6 results
Access to firearms: essential factor for risk management in psychiatry
- Donnchadh Walsh, Una Fallon, Sonn Patel, Elizabeth Walsh
-
- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S121
-
- Article
-
- You have access Access
- Open access
- Export citation
-
Objective
Increase awareness of the risk associated with access to firearms in clinical practice.
Case reportA 57-year-old man, with a 30 year history of schizophrenia, was reviewed routinely at home. His illness is predominantly characterised by chronic delusions of a grandiose nature. He believes he has been offered various senior employment positions and has acted on these beliefs by presenting at workplaces in business attire. He has no insight into his condition. At review, he described awakening a week earlier in a panic and seizing hold of his legally held shotgun. He planned to shoot out the window as he believed people were breaking in. His wife prevented him from doing so by taking the gun and hiding it. A few days later he found the gun and intended to frighten off potential pursuers by pretending to shoot birds. He was persuaded to surrender the gun and it was taken to the local Garda (Police). A short time later, he presented to Garda Headquarters, over an hour away, seeking the return of his gun. At review, he had limited insight into the potential seriousness of the situation. The team immediately liaised with Gardaí, a HCR- 20 risk assessment was completed and clozapine levels checked.
DiscussionWe had not know that our patient owned a shotgun despite very regular contact with him. During a comprehensive psychiatric history we routinely ask about risk of harm to self and others, but rarely ask specifically about access to or ownership of guns. Working on a farm, rural living or having an interest in shooting sports may raise the issue. Suicide, security breaches and homicide are the main risks conferred by firearms in mental illness. Mental illness is not necessarily prohibitive to gun ownership. Applicants for gun certificates in the UK must disclose specific medical conditions, including a psychotic illness, and an automatic medical report is sought. In the Irish Republic it is the responsibility of the applicant to declare any specific physical or mental health condition. Although a medical report may be sought, it is not automatic in all cases. Lack of insight into psychotic illness may potentially influence self-declaration upon application for a certificate.
ConclusionAwareness of a persons access to firearms should be part of our routine risk assessment.
Quetiapine: off-label prescribing in a community mental health team
- Ala Abdelgadir, Richard Walsh, Elizabeth Walsh, Sonn Patel
-
- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S63-S64
-
- Article
-
- You have access Access
- Open access
- Export citation
-
Aims
Quetiapine is an atypical anti-psychotic medication licensed for the treatment of schizophrenia, bipolar disorder and adjunctive use in major depressive disorder. It's off-label use in low doses is increasing, possibly due to its sedative qualities, tolerability, low risk of extrapyramidal symptoms and to limit the unnecessary use of benzodiazepines. However, previous research highlights the risk of metabolic consequences even in low doses. Our aim is to establish the prescribing patterns and off-label use of quetiapine within a complete comminity mental health team population (CMHT).
MethodThe GR1 CMHT provides care to a population of 25,000 people in a mixed urban and rural area. Multi-disciplinary case notes for all registered patients were reviewed for a one-year period. A database was created to include sociodemographic details, diagnosis, and medication. The proportion of patients prescribed quetiapine was identified and the dosage divided into multiple increments. The team's consultant reviewed and verified all ICD-10 diagnoses. Quetiapine dose by diagnosis was examined using descriptive statistics.
ResultOf 246 registered patients, 62 (25% of CMHT caseload) were prescribed Quetiapine. Quetiapine was prescribed across a range of disorders including psychotic 17 (27%), mood 18 (29%), anxiety 14 (22 %), personality disorders 11 (18%) and others 2 (3%). Doses spanned between 25 mg – 800 mg daily. 19 patients (31%) were prescribed less than 25 mg, 20 patients (32%) between 25 mg and 100 mg and 23 patients (37%) above 100 mg. In psychotic and mood disorders, dosage varied widely between the low and high range. Furthermore, of the psychotic disorders, 11 (65%) were prescribed a second antipsychotic medication. For diagnoses in which the prescribing indication was clearly off-label, the dosages were predominantly low (100 mg or less).
ConclusionQuetiapine was commonly prescribed in our patient population. Its frequent off-label use in low doses suggests that its prescription was for its additional qualities. Our findings highlight the importance of assessing the risk-benefit profile for every patient given the potential side effects, involving patients in the consultation of its off-label use and appropriate monitoring.
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
- Karthika Srikumar, Richard Walsh, Donnchadh Walsh, Sonn Patel, Sheila O'Sullivan
-
- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S106
-
- Article
-
- You have access Access
- Open access
- Export citation
-
Aims
Psychiatric 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.
Reducing high dose antipsychotic therapy (HDAT) in a community mental health team (CMHT)
- Richard Walsh, Sonn Patel, Valentina Loddo, Rebecca Fahy, Elizabeth Walsh
-
- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S110-S111
-
- Article
-
- You have access Access
- Open access
- Export citation
-
Aims
The consensus statement (CR190) of The Royal College of Psychiatrists states that the benefit of prescribing HDAT does not outweigh the risk of the increased side effect burden. HDAT is defined as the “daily dose of a single antipsychotic exceeding the upper limit for that drug as stated in the Summary of Product Characteristic (SPC) or British National Formulary (BNF),” and as the cumulative daily dose of two or more antipsychotics (for combined prescription). The prevalence of HDAT has been shown to vary widely and protocols for monitoring poorly implemented. In 2018 we completed a baseline survey of the prevalence of HDAT within our CMHT. We assessed our prescribing practice as compared to seven best practice audit criteria, which were adopted. Our aim is to resurvey closing the audit loop to 1) establish the current prevalence of HDAT and 2) assess the impact the intervention on prescribing practice.
MethodMulti-disciplinary case notes for all registered patients were studied. A database was created including sociodemographic details, chart diagnosis, and medication. The proportion of patients prescribed antipsychotic medication was identified. The dose of each medication was converted into a percentage of BNF maximum recommended dose for that drug. For combined antipsychotic prescription, the cumulative dose was obtained adding the single percentages together. Exceeding 100% was regarded as HDAT. All HDAT patients were assessed against identified audit criteria as outlined by the Humber NHS Foundation Trust.
ResultOf a total of 246 patients, 177 (72%) were prescribed antipsychotic medication. Of these, 14 (8%) were in receipt of HDAT. This compared to 68% prescribed antipsychotics and 9% in receipt of HDAT in the baseline audit. The average cumulative dose for every category (oral medication, depot and both) was calculated with a range from 1% to 168% (mean = 70%) for oral antipsychotic (single/combined), 1% to 193% (mean = 50%) for depots and 20% to 257% (mean = 95%) for combination of oral and depot. This compares with ranges of 1.6% to 215% (mean = 44.3%) for oral antipsychotic (single/combined), 0.04% to 100% (mean = 25.8%) for depots and 21% to 425% (mean = 119.6%) for combination of oral and depot in the baseline audit. Similar to the baseline survey no patient met all seven audit criteria but there was better adherence overall with best practice guidance. Blood and ECG monitoring were the most consistent parameters measured.
ConclusionLower HDAT was achieved post intervention. Results, whilst positive, indicate the need for ongoing audit to maintain best standards.
Professional training and case-load mix within a community mental health team
- Richard Walsh, Rebecca Fahy, Ala Abdelgadir, Elizabeth Walsh, Sonn Patel
-
- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S226
-
- Article
-
- You have access Access
- Open access
- Export citation
-
Aims
Community Mental Health Teams (CMHTS) are now the cornerstone of modern mental health care and play a central role in assessment, diagnosis and care coordination. CMHTs vary widely in their service provision and composition. Within teams there is latitude for variation of professional roles but the extent to which different disciplines undertake generic and profession-specific work is poorly defined. This cross-sectional study aims to establish how professional training influences the distribution of case-load mix within a general adult CMHT
MethodThe GR1 CMHT provides care to a mixed urban/rural population of 25,000 in Galway city and Connemara. A review was conducted of multi-disciplinary case notes for all patients actively registered with the team for a period of one year. Name, age, gender, whether referred or admitted in the past year, medication and day hospital attendance were recorded. Clinical diagnoses were recorded but, where missing, verified with a relevant team member. The team consultant reviewed and verified the 1CD-10 primary clinical diagnosis for all patients. Evidence of clinical input by multidisciplinary team members was recorded from clinical files with the final electronic database being checked by each professional for accuracy. We examined any input over the past year rather than
frequency of input. Patient characteristics and diagnosis by professional discipline were examined using descriptive statistics.
ResultOf a total of 246 patients registered to the team, 37.8% (N = 93) saw one, 34.6% (N = 85) saw two and 24.4% (N = 60) saw 3 or more team members. Of those who saw three or more team members, psychotic disorders represented the majority diagnoses (40%, N = 24) followed by personality disorders (25%, N = 15) and affective disorders (15%, N = 9). Patients were most commonly seen by a doctor (91.5%, N = 225) followed by community mental health nurses (CMHNs) (52.8%, N = 130). Doctors saw 85% or more of all patients grouped by ICD-10 diagnoses. The majority of social work and occupational therapy case-mix comprised psychotic disorders (SW = 44.2%, OT = 34.2%) followed by personality disorders (SW = 25.6%, OT = 23.7%). Of psychology case-mix, the highest was personality
disorders at 41.6% (N = 13) followed by anxiety and related disorders at 25% (N = 8). CMHN case-mix was highest for psychotic disorders at 44.6% (N = 58) followed by 21.5% mood disorders (N = 28).
ConclusionThis cross sectional survey informs how we currently target our specialist resources. We will now develop this to include frequency of contact to inform resource allocation and skill mix.
Hyperkinetic disorder in a community service for people with intellectual disability
- Sonn Patel, Evan Yacoub
-
- Journal:
- Irish Journal of Psychological Medicine / Volume 38 / Issue 3 / September 2021
- Published online by Cambridge University Press:
- 03 October 2018, pp. 177-181
- Print publication:
- September 2021
-
- Article
- Export citation
-
Background
There appears to be a higher rate of prevalence of hyperkinetic disorder in the intellectual disability (ID) population, although there is a large variability in rates in previous studies. Hyperkinetic disorder can be a challenge to diagnose in a population with ID and can present a barrier to the development of the activities of daily living in an already vulnerable population.
ObjectivesOur objective was to examine the point prevalence of hyperkinetic disorder in the ID population in a community ID service and also to determine the prevalence of hyperkinetic disorder based on the level of ID.
MethodsA cross-sectional review of the Online Information Service ‘OLIS’ database was undertaken to establish the total number of patients with ID and those with comorbid hyperkinetic disorder. The overall point prevalence and prevalence based on the level of ID was calculated from the collected data.
ResultsThe point prevalence of hyperkinetic disorder in the population with ID was similar to that found in studies in the general population at 3.1% in adults and 32.6% in children. When divided by the level of disability, the calculated point prevalence in both adults and children was highest in the population with mild ID and decreased as the level of disability increased.
ConclusionThis report contributes to previous research establishing the rates of hyperkinetic disorder in an ID population and establishes the point prevalence of hyperkinetic disorder in individuals diagnosed with ID in a clinical sample.