Prescribing for people with a personality disorder POMH-UK QIP 12b
Personality disorder Personality disorders are a heterogeneous group of conditions which vary greatly in their severity Characterised by long-standing, pervasive patterns of thinking, feeling and relating to others that lead to social problems and poor mental health Problems with inter-personal relationships are a defining feature Among people in contact with mental health services, the most common type of personality disorder is emotionally unstable personality disorder () Characterised by affective instability, impulsivity, anger, transient psychotic or dissociative symptoms and intense, unstable relationships
UK Pharmacotherapy guidelines The current evidence-based guidelines for borderline personality disorder from NICE, which are applicable to, state that, while it is important to treat comorbid mental health problems, drug treatment should not be used specifically to alleviate intrinsic features of personality disorder Australia Australian guidelines state that medicines should not be a primary therapy for but time-limited use can be considered as an adjunct to psychological therapy to manage specific symptoms USA American Psychiatric Association guidelines endorse a symptomtargeted approach Pharmacological algorithms for treating symptom domains: impulsivity, aggression and affective instability
QIP 12b: clinical practice standards 1. A clinician s reasons for prescribing antipsychotic medication (i.e. target symptoms or behaviour) are documented in the clinical records 2. There is a written crisis plan which is accessible in the clinical records 3. There is evidence that the patient s views have been sought in the development of the crisis plan
QIP 12b: treatment targets 1. Antipsychotic drugs should not be prescribed for more than four consecutive weeks in the absence of a co-morbid psychotic illness Derived from NICE CG078 recommendation 6.12.1.2 2. Z-hypnotics should not be prescribed for more than four consecutive weeks. 3. Benzodiazepines should not be prescribed for more than four consecutive weeks 4. Medication prescribed for more than four consecutive weeks should be reviewed, and such a review should: Take account of therapeutic response Take account of possible adverse effects Be documented in the clinical records
Method Baseline audit 2012 41 Mental Health Trusts participated 438 clinical teams 2,600 patients Re-audit 2014 51 Mental Health Trusts participated 522 clinical teams 4,014 patients Audit data collected Demographic, diagnosis, type of service Antipsychotic(s), z-hypnotics and benzodiazepine prescribed, duration Clinical indications/reasons for prescribing Other medicines prescribed Information about medication review
Documentation of clinical reasons for prescribing the most recently initiated antipsychotic Baseline (n=1,673) and Re-audit (n=2,758) Audit standard 1. A clinician s reasons (i.e. target symptoms or behaviour) for prescribing antipsychotic medication are documented in the clinical records. 17% 28% Fully documented 34% 48% 28% 45% Partially documented Not documented/ unclear Baseline, 2012 Re-audit, 2014
Prison - inreach team FSPD - IP Forensic -IP SPD - IP FSPD - OP Adult - IP SPD - OP Adult - OP Forensic - OP Other TNS Proportion of patients Crisis plan: across clinical settings nationally Proportion of patients for whom there is a crisis plan in the clinical records at re-audit (n=4,014) Audit standards 2. There is a written crisis plan in the clinical records. 3. There is evidence that the patient s views have been sought in the development of the crisis plan. 100% 80% 60% 40% 20% 0% Patient did not have a crisis plan Patient had a crisis planbut no involvement in its development Patient had a crisis plan and was involved in its development Baseline: patient had a crisis plan and was involved in its development Clinical setting Key: IP = inpatients, OP =outpatients, SPD= specialist personality disorder, FSPD = forensic specialist personality disorder
Prison - inreach team FSPD - IP Forensic - IP SPD - IP FSPD - OP Adult - OP SPD - OP Adult - IP Forensic - OP Other TNS B TNS R Proportion of patients 100% Reference to medication in the crisis plan (n=4,014) 80% Patient did not have a crisis plan 60% 40% 20% 0% Patient had a crisis plan but it did not refer to medication Patient had a crisis plan which refered to medication Patient setting Key: IP = inpatients, OP =outpatients, SPD= specialist personality disorder, FSPD = forensic specialist personality disorder
Antipsychotic medication prescribed for patients with personality disorder Treatment target 1. Antipsychotic drugs should not be prescribed for more than four consecutive weeks in the absence of a co-morbid psychotic illness. Antipsychotics Personality disorder (no comorbid psychiatric diagnosis) Prescribed for more than 4 weeks Duration of prescription unclear Prescribed for less than 4 weeks Not prescribed an antipsychotic n (%) n (%) n (%) n (%) Any personality disorder (n=1,689) Emotionally unstable personality disorder (F60.3): n=1,366 Dissocial personality disorder (F60.2): n=175 Paranoid personality disorder (F60): n=63 802 (47) 201 (12) 57 (3) 629 (37) 700 (51) 161 (12) 45 (3) 460 (34) 81 (46) 16 (9) 4 (2) 74 (42) 32 (51) 9 (14) 3 (5) 19 (30)
Medication review Patients prescribed a drug from any of the four groups of psychotropic medication for more than 4 consecutive weeks: baseline (n=2,138) and re-audit (n=3,172) Treatment target 4. Medication prescribed for more than four consecutive weeks should be reviewed, and such a review should take into account a) therapeutic response and b) possible adverse effects and also c) be documented in the clinical records. Documented medication review Clinical factors considered at medication review Proportion with no documented evidence of a medication review Proportion with documented evidence of a medication review Therapeutic response Side effects/ tolerability Patient s views sought Adherence Baseline 349 (18%) 1,744 (82%) 1,471 (84%) 1,135 (65%) 1,300 (74%) 947 (54%) Re-audit 414 (13%) 2,758 (87%) 2,306 (84%) 1,837 (67%) 2,136 (77%) 1,577 (57%)
Prescribing for 2,600 patients with a diagnosis of personality disorder, at re-audit More than two-thirds (68%) had a diagnosis of Almost all (92%) patients in the subgroup were prescribed psychotropic medication Most comm an antidepressant or antipsychotic, principally for symptoms and behaviours that characterize, particularly affective dysregulation 28% were taking medications from 2 different medication classes, 23% from 3 classes, and 16% from 4 or more classes
Prevalence of prescribing of different classes of psychotropic medication in the subsamples with alone (n= 786) or with comorbid depression (n= 344) 100% 80% 60% 40% Not prescribed for more than four consecutive weeks Prescribed for more than four consecutive weeks 20% 0% + depression + depression + depression + depression + depression Antidepressant Antipsychotic Benzodiazepine Z-hypnotic Mood stabilisers
Prevalence of prescribing of different classes of psychotropic medication in the subsamples with alone (n= 786) or with comorbid schizophrenia spectrum disorder (F20-29; n= 169) 100% 80% 60% 40% Not Less than prescribed 4 weeks for more than four consecutive weeks Prescribed More than for more 4 weeks than four consecutive weeks 20% 0% + F20-F29 + F20-F29 + F20-F29 + F20-F29 + F20-F29 Antidepressant Antipsychotic Benzodiazepine Z-hypnotic Mood stabilisers
Prevalence of prescribing of different classes of psychotropic medication in the subsamples with alone (n= 786) or with comorbid bipolar disorder (n= 95) 100% 80% Not Less prescribed than for 4 weeks more than four consecutive weeks 60% 40% Prescribed More than for more 4 weeks than four consecutive weeks 20% 0% + bipolar + bipolar + bipolar + bipolar + bipolar Antidepressant Antipsychotic Benzodiazepine Z-hypnotic Mood stabilisers
Clinical reasons for prescribing to patients with alone (n=786) AFFECTIVE DYSREGULATION % prescribed at least 1 drug for indication Antidepressant Antipsychotic Mood stabiliser Sedatives Depressive symptoms 52% 50% 6% <1% 1% Affective/emotional instability 45% 16% 27% 17% 4% Aggression/hostility 19% 1% 14% 4% 7% IMPULSIVE-BEHAVIOURAL Impulsivity 17% 4% 12% 3% 3% Self-harm 18% 8% 12% 3% 3% COGNITIVE-PERCEPTUAL Transient psychotic-like experiences or symptoms 15% <1% 14% 1% <1% Depersonalisation/derealisation 2% <1% 1% 1% - Suspected psychotic illness 3% - 3% <1% - OTHER REASONS Anxiety (including phobic anxiety and panic) 37% 17% 14% 1% 19% Disturbed sleep 38% 10% 7% <1% 30% Distress 22% 7% 10% 2% 11% Patient request 15% 3% 4% <1% 4% Other specified reason 16% 2% 4% <1% 4% Not known 15% 8% 7% 2% 4%
Summary of findings Psychotropic medication is comm prescribed off-label for people with emotionally unstable personality disorder () who do not have a comorbid mental illness Such prescribing is for a wide variety of target symptoms, most comm depressive symptoms, affective instability, anxiety, and disturbed sleep Prescribing patterns are similar between those who have a diagnosed comorbid mental illness and those who have alone Whether the treatment target is identified as intrinsic symptoms of or comorbid mental illness may depend on the diagnostic threshold of individual clinicians Compared with prescribing for where there is judged to be a comorbid mental illness, the use of off-label medication for alone is less systematically reviewed and monitored Treatment may be continued long term by default Paton C, Crawford MJ, Bhatti SF, Patel MX, Barnes TR. Journal of Clinical Psychiatry 2015;76:e512-e518