Before writing that script: use of antipsychotic medication in patients with dementia in a CMHTOA

AimsA 2009 independent review commissioned by the UK government to review the use of antipsychotic medication in patients diagnosed with dementia produced the Time for Action report, often referred to as the Banerjee Report. It highlighted the common practise of using antipsychotics in the treatment of Behavioural and Psychological Symptoms of Dementia (BPSD) and the clinical issues this could raise especially when these medications were not being regularly reviewed. The audti was therefore carried out to determine whether patinets with BPSD in a Community Mental Health Team for Older adults (CMHTOA) in Mid Surrey, who had been diagnosed with BPSD, were being adequately assessed and managed in line with the current guidelines.MethodPatients with a diagnosis of dementia open to one of three teams in the CMHTOA during the months of October and November 2019 were identified, those being prescribed antipsychotic medication were selected and data from their electronic records collected and analysed to determine if clinicians: a) identified and documented the target behaviours, b) carried out a structured assessment using an ABC chart before commencing medication, c) reviewed the antipsychotic medication 6 weeks after it was commenced.ResultOf the 87 patients with a diagnosis of Dementia from October to November 2019, 18 were on antipsychotic medication. 100% of these had target behaviours identified and clearly documented, a sixth had a structured assessment prior to starting medication and 61% had been reviewed after the first 6 weeks of starting antipsychotics.ConclusionThe findings showed that a good proprotion of patients did not have the required structured assessment before commencement of treatment and that more needed to be done by way of improving regular reviews after antipsychotic treatment is commenced.

Patient factors associated with the use of psychotropic polypharmacy in patients under the care of a community mental health team in the West of Ireland

AimsPsychiatric polypharmacy refers to the prescription of two or more psychotropic medications to any one patient. This definition is purely quantitative and does not take into account whether such a prescription is detrimental, or unnecessary. In many cases, polypharmacy has been implemented in challenging illnesses, and some studies have shown that it can improve overall outcomes for certain patients. Evidence suggests that the prevalence of psychotropic polypharmacy is increasing, despite advances in psychosocial interventions. The aim of this study was to assess the current prevalence of polypharmacy among patients being treated by a community mental health team (CMHT), and the patient factors associated with its use.MethodWe performed a cross-sectional study of all patients registered with a CMHT in a mixed urban/rural area on a single date. Case records were examined to determine the most recently prescribed drug regimen for each patient. Clinical chart diagnoses were recorded and each one independently verified by the team consultant using ICD-10. A number other sociodemographic variables were recorded. Using Microsoft Excel, we analysed the medications prescribed as well as rates and levels of polypharmacy based on multiple different patient characteristics.ResultOf the 245 patients, the mean age was 56.3 and 51.2% (n = 126) were female. Psychotropic polypharmacy was seen in 62% (n = 152) of patients. 33% (n = 82) of patients were on two psychotropic medications, and of this subset, a combination of one antipsychotic and one antidepressant was the most common drug regimen, seen in 16.7% (n = 41) of all patients. Polypharmacy was more prevalent in females, with 68% (n = 85) being on two or more psychotropics, in comparison to 58% of male patients. In relation to age, patients aged between 51 to 65 years had the highest prevalence of polypharmacy, at a rate of 71% (n = 49). Among all primary diagnoses, polypharmacy was most common in patients with affective disorders, with 80% (n = 40) of this patient cohort on two or more medications. Second to this was psychotic disorders, with polypharmacy seen in 65% (n = 62) of this group.ConclusionWe found that psychotropic polypharmacy is highly prevalent in psychiatric patients being treated in a community setting. Certain demographics and patient factors, such as age, gender and psychiatric diagnosis influenced the rate of polypharmacy and certain drug combinations were more commonly prescribed than others.

Increasing staff confidence about domestic abuse identification, disclosure and safeguarding in a community mental health team

AimsTo increase staff confidence about identifying Domestic Abuse (DA), particularly regarding ‘how to ask’ to encourage disclosure and the pathways available for appropriately safeguarding survivors; in a Community Mental Health Team (CMHT) setting.BackgroundDA is bi-directionally associated with mental health (MH) disorders; 1:4 women in contact with MH services are currently experiencing DA. MH professionals (MHPs) are in a privileged position to identify DA and support survivors. However, this is dependent on MHPs receiving adequate training about DA. For this, we collaborated with Pathfinder, a national pilot project run by a consortium of five expert partners that aims to establish comprehensive health practice in relation to DA and Violence Against Women & Girls in Acute Hospital Trusts, MH Trusts and Primary Care. In Southampton, Pathfinder has funded two domestic and sexual abuse (DSA) advocates to both train MH staff and take a small caseload of MH service users who are experiencing abuse.MethodWe conducted a baseline survey of staff confidence across the following domains:Knowing the legal definition of DA,The process used to escalate a DA concern,How to make a referral,How to complete DASH forms,How and when to refer to Pathfinder,What the following acronyms mean: PIPPA, MAPPA, MARAC, IDVA, DASH,What HRDA and MASH mean,How to ask about DA,Who to signpost service users to if they make a disclosure, and when to involve the police.We presented the survey results at the regional Pathfinder strategic group, with Trust management representatives present. This project fits within the strategic group's sustainability aims to increase DA awareness and safeguarding processes across the Trust.The Pathfinder funded DSA Advisors delivered a four-hour training package targeting the surveyed questions and wider information on DA. We then re-surveyed to see if staff confidence had increased. We are currently analyzing the number of referrals to the Pathfinder service pre- and post-training.ResultStaff confidence increased across all domains following the training (% mean increase): Qs1 (35%), Qs2 (9%), Qs3 (45%), Qs4 (81%), Qs5 (25%), Qs6 (49%), Qs7 (89%), Qs8 (62%) and Qs9 (48%).We have now arranged a bi-monthly drop-in at the CMHT by the DSA advisor who provided the training, to embed the link between the services and maintain staff confidence. We will circulate these results to advocate that this training is provided across the Trust.

The clinical complexity of cases of schizophrenia in a community mental health team: a 3 year comparison

AimsTo describe the changes in complexity and management of individuals with schizophrenia in a community mental health team (CMHT) over a three year period.BackgroundIt is often believed that individuals receiving care from CMHTs are those with low levels of complexity and risk, and are relatively stable, with more complex individuals being managed by assertive outreach or other specialist teams. Here, we describe changes in the complexity, comorbidity, service-usage and management, of patients with a diagnosis of schizophrenia in a CMHT between 2016 and 2019.MethodData were collected from an electronic patient record system (RiO) for all individuals with schizophrenia in a CMHT in Birmingham (n = 84 in 2016, n = 71 in 2019), examining demographic variables, comorbidity, use of mental health services and current management.ResultKey findings included: - •63% were managed through care programme approach (CPA) in 2016, compared to only 31% in 2019.•21% had required home treatment or inpatient care in the preceding 12 months in 2016; this had improved to 8.5% in 2019.•Significant levels of psychiatric comorbidity, including addictions with almost half of patients (46.5%) having a known history of substance use in 2019, compared to only 15.5% noted in 2016.•Pharmacological management has remained broadly similar; in 2016 21% patients were taking a combination of 2 antipsychotics compared to only 10% in 2019 and 25% were taking clozapine in 2016 (21% in 2019). 39% were prescribed a long acting antipsychotic injection in 2016, compared to 32% in 2019.•In 2016, medication was being prescribed in the majority of cases within secondary care (55%) patients and in primary care in only 21%. GPs have now taken on greater prescribing responsibility in 2019, prescribing in 44% of cases, with 47% being prescribed by the CMHT.ConclusionThe acuity and management of individuals with a diagnosis of schizophrenia under the care of a CMHT has changed over a 3 year period. It is positive to note the reduced use of crisis services and lower rates of polypharmacy. There is a reduction in the proportion of patients receiving management through CPA, and a move towards more medication being prescribed in primary care. The reasons for this change are however unclear and may reflect change in available resources, given that more than half of this group receive clozapine or long acting injections, and have high levels of comorbidity.

Prescribing and monitoring high dose and combined antipsychotics in community mental health team

AimsThe aim was to establish the prevalence of prescription of combined and high dose antipsychotics in the community mental health team and to see if such patients were being offered regular monitoring as advised by NICE guidelines.BackgroundThe use of high dose antipsychotic treatment (HDAT) should be in line with the recommendations of the Royal College of Psychiatrists Consensus statement on high dose antipsychotic Treatment. Such treatment should be initiated only when standard treatments have failed. As high dose prescribing of antipsychotic medications can potentially harm than benefit causing serious side effects and sudden death. Close monitoring and documentation are required. Also, reviewing these patients at regular intervals is recommended.MethodA retrospective audit of 50 case notes of patients currently on antipsychotics was done. Case notes were selected randomly from a pool of 300 plus patients under the care of Isle of Wight NHS Trust in the HoNos Cluster 11 and 12 care pathways. Data were gathered on patients` demographics, diagnosis, medication monitoring. Data were analysed and discussed with consultant psychiatrist and senior mental health pharmacist. Patients who were not on any antipsychotic medications were not included in the audit.Result90% of the patients were on single antipsychotic (45 out of 50), 4.45% (2 out of 45)were above BNF recommended dose. 10% (5) patients were prescribed combined antipsychotics. 40% (2)of them were above BNF recommended maximum dose. A total of 8% (4 out of 50) patients were on above BNF recommended maximum dose. All the patients on high dose antipsychotics had a clear plan documented in the system. Documented monitoring of Full blood count was found in 75%, blood glucose in 50%, lipid in 75%, cardiac monitoring (Electrocardiogram or ECG) in 0%, physical health monitoring in 0%ConclusionAs far as we know, this is the first time an audit has been done on the patients under the Community Mental Health Team on high dose antipsychotic treatment. The data showed areas of good practice as the majority of the patients were on monotherapy, and all the patients on a high dose or combined antipsychotics had clear management plans outlined in their notes. However, the audit also highlighted areas that currently need improvements such as regular monitoring of the patients on high dose and combined antipsychotics. It should also be clearly documented, recorded, and reviewed at six-monthly intervals.

Compliance with nice guidelines for management of depression in a community mental health team

AimsTo evaluate compliance within a Community Mental Health Team (CMHT) to the NICE guidelines for the management of depression.BackgroundReducing the prevalence of depression continues to be a major public health challenge.Given the complexity and recurrent nature of the condition, the NICE guideline CG90 is an invaluable resource to aid the effective management of depression. Here we present an audit of adherence to this guideline within a CMHT.MethodA retrospective electronic casenote review of all patients diagnosed with depression between January 2016 and October 2019 under the care of a Birmingham CMHT (n = 35), assessing key performance areas including: quality of assessment and coordinated care, risk assessment, choice of pharmacological and psychological treatment using the stepped care model and appropriate crisis resolution planning.ResultKey results include: The majority of patients were Caucasian (63%). Ages ranged from 27 to 69 (mean age 48 years old).Severity of disorder was typically moderate (46%) or severe (48%). Of those with a diagnosis of severe depression, 41% had associated psychotic symptoms.Psychiatric comorbidity was high (49%), of which generalised anxiety disorder was the most common (59%).Referrals were typically from primary care (77%). Approximately half (51%) had reported suicidal thoughts according to the referral.A quarter of patients (26%) were seen by CMHT within 8 weeks of referral; 20% of referrals however waited over 12 months before being assessed.Risk assessments were out of date for 71% of patients.100% of patients had a crisis plan noted within their most recent clinic letter; however, none of these met the required standards.Polypharmacy was common (60%), with 34% prescribed two antidepressants. Use of lithium augmentation was uncommon, with only one patient prescribed this. 43% were prescribed an antipsychotic; of which, 29% had appropriate physical health monitoring completed.Over half of patients (60%) had been referred to psychology services; of these, 38% had either completed or were in ongoing treatment at the time of review.ConclusionCMHTs manage the care of individuals with depression who have high levels of active symptoms and disability, psychiatric comorbidity, care requirements, and complex treatment plans. Pharmacological management was broadly in line with guidelines, and rates of referral to psychology were satisfactory. Risk assessment and crisis planning are clear areas in need of urgent attention in order to comply with guidelines and ensure patient safety.

Physical health monitoring of patients prescribed depot antipsychotic medication in north west Edinburgh community mental health team

AimsTo monitor the quality of physical health monitoring of patients prescribed depot antipsychotic medication in the North West Edinburgh Community Mental Health Team (CMHT). We also evaluated the completeness of prescriptions and Mental Health Act (Scotland) (Act) 2003 paperwork where relevant.BackgroundAntipsychotic medications are medicines for treating conditions such as Schizophrenia, but some may be associated with an increased risk of Metabolic Syndrome. Moreover, evidence indicates that patients with major mental disorder have a reduced life expectancy in comparison to those without such diagnoses. These two factors illustrate the importance of the physical health of this patient cohort being monitored on a regular basis. This project will evaluate how a local CMHT is performing, with the possibility of enacting service improvements if required.MethodThe records of the 60 patients prescribed depot antipsychotic medication administered by this CMHT were reviewed. A check-list was created consisting of 14 categories analysing the quality of physical health monitoring, as well as compliance with prescription standards and, where relevant, Mental Health Act (Scotland) (Act) 2003 paperwork. We compared patient records against our checklist for the calendar year of 2019. The Scottish Intercollegiate Guidelines Network (SIGN) 131 (Management of Schizophrenia) section 5.2 was used as the gold standard for physical health monitoring against which the data we collected was compared.ResultWe identified a wide range of flaws with the current system and implementation of monitoring, and difficulty in locating the required information. There was no consistent monitoring of physical observations on electronic record, nor an accepted alternative way in which this was documented. Furthermore, blood tests were not consistently obtained either by the service or GP practices in a reproducible manner. This led to discussions within the CMHT regarding creation of a new pathway for the monitoring of this patient cohort using a Quality Improvement model, with the ultimate goal to establish a regular physical health clinic.ConclusionThere is significant evidence that patients with major mental disorder do not access healthcare as consistently as those without, leading to a disparity in life expectancy. In light of the fact that antipsychotic medications can be associated with Metabolic Syndrome, we have an even greater responsibility to tackle this marked health inequality by appropriately monitoring our patients. This was not done well in this particular CMHT, but this project will lead to improvements in the service and ultimately patient care.

An audit to assess whether patients under the care of a community mental health team who are taking clozapine are having their lipid profile checked annually and are given lifestyle advice and have had a QRISK3 assessment

Aims‘All cause’ mortality is higher among patients with serious mental illness than the general population and a significant contributor from this is cardiovascular disease. Mean triglyceride levels have been shown to double and cholesterol levels to increase by at least 10% after 5 years’ treatment with clozapine. NICE guidelines state all patients should have their lipids measured at baseline, 3 months after starting treatment with a new antipsychotic, and then annually.The first aim of our audit was to identify whether patients who had been on clozapine for at least 3 months from our community mental health team (CMHT) who were not taking cholesterol lowering medication are having their lipid profile checked annually. The second aim was to see whether these patients have high total cholesterol levels and whether they had had a documented discussion about exercise, diet or lifestyle and a QRISK3 assessment.MethodWe constructed a list of 56 patients who were taking clozapine from the CMHT. We excluded 17 patients who were on cholesterol lowering medication and would have excluded any patients who had been on clozapine for less than 3 months. We then looked at whether the patients had had a lipid profile and identified patients with a cholesterol level >5.0 to indicate a ‘high cholesterol level.’ We then searched through the last year of each of the patient's case notes to see whether they had had a QRISK assessment or lifestyle advice by searching for the words ‘diet, exercise, lifestyle and QRISK’.Result36 of the 39 (92%) patients had lipid levels checked in the last 12 months. 21 of the 39 (54%) patients had a cholesterol over 5.0. 9 of the 39 (23%) patients had a documented discussion regarding lifestyle, diet or exercise in the last year. 0 of the 39 (0%) patients had a documented QRISK3 assessment.ConclusionMost (92%) patients from the CMHT had their lipid profile checked in the last year. 54% had total cholesterol level over 5.0. Only a small proportion (23%) had documented lifestyle discussion and none of the patients had a QRISK3 assessment. The results will be presented to the CMHT and we will organise teaching on giving lifestyle advice and QRISK3 assessments.