Setting

This audit is relevant to many psychiatric services, but particularly to adult inpatient wards.

Background

The use of antipsychotic medication in combination or at high dose – defined as exceeding the maximum dose recommended in the British National Formulary (BNF) (Joint Formulary Committee, 2009) – has been relatively consistent over time, despite the existence of evidence-based, national guidance advising against such practice. Neither the effectiveness nor the side-effect burden associated with this approach has been studied systematically in clinical trials. The evidence that does exist suggests that the potential for harm may outweigh the potential for benefit.

This audit was designed as part of a quality improvement programme from the Prescribing Observatory of Mental Health (POMH-UK; see http://www.rcpsych. ac.uk/pomh) on the prescription of high-dose and combined antipsychotics on adult acute and intensive-care wards.

Standards

The standards were derived from the schizophrenia guideline produced by the National Institute for Health and Clinical Excellence, as updated in 2009, and the Royal College of Psychiatrists’ 2006 Consensus Statement on High Dose Antipsychotic

Medication.

ᐅ The dose of an individual antipsychotic should be within its BNFlimits A ‘high dose’ of antipsychotic is defined here as a total daily dose (whether of a single antipsychotic or combined antipsychotics) greater than the maximum recommended daily dose.

ᐅ Individuals receive only one antipsychotic at a time (with the exception of individuals with schizophrenia who are receiving clozapine but who have not responded sufficiently; and individuals who are changing from one antipsychotic to another).

ᐅ First- (typical) and second-generation (atypical) antipsychotic drugs are not prescribed concurrently (unless ‘Any concurrent prescriptions are for a short period to cover changeover of medication’, and ‘Local teams should agree on what constitutes a changeover period for audit purposes’).

Method

Data collection

Each participating mental health trust was invited to include as many acute adult admission and psychiatric intensive-care units as it wished. Teams were asked to submit data for all patients who, on a census day, occupied a bed on the selected wards and were being prescribed one or more antipsychotic drugs.