Exploring the clinical factors affecting lithium dose and plasma level and the effect of brand.

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 the relationship between lithium dose and plasma level and determine whether there is an independent effect of lithium brand.

Understanding the medication regimens associated with anticholinergic burden in older people's mental health services in the UK.

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 standardised data collection tool.

Quality of melatonin use in children and adolescents: findings from a UK clinical audit.

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 for Mental Health conducted a retrospective clinical audit in UK services for children and adolescents.

Management of medically assisted withdrawal from alcohol in acute adult mental health and specialist addictions in-patient services: UK clinical audit findings.

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).

Who is prescribed valproate and how carefully is this treatment reviewed in UK mental health services? Data from a clinical audit.

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 quality improvement (QI) programme in UK mental health services.

Prescribing clozapine in the UK: Quality improvement issues identified by clinical audit.

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 patients, respectively.

The clinical effectiveness and cost effectiveness of clozapine for inpatients with severe borderline personality disorder (CALMED study): a randomised placebo-controlled trial.

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 medications.

Can the use of long-acting injectable antipsychotic preparations be increased in routine clinical practice and the benefits realised?

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 of the potential benefits of LAI antipsychotic formulations, (2) increase use of these formulations for the treatment of schizophrenia in routine clinical practice and thereby (3) reduce the number of relapses requiring hospitalisation in patients with schizophrenia under our care.

Plus ça change? Switching lithium preparations.

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 lithium from a pharmacokinetic perspective.

Results: Data on the treatment of 37 patients switched from Priadel tablets were analysed.

Prescribing antipsychotic medication for adults with intellectual disability: shared responsibilities between mental health services and primary care.

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 intellectual disability, receiving antipsychotic medication for more than a year, for whom prescribing responsibility had been transferred to primary care. Therapeutic effects had been monitored in the past 6 months in 80% of cases with a documented communication indicating which service was responsible for this and 72% of those with no such communication.

Side-effect monitoring of continuing LAI antipsychotic medication in UK adult mental health services.

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 Health, a clinical audit addressed documented side-effect monitoring in patients prescribed continuing LAI antipsychotic medication under the care of United Kingdom adult mental health services.

Switching antipsychotic medication to reduce sexual dysfunction in people with psychosis: the REMEDY RCT.

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.

The physical health and side-effect monitoring of patients prescribed clozapine: data from a clinical audit conducted in UK mental health services.

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 practice.

Results: Data relating to 6948 adult patients prescribed clozapine were submitted by 63 NHS trusts/healthcare organisations.

Prescribing for moderate or severe unipolar depression in patients under the long-term care of UK adult mental health services.

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 patients, under the care of a community psychiatric team (CMHT) for at least a year, with a diagnosis of moderate or severe unipolar depression, 54% of whom had a comorbid psychiatric diagnosis.

Physical health monitoring after rapid tranquillisation: clinical practice in UK mental health services.

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 behavioural disturbance in mental health services in the UK.

Results: Data relating to a total of 2454 episodes of RT were submitted by 66 mental health services.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology.

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.

The pharmacological management of acute behavioural disturbance: Data from a clinical audit conducted in UK mental health services.

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 submitted data on 2172 episodes of acutely disturbed behaviour.

Amisulpride augmentation of clozapine for treatment-refractory schizophrenia: a double-blind, placebo-controlled trial.

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 amisulpride, involving 68 adults with treatment-resistant schizophrenia and persistent symptoms despite a predefined trial of clozapine.

Results: There were no statistically significant differences between the amisulpride and placebo groups on the primary outcome measure (clinical response defined as a 20% reduction in total Positive and Negative Syndrome Scale score) or other mental state measures.

Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation.

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 with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder.

A UK clinical audit addressing the quality of prescribing of sodium valproate for bipolar disorder in women of childbearing age.

Objectives: To review prescribing practice concerning valproate, an established human teratogen, for the management of bipolar disorder in women of childbearing age.

Design: The Prescribing Observatory for Mental Health conducted a baseline clinical audit in the UK, as part of a quality improvement programme.

Participants: Six hundred and forty-eight clinical teams from 55 mental health Trusts submitted retrospective treatment data relating to patients with a diagnosis of bipolar disorder.

Lamotrigine for people with borderline personality disorder: a RCT.

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.

The Clinical Effectiveness and Cost-Effectiveness of Lamotrigine in Borderline Personality Disorder: A Randomized Placebo-Controlled Trial.

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 criteria for borderline personality disorder.

Amisulpride augmentation in clozapine-unresponsive schizophrenia (AMICUS): a double-blind, placebo-controlled, randomised trial of clinical effectiveness and cost-effectiveness.

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 clozapine medication with a second antipsychotic, amisulpride, for the management of treatment-resistant schizophrenia.

Design: The study was a multicentre, double-blind, individually randomised, placebo-controlled trial with follow-up at 12 weeks.

Quality of prescribing of antipsychotic medication for people with intellectual disability under the care of UK mental health services: a cross-sectional audit of clinical practice.

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.

Antidepressant Controlled Trial For Negative Symptoms In Schizophrenia (ACTIONS): a double-blind, placebo-controlled, randomised clinical trial.

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.