Prescription of High Dose of Antipsychotics in Two Rehabilitation Wards of Chronically Unwell Patients

Abstract

Aims

The Royal College of Psychiatry (RCPsych) Consensus and the NICE guidelines have set out quality standards for the prescription of antipsychotics. There are concerns, however, regarding the over prescription across different psychiatric units: doses above BNF limits, multiple antipsychotics prescribed, lack of adequate monitoring of physical health and lack of availability of a clear rationale when high dose antipsychotic therapy (HDAT) is used. In the current audit, we sought to review the frequency HDAT is used in a female rehabilitation ward of patients with psychosis and a male rehabilitation ward of patients with dual diagnosis psychosis and/or autism. We also examined whether appropriate considerations are taken prior to prescribing HDAT and if the mandatory monitoring is in place when someone is on HDAT.

Methods

A set of standards was set out and an audit tool was formulated that took the format of a table for data collection. Data were collected and anonymised, by looking at the medication charts and patients’ records, to identify if essential steps prior to/during HDAT prescribing are followed. All service users, 10 in each ward, that were in admission during the period between 7th and 13th November 2022, where included in the study.

Data were compared directly with standards set out based on NICE guidelines and the RCPsych consensus. The data were input into Excel spreadsheet, then analysed and presented in tabular and graphs’ format.

Results

A total of 20 medication charts were reviewed over the five-day period. Only one out of ten individuals with ASD in Springs Centre was treated on HDAT and a clear rationale was documented to justify its use. All patients in both wards had the HDAT form and side effects scale form completed and filed. All patients had documentation of HDAT use on T2/T3 forms.

40% of patients at Kenton Lodge were on HDAT. These patients required use of at least one depot due to lack of compliance. There was four patients overall treated on combination of antipsychotics. One patient did not have physical health monitoring at baseline due to refusing consent.

Conclusion

In a small proportion of cases, HDAT may be justified, as long as the safety implications are considered and monitoring requirements observed.

We recommend that audits of high dose antipsychotic prescribing can be performed periodically as a matter of routine practice. Also, to introduce a formal psychosis assessment scale to identify whether improvement has been accomplished since HDAT initiation.