Carol Paton

• Oxleas NHS Foundation Trust

Background Optimal use of lithium involves adjustment of the dose, to keep the plasma level within the narrow, recommended range. Brand-specific prescribing has long been considered critical to achieving this aim, but this is a convention based on very limited data. Objectives To explore the effect of selected demographic and clinical factors on t...

Background Medications with anticholinergic properties are associated with a range of adverse effects that tend to be worse in older people. Aims To investigate medication regimens with high anticholinergic burden, prescribed for older adults under the care of mental health services. Method Clinical audit of prescribing practice, using a standard...

Background Melatonin is commonly used to treat sleep disturbance in children and adolescents, although uncertainties about its optimal use remain. Objective To determine to what extent prescribing of melatonin complies with evidence-based clinical practice standards. Methods As part of a quality improvement programme, the Prescribing Observatory...

Introduction: Clozapine is the most effective antipsychotic medication for treatment-refractory schizophrenia but is reported to be under-used in the UK, potentially compromising outcomes for patients. The report from the national audit of psychosis in early intervention services suggests that involving a mental health pharmacist to identify indivi...

Background: Medically assisted alcohol withdrawal (MAAW) is increasingly undertaken on acute adult psychiatric wards. Aims: Comparison of the quality of MAAW between acute adult wards and specialist addictions units in mental health services. Method: Clinical audit conducted by the Prescribing Observatory for Mental Health (POMH). Information...

Background The licensed indications for valproate are narrow, yet this medication is commonly prescribed in mental health services. Objectives To explore the target symptoms/behaviours for which valproate is prescribed and how well the efficacy and tolerability of this treatment are monitored in routine clinical practice. Design An audit-based qu...

Introduction The Prescribing Observatory for Mental Health initiated a quality improvement (QI) programme on clozapine use in UK mental health services. Methods Clinical audits conducted in 2019 and 2021. Results Sixty-three participating NHS Trusts/healthcare organisations in 2019, and 61 in 2021, submitted treatment data for 6948 and 8155 patie...

Background Data from case series suggest that clozapine may benefit inpatients with borderline personality disorder (BPD), but randomised trials have not been conducted. Methods Multicentre, double-blind, placebo-controlled trial. We aimed to recruit 222 inpatients with severe BPD aged 18 or over, who had failed to respond to other antipsychotic m...

Aims and method A supply disruption alert in 2020, now rescinded, notified UK prescribers of the planned discontinuation of Priadel ® (lithium carbonate) tablets. This service evaluation explored lithium dose and plasma levels before and after the switching of lithium brands, in order to determine the interchangeability of different brands of lithi...

Background The use of continuing antipsychotic medication is an established evidence-based strategy for preventing relapse in people with schizophrenia, but medication adherence is known to be suboptimal. Covert non-adherence can be eliminated by the use of long-acting injectable (LAI) formulations. We sought to (1) raise awareness among clinicians...

Aims and method We conducted a secondary analysis of data from a Prescribing Observatory for Mental Health audit to assess the quality of requests from intellectual disability services to primary care for repeat prescriptions of antipsychotic medication. Results Forty-six National Health Service Trusts submitted treatment data on 977 adults with i...

Background Long-acting injectable (LAI) antipsychotic medications are used to optimise treatment outcomes in schizophrenia. Guaranteed medication delivery increases the responsibility of prescribers to monitor and manage adverse effects. Methods In the context of a quality improvement programme conducted by the Prescribing Observatory for Mental H...

Background: Sexual dysfunction is common among people who are prescribed antipsychotic medication for psychosis. Sexual dysfunction can impair quality of life and reduce treatment adherence. Switching antipsychotic medication may help, but the clinical effectiveness and cost-effectiveness of this approach is unclear. Objective: To examine whethe...

Background In addition to mandatory haematological monitoring, treatment guidelines recommend routine monitoring of adverse effects and physical health in patients prescribed clozapine. Methods NHS trusts/healthcare organisations participated in a clinical audit in the context of a UK quality improvement programme addressing clozapine-prescribing...

Background A quality improvement programme addressing prescribing practice for depression was initiated by the Prescribing Observatory for Mental Health. Methods A baseline clinical audit against evidence-based practice standards was conducted in UK adult mental health services. Results A total of 55 mental health services submitted data for 2082...

Background We aimed to assess the quality of physical health monitoring following rapid tranquillisation (RT) for acute behavioural disturbance in UK mental health services. Methods The Prescribing Observatory for Mental Health (POMH-UK) initiated an audit-based quality improvement programme addressing the pharmacological treatment of acute behavi...

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider t...

Background A quality improvement programme addressing prescribing practice for acutely disturbed behaviour was initiated by the Prescribing Observatory for Mental Health. Method This study analysed data from a baseline clinical audit conducted in inpatient mental health services in member trusts. Results Fifty-eight mental health services submitt...

Background A second antipsychotic is commonly added to clozapine to treat refractory schizophrenia, notwithstanding the limited evidence to support such practice. Methods The efficacy and adverse effects of this pharmacological strategy were examined in a double-blind, placebo-controlled, 12-week randomized trial of clozapine augmentation with ami...

The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals wit...

The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals wit...

Background No drug treatments are currently licensed for the treatment of borderline personality disorder (BPD). Despite this, people with this condition are frequently prescribed psychotropic medications and often with considerable polypharmacy. Preliminary studies have indicated that mood stabilisers may be of benefit to people with BPD. Objecti...

Objective: The authors examined whether lamotrigine is a clinically effective and cost-effective treatment for people with borderline personality disorder. Method: This was a multicenter, double-blind, placebo-controlled randomized trial. Between July 2013 and November 2016, the authors recruited 276 people age 18 or over who met diagnostic crit...

Background When treatment-refractory schizophrenia shows an insufficient response to a trial of clozapine, clinicians commonly add a second antipsychotic, despite the lack of robust evidence to justify this practice. Objectives The main objectives of the study were to establish the clinical effectiveness and cost-effectiveness of augmentation of c...

Background: Capturing service users' perspectives can highlight additional and different concerns to those of clinicians, but there are no up to date, self-report psychometrically sound measures of side effects of antipsychotic medications. Aim To develop a psychometrically sound measure to identify antipsychotic side effects important to service...

Background: The negative symptoms of schizophrenia represent deficiencies in emotional responsiveness, motivation and socialization that tend to be persistent despite standard antipsychotic treatment. Two sub-domains of expressive deficits (affective flattening and poverty of speech) and avolition-amotivation for daily-life and social activities (a...

Background: In around a third of people with schizophrenia, the illness responds poorly to standard treatment with antipsychotic medication. Clozapine is the only antipsychotic medication with robust evidence for efficacy in strictly defined treatment-resistant schizophrenia, but even then, an adequate response is seen in only 30%–60% of patients....

Objectives To determine the prevalence and quality of antipsychotic prescribing for people with intellectual disability (ID). Design A clinical audit of prescribing practice in the context of a quality improvement programme. Practice standards for audit were derived from relevant, evidence-based guidelines, including NICE. Data were mainly collect...

Excess deaths from cardiovascular disease are a major contributor to the significant reduction in life expectancy experienced by people with schizophrenia. Important risk factors in this are smoking, alcohol misuse, excessive weight gain and diabetes. Weight gain also reinforces service users' negative views of themselves and is a factor in poor ad...

Excess deaths from cardiovascular disease are a major contributor to the significant reduction in life expectancy experienced by people with schizophrenia. Important risk factors in this are smoking, alcohol misuse, excessive weight gain and diabetes. Weight gain also reinforces service users’ negative views of themselves and is a factor in poor ad...

Background: Negative symptoms of schizophrenia represent deficiencies in emotional responsiveness, motivation, socialisation, speech and movement. When persistent, they are held to account for much of the poor functional outcomes associated with schizophrenia. There are currently no approved pharmacological treatments. While the available evidence...

The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of i...

Objectives To increase the frequency and quality of screening for the metabolic syndrome in people prescribed continuing antipsychotic medication. Design An audit-based, quality improvement programme (QIP) with customised feedback to participating mental health services after each audit, including benchmarked data on their relative and absolute per...

Background: People with borderline personality disorder (BPD) experience rapid and distressing changes in mood, poor social functioning and have high rates of suicidal behaviour. Several small scale studies suggest that mood stabilizers may produce short-term reductions in symptoms of BPD, but have not been large enough to fully examine clinical a...

Guideline recommendations for the pharmacologic treatment of personality disorder lack consensus, particularly for emotionally unstable personality disorder (EUPD), and there is limited information on current prescribing practice in the United Kingdom. To characterize the nature and quality of current prescribing practice for personality disorder a...

Audit is an important tool for quality improvement. The collection of data on clinical performance against evidence-based and clinically relevant standards, which are considered by clinicians to be realistic in routine practice, can usefully prompt reflective practice and the implementation of change. Evidence of participation in clinical audit is...

The study was designed to test an audit-based quality improvement programme (QIP) addressing lithium prescribing and monitoring in UK mental health services. A baseline clinical audit was conducted against the following standards: (i) measurement of renal and thyroid function before initiating treatment with lithium and (ii) recommended monitoring...

Positive change in prescribing practice in psychiatric services can be achieved with participation in the UK Prescribing Observatory for Mental Health (POMH-UK) quality improvement programmes. Key elements are feedback of benchmarked performance for local clinical reflection and customised change interventions informed by the national audit finding...

Up to a quarter of people in the UK with a diagnosis of dementia are prescribed an antipsychotic in any year. The potential risks of such treatment are becoming clearer, but the benefits remain uncertain. Concern about the frequency and quality of such prescribing was expressed in the National Dementia Strategy for England in 2009. To provide an es...

Patient Group Directions (PGDs) have been used in clinical practice for a decade. They enable non-medical practitioners to supply medicines to patients, in certain legally defined circumstances, without a doctor's prescription and in accordance with a pre-defined protocol. The authors aimed to review the existing literature in order to identify and...

Nocturnal enuresis can be discomfiting and troublesome. There is increasing evidence that as a side-effect of second-generation antipsychotics, particularly clozapine, it may be underrecognised. Direct but sensitive questioning may be required to elicit this side-effect. We briefly review possible mechanisms of this problem, and management and trea...

Medication errors are a common cause of avoidable morbidity, and transfer between clinical settings is a known risk factor for such errors. Medicines reconciliation means there is no unintended discrepancy between the medication prescribed for a patient prior to admission and on admission. Our aim was to improve the quality of practice supporting m...

Data from the UK Prescribing Observatory for Mental Health (POMH-UK) suggest that while positive change in prescribing practice can be achieved with focused, audit-based, quality improvement programmes (QIPs) that include feedback of benchmarked performance data and customized change interventions, the time frame for progress is long and improvemen...

Antipsychotics are perceived to be over-used in the management of behavioural problems in people with an intellectual disability (ID). Published guidelines have set good practice standards for the use of these drugs for behavioural indications. We sought to identify the range of indications for which antipsychotic drugs are prescribed in people wit...

To examine the extent of use and clinical rationale for the prescribing of psychotropic drugs for people with personality disorder (PD) who are in contact with mental health services. Clinical records of 278 patients with a primary diagnosis of PD were examined. Just over 80% (N = 225) of patients were being prescribed psychotropic medication. One...

The negative symptoms of schizophrenia comprise a range of deficits in communication, emotional responsiveness, socialisation, capacity for experiencing pleasure, and motivation. Negative symptoms occur alongside positive symptoms such as delusions and hallucinations in acute psychotic episodes, where they generally respond to treatment with antips...

Antipsychotic polypharmacy refers to the co-prescription of more than one antipsychotic drug for an individual patient. Surveys of prescribing in psychiatric services internationally have identified the relatively frequent and consistent use of combined antipsychotics, usually for people with established schizophrenia, with a prevalence of up to 50...

The use of lithium for the treatment of mania, prophylaxis of bipolar disorder and augmentation of antidepressants in treatment-refractory unipolar depression is supported by British Association for Psychopharmacology and National Institute for Health and Clinical Excellence guidelines. We describe prescribing patterns with lithium in a large sampl...

Lithium is a commonly prescribed drug for treating bipolar disorder and unipolar (refractory) depression. Over 800 000 prescriptions for lithium salts were dispensed in England in 2008.1 Lithium has a narrow therapeutic range and may be affected by changes in renal function and fluid balance (for example, when a person is dehydrated or pregnant).2...

Lithium is a commonly prescribed drug with a narrow therapeutic index, and recognised adverse effects on the kidneys and thyroid. Clinical guidelines for the management of bipolar affective disorder published by The National Institute for Health and Clinical Excellence (NICE) recommend checks of renal and thyroid function before lithium is prescrib...

The use of antipsychotics for the treatment of behavioural and psychological symptoms of dementia (BPSD) is controversial. Antipsychotics cause harm and evidence-based guidelines advise against their use. We argue that antipsychotics may be justified using a palliative model: by reducing severe distress in those whose life expectancy is short.

Clinical studies of antipsychotic medication are a primary source of data on the nature of, and relative liability for, adverse effects, relevant to prescribing decisions in clinical practice. To identify how safety and tolerability data were collected and reported in recent clinical studies of antipsychotics. A survey was conducted of all 167 elig...

The NICE guideline titled, „Schizophrenia: core interventions in the treatment and management of schizophrenia in adults in primary and secondary care“, appeared in 2002, and was the first NICE guideline to be published. It was updated in 2009, and this article comments on some of the revised recommendations relating to pharmacotherapy. The accumul...

Data from the USA, Australia and Europe suggest that the proportion of patients with schizophrenia prescribed an antipsychotic long-acting injection (LAI) varies from around a quarter to a third. Use of LAIs has been associated with male gender and younger age. To characterise the use of LAIs in people with schizophrenia in three clinical settings...

Introduction: Although their primary purpose is to treat psychosis, antipsychotics are commonly prescribed for the elderly to treat the behavioural disturbances and agitation associated with dementia. Such use is controversial. Atypical antipsychotics cause fewer extrapyramidal sideeffects than the older drugs in younger adults, but the evidence b...

Introduction: There are no conclusive data to support the superior efficacy of any one antidepressant, while costs and side-effects are known to differ. The use of venlafaxine has been observed to be increasing within local services and this is associated with significant cost. This survey examined the patterns of use of new antidepressants by psy...

Objective. It takes 6 weeks for plasma levels of risperidone long-acting injection (RLAI) to reach steady state, and randomised controlled trials demonstrate a flat dose–response curve. In clinical practice, the dose of RLAI is often increased rapidly at the start of treatment and many patients receive a dose above 25 mg/2 weeks. We sought to under...

Although the majority of the population regularly consume caffeine, there are wide variations between individuals in both daily intake and susceptibility to caffeine's effects. These differences are at least partially genetically determined, possibly via variations in adenosine receptors or caffeine metabolism. Caffeine toxicity is well recognized....

Introduction: Adverse drug reactions (ADRs) are a recognized cause of avoidable morbidity and mortality in healthcare systems throughout the world. Drug allergies are one type of ADR. The Clinical Negligence Scheme for Trusts standards require that information regarding drug allergies should be readily accessible in clinical records to prevent re-e...

Introduction: The NICE technology appraisal for atypical antipsychotics in patients with schizophrenia recommends that prescribers and patients should make the choice of antipsychotic drug jointly. In order to make an informed choice, patients must feel that they have been given sufficient information. The aim of this study was to survey patients'...

Background: Valproate, carbamazepine and lithium are widely used in psychiatry but are teratogenic and require special caution when prescribed for women of child-bearing age. Aims: To evaluate the knowledge and stated practice of consultant psychiatrists with respect to the prescribing of these drugs to women of child-bearing age. Method: Semi-stru...

In the context of a project to benchmark anti-dementia drug prescribing practice against standards derived from evidence-based guidelines, the authors sought to estimate the proportion of people with dementia who were receiving treatment with an anti-dementia drug and whether this varied across Primary Care Trust (PCT) populations.They also explore...

The aim was to evaluate a quality improvement programme designed to increase screening for the metabolic syndrome in community psychiatric patients prescribed antipsychotics. Baseline audit against evidence-based standards, followed by provision of benchmarked data and a range of change interventions, with re-audit 1 year later. At baseline, 48 ass...

Midazolam is a benzodiazepine known to be effective as a treatment for status epilepticus and for rapid tranquillisation. Buccal midazolam has recently become available in the UK. We introduced it as a treatment option for rapid tranquillisation on our intensive care wards. Buccal midazolam was found to be effective and well tolerated. Target level...

Clinical guidelines recommend the routine use of a single antipsychotic drug in a standard dose, but prescriptions for high-dose and combined antipsychotics are common in clinical practice. To evaluate the effectiveness of a quality improvement programme in reducing the prevalence of high-dose and combined antipsychotic prescribing in acute adult i...

Psychotropic drugs reduce morbidity and mortality related to maternal mental illness but may also cause harm to the foetus, the nature and magnitude of which is not completely understood. Up-to-date information should be shared as fully as possible with the pregnant woman and a treatment plan agreed jointly.

Behavioural and psychological symptoms in dementia (BPSD) are common and distressing to both patients and carers. The use of antipsychotics to treat BPSD is associated with a high burden of side-effects and alternative strategies are required. Aromatherapy is an option that has been recommended for use in dementia. We aimed to review the evidence s...

Historically, psychiatry has been judged by its management of the ‘furiously mad’ (Turner 1996). In the current climate where inquiries into the care of patients are becoming increasingly common, considerable care has to be taken because of the risk of untoward incidents with acutely disturbed patients. On the one hand there is the necessity to pro...

Historical background Throughout human history different cultures have had to manage their most behaviourally disturbed and mentally ill members. Turner (1996) has written that historically psychiatry has been judged by its management of the ‘furiously mad’. Nearly three thousand years ago the King of Babylon was put to pasture (literally) after he...

‘Why do we need a book about psychiatric intensive care?’ ‘What IS psychiatric intensive care?’, ‘Is there any difference between intensive care and general psychiatry?’ ‘Where is the distinction between forensic psychiatry and psychiatric intensive care?, ‘What special skills do PICU staff require?’ Our first attempt to address some of these quest...

The first edition of this textbook was published in 2001 and its success surpassed our expectations. The editors have received many positive comments about the usefulness of the text and its relevance to everyday practice. The interest in the care of our most disturbed patients has been highlighted by both sales overseas and by the rapid translatio...

Midazolam is a benzodiazepine known to be effective as a treatment for status epilepticus and for rapid tranquillisation. Buccal midazolam has recently become available in the UK. We introduced it as a treatment option for rapid tranquillisation on our intensive care wards. Buccal midazolam was found to be effective and well tolerated. Target level...

Significantly expanded and updated from the first edition, this edition of Psychiatric Intensive Care is essential reading for all healthcare professionals and managers involved in the care of the mentally ill patient, particularly in the intensive care environment. It provides practical and evidence-based advice on the management of disturbed and...

Lithium, carbamazepine and valproate are established human teratogens. Women of childbearing potential who are prescribed these drugs should be informed of their teratogenic potential and advised of the need for adequate contraception and the protective role of folate. We reviewed the clinical records of all women of childbearing age in long-term c...

Reviews of the association between psychotic disorder, the metabolic syndrome, diabetes, and antipsychotic drugs conclude that there is a need for active, routine physical health screening of patients' prescribed antipsychotic drugs. From published guidelines, we derived the audit standard that all such patients should, as a minimum, have their blo...

Clozapine is associated with non-neurological side effects that can be subjectively unpleasant and/or clinically serious. We sought to: (i) assess the nature and prevalence of side effects experienced by patients receiving maintenance treatment with clozapine and (ii) explore the relationship between clozapine plasma concentration and side effect b...

Aims and Method Selective serotonin reuptake inhibitors (SSRIs) are recommended by the National Institute for Clinical Excellence as first-line drugs for the treatment of depression, but there is emerging evidence that they might not be entirely safe in pregnancy. We reviewed the literature in this area. Results Some data indicate an association b...

To conduct a meta-analysis of randomized placebo-controlled trials (RCTs) of clozapine augmentation with another antipsychotic drug in patient with schizophrenia who partially respond to clozapine and compare the results with the findings of relevant open studies. A systematic literature search was conducted to identify eligible RCTs. All baseline,...

It has been estimated that medication error harms 1-2% of patients admitted to general hospitals. There has been no previous systematic review of the incidence, cause or type of medication error in mental healthcare services. A systematic literature search for studies that examined the incidence or cause of medication error in one or more stage(s)...

With the exception of tetrabenazine which is used to treat choreiform movements, no placebo controlled or randomised controlled trials were identified. The literature consists entirely of case reports and case series. Most are old and treatment is largely empirical. There is, therefore, poor evidence on which to base decisions for the management of...

Two generic preparations of clozapine have been licensed in the UK. The bioequivalence of these products compared with Clozaril has not been unequivocally demonstrated. Clinical equivalence has also been questioned. The objective of this study was to determine clinical outcomes for all patients switched from Clozaril to a generic formulation in one...

Rapid Tranquillisation (RT), defined as “the use of psychotropic medication to control agitated, threatening or destructive psychotic behaviour”, is a last resort pharmacological intervention. The withdrawal of the widely used droperidol in 2001 due to concerns over QTc prolongation may have increased the variability in RT practice across the UK. T...

Lipid abnormalities are common in the general population and early data suggests that they may be more common in people with schizophrenia. Little data exist from treatment-naive patients making it difficult to differentiate any genetic contribution associated with a diagnosis of schizophrenia from the lifestyle risks associated with this diagnosis...

Gastroprotection may be justified in some patients

Background: psychiatric intensive care facilities have previously been poorly defined, with uncertainty existing about the appropriateness of admissions. aim: to offer the first large-scale systematic survey describing the clinical characteristics of patients admitted to psychiatric intensive care units. method: a questionnaire was sent to ward man...