POMH-UK Topic 10a baseline report Prescribing antipsychotics for children and adolescents September 2010 Prepared by the Prescribing Observatory for Mental Health-UK for Coventry and Warwickshire Partnership Trust. Please use the following to cite this report: Prescribing Observatory for Mental Health (2010). Topic 10a baseline report: Prescribing antipsychotics for children and adolescents. CRTU095 (data on file). 2010 The Royal College of Psychiatrists.
2010 The Royal College of Psychiatrists 1
Executive summary Background The Prescribing Observatory for Mental Health (POMH-UK) runs national auditbased quality improvement programmes open to all specialist mental health services in the UK. The aim is to help mental health services improve prescribing practice in discrete areas ( Topics ). This report presents the results of the baseline audit for Topic 10, a quality improvement programme addressing the use of antipsychotic medication in children and adolescents. Data are presented at national and Trust level. Audit standards 1. For all children and adolescents prescribed antipsychotic medication the indication(s) for treatment with antipsychotic(s) should be documented in the clinical records. 2. For all children and adolescents prescribed antipsychotic medication, the side effects of antipsychotics should be reviewed at least once every six months. This review should include, as appropriate, the assessment of body weight, blood pressure, blood glucose, plasma lipids and raised plasma prolactin, and examination for the presence of extrapyramidal side effects (EPS). Sample Forty-two specialist mental health Trusts participated in the audit, submitting data from 194 clinical teams for 1,575 children and adolescents who were prescribed one or more antipsychotics. Antipsychotic treatment had been initiated within the past three months in 380 patients; and initiated more than three months ago in 1,195 patients. What happens next? 1. POMH hopes that this report will stimulate reflection on local practice. 2. POMH will develop bespoke change interventions to be provided to each participating Trust, including: PowerPoint slide sets summarising the benchmarked findings, customised for each participating Trust; Opportunities for sharing good practice between services. 3. A re-audit will be conducted in November 2011. 2010 The Royal College of Psychiatrists 2
Key findings 1. The indication for treatment was clearly described in 99% of the clinical records. 2. The most common indications for antipsychotic prescribing in the total national sample (n=1,575) were agitation/anxiety (33%), followed by chronic behavioural disturbance with persistent aggression (32%), and psychotic symptoms (30%). 3. For those patients in whom antipsychotic treatment was initiated more than three months ago (n=1,194), documented evidence of side effect assessment in the past six months was as follows: Weight/BMI: 74% of patients (29-100%) Blood pressure: 66% of patients (0-100%) Blood glucose: 38% of patients (range across Trusts 0-100%) Extrapyramidal (motor) side effects: 38% of patients (0-100%) Lipid profile: 37% of patients (0-100%) Prolactin: 32% of patients (0-100%). 4. Of the side effect assessments listed in point 3 above, 16% of patients had no documented evidence of any of them being conducted in the past six months. 10% of patients had evidence of one assessment, 24% had evidence of two, and 50% had evidence of three or more. 5. Risperidone was the most commonly used antipsychotic, being prescribed for 62% of the total national sample. Olanzapine was prescribed for 13% of patients, and Aripiprazole for 12%. 6. Only 3% of the total national sample were prescribed antipsychotic medication in a high dose (in excess of the BNF recommended dosage), and 4% were prescribed a combination of antipsychotics. Conclusions The indications for prescribing antipsychotic medication were clearly documented in the clinical records. High doses and combinations of antipsychotics are prescribed less commonly than in adult mental health services (*see references below). The continuing need for antipsychotic medication was regularly reviewed and documented in almost all patients in this sample. The high proportion of patients having medicines changed at review suggests thoughtful and thorough practice in this area. In 191 children and adolescents (16%), no side effect monitoring had been documented in the past six months. Potentially remediable physical health problems may therefore not be detected. *Prescribing Observatory for Mental Health (2009). Topic 1 report 1d. Prescribing of high-dose and combination antipsychotics on adult acute and intensive care wards: supplementary audit. Prescribing Observatory for Mental Health, CRTU071. *Prescribing Observatory for Mental Health (2008). Topic 3 report 3b. Prescribing of high-dose and combined antipsychotics for patients on forensic wards: re-audit. Prescribing Observatory for Mental Health, CRTU060 2010 The Royal College of Psychiatrists 3
Table of contents Executive summary... 2 Background... 2 Sample... 2 What happens next?... 2 Key findings... 3 Conclusions... 3 Table of contents... 4 Introduction... 10 POMH-UK... 10 How to use this report... 10 Further analysis of your Trust s data... 10 Clinical background... 11 Efficacy of antipsychotics in children and adolescents... 11 Dosage... 12 Adverse effects... 12 Baseline investigations and monitoring... 12 Summary... 13 Audit standards... 14 Method... 15 1. National level results... 18 1.1: Patient demographic and clinical characteristics... 19 1.2: Status of clinical service and current antipsychotic prescribing responsibility... 22 1.3: Indications for treatment with antipsychotic medication... 24 1.4: Antipsychotic prescribing practice... 26 1.5: The use of other medicines to treat mental illness, behavioural problems or epilepsy... 29 1.6: Baseline physical health monitoring for patients prescribed antipsychotic medication for less than three months (n=380)... 30 1.7: Review of medicines and side effects for patients prescribed antipsychotic medication for more than three months (n=1,194)... 32 1.7.1: Medicine review... 32 1.7.2: Side effect monitoring... 33 2. Trust level results... 36 2.1: Patient demographic and clinical characteristics... 37 2.2 Patients prescribed antipsychotic medication for three months or less.... 42 2.3 Patients prescribed antipsychotic medication for more than three months.... 47 3. Clinical team level results... 52 3.1: Patient characteristics... 53 3.2 Patients prescribed antipsychotic medication for three months or less.... 54 3.3 Patients prescribed antipsychotic medication for more than three months.... 55 Appendix A: Data ownership... 60 Appendix B: Participating Trusts... 62 Appendix C: Audit data collection guide and form... 64 Appendix D: References... 0 Appendix E: POMH-UK Topic 10a Advisory Group... 2 2010 The Royal College of Psychiatrists 4
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List of Figures Figure 1: Indication profiles for the three most commonly prescribed antipsychotics*... 27 Figure 2: Indication profiles for the four most commonly documented diagnoses*... 28 Figure 3: Documentation of decision at medication review conducted within the past 12 months.... 32 Figure 4: Proportion of males and females for each Trust and the total national sample... 38 Figure 5: Distribution of age groups by Trust and in the total national sample.. 38 Figure 6: Distribution of the most common ethnic groups by Trust and in the total national sample... 39 Figure 7: Proportion of patients under the care of an outpatient service prescribed antipsychotics by a GP for each Trust and the total national sample 41 Figure 8: Proportion of patients under the care of an inpatient service prescribed antipsychotics by a CAMHS psychiatrist for each Trust and the total national sample... 41 Figure 9: Proportion of patients in each Trust for whom the indication for antipsychotic prescribing is clearly documented... 42 Figure 10: Proportion of patients in each Trust for whom the continuing need for antipsychotic medication was reviewed in the past six months... 47 Figure 11: Proportion of patients in each Trust and the total national sample with documented evidence in their clinical records of assessment of EPS in the past six months.... 48 Figure 12: Distribution of age groups by team and in the total national sample 53 Figure 13: Proportion of patients under the care of an outpatient service prescribed antipsychotics by a GP for each team and the total national sample 53 Figure 14: Proportion of patients in each team for whom the indication for antipsychotic prescribing is clearly documented... 54 Figure 15: Proportion of patients in each team for whom the continuing need for antipsychotic medication was reviewed in the past six months... 55 Figure 16: Proportion of patients in each team and the total national sample with documented evidence in their clinical records of assessment of EPS in the past six months.... 57 2010 The Royal College of Psychiatrists 6
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List of Tables Table 1: Clinical and demographic characteristics of the total patient sample (n=1580)... 19 Table 2: Status of clinical service and current antipsychotic prescribing responsibility... 22 Table 3: Clinical characteristics of inpatient and outpatient samples... 23 Table 4: Dosing details for the most five most commonly prescribed antipsychotics... 26 Table 5: Proportion of patients in the total national sample prescribed additional medication (n=1575)... 29 Table 6: Evidence in the clinical records of physical health checks in the three months prior to antipsychotic treatment... 30 Table 7: Evidence in the clinical records of screening* in the three months prior to antipsychotic treatment... 30 Table 8: Proportions of patients with documented evidence in their clinical records of EPS assessment in the past six months... 33 Table 9: Evidence in the clinical records of physical health checks in the past six months... 33 Table 10: Evidence in the clinical records of screening for potential side effects in the past six months... 34 Table 11: Number of clinical teams and patient records submitted by each participating Trust... 37 Table 12: Proportions of patients with the most common diagnoses by Trust and in the total national sample... 40 Table 13: Proportion of patients in each Trust and the total national sample with documented pre-treatment assessment of body weight, blood glucose, plasma lipids and raised plasma prolactin.... 43 Table 14: Proportion of patients in each Trust and the total national sample with documented physical health checks in the three months prior to antipsychotic treatment... 45 Table 15: Proportion of patients in each Trust and the total national sample with documented assessment of body weight, blood glucose, plasma lipids and raised plasma prolactin in the past six months.... 49 Table 16: Proportion of patients in each team and the total national sample with documented assessment of body weight, blood glucose, plasma lipids and raised plasma prolactin in the past six months.... 56 2010 The Royal College of Psychiatrists 8
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Introduction POMH-UK The Prescribing Observatory for Mental Health (POMH-UK) runs national auditbased quality improvement programmes open to all specialist mental health services in the UK. The aim is to help mental health services improve prescribing practice in discrete areas ( Topics ). This report presents the baseline results for a quality improvement programme (Topic 10) addressing the use of antipsychotic medication in children and adolescents. How to use this report Data from each clinical team or Trust are presented by code only. The POMH-UK central project team does not know the identity of individual teams. Only the local project team (LPT) lead for your Trust has the key to team codes for your Trust. You should contact this person if you need to identify data for your own particular team. Further analysis of your Trust s data Ownership of data submitted to POMH-UK is retained by the Trust that provided it. See Appendix A for further information on data ownership. An Excel file containing the data submitted by your Trust has been made available to your LPT lead. Please contact this person if you wish to conduct further analyses on your data. 2010 The Royal College of Psychiatrists 10
Clinical background A recent survey of antipsychotic prescribing practice among child and adolescent psychiatrists in the UK found that well over 95% had prescribed antipsychotics over a 12 month period with the vast majority (almost 90%) choosing second generation antipsychotics (SGAs) (Otasowie et al. 2010). A similar survey conducted in the same region of the UK in the late 1990s found that under 60% of child and adolescent psychiatrists had used antipsychotics over a two year period with only 11% using SGAs (Slaveska et al. 1998). Otasowie et al. also surveyed community paediatricians among whom a third (33%) had prescribed antipsychotics (all used SGAs) over the previous year. Psychosis, followed by challenging behaviour in autism spectrum disorder (ASD) and Tourette's syndrome are the most common reasons for child and adolescent psychiatrists to prescribe antipsychotics. In contrast, paediatricians most frequently use antipsychotics for non-psychotic developmental disorders including challenging behaviour in ASD and ADHD reflecting the fact that psychosis is treated almost exclusively by psychiatrists. Taking paediatricians and child psychiatrist together, antipsychotics are most commonly prescribed for challenging behaviour in non-psychotic developmental disorders (e.g. learning disability/asd) followed by psychosis. Risperidone is the antipsychotic favoured by most clinicians treating children and adolescents, followed some way behind by aripiprazole and olanzapine (Otasowie et al. 2010). The majority of antipsychotics are prescribed off-label to children and adolescents, a common situation for drugs used in paediatric populations where clinical trial data are often lacking. However, several antipsychotics are licensed for use in children, for various indications and at different age ranges (see BNF for Children 2010-11 for details). Notably, low-dose risperidone is licensed for the short-term treatment of severe aggression associated with conduct disorder in children (age 5 years and older), short-term treatment of severe aggression in autism (age 5 years and older) and acute and chronic psychoses (age 12 years and older), while aripiprazole is licensed for the treatment of schizophrenia and mania in young people (aged 13 years and older). Efficacy of antipsychotics in children and adolescents There is a relatively limited evidence-base of randomised clinical trials to support antipsychotic prescribing in children and adolescents. However, evidence is accumulating to indicate the efficacy of antipsychotic drugs in the treatment of children and adolescents with psychosis/schizophrenia, including clozapine (Kumra et al. 1996), risperidone (Sikich et al. 2004, 2008) and aripiprazole (Findling et al. 2008). Other indications where antipsychotic efficacy in childhood is supported by clinical trial evidence includes management of challenging behaviour in ASD with risperidone (RUPP Autism Network, 2002) and aripiprazole (Owen et al. 2009), treatment of Tourette s syndrome with risperidone (Scahill et al. 2003) and risperidone for management of aggression with conduct disorder (Findling et al. 2000) and learning disability (Aman et al. 2002). 2010 The Royal College of Psychiatrists 11
Recent head-to-head comparisons of SGAs (risperidone and olanzapine) with first generation antipsychotics (FGA: haloperidol) in adolescents with schizophrenia have reported broadly similar efficacy against psychotic symptoms (with a nonsignificant trend in favor of SGAs) but a differing profile of adverse effects (Gothelf et al. 2003; Sikich et al. 2008). These findings broadly replicate results from the large NIMH CATIE pragmatic trial that found no overall difference in effectiveness between FGAs and SGAs in adults, whereas there were differences in tolerability and side effect profiles (Lieberman et al. 2005). Dosage One of the main differences in prescribing between psychotic and non-psychotic disorders is in the dose of antipsychotic used. For example, while the dose of risperidone typically used to treat psychosis in children and adolescents is in the range of 4-6mg/day, considerably lower doses are used to treat challenging behaviour in ASD or tics/tourette s with a typical dose range of 0.5-2mg/day. Adverse effects Children and adolescents appear to show greater sensitivity to a range of antipsychotic-related adverse events than adults, including extrapyramidal side effects (EPS) with FGAs (Kumra et al. 1998), and weight gain, obesity, and metabolic syndrome with the newer SGAs (Ratzoni et al. 2002). Individual drugs differ importantly in terms of tolerability and side effect profiles when prescribed to children and adolescents. In younger patients (children and adolescents), EPS are more common with haloperidol and high-dose risperidone than with olanzapine. Weight gain and obesity are most common with olanzapine then with risperidone, and least with haloperidol. Sedation is greater with olanzapine and haloperidol than with risperidone (Toren et al. 2004). Further evidence is emerging that children and adolescents experience more rapid and serious weight gain on olanzapine and risperidone than do adults (Ratzoni et al. 2002). Morbid obesity [body mass index (BMI) > 90th percentile] is found in up to 50% of adolescents and young people chronically treated with SGAs (Theisen et al. 2001). Complications of obesity include hyperglycaemia (Type 2 diabetes), hyperlipidemia, and hypercholesterolaemia. It is recommended that dietary advice (reducing carbohydrate intake) combined with regular exercise should be prescribed before initiating SGAs in children and adolescents. It should be noted that most data relating to tolerability and adverse effects of antipsychotics in children and adolescents are based on the treatment of psychosis in short-term clinical trials over 6 to 12 weeks. There is a lack of adequate information on the adverse effects associated with both longer term prescribing and lower doses typically used in non-psychotic developmental disorders. Baseline investigations and monitoring Guidelines on appropriate investigations and monitoring of children and adolescents treated with antipsychotics are lacking. In practice, clinicians have to refer to guidelines developed for use in adults with psychosis (NICE 2010 The Royal College of Psychiatrists 12
Schizophrenia Guideline, 2009). Otasowie et al. (2010) found very little consistency in antipsychotic monitoring practice among child psychiatrists and paediatricians. Most clinicians surveyed said they would only routinely measure height, weight and blood pressure. Reluctance to undertake laboratory investigations among some clinicians may reflect various factors including ethical and practical difficulties in taking blood from children and uncertainty regarding the impact of abnormal results on clinical management (e.g. asymptomatic hyperprolactinaemia). However, most clinicians support the development of clinical prescribing and monitoring guidelines for antipsychotic use in children and adolescents. Summary Antipsychotics are prescribed by the vast majority of child and adolescent psychiatrists in the UK and a significant proportion of community pediatricians. The indications and most common uses of antipsychotics in children and adolescents include challenging behaviour/aggression in autism and conduct disorder, psychosis, and tics/tourette s syndrome. However, there is a growing awareness of the adverse-effect profiles of different drugs and greater sensitivity to these effects in children and adolescents. Currently in the UK, monitoring practice is inconsistent and most clinicians would welcome antipsychotic prescribing guidelines for children and adolescents covering initiation, dosing and monitoring in both psychotic and non-psychotic disorders. The present audit focuses on the monitoring of side-effects and the use of antipsychotics in children and adolescents, areas for which there are wellestablished standards for practice and a large body of comparative data in adult mental health services in the UK (see POMH website: www.rcpsych.ac.uk/pomh). It is the first time that national prescribing practice in child and adolescent mental health services (CAMHS) has been reviewed and benchmarked in this way. In addition, it has taken advantage of what is a unique opportunity to collect data on aspects of psychiatric diagnosis, types of behavioural problem being treated and patterns of co-morbidity. 2010 The Royal College of Psychiatrists 13
Audit standards These audit standards have been agreed by clinical advisers in CAMHS services, and have been extrapolated from relevant recommendations in the NICE schizophrenia guideline for adults (2009). Audit standards 1. For all children and adolescents prescribed antipsychotic medication the indication(s) for treatment with antipsychotic(s) should be documented in the clinical records. 2. For all children and adolescents prescribed antipsychotic medication, the side effects of antipsychotics should be reviewed at least once every six months. This review should include, as appropriate, the assessment of body weight, blood pressure, blood glucose, plasma lipids and raised plasma prolactin, and examination for the presence of extrapyramidal side effects (EPS). 2010 The Royal College of Psychiatrists 14
Method The Prescribing Observatory for Mental Health (POMH-UK) invited all National Health Service (NHS) Trusts in the United Kingdom providing specialist mental health services to participate in a project to benchmark the use of antipsychotics in children and adolescents. Each Trust that formally agreed to take part was asked to form a Local Project Team (LPT), with minimum core membership of a senior psychiatrist, a senior pharmacist, and a member of the clinical audit/clinical effectiveness team. It was suggested that nurses, other clinicians and service users be co-opted from relevant services to advise on local participation. LPTs were invited to attend one of six regional introductory workshops to discuss and review the aims, objectives and methodology of the proposed audit. Comment and discussion at the workshops led to refinements of the audit methodology and data collection tool. All Trusts and clinical teams were self-selected in that they chose to participate. All participating Trust/healthcare organisations (hereafter referred to as Trusts ) are listed in alphabetical order in Appendix B. A clinical records based audit of the use of antipsychotic medication in children and adolescents was conducted. A questionnaire/audit tool was sent to Trusts with instructions that copies should be made available to allow clinical teams to audit all current inpatients prescribed an antipsychotic, and for outpatient services everyone on the current caseload if possible, or (if the caseload were too large to audit) every patient who had an outpatient appointment in the two months prior to the audit (minimum expected sample: 10 patients). The following data were collected on each patient: Demographic variables Psychiatric diagnoses Type of service providing care Information about antipsychotic(s) currently prescribed and the clinical indications Other medicines prescribed Duration of current antipsychotic prescription o For children and adolescents who had been prescribed the current antipsychotic for less than three months, information about baseline monitoring was collected o For children and adolescents who had been prescribed the current antipsychotic for three months or longer, information about physical health screening and side effect monitoring was collected Information about medication review A copy of the data collection tool can be found in Appendix C. The LPT lead for each participating Trust will be sent an Excel dataset containing their Trust s data. This allows Trusts to conduct further analyses on their own data should they wish. 2010 The Royal College of Psychiatrists 15
Data cleaning Data were collected using SNAP (electronic survey software), and stored and analysed using SPSS. Data were cleaned to correct instances of obvious data entry error. Details of corrections are held on file by POMH-UK; please contact pomhuk@cru.rcpsych.ac.uk if you wish to examine these. All figures are rounded to zero decimal places for clarity of presentation. Therefore the total percentages for some charts or graphs add up to 99% or 101%. The abbreviation TNS on some charts refers to the combined data set of the total national sample. 2010 The Royal College of Psychiatrists 16
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1. National level results Forty-two specialist mental health Trusts within the UK (listed in Appendix B) and some of their associated paediatric services participated in the baseline audit of this quality improvement programme on the use of antipsychotic medication in children and adolescents. Data were submitted for 1,575 patients from 194 clinical teams. The analyses presented in this section of the report were conducted on the total national sample (n=1,575) Audit standards 1. For all children and adolescents prescribed antipsychotic medication the indication(s) for treatment with antipsychotic(s) should be documented in the clinical records. 2. For all children and adolescents prescribed antipsychotic medication, the side effects of antipsychotics should be reviewed at least once every six months. This review should include, as appropriate, the assessment of body weight, blood pressure, blood glucose, plasma lipids and raised plasma prolactin, and examination for the presence of extrapyramidal side effects (EPS). 2010 The Royal College of Psychiatrists 18
1.1: Patient demographic and clinical characteristics Table 1: Clinical and demographic characteristics of the total patient sample (n=1,575) Key demographic characteristics Total sample n % Gender Male 1082 69% Ethnicity White/White British 1171 74% Black/ Black British 70 4% Asian 84 5% Mixed or other 26 2% Not specified or unknown 224 13% Service Inpatient CAMHS 275 18% Inpatient Paediatrics 16 1% Outpatient CAMHS 1138 72% Outpatient Paediatrics 146 9% Who is currently prescribing the antipsychotic? Adult psychiatrist 35 2% CAMHS psychiatrist 975 62% Learning disability psychiatrist 9 <1% GP 369 23% Paediatrician 152 10% Age Mean age in years (SD) 15 (2.8) Min - max 4-21 10 years or under 119 8% 11-15 years 618 39% 16-18 years 763 48% 19-21 years 75 5% Current antipsychotic Initiated within the previous three months 380 24% prescribing Initiated over three months ago 1194 76% Documented psychiatric diagnoses: ICD-10* F20-F29 (schizophrenia spectrum disorder) 301 19% F30-F39 (mood disorder - bipolar) 101 6% F30-F39 (mood disorder - other) 150 10% F40-F49 (neurotic) 172 11% F70-F79 (learning disability) 259 16% F80-F89 (autistic spectrum disorder) 475 30% F90 (hyperkinetic inc ADHD) 443 28% F95 (tic disorder inc Tourette s) 140 9% F90-F98 (other behavioural/emotional) 142 9% G40 (epilepsy) 27 2% Diagnosis not yet reached 36 2% Substance use Yes documented use of substances 220 14% Documented no use of substances 466 30% No statement regarding substance use 877 56% *The diagnoses are not mutually exclusive. Diagnoses that were only made in a small proportion of the total national sample (TNS) have not been shown here, unless the diagnosis was thought to be relevant to the interpretation of the overall sample data. 2010 The Royal College of Psychiatrists 19
Diagnoses The children and adolescents in the sample had received a broad range of diagnoses, the most common being disorders of psychological development (including autistic spectrum disorder: ASD), hyperkinetic disorder (including ADHD), and schizophrenia spectrum disorder. Learning disabilities were also common. More than one psychiatric diagnosis was documented in 759 (48%) patients. In line with clinical expectations, patients with a diagnosis of schizophrenia spectrum disorder tended to be older, and with a higher proportion of documented substance use. Patients with a diagnosis of autistic spectrum disorder or other disorders of psychological development (F80-89) tended to be younger with less substance use. Only 2% of the children and adolescents in this sample did not yet have a psychiatric diagnosis. Other recent POMH-UK audits have found the equivalent figures to be around 5% in adult acute and psychiatric intensive care wards 1, and also 5% in adults (aged over 16) with a learning disability 2. All patients in these samples were prescribed one or more antipsychotic drugs at the time of the audits. CAMHS and paediatric services Ten percent of the children and adolescents in this sample were under the care of inpatient or outpatient paediatrics services. Compared to CAMHS, the patients seen by paediatric services tended to be less ethnically diverse, and younger; a quarter (25%) were under 10 years of age, with 54% aged 11-15 years (6%, and 35% respectively in CAMHS). The paediatric sample also differed in their diagnostic profile. Children and adolescents under the care of paediatric services were less likely to have a diagnosis of schizophrenia spectrum disorder (4% in paediatrics, 21% in CAMHS), mood disorder (4%, 17%) or a learning disability (8%, 17%), but more often had a diagnosis of hyperkinetic disorder including ADHD (73%, 23%). The proportions of patients with disorders of psychological development (including ASD) were similar for both types of services. Patients under the care of paediatric services were more likely to have had their current antipsychotic initiated four months ago or longer (94% paediatric, 74% CAMHS), and all paediatric patients were prescribed a single antipsychotic, whereas 5% of CAMHS patients were prescribed a combination of antipsychotics. Young adults All patients in the total national sample (TNS) are currently prescribed an antipsychotic and are under the care of a CAMHS/paediatric service. The majority of these patients are children and adolescents, however a small proportion of the sample is aged 19-21 years and could be considered young adults. Why these patients remain in CAMHS rather than being transferred to adult services is unclear. Relevant factors may include the nature and severity of the illness, and local service provision and arrangements. The proportion of patients aged 19-21 years with a diagnosis of schizophrenia is double the proportion in the TNS (39% 19-21 year olds, 19% TNS), similarly the proportions with a learning disability or a diagnosis of a mood disorder are higher than in the TNS (Leaning disability: 2010 The Royal College of Psychiatrists 20
23% 19-21 year olds, 16% TNS. Mood disorder: 24% 19-21 year olds, 16% TNS). As expected, the proportion of patients with a documented statement of current substance abuse increases with age, patients aged 19-21 years are twice as likely to have a documented statement of current substance use than the TNS (32%, 14%). 1 Prescribing Observatory for Mental Health (2010). Topic 1e supplementary report: Prescribing of high-dose and combination antipsychotics on adult acute and intensive care wards. Prescribing Observatory for Mental Health, CRTU088 (data on file). 2 Prescribing Observatory for Mental Health (2009). Topic 9a baseline report: Use of antipsychotic medication in people with a learning disability. Prescribing Observatory for Mental Health, CRTU082 (data on file). 2010 The Royal College of Psychiatrists 21
1.2: Status of clinical service and current antipsychotic prescribing responsibility Table 2: Status of clinical service and current antipsychotic prescribing responsibility Inpatient CAMHS Inpatient Paediatrics Outpatient CAMHS Outpatient Paediatrics Total national sample (TNS) Antipsychotic prescribed by: Adult psychiatrist CAMHS psychiatrist LD psychiatrist n % N % n % n % n % 14 5% 8 50% 13 1% 0 0% 35 2% 235 86% 3 19% 733 64% 4 3% 975 62% 1 <1% 0 0% 8 1% 0 0% 9 <1% GP 0 0% 0 0% 365 32% 4 3% 369 23% Paediatrician 0 0% 5 31% 9 1% 138 95% 152 10% Other 25 9% 0 0% 10 1% 0 0% 35 2% Total national sample (TNS) 275 100% 16 100% 1138 100% 146 100% 1575 100% There are four main groupings of services and prescribing responsibilities in the sample: 1. Outpatient CAMHS with antipsychotic prescribing by a CAMHS psychiatrist 2. Outpatient CAMHS with antipsychotic prescribing by a GP 3. Inpatient CAMHS with antipsychotic prescribing by a CAMHS psychiatrist 4. Outpatient paediatrics with antipsychotic prescribing by a paediatrician. The vast majority of patients under the care of paediatric services are prescribed their antipsychotic medication by a paediatrician. This puts paediatricians in a good position to monitor the effectiveness and side effects of the medication. In relation to prescribing responsibilities, General Practitioners are predominantly involved with CAMHS outpatients. 2010 The Royal College of Psychiatrists 22
Table 3: Clinical characteristics of inpatient and outpatient samples Diagnosis Inpatient services Outpatient services Autistic spectrum disorder 10% 35% Hyperkinetic (incl ADHD) 8% 33% Schizophrenia spectrum disorder 35% 16% Learning disability 17% 16% None of the above diagnoses 44% 27% Age in years (median, range) 17, 12-21 15, 4-21 Antipsychotic prescribing initiated within the past three months 47% 19% As might be expected, young people with a psychotic illness were disproportionally more likely to be inpatients. Please see section 1.1 for further details regarding the clinical characteristics of children and adolescents under the care of CAMHS or paediatric services. 2010 The Royal College of Psychiatrists 23
1.3: Indications for treatment with antipsychotic medication Audit standard 1: For all children and adolescents prescribed antipsychotic medication the indication(s) for treatment with antipsychotic(s) should be documented in the clinical records. Clinical indications for antipsychotic prescribing* documented in at least 5% of patients in whom prescribing was initiated within the past three months (n=380): 1. Psychotic symptoms (43%): 61% of these patients have an F20-29 diagnosis. 2. Agitation/anxiety (34%) 3. Acute behavioural disturbance (22%) 4. Chronic behavioural disturbance with aggression (19%) 5. Self injurious or self harming behaviour (9%) 6. Depressive symptoms (8%) 7. Overactivity/hyperactivity (7%) 8. Sleep difficulties (7%) 9. Chronic behavioural disturbance without aggression (6%) 10. Other (6%) *Note that individual patients may have been prescribed antipsychotic medication for more than one indication. For four children and adolescents the indication for prescribing the antipsychotic medication was unclear. In relation to audit standard 1, this means that in 376 (99%) cases the rationale for initiating treatment with an antipsychotic within the past three months was clearly documented in the clinical records. Clinical indications for antipsychotic prescribing* documented in at least 5% of patients in whom prescribing was initiated more than three months ago (n=1,194): 1. Chronic behavioural disturbance with aggression (36%) 2. Agitation/anxiety (33%) 3. Psychotic symptoms (26%). 62% of these patients have an F20-29 diagnosis. 4. Overactivity/hyperactivity (18%) 5. Acute behavioural disturbance (14%) 6. Chronic behavioural disturbance without aggression (10%) 7. Tics and related motor disturbance (10%) 8. Self injurious or self harming behaviour (8%) 9. Sleep difficulties (7%) 10. Manic symptoms (6%) 11. Depressive symptoms (6%) 12. Obsessive behaviours including rituals (6%) *Note that individual patients may have been prescribed antipsychotic medication for more than one indication. 2010 The Royal College of Psychiatrists 24
For 18 children and adolescents the indication for prescribing the antipsychotic medication was unclear. In relation to audit standard 1, this means that in 1176 (99%) cases the rationale for initiating treatment with an antipsychotic more than three months ago was clearly documented in the clinical records, which must be seen as a high standard of practice. 2010 The Royal College of Psychiatrists 25
1.4: Antipsychotic prescribing practice The prevalence of high-dose and combined antipsychotic prescribing identified in this audit is notably lower than in general adult psychiatry (Paton et al, 2008). Only 3% of the children and adolescents in the total national sample were prescribed a high dose, and 4% prescribed a combination of antipsychotics. Antipsychotics prescribed* for more than 5% of patients in the total national sample, in descending order 1. Risperidone (n=970, 62%) 2. Olanzapine (n=206, 13%) 3. Aripiprazole (n=187, 12%) * 69 (5%) children and adolescents were prescribed more than one antipsychotic 4. Quetiapine (n=128, 8%) 5. Haloperidol (n=77, 5%) Table 4: Dosing details for the most five most commonly prescribed antipsychotics Use: n (%) Dose: median (range) Drug Monotherapy Combination PRN Oral Oral PRN IM IM PRN Risperidone 941 (97%) 29 (3%) 37 (4%) 1mg (0.125-8mg) 0.5mg (0.125-2mg) n/a n/a Olanzapine 174 (85%) 32 (15%) 41 (20%) 10mg (2.5-25mg) 10 mg (5-20mg) 10 mg (10-10mg) 15 mg (5-20mg) Aripiprazole 169 (90%) 18 (10%) 5 (3%) 5mg (0.5-30mg) 2.5mg (0.25-10mg) - - Quetiapine 124 (97%) 4 (3%) 8 (6%) 200mg (25-1000mg) 75mg (50-100mg) n/a n/a Haloperidol 41 (53%) 36 (47%) 60 (78%) 2mg (0.3-15mg) 15mg (2-30mg) - 15 mg (2-30mg) Haloperidol was most commonly prescribed as PRN medication, in relatively high dosage. 2010 The Royal College of Psychiatrists 26
Figure 1: Indication profiles for the three most commonly prescribed antipsychotics* Risperidone Olanzapine Aripiprazole *Please note that indications are not mutually exclusive; i.e. one drug may be prescribed for more than one indication; and similarly, more than one drug may be prescribed to target a particular indication. 2010 The Royal College of Psychiatrists 27
Figure 2: Indication profiles for the four most commonly documented diagnoses* F80-89 (ASD) F70-79 (learning disability) F20-29 (schizophrenia) F90 (hyperkinetic including ADHD) *Please note that indications are not mutually exclusive; i.e. one diagnosis may have multiple indications; and similarly, more than one indication may be part of different diagnoses. 2010 The Royal College of Psychiatrists 28
1.5: The use of other medicines to treat mental illness, behavioural problems or epilepsy The majority of patients in the total national sample were also prescribed one or more other regular medication(s) for mental illness, behavioural problems or epilepsy. The most common co-prescriptions were methylphenidate, SSRI antidepressants, melatonin or benzodiazepines. These include both regular and PRN prescriptions. Despite the relatively common use of anti-convulsant drugs, only a small proportion of the children and adolescents in the sample were diagnosed with epilepsy (2%), this reflects the use of these medicines for mood and other disorders. Table 5: Proportion of patients in the total national sample prescribed additional medication (n=1575) Other medication prescribed in addition to an antipsychotic Total sample Methylphenidate 298 19% Antidepressant - SSRI Melatonin Benzodiazepine Valproate Atomoxetine Dexamfetamine (or other amfetamine preparation) Carbamazepine Lithium Lamotrigine Antidepressant - TCA Antidepressant - Other Clonidine Anticonvulsant drug - Other Other Prescribed none of the above 290 18% 230 15% 175 11% 91 6% 66 4% 32 2% 28 2% 23 2% 18 1% 14 1% 14 1% 14 1% 12 1% 133 8% 581 37% Prescribed any of the above 994 63% Of the children and adolescents in the total national sample, 42% were prescribed one additional psychotropic medicine, 16% were prescribed two, and 5% were prescribed three or more. 2010 The Royal College of Psychiatrists 29
1.6: Baseline physical health monitoring for patients prescribed antipsychotic medication for less than three months (n=380) Baseline physical health monitoring may inform drug choice and allow clinicians to assess the impact of treatment emergent side effects. The tables below look at patients prescribed antipsychotic medication for less than three months (n=380), and show the proportion of patients who had no documented evidence of screening, some reference to screening, or a test result or measurement in the clinical records. Suitable tests to be performed depend on the antipsychotic to be prescribed and its potential side effects; not all tests should be done on all patients. Table 6: Evidence in the clinical records of physical health checks in the three months prior to antipsychotic treatment No evidence of screening found Some reference to screening or relevant observation made, but no result or value recorded Test result or measurement is recorded Full blood count 35% 15% 50% Renal function tests 36% 15% 49% Liver function tests 38% 14% 48% Thyroid function tests 44% 11% 43% Table 7: Evidence in the clinical records of screening* in the three months prior to antipsychotic treatment No evidence of screening found Some reference to screening or relevant observation made, but no result or value recorded Test result or measurement is recorded Body weight 32% 10% 59% Blood pressure 32% 10% 59% Pulse 35% 8% 57% Blood glucose 48% 13% 38% Lipid profile 51% 12% 37% ECG 54% 10% 36% Plasma prolactin 63% 12% 25% * Tests relevant to potential side effects. The previous two tables are ordered by frequency of a test result or measurement being documented in the clinical records. In the sample of children and adolescents prescribed antipsychotic medication for three months or less, 10% (n=37) had evidence of a test result or measurement documented for all of the above assessments. All patients had some reference to, or evidence of, at least one baseline physical health monitoring or side effect screening in the three months prior to treatment. 2010 The Royal College of Psychiatrists 30
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1.7: Review of medicines and side effects for patients prescribed antipsychotic medication for more than three months (n=1,194) 1.7.1: Medicine review The clinical need for continued treatment with an antipsychotic should be reviewed at least every six months. Following this review, the decision to either maintain the treatment or make a change to the drug/dose or frequency should be documented. Of those patients receiving antipsychotic treatment for over three months (n=1194), 1065 (89%) had a documented medication review against target symptoms in the past six months; in 98% of these cases there was a record of the clinical decision as to whether the medication was to remain the same or change. For those with such a documented decision, the rationale for either keeping the medicine the same or changing was documented in 93% Figure 3: Documentation of decision at medication review conducted within the past 6 months. The proportion of patients for whom a clinical medication review had been documented in the previous year is very close to the standard, and higher than that seen in general adult psychiatry (POMH 2008a). 2010 The Royal College of Psychiatrists 32
1.7.2: Side effect monitoring In relation to audit standard 2, this section gives details about the prevalence of documented side-effect monitoring in the subgroup of patients who had been prescribed antipsychotic treatment for over three months. Audit standard 2: For all children and adolescents prescribed antipsychotic medication, the side effects of antipsychotics should be reviewed at least once every six months. This review should include, as appropriate, the assessment of body weight, blood pressure, blood glucose, plasma lipids and raised plasma prolactin, and examination for the presence of extrapyramidal side effects (EPS). Suitable tests to be performed depend on the antipsychotic prescribed and its potential side effects; not all tests are relevant for all patients. All patients should be monitored for metabolic side effects. Table 8: Proportions of patients with documented evidence in their clinical records of EPS assessment in the past six months No documented evidence of assessment Statement side effect not present Statement side effect present EPS: (%) 62% 28% 4% 6% Evidence of formal assessment Antipsychotic drugs, particularly the first generation agents, are associated with extrapyramidal (motor) side effects. These side effects can be subjectively unpleasant (akathisia, dystonia), interfere with the ability to undertake routine daily tasks (tremor) and be stigmatising (tardive dyskinesia). They can also confound clinical assessment; akathisia for example may be mistaken for anxiety or agitation. Antipsychotic drugs can also cause weight gain and have been associated with impaired glucose control and dyslipidaemia. The NICE guideline for schizophrenia recommends that all patients who are prescribed antipsychotic drugs should be regularly assessed for side effects, including those that increase cardiovascular risk. Table 9: Evidence in the clinical records of physical health checks in the past six months No evidence of screening found Some reference to screening or relevant observation made, but no result or value recorded Full blood count 54% 16% 30% Renal function tests 56% 15% 29% Liver function tests 57% 15% 28% Thyroid function tests 64% 13% 23% Test result or measurement is recorded 2010 The Royal College of Psychiatrists 33
Table 10: Evidence in the clinical records of screening for potential side effects in the past six months No evidence of screening found Some reference to screening or relevant observation made, but no result or value recorded Body weight 26% 9% 65% Blood pressure 34% 7% 59% Pulse 42% 7% 51% Blood glucose 62% 14% 24% Plasma lipid profile 63% 13% 24% Plasma prolactin 68% 12% 20% ECG 73% 11% 16% Test result or measurement is recorded The above tables are ordered by frequency of a test result or measurement being documented in the clinical records. In the sample of children and adolescents prescribed antipsychotic medication for over three months, 4% (n=68) had evidence of a test result or measurement documented for all of the above assessments. All patients had some reference to or evidence of at least one physical health monitoring or side effect screening in the past six months. The proportions of children and adolescents with documented physical health and side effect assessments in the past six months diminishes the longer the antipsychotic has been prescribed. For example, there was no evidence of blood glucose assessment in 56% of children and adolescents prescribed an antipsychotic for 4-6 months. This proportion rose to 59% when the antipsychotic had been initiated 7-12 months ago, and 65% where the antipsychotic had been initiated over a year ago. It may therefore be that clinicians are missing the chance to detect potentially harmful or distressing side effects. 2010 The Royal College of Psychiatrists 34
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2. Trust level results Analyses presented in this section were conducted for each Trust individually and for the total sample to allow benchmarking. Data from each Trust are presented by code. Your Trust code is 40. Audit standards 1. For all children and adolescents prescribed antipsychotic medication the indication(s) for treatment with antipsychotic(s) should be documented in the clinical records. 2. For all children and adolescents prescribed antipsychotic medication, the side effects of antipsychotics should be reviewed at least once every six months. This review should include, as appropriate, the assessment of body weight, blood pressure, blood glucose, plasma lipids and raised plasma prolactin, and examination for the presence of extrapyramidal side effects (EPS). 2010 The Royal College of Psychiatrists 36
2.1: Patient demographic and clinical characteristics Table 11: Number of clinical teams and patient records submitted by each participating Trust Trusts (by code) Number of participating clinics/teams from each Trust Total number of patient records submitted by each Trust 2 2 37 5 6 51 6 9 62 8 13 43 12 3 31 13 3 39 16 4 17 17 1 16 18 1 26 19 6 65 20 1 7 21 9 46 22 3 18 25 5 21 27 7 68 28 6 70 29 7 51 30 2 16 31 2 17 40 4 42 42 5 24 50 6 26 51 5 25 56 1 16 59 10 44 61 1 4 62 1 2 65 1 4 69 16 50 70 2 39 71 1 5 73 6 46 77 6 30 78 4 15 79 3 46 80 8 78 81 1 27 82 1 146 83 1 67 84 1 29 85 8 64 87 11 45 Total: 42 Trusts 193 teams 1575 patients 2010 The Royal College of Psychiatrists 37
Figure 4: Proportion of males and females for each Trust and the total national sample The Trust that submitted data for the highest proportion of males is on the left hand side of the Figure and the Trust with the lowest on the right. In this Figure, and all such subsequent figures, the proportions in the TNS are shown on the far right of the Figure. This Figure allows Trusts to compare the demographic characteristics of their sample of patients against the total national sample. Figure 5: Distribution of age groups by Trust and in the total national sample The Trusts with the highest proportion of patients aged 15 years and under are on the left hand side of the Figure and the Trust with the lowest proportion on the right. This Figure allows Trusts to compare the demographic characteristics of their sample of patients against the total national sample. 2010 The Royal College of Psychiatrists 38
Figure 6: Distribution of the most common ethnic groups by Trust and in the total national sample The Trusts with the highest proportion of White British/Irish patients are on the left hand side of the Figure and the Trust with the lowest proportion on the right. This Figure allows Trusts to compare the demographic characteristics of their sample of patients against the total national sample. Trust teams may like to compare the ethnic breakdown of their patients with those of their catchment area population. 2010 The Royal College of Psychiatrists 39
Table 12: Proportions of patients with the most common diagnoses by Trust and in the total national sample Trust code F20-F29 (schizophrenia) Proportion of patients in each Trust with a diagnosis of: F30-39 (mood disorder) F40-49 (neurotic) F70-79 (learning disability) F80-89 (ASD) F90 (hyperkinetic inc ADHD) F90-F98 (other behavioural/ emotional) 2 5% 30% 14% 11% 5% 38% 22% 5 22% 8% 22% 16% 31% 27% 14% 6 16% 16% 8% 16% 37% 44% 15% 8 28% 9% 5% 49% 12% 23% 19% 12 48% 26% 6% 6% 10% 10% 6% 13 26% 21% 15% 56% 51% 26% 18% 16 41% 24% 0% 6% 12% 0% 6% 17 0% 6% 38% 50% 50% 13% 31% 18 0% 12% 4% 4% 54% 8% 4% 19 8% 5% 8% 26% 45% 34% 9% 20 57% 29% 0% 0% 0% 0% 0% 21 13% 35% 26% 15% 43% 17% 2% 22 44% 6% 6% 0% 0% 0% 11% 25 76% 14% 0% 0% 10% 0% 5% 27 18% 9% 16% 22% 41% 35% 7% 28 17% 13% 11% 19% 17% 36% 7% 29 31% 31% 4% 24% 20% 10% 0% 30 75% 25% 0% 6% 0% 0% 0% 31 53% 18% 12% 12% 24% 0% 6% 40 5% 26% 21% 0% 43% 40% 12% 42 33% 46% 25% 4% 17% 8% 0% 50 23% 4% 8% 15% 62% 42% 4% 51 12% 8% 0% 28% 20% 24% 0% 56 13% 50% 50% 0% 6% 6% 0% 59 25% 9% 18% 16% 18% 25% 23% 61 25% 25% 0% 25% 25% 25% 0% 62 50% 100% 0% 0% 0% 0% 0% 65 0% 0% 0% 25% 25% 0% 69 44% 18% 8% 4% 2% 0% 8% 70 8% 5% 3% 54% 21% 3% 71 0% 0% 20% 60% 20% 0% 73 17% 20% 7% 13% 39% 28% 4% 77 7% 17% 7% 20% 67% 30% 3% 78 7% 27% 7% 0% 20% 13% 0% 79 24% 24% 9% 15% 52% 35% 4% 80 10% 8% 13% 13% 44% 15% 6% 81 30% 19% 22% 7% 7% 37% 11% 82 1% 1% 5% 6% 27% 82% 15% 83 16% 16% 24% 46% 16% 15% 18% 84 21% 21% 3% 28% 34% 3% 0% 85 19% 19% 5% 6% 34% 31% 8% 87 16% 27% 2% 18% 33% 13% 0% TNS 19% 16% 11% 16% 30% 28% 9% Trusts may like to compare the diagnostic profile of their population with other Trusts. The diagnostic profiles across Trusts are very heterogeneous which may partially reflect sample size and selection. Please note that patients may have more than one diagnosis, and some diagnoses are not show in this table. 2010 The Royal College of Psychiatrists 40
Figure 7: Proportion of patients for each Trust (and the total national sample) under the care of an outpatient service prescribed antipsychotics by a GP or by another prescriber Figure 8: Proportion of patients for each Trust Trust (and the total national sample) under the care of an inpatient service prescribed antipsychotics by a CAMHS psychiatrist or by another prescriber For both of the Figures above, the Trusts with the highest proportion of patients under the care of an outpatient service are on the left hand side and the Trusts with the lowest proportion (i.e. Trusts with the highest proportion of patients under the care of an inpatient service) on the right. These Figures allow Trusts to compare the proportions of their samples in inpatient and outpatient care, and the source of the current antipsychotic prescription. 2010 The Royal College of Psychiatrists 41
2.2 Patients prescribed antipsychotic medication for three months or less. This Figure relates to audit standard 1: For all children and adolescents prescribed antipsychotic medication the indication(s) for treatment with antipsychotic(s) should be documented in the clinical records. Figure 9: Proportion of patients in each Trust for whom the indication for antipsychotic prescribing is clearly documented The Trusts with the highest proportion of patients with clear documented indications are on the left hand side of the Figure and the Trust with the lowest proportion on the right. 2010 The Royal College of Psychiatrists 42
Table 13: Proportion of patients in each Trust and the total national sample with documented pre-treatment measurement of body weight, blood glucose, plasma lipids and raised plasma prolactin. This Table shows the proportion of documented pre-treatment measurements of body weight, blood glucose, plasma lipids and raised plasma prolactin (either a recorded result or test measurement, or some reference to screening or other relevant observation made) in patients who have been prescribed antipsychotic medication for three months or less. Suitable tests to be performed depend on the antipsychotic prescribed and its potential side effects; not all tests are relevant for all patients. All patients should be monitored for metabolic side effects. Proportion of patients in each Trust with documented pre-treatment measure of: Trust code Body weight Blood glucose Plasma lipids Raised plasma prolactin 2 80% 100% 100% 80% 5 72% 67% 61% 56% 6 56% 44% 39% 33% 8 65% 47% 24% 12% 12 75% 50% 50% 50% 13 60% 60% 60% 60% 16 50% 20% 30% 40% 17 75% 75% 50% 50% 18 75% 100% 100% 100% 19 58% 25% 17% 0% 20* - - - - 21 67% 83% 67% 58% 22 100% 33% 83% 67% 25 75% 50% 50% 13% 27 27% 27% 18% 18% 28 56% 78% 78% 78% 29 42% 8% 8% 8% 30 100% 78% 78% 67% 2010 The Royal College of Psychiatrists 43
Proportion of patients in each Trust with documented pre-treatment measure of: * No eligible cases submitted. Trust code Body weight Blood glucose Plasma lipids Raised plasma prolactin 31 100% 80% 60% 60% 40 63% 0% 0% 0% 42 87% 53% 27% 7% 50 33% 0% 0% 0% 51 33% 67% 67% 50% 56 62% 46% 31% 23% 59 50% 50% 50% 25% 61 50% 100% 100% 100% 62 100% 100% 100% 50% 65 100% 0% 0% 0% 69 60% 73% 73% 53% 70 40% 60% 60% 0% 71 33% 67% 67% 67% 73 75% 75% 67% 67% 77 50% 50% 50% 50% 78 25% 25% 25% 0% 79 83% 33% 33% 0% 80 68% 32% 52% 48% 81 50% 50% 50% 83% 82 100% 0% 0% 0% 83 100% 72% 72% 39% 84 75% 50% 50% 50% 85 88% 25% 31% 19% 87 100% 76% 67% 19% TNS 69% 51% 49% 37% 2010 The Royal College of Psychiatrists 44
Table 14: Proportion of patients in each Trust and the total national sample with documented pre-treatment physical health checks This Table shows the proportion of documented pre-treatment measurements of physical health checks (either a recorded result or test measurement, or some reference to screening or other relevant observation made) in patients who have been prescribed antipsychotic medication for three months or less. Suitable tests to be performed depend on the antipsychotic prescribed and its potential side effects; not all tests are relevant for all patients. All patients should be monitored for metabolic side effects. Proportion of patients in each Trust with documented pre-treatment measure of: Trust code Full blood count Renal function tests Liver function tests Thyroid function tests 2 100% 100% 80% 80% 5 67% 67% 78% 56% 6 56% 56% 56% 56% 8 65% 65% 65% 53% 12 75% 75% 75% 75% 13 60% 60% 60% 60% 16 50% 50% 50% 60% 17 75% 75% 75% 25% 18 100% 100% 100% 100% 19 25% 25% 25% 25% 20* - - - - 21 92% 92% 92% 83% 22 100% 100% 83% 83% 25 63% 63% 63% 50% 27 36% 36% 36% 36% 28 78% 78% 78% 67% 29 25% 17% 17% 17% 2010 The Royal College of Psychiatrists 45
Proportion of patients in each Trust with documented pre-treatment measure of: Trust code Full blood count Renal function tests Liver function tests Thyroid function tests 30 100% 100% 100% 89% 31 100% 100% 100% 100% 40 25% 25% 25% 25% 42 67% 67% 67% 33% 50 33% 33% 33% 33% 51 67% 67% 67% 50% 56 69% 62% 54% 62% 59 50% 50% 50% 50% 61 100% 100% 100% 50% 62 100% 100% 100% 100% 65 0% 0% 0% 0% 69 93% 80% 80% 80% 70 80% 80% 80% 80% 71 33% 67% 67% 67% 73 67% 75% 75% 50% 77 50% 50% 50% 50% 78 25% 25% 25% 25% 79 50% 50% 50% 50% 80 60% 60% 60% 48% 81 83% 83% 67% 50% 82 100% 100% 100% 0% 83 83% 78% 72% 56% 84 75% 75% 63% 50% 85 44% 38% 31% 31% 87 76% 76% 76% 62% TNS 65% 64% 62% 54% 2010 The Royal College of Psychiatrists 46
2.3 Patients prescribed antipsychotic medication for more than three months. This Figure relates to audit standard 2: For all children and adolescents prescribed antipsychotic medication, the side effects of antipsychotics should be reviewed at least once every six months. This review should include, as appropriate, the assessment of body weight, blood pressure, blood glucose, plasma lipids and raised plasma prolactin, and examination for the presence of extrapyramidal side effects (EPS). Figure 10: Proportion of patients in each Trust for whom the continuing need for antipsychotic medication was reviewed in the past six months The Trusts with the highest proportion of patients having had the need for antipsychotic medication reviewed in the past six months are on the left hand side of the Figure and the Trust with the lowest proportion on the right. 2010 The Royal College of Psychiatrists 47
This Figure relates to audit standard 2: For all children and adolescents prescribed antipsychotic medication, the side effects of antipsychotics should be reviewed at least once every six months. This review should include, as appropriate, the assessment of body weight, blood pressure, blood glucose, plasma lipids and raised plasma prolactin, and examination for the presence of extrapyramidal side effects (EPS). Figure 11: Proportion of patients in each Trust and the total national sample with documented evidence in their clinical records of assessment of EPS in the past six months. The Trust with the highest proportion of patients having had an assessment of EPS in the past six months is on the left hand side of the Figure and the Trust with the lowest proportion on the right. 2010 The Royal College of Psychiatrists 48
This Table relates to audit standard 2: For all children and adolescents prescribed antipsychotic medication, the side effects of antipsychotics should be reviewed at least once every six months. This review should include, as appropriate, the assessment of body weight, blood pressure, blood glucose, plasma lipids and raised plasma prolactin, and examination for the presence of extrapyramidal side effects (EPS). Table 15: Proportion of patients in each Trust and the total national sample with documented measurement of body weight, blood glucose, plasma lipids and raised plasma prolactin in the past six months. Proportion of patients in each Trust with documented measure of: Trust code Body weight Blood glucose Plasma lipids Raised plasma prolactin 2 72% 52% 52% 39% 5 79% 45% 33% 36% 6 66% 39% 34% 32% 8 69% 38% 19% 0% 12 63% 44% 41% 30% 13 86% 69% 69% 69% 16 29% 29% 14% 14% 17 58% 33% 25% 42% 18 41% 36% 32% 32% 19 94% 11% 11% 2% 20 100% 100% 100% 100% 21 74% 44% 47% 44% 22 100% 50% 58% 50% 25 77% 54% 62% 23% 27 79% 14% 7% 12% 28 43% 49% 48% 48% 29 54% 44% 54% 44% 30 100% 57% 57% 71% 31 67% 50% 50% 33% 40 79% 6% 3% 6% 42 78% 78% 67% 11% 2010 The Royal College of Psychiatrists 49
Proportion of patients in each Trust with documented measure of: Trust code Body weight Blood glucose Plasma lipids Raised plasma prolactin 50 83% 48% 39% 61% 51 84% 21% 21% 32% 56 67% 33% 67% 33% 59 69% 59% 53% 38% 61 50% 50% 50% 0% 65 100% 33% 33% 33% 69 53% 51% 51% 51% 70 68% 15% 15% 9% 71 100% 100% 100% 100% 73 82% 32% 32% 29% 77 62% 23% 27% 27% 78 36% 0% 0% 0% 79 95% 80% 78% 68% 80 51% 23% 26% 30% 81 67% 33% 29% 29% 82 92% 33% 34% 31% 83 100% 76% 71% 41% 84 52% 29% 29% 24% 85 77% 6% 25% 21% 87 92% 46% 38% 25% TNS 74% 38% 37% 32% This Table shows the proportion of documented side effect assessments of body weight, blood glucose, plasma lipids and raised plasma prolactin in the past six months (either a recorded result or test measurement, or some reference to screening or other relevant observation made) in patients who have been prescribed antipsychotic medication for over three months. 2010 The Royal College of Psychiatrists 50
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3. Clinical team level results Analyses presented in this section were conducted for each clinical team from your Trust individually, for your total Trust sample and for the total national sample to allow benchmarking. Data from each Trust clinical team are presented by code only. The POMH-UK Central Project Team does not know the identity of individual teams. Only the Local Project Team Lead (LPTL) for your Trust or organisation has the key to team codes. You should contact this person if you need to identify data for your own particular team. 2010 The Royal College of Psychiatrists 52
3.1: Patient characteristics Figure 12: Distribution of age groups by team and in the total national sample The teams with the highest proportion of patients aged 15 years and under are on the left hand side of the Figure and the team with the lowest proportion on the right. This Figure allows team to compare the demographic characteristics of their sample of patients against the total national sample. Figure 13: Proportion of patients under the care of an outpatient service prescribed antipsychotics by a GP for each team and the total national sample 2010 The Royal College of Psychiatrists 53
3.2 Patients prescribed antipsychotic medication for three months or less. This Figure relates to audit standard 1: For all children and adolescents prescribed antipsychotic medication the indication(s) for treatment with antipsychotic(s) should be documented in the clinical records. Figure 14: Proportion of patients in each team for whom the indication for antipsychotic prescribing is clearly documented The teams with the highest proportion of patients with clear documented indications are on the left hand side of the Figure and the team with the lowest proportion on the right. Pre-treatment assessment Data regarding pre-treatment assessments are not provided in this section, as for most teams the number of eligible patients is very small. 2010 The Royal College of Psychiatrists 54
3.3 Patients prescribed antipsychotic medication for more than three months. This Table relates to audit standard 2: For all children and adolescents prescribed antipsychotic medication, the side effects of antipsychotics should be reviewed at least once every six months. This review should include, as appropriate, the assessment of body weight, blood pressure, blood glucose, plasma lipids and raised plasma prolactin, and examination for the presence of extrapyramidal side effects (EPS). Figure 15: Proportion of patients in each team for whom the continuing need for antipsychotic medication was reviewed in the past six months The teams with the highest proportion of patients having had the need for antipsychotic medication reviewed in the past six months are on the left hand side of the Figure and the team with the lowest proportion on the right. 2010 The Royal College of Psychiatrists 55
Table 16: Proportion of patients in each team and the total national sample with documented measures of body weight, blood glucose, plasma lipids and raised plasma prolactin in the past six months. Proportion of patients in each Trust with documented measure of: Trust code Body weight Blood glucose Plasma lipids Raised plasma prolactin 40.28 67% 0% 0% 0% 40.30 86% 14% 0% 14% 40.31 72% 6% 6% 6% 40.32 100% 0% 0% 0% Trust 40 79% 6% 3% 6% TNS 74% 38% 37% 32% This Table shows the proportion of documented side effect assessments of body weight, blood glucose, plasma lipids and raised plasma prolactin in the six months (either a recorded result or test measurement, or some reference to screening or other relevant observation made) in patients who have been prescribed antipsychotic medication for over three months. 2010 The Royal College of Psychiatrists 56
Figure 16: Proportion of patients in each team and the total national sample with documented evidence in their clinical records of assessment of EPS in the past six months. The team with the highest proportion of patients having had an assessment of EPS in the past six months is on the left hand side of the Figure and the team with the lowest proportion on the right. 2010 The Royal College of Psychiatrists 57
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Appendix A: Data ownership As outlined in the original memorandum of understanding, the following statement outlines the agreement between POMH-UK and Trusts regarding ownership of data. Data collected by a Local Project Team will belong to that Trust. These Trust data will be made available to POMH-UK in a way that is anonymous with the exception of the identity of the source Trust. The national data will be analysed by POMH-UK and a report summarising the audit results will be returned to each Trust. In this report all data will be anonymous except that of the receiving Trust. However, it will allow for benchmarking with comparable Trusts. There is a publication strategy allowing POMH-UK to publish the anonymous aggregated data on its web site and in appropriate scientific journals. Any requests from other organisations for audit data will be referred to the POMH-UK reports in the public domain or provided with a list of member Trusts and asked to approach individual Trusts directly. 2010 The Royal College of Psychiatrists 60
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Appendix B: Participating Trusts The Trusts that participated in this audit are listed below in alphabetical order. 5 Boroughs Partnership NHS Foundation Trust Barnet, Enfield & Haringey Mental Health Trust Bedfordshire & Luton Partnership NHS Trust Belfast Health and Social Care Trust Berkshire Healthcare NHS Foundation Trust Birmingham and Solihull Mental Health NHS Foundation Trust Bradford District Care Trust Cambridgeshire and Peterborough NHS Foundation Trust Central and North West London NHS Foundation Trust Cheshire and Wirral Partnership NHS Foundation Trust Cornwall Partnership NHS Foundation Trust Coventry and Warwickshire Partnership Trust Derbyshire Mental Health Services NHS Trust East London NHS Foundation Trust Greater Manchester West Mental Health NHS Foundation Trust Hertfordshire Partnership NHS Foundation Trust Hywel Dda Health Board Isle of Wight NHS Primary Care Trust Kent and Medway NHS and Social Care Partnership Trust Lancashire Care NHS Foundation Trust Milton Keynes Primary Care Trust North Essex Partnership Foundation Trust North Staffordshire Combined Healthcare NHS Trust Northumberland Tyne and Wear NHS Foundation Trust Nottinghamshire Healthcare NHS Trust Oxfordshire and Buckinghamshire Mental Health Partnership NHS Trust Oxleas NHS Foundation Trust Pennine Care NHS Foundation Trust Rotherham, Doncaster and South Humber Mental Health NHS Foundation Trust Sandwell Mental Health and Social Care Foundation Trust Sheffield Health and Social Care NHS Foundation Trust Somerset Partnership NHS Foundation Trust South Essex Partnership University NHS Foundation Trust South London and Maudsley NHS Foundation Trust South Staffordshire & Shropshire Healthcare NHS Foundation Trust South West London and St George's MH Trust Southern Health and Social Care Trust St Andrews Healthcare Suffolk Mental Health Partnership NHS Trust Sussex Partnership NHS Foundation Trust Tees Esk and Wear Valleys NHS Foundation Trust West London Mental Health NHS Trust 2010 The Royal College of Psychiatrists 62
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Appendix C: Audit data collection guide and form 2010 The Royal College of Psychiatrists 64
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