An audit to look at the prescribing of psychotropic medication in the general adult inpatient setting in patients with emotionally unstable personality disorder

AimsTo assess the frequency of prescription of psychotropic medication in patients with a primary diagnosis of emotionally unstable personality disorder (EUPD) following admission to Clock View Hospital, an inpatient unit in Mersey Care NHS Foundation Trust.MethodA retrospective analysis of the electronic (RiO) record of 50 patients discharged from Clock View Hospital between 1 January 2020 and 1 November 2020 was performed to assess prescribing practice.Twenty-five patients with a diagnosis of EUPD and no associated psychiatric comorbidities were included in the sample, as well as 25 patients with a diagnosis of EUPD and associated psychiatric comorbidities.Result80% of the 25 patients with EUPD and associated psychiatric comorbidities were prescribed psychotropic medication prior to admission to hospital (56% an antidepressant, 24% a mood stabiliser, 60% an antipsychotic and 8% a benzodiazepine). 64% of patients were prescribed two or more psychotropic medications. 28% were initiated on new psychotropic medications following admission. For four of the seven prescriptions commenced on psychotropic medication, prescribing practice was as advised in Mersey Care's EUPD guidelines.Of the 25 patients with EUPD and no associated psychiatric comorbidities, 96% of the patients were prescribed psychotropic medication prior to admission to hospital (56% an antidepressant, 20% a mood stabiliser, 72% an antipsychotic and 12% a benzodiazepine). 68% of patients were prescribed two or more psychotropic medications. Following admission, 28% of patients were initiated on new regular psychotropic medications. For five of the eight prescriptions for new psychotropic medication, prescribing practice was as advised in Mersey Care's EUPD guidelines.78% of the 50 patients were prescribed as required (PRN) psychotropic medication. In 21 patients, PRN medication was prescribed for longer than one week.ConclusionThere is a higher rate of prescribing of antipsychotic prescription in those EUPD patients with no psychiatric comorbidities compared to associated psychiatric comorbidities (72% vs 60%). Surprisingly, there was a lower rate of psychotropic polypharmacy in those with psychiatric comorbidities.Use of PRN psychotropic medication for longer than a week was higher in those patients with psychiatric comorbidities compared to those without psychiatric comorbidities (58% vs 50%). Benzodiazepines were overwhelmingly the most consistently prescribed PRN medication for patients with EUPD.One action to consider would be highlighting the importance of trialling psychologically-minded interventions and supportive psychotherapy prior to initiation of psychotropic medication. There also needs to be consideration to use of the sedative antihistamine promethazine as a first-line PRN medication for acute agitation.

Impact of the COVID-19 pandemic on remote mental healthcare and prescribing in psychiatry: an electronic health record study

ObjectivesThe recent COVID-19 pandemic has disrupted mental healthcare delivery, with many services shifting from in-person to remote patient contact. We investigated the impact of the pandemic on the use of remote consultation and on the prescribing of psychiatric medications.Design and settingThe Clinical Record Interactive Search tool was used to examine deidentified electronic health records of people receiving mental healthcare from the South London and Maudsley (SLaM) NHS Foundation Trust. Data from the period before and after the onset of the pandemic were analysed using linear regression, and visualised using locally estimated scatterplot smoothing.ParticipantsAll patients receiving care from SLaM between 7 January 2019 and 20 September 2020 (around 37 500 patients per week).Outcome measures(i) The number of clinical contacts (in-person, remote or non-attended) with mental healthcare professionals per week.(ii) Prescribing of antipsychotic and mood stabiliser medications per week.ResultsFollowing the onset of the pandemic, the frequency of in-person contacts was significantly reduced compared with that in the previous year (β coefficient: −5829.6 contacts, 95% CI −6919.5 to −4739.6, p<0.001), while the frequency of remote contacts significantly increased (β coefficient: 3338.5 contacts, 95% CI 3074.4 to 3602.7, p<0.001). Rates of remote consultation were lower in older adults than in working age adults, children and adolescents. Despite this change in the type of patient contact, antipsychotic and mood stabiliser prescribing remained at similar levels.ConclusionsThe COVID-19 pandemic has been associated with a marked increase in remote consultation, particularly among younger patients. However, there was no evidence that this has led to changes in psychiatric prescribing. Nevertheless, further work is needed to ensure that older patients are able to access mental healthcare remotely.

Impact of the COVID-19 pandemic on remote mental healthcare and prescribing in psychiatry

ObjectivesThe recent COVID-19 pandemic has disrupted mental healthcare delivery, with many services shifting from in- person to remote patient contact. We investigated the impact of the pandemic on the use of remote consultation and on the prescribing of psychiatric medications.Design and settingThe Clinical Record Interactive Search tool (CRIS) was used to examine de-identified electronic health records (EHRs) of people receiving mental healthcare from the South London and Maudsley (SLaM) NHS Foundation Trust. Data from the period before and after the onset of the pandemic were analysed using linear regression, and visualised using locally estimated scatterplot smoothing (LOESS).ParticipantsAll patients receiving care from SLaM between 7th January 2019 and 20th September 2020 (around 37,500 patients per week).Outcome measuresThe number of clinical contacts (in-person, remote or non-attended) with mental healthcare professionals per weekPrescribing of antipsychotic and mood stabiliser medications per weekResultsFollowing the onset of the pandemic, the frequency of in-person contacts was significantly reduced compared to that in the previous year (β coefficient: −5829.6 contacts, 95% CI −6919.5 to −4739.6, p<0.001), while the frequency of remote contacts significantly increased (β coefficient: 3338.5 contacts, 95% CI 3074.4 to 3602.7, p<0.001). Rates of remote consultation were lower in older adults than in working age adults, children and adolescents. Despite this change in the type of patient contact, antipsychotic and mood stabiliser prescribing remained at similar levels.ConclusionsThe COVID-19 pandemic has been associated with a marked increase in remote consultation, particularly among younger patients. However, there was no evidence that this has led to changes in psychiatric prescribing. Nevertheless, further work is needed to ensure that older patients are able to access mental healthcare remotely.

Psychotic disorders as an adverse effect of levetiracetam or discontinuation of mood stabilising drugs

Patients using antiepileptic drugs (AEDs) suffer from relatively common adverse effects manifested by psychotic and behavioural disorders. This is particularly true in patients with a history of psychiatric disorders and using levetiracetam. This has important therapeutic implications because very often discontinuation of AED is the only available option. Simultaneous use of mood-stabilising AEDs reduces this risk; however, too rapid withdrawal of such AEDs can also induce psychotic symptoms. We present four cases of epilepsy patients who experienced psychiatric disorders induced by LEV. In one of them, they occurred after adding LEV to the treatment; in two – after discontinuation of a mood-stabiliser; and in one both modifications were made simultaneously. Our cases show that LEV-induced behavioural disorders are dose-dependent and do not always require discontinuation of the drug. This seems to be justified by good seizure control ensured by the use of LEV, and using mood-stabiliser reduces LEV adverse effects.

Defining a mood stabiliser: novel framework for research and clinical practice

SummaryThe term ‘mood stabiliser’ is ill-defined and lacks clinical utility. We propose a framework to evaluate medications and effectively communicate their mood stabilising properties – their acute and prophylactic efficacy across the domains of mania and depression. The standardised framework provides a common definition to facilitate research and clinical practice.Declaration of interestThe Treatment Algorithm Group (TAG) was supported logistically by Servier who provided financial assistance with travel and accommodation for those TAG members travelling interstate or overseas to attend the meeting in Sydney (held on 18 November 2017). None of the committee were paid to participate in this project and Servier have not had any input into the content, format or outputs from this project.

Recalibrating the risks and benefits of lithium therapy

SummaryRecent data might subtly recalibrate the risk/benefit ratio of lithium, the prototypical mood stabiliser for bipolar disorder. There are hints that lithium might be associated with a reduction in dementia risk and as noted in this Journal, a surprising reduction in the risk of cancer.