safe administration of medicines. To determine and operate a system to ensure full evaluation of new medicines before introduction to the hospital. To monitor drug expenditure within the hospital and provide information on good practice for the optimal use of medicines. To advise the Clinical Governance Committee on ethical issues relating to medicine use. 2.4 Meeting frequency and dates met Meetings are planned for every 2 months and over the last 12 months (1 st October to 30 th September) there has been five held. November, January, March, May, August. The July meeting was postponed in to August due to the holiday period. Group communication is also used between meetings. 2.5 Strategy and workplan The workplan of the committee is largely based around four key areas which emanate from strands of the Local Delivery Plan. These are: Medicines Management expenditure, formulary developments, Scottish Medicine Consortium guidance, unlicensed medicine usage, Individual Patient Treatment Requests (IPTR), product supply problems Safe Use of Medicines policy updates, treatment guidelines, medication incidents, drug safety data, patient group directions (PGDs) Clinical Effectiveness local and national clinical audits, gap analysis of national guidelines (SIGN, NICE) Patient Safety liaising with local Patient Safety Group and also national Scottish Patient Safety Programme (SPSP), medicine management workstream on priority topics e.g. medicines reconciliation, high risk medicines 2.6 Management arrangements The committee reports directly to the Clinical Governance Group. 3 Key pieces of work undertaken during the year 3.1 Guidance for Use of Unlicensed Intramuscular Clozapine Clozapine is the only licensed antipsychotic medication for treatment resistant schizophrenia and as such is widely used in approximately a third of State Hospital patients. To date only the licensed tablets have been used in the hospital but recent UK networking has highlighted the availability from the Netherlands of an unlicensed short acting injection. The aim of using clozapine injection is a short-term intervention to initiate clozapine for patients who refuse medication, with a view to convert to oral clozapine as soon as possible.the administration of the injection will be required under restraint. Guidance was produced and approved by the Medicines Committee and Clinical Governance Group for use in exceptional circumstances and with an agreed authorisation process. Medicines Committee 12 Monthly Report

5 3.2 Policy and Document updates Three key documents were updated and implemented in the last 12 months. These include the Safe Use of Medicines Policy and Procedures, Use of Unlicensed/Off-label Medicines and the Individual Patient Treatment Request (IPTR) Policy. 3.3 National Guidance Adopted The Scottish Government issued national standards for monitoring of all patients on clozapine and lithium. These have been integrated into practice. There was also agreement to make available on the intranet the College of Mental Health Pharmacy guidance on Administration to Adults of Oil-based Depot and other Long-Acting Intramuscular Antipsychotic Injections. 3.4 Pharmacist Independent Prescribing The hospital supported registration of the first Pharmacist Independent Prescriber who finished the qualification course in May Implementation was undertaken in Iona Hub towards the end of The prescribing framework that had been agreed through the Medicines Committee was signed off by the Iona RMO s. This primarily covered initiation/change of psychotropic therapy as agreed via MDT and medicines to treat psychotropic medicine side effects. An evaluation was undertaken pre and post implementation which demonstrated that in the 3 month period before the pharmacist was prescribing of 21 recommendations from the pharmacist that were agreed to and acted on 12 took longer than 7 days to be implemented by medical staff. Once the pharmacist could prescribe however decisions were acted upon faster. 3.5 Clinical Effectiveness Clinical Audit Projects - National Prescribing Observatory in Mental Health (POMH) Projects These are national benchmarking projects that The State Hospital now participates in as part of the Forensic Network (code 95). The funding, co-ordination and data input of the projects sits with The State Hospital. Primarily these are facilitated by the Clinical Effectiveness Department. Junior medical staff are often involved with the data collection. Monitoring of Patients Prescribed Lithium Re-audit The total national sample this year was 5,182 patients with 7 sites from the Forensic Network taking part (30 patients) including The State Hospital. All patients within the Forensic Network had received the appropriate level of monitoring with regard lithium levels (see graph), renal function and weight measurements. Thyroid and calcium monitoring was not so well met but still placed the network at the upper end of the benchmarking graph. Assessment and recording of side effects was similar to the total national sample. Action has been taken to add calcium monitoring to the regular monitoring and clarify 6 monthly thyroid levels. Maintenance treatment: Trust level Monitoring in relation to practice standard 2: 2: The following tests/measures should be conducted during maintenance treatment: a) Serum lithium level every 6 months; 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% TNS 2 or more tests (standard met) 1 test No tests 2 or more tests at 2013 supplementary audit Medicines Committee 12 Monthly Report

6 Rapid Traquilisation in Acute Disturbed Behaviour Data was submitted for episodes UK wide, 15 of those from 3 sites in the Forensic Network including the State Hospital. The good news was that the Forensic Network as a whole had very few episodes in the audit period of intra-muscular medicine administrations. In summary the Forensic Network demonstratred good practice compared to other UK sites in relation to cardiac monitoring (ECG), behavioural state recording and care planning after rapid tranquilisation. Comparable practice was demonstrated with considering patient wishes for future episodes. Areas for improvement include physical health recording and completion of a debrief after an episode. Work with the patient safety group is planned to address these Clinical Audit Projects Local Adherence to Antimicrobial Formulary 16 patients were prescribed antimicrobials during the audit period (14/11/16 22/01/17). There were, in total, 20 treatment episodes as 3 patients were given more than one antimicrobial during the audit period. Results show a high level of compliance with NHSL empirical policy and formulary with clear documentation in relation to treatment agent choice and duration. The most common indications continue to be for skin, urinary infections and respiratory complaints. As required Psychotropic Re-audit The final report showed that 92 out of 111 patients (83%) were written up for psychotropic (antipsychotic or benzodiazepine) PRN medication and 20 were administered it during the 4 week audit period (22%). Only 3 patients received an IM preparation. These results were similar to the previous year s audit. Over the years there has been a significant reduction of prescribing of PRN IM antipsychotic medication. This reflects practice that emergency IM medication needs to be individualised to patient need and use of blanket prescribing is no longer appropriate. Post injection observation and physical health monitoring recording however was again noted to be poor. With the introduction of new monitoring charts for all physical health care (NEWS) this should improve at the next audit. Guidance on the Use of IM Medication for Acutely Disturbed or Violent Behaviour In addition to the national UK audit The State Hospital completed an audit looking at adherence to the local guidance that was introduced last year for use of intra-muscular medication for acutely disturbed or violent behaviour. It identified that only 35 patients were prescribed an intramuscular medication for this indication. This is a significant drop from previous years when it was routine practice to prescribe in all patients. Another positive was the high proportion of patients prescribed only one intramuscular agent as opposed to two simultaneously which until recently had been standard practice The primary area for improvement is the incorporation of the use of IM PRN as a treatment strategy within the CPA care plan. In over 70% of cases this is not recorded. Raising awareness of this will be a priority via the Medical Advisory Committee. Medicine Trolley Re-Audit A re-audit looking at the systematic layout of medicines in the ward trolley to help prevent administration errors (2015) showed improvement in most wards. The 2016 repeat audit however showed some deterioration again in both compliance with alphabetical and strength order. This was therefore directed to the Hub business meetings and is to be added to the regular checks at ward level. Prescription Sheet Re-Audit Over-all there was good compliance with the standards for prescription writing in this project although the data collector observed this was generally due to pharmacy endorsing some elements on the prescription sheet. A repeat was therefore undertaken to assess compliance with the standards when the pharmacy endorsements were not included. The main areas where pharmacy had clarified the prescription for compliance were around T2/T3 indication, drug Medicines Committee 12 Monthly Report

7 name, CHI, route, dose and the high dose alert section. Both projects were shared with medical staff via the Medical Advisory Committee Implementation of National Clinical Guidelines & Standards Over the last 12 months (1 October 2016 to 30 September 2017), there were 3 documents reviewed by the Medicines Committee. One of these was standards from the Scottish Government regarding monitoring the physical health of people being treated with Clozapine. These standards were adopted via the Clozapine Clinic. The MWC released a document entitled Covert Medication. This document has been referenced within the Safe Administration of Medicines policy and is accessed via hyperlink. SIGN also released draft guidance for consultation regarding pharmacological management of migraine, the content of which was reviewed although no feedback was submitted. Guidelines/Standards Body No of Publications Reviewed No Applicable to The State Hospital Scottish Intercollegiate Guideline 1 1 Network (SIGN) Healthcare Improvement Scotland 1 0 (HIS) Scottish Government 1 1 Mental Welfare Commission (MWC) 1 1 National Institute for Health & Clinical Excellence (NICE) 66 0 In addition, 1HIS report, 1 NICE guideline and 64 NICE Medication Technology Appraisals (MTAs) were reviewed which is an increase of 6 MTAs from the previous year. All 66 documents were deemed to be either not relevant to our setting or were covered by a similar Scottish guideline. As the 64 MTA s were released by NICE, that are English based, both Clinical Effectiveness and Pharmacy are involved in the process of reviewing these against medications released by the Scottish Medicines Consortium and the Lothian Joint Formulary. Pharmacy staff are also members of other professional groups that review guidelines/standards and can complete the medication components of these. 3.6 Scottish Patient Safety programme (SPSP) There is now a specific Medicines programme focusing on Medicines Reconciliation and high risk medicines. The Hospital has a robust medicines reconciliation process at both admission and discharge. Now looking at medicines reconciliation for patients admitted back from a period in acute care at Wishaw General Hospital. Excellent progress has been made with the level of information that patients feel they get around the side effects of medication. This was evidenced in the results of the latest patient safety survey. Although there was a reduced percentage of those that felt very confident, overall 80.5% were very confident or confident in the information in 2016 compared to 61.4% in This is likely to be linked to the introduction of individualised summary information produced from the MaPPs system (covers physical and mental health medicines) that the clinical pharmacist produces for patient case reviews. These are offered to all patients with an average of 65% of patients accepting the written information in the last 12 months. This is a reduction from the initial introduction months which was around 85%. Medicines Committee 12 Monthly Report

8 Extracted from Patient Safety Survey Results 2016 Consultation is also on-going with the patient safety group around electronic recording of as required medication. 3.7 Electronic Prescribing SMT accepted the recommendation that the hospital should not go alone with an electronic prescribing module (linked to RiO) that had not been recognised for use in NHS Scotland by the Scottish Government. The State Hospital was then included in the national business case that has been accepted. Implementation for NHS Scotland is planned over the coming 5 years on a regional basis. A lead has been identified within the hospital to progress the resource and funding options both of which are significant. 3.8 Glasgow Antipsychotic Side Effect Rating Scale (GASS) This electronic side effect rating scale on RiO has now been implemented. 3.9 Diabetes Work continues to ensure the diabetic population in the hospital receive appropriate treatment and monitoring regimes. 4. Key Performance Indicators 4.1 Medicines Expenditure Monthly invoices continue to be checked and authorised by Pharmacy against NHS Lothian Medicines Management reports. A live electronic link to NHS Lothian streamlines the medicine ordering process. 1 st and 2 nd quarter totals - 6 months 17/18 (Top line budget 115,750) Total Apr 16 Mar 17 (Top line 12 month budget 231,500) Stores 76, ,117 Dispensary 8,488 17,480 Clozapine Dispensing 6,965 13,720 TOTAL 91, ,317 Target (incl.savings) 100, ,500 Savings under target 9,259 35,183 Savings to top-line 24,259 63,183 Medicines Committee 12 Monthly Report

9 For the year 2016/17 the medicines budget contributed 63,183 non-recurring to hospital savings. For 2017/18 so far the medicines budget has hit the years savings target at 6 months although there are going to be new pressures with regard oral olanzapine tablets coming off national contract. Oral quetiapine is going the same way off contract. The top monthly expenditure remains with the long acting atypical antipsychotic injection paliperidone. Other items in the top 10 include further atypical antipsychotics (olanzapine, aripiprazole, clozapine, quetiapine), vitamin D, nicotine replacement therapy. Some individual patient physical health items are also present. The committee has actively reviewed these products and made local changes as appropriate to reduce costs where possible e.g. switch to procyclidine tablets from the higher costing liquid, reduced need for glucose monitoring strips. In 2004/05 there were approximately 227 patients in the hospital. This was an average spend of 222 per patient per month. The average for this year so far is 145 per patient per month. Primarily this is due to availability of generic products although tight formulary management has also impacted. Some patients receive specialist treatment via Infection Control services in Lanarkshire for hepatitis C. The hospital is able to cross charge patients home health board for these high cost medicines as they are very effective and prevent serious liver disease further down the line. Level of stock holdings on the wards are reviewed each week by the pharmacy top-up service and monitored via medicines management issue reports. 4.2 Prescribing reports Six monthly prescribing reports on antipsychotic medication are reported to the Consultant group. These are used to identify patient outliers who may be receiving unusual antipsychotic regimes. Peer review discussion then takes place on these more complex medication combinations. A selection of reports is available. See Appendix 1. Benchmarking work with the Prescribing Observatory in Mental Health has demonstrated that regular high dose and combination antipsychotic use is equal to or even less that other UK sites. Results of a recent POMH re-audit is due shortly and will be shared in future reports. Medicines Committee 12 Monthly Report

10 4.3 Non- Formulary Medicines Use The pharmacy department continues to monitor adherence to formulary in the GP prescribing for both short and longer term medicines with ongoing excellent adherence. Antibiotic prescribing adherence to the Lanarkshire antimicrobial formulary continues to be monitored and reviewed (see section 4.6). An IPTR process is available for non SMC approved medication requests (see section 4.5) 4.4 Unlicensed/Off Label Prescribing The list of unlicensed and off label medicines accepted for use within the hospital is available on the intranet and is regularly updated. The medicines committee reviews requests for unlicensed or off label medicines (as per hospital policy). Our main use of an unlicensed medicine continues to be pirenzepine for the treatment of clozapine induced hypersalivation. Off- label approval for this year has included e.g.metformin for antipsychotic weight gain, minocycline as an adjunct in schizophrenia and aripiprazole for hyperprolactinaemia. 4.5 Individual Patient Treatment Request (IPTR) Applications Three IPTR applications have been submitted for review by the Medicines Committee and approval by Senior Management Team this year. These include an opioid analgesic 7 day patch (specialist recommendation) plus melatonin tablets for sleep. IPTR is to be replaced by the Scottish Government to a new national system to be applied locally which will be clinically led. There will be standard application forms for NHSScotland. 4.6 Antimicrobial prescribing The State Hospital has a Service Level Agreement with NHS Lanarkshire for the provision of sessional input from an Antimicrobial Pharmacist who is also a member of The State Hospital Infection Control Committee. There is also close liaison with the on-site pharmacy team and Medicines Committee. Three monthly usage reports continue to be produced for the Infection Control and Medicines Committee. Adherence to the antimicrobial formulary has been shown to be excellent Prescribers have embraced the policy which minimises use of cephalosporans, quinilones, coamoxiclav and clindamycin (antibiotics more associated with Clostridium difficile infection) into daily clinical practice and this is evidenced through an annual audit. Due to the high adherence rate and the length of time required to get a suitable sample size a recommendation has gone to the infection control committee that this be changed to every 2 years. Pharmacy input to the GP clinic addresses any issues on a week to week basis. 4.7 Controlled Drugs All controlled drug supplies continue to be monitored and any anomalies recorded through the DATIX system. The Associate Medical Director is the named Accountable Officer for the Board and the Lead Nurses have been newly appointed as responsible persons to witness any controlled drug destructions necessary on site. The controlled drugs used in the last 12 months include methadone (only in patients admitted on it), methylphenidate for ADHD and tramadol an opiate analgesic. Use of tramadol within the hospital has reduced significantly since the medicine became a more controlled drug. It is anticipated that gabapentin and pregabalin will be becoming controlled next year in the UK due to their increased level of abuse. Medicines Committee 12 Monthly Report

11 4.8 Medication incidents Type of Incident Oct 16 Sep 17 Dispensing/supply problem, including 3 - clozapine dispensing errors, missing clozapine tablets Administration, including 27 - wrong dose given (7) - clozapine given when should have been withheld (5) - discontinued medicine given (4) - PRN recording error (4) - patient took another patients medication (2) - wrong route (2) - missed dose (2) - wrong medicine (1) Prescribing, including 4 - medicine discontinued in error - no administration time ticked - depot missed off rewritten kardex - clozapine dose represcribed at wrong dose Patient Non-compliance tablets found discarded 6 Other - including broken ampoules 5 TOTAL 45 (30 low, 15 med) Every DATIX that is marked as a medication incident is flagged to Senior Clinical staff including the Lead Nurse for the Hub and the Lead Pharmacist. Any short term actions that need to be taken are addressed including discussion with staff involved. The incidents are then reviewed by the Lead Pharmacist and Risk manager on a regular basis with full discussion undertaken via the Medicine Committee. Feedback to staff is in place with Medicine Incident Awareness Bulletins. In the last 12 months one incident was investigated as a Serious Untoward Incident (SUI) then raised to a Critical Incident Review (CIR). Now the hospital has increased incident recording it is hoped to be able to compare the medication incidents with NHS Lothian colleagues overseeing the Royal Edinburgh Hospital. 5. Comparison with last annual report Update from the future areas identified last year please also refer to key areas and key performance indicators. Policies Updated and Implemented The Safe Use of Medicines Policy and Procedures, Unlicensed/off label Medicines Policy and Individual Patient Treatment Request (IPTR) policies have all been reviewed and implemented. Healthy Choices Implementation The committee was consulted on changes in the CPA document to improve recording on the use of medicines that should be considered best options for individual patients around metabolic syndrome and weight gain. Electronic Prescribing The Committee continues to engage as necessary with progressing towards this national e- Health target. Supports the model of working with another Health Board. Clozapine The Committee has developed a policy for administration of intra-muscular unlicensed clozapine injection in the rare event that this option may be considered. It would require second opinion approval from the Mental Welfare Commission. The committee felt this was a better option for patients that refuse oral clozapine that enforcing naso-gastric administration. Medicines Committee 12 Monthly Report

12 Change of medicine supplier Due to legislative changes around wholesale dealer licenses there has been a change of where the hospital receives its medicine from. Supplies continue from NHS Lothian but they are now from St John s hospital who hold the necessary licenses. 6. Areas of good practice Overall the hospital can be assured that processes continue to be in place for the safe and effective use of medicines. These are evidenced with regular monitoring, review and audit. 7. The Patients Voice Patients continue to have greater access to information on their medicines via MaPPs documentation and Choice and Medication leaflets. In addition there has been a continued increase in the percentage of patients discussing their medicines with a pharmacist as part of the multidisciplinary team. This is evidenced via monthly VAT data. As well as confident in the information they receive on their medicines the patient safety survey also demonstrated confidence in the way medicines are prepared within the hospital. There continues to be feedback to clinical teams on issues raised by patients at the clozapine clinic on side effects of their medication as well as direct access to a dietician at the clinic. All medicine policies are referred through the Patient Partnership Group for comment. Feedback from a patient in the Pharmacist prescribing evaluation included: Got medication next day. I was suffering from bad tremors, but within a couple of days of the new medication my tremors had gone. The pharmacist.also monitored me for a few weeks after that was really good. I would definitely recommend independent prescribing as it made such a huge difference to my quality of life in such a small space of time. 8. Future areas of work As well as the regular workplan around medicine management, the safe use of medicines and the extensive clinical audit programme the following areas will be addressed: Medicines Misuse To keep abreast of developments in the status of medicines at risk of abuse e.g. gabapentin, pregabalin Competencies for Administration of Medicines To explore the process of competency assessments on safe administration of medicines for new staff. Electronic Prescribing To support the project lead in the planning of resources and funding requirements. Patient Safety Programme The Medicine Committee will continue to work with the hospital Patient Safety Group on the national medicines management workstream. Non- Medical Independent Prescribing Following evaluation of the first independent prescriber the Committee will consider any further development of this service. GASS review Monitoring and review of this new antipsychotic side effect rating scale will be considered. 9. Next review date The next review date for Clinical Governance Committee is November 2018 Medicines Committee 12 Monthly Report

13 Consultant Prescribing Reports Appendix (page 1 of 2) No. Patients on oral atypical antipsychotics and average daily doses Amisulpride Aripiprazole Clozapine Olanzapine Quetiapine Risperidone Lurasidone Jul 2014 (126) Jul 2015 (123) Jul 2016 (119) Oct 2017 (112) More historical data is available ( ) number in brackets = total number of patients in the hospital There is still some use of the older antipsychotics - often as part of a combination regime in patients with complex regimes. Number of Patients on Regular Oral Typical (older) Antipsychotics 2017 Chlorpromazine 3 (1 in a combination regime) Sulpiride 3 (2 in a combination regime) Zuclopenthixol 1 Number of Patients on Depot/Long Acting Injections Product No.Patients 2017 No.Patients 2016 No.Patients 2015 No.Patients 2014 No.Patients 2013 Aripiprazole 1 Flupentixol Fluphenazine Haloperidol Olanzapine Risperidone Paliperidone Zuclopenthixol TOTAL 17 (15%) 16 (14%) 21 (17%) 23 (19%) 27 (21%) The percentage of patients on long acting antipsychotic injections is consistent with last year. The second generation long acting injection paliperidone has now levelled out in number of patients. This product currently tops the monthly list of high cost items. Medicines Committee 12 Monthly Report

14 Consultant Peer Review Prescribing Reports - Regular Antipsychotics Appendix page 2 of 2 Local Delivery Plan Target no more than 20 patients to receive regular high dose antipsychotic regimes Please note patients can fall into both categories if they are on 2 or more antipsychotics and are receiving these HD Consultant High Dose (HD) Antipsychotics - 10 Multiple Antipsychotics - 17 A 2 patients olanzapine monotherapy quetiapine + aripiprazole* 4 patients (1HD) clozapine + amisulpride zuclopenthixol depot + aripiprazole (for physical side effects) B C D E 1 patient olanzapine monotherapy 1 patient olanzapine monotherapy 1 patient paliperidone LA injection + risperidone * 3 patients olanzapine monotherapy zuclupenthixol depot + aripiprazole (for physical side effects) chlorpromazine + aripiprazole* clozapine + aripiprazole 3 patients clozapine + amisulpride haloperidol depot + aripiprazole* 3 patients clozapine + sulpiride aripiprazole + risperidone* clozapine + amisulpride 1 patient (1HD) 3 patients (2HD) risperidone + sulpiride* F - 1 patient clozapine + aripiprazole G 1 patient zuclopenthixol depot + aripiprazole (for physical side effects) 2 patients (1HD) clozapine + aripiprazole H 1 patient olanzapine monotherapy - *Regimes not listed in refractory schizophrenia The Maudsley Prescribing Guidelines 12 th Edition Medicines Committee 12 Monthly Report