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Prescribing & monitoring high dose & combined antipsychotics in CMHT

Dipanjan Banerjee*, Umama Khan, Tracey Green

Background: Antipsychotics are the cornerstone of the management of psychotic disorders. Many causes, including treatment resistance, might prompt clinicians to prescribe multiple antipsychotics or over BNF recommended maximum dose, which is associated with reduced patient compliance and an increased risk of undesired pharmacological effects necessitating regular monitoring.

Aims: The aim was to establish the prevalence of prescription of combined and high dose antipsychotics in community mental health teams and to see if such patients were being offered regular monitoring, as advised by NICE guidelines.

Method: A retrospective audit of 50 case notes of patients currently on antipsychotics was done. Case notes were selected randomly from a pool of 300 patients in cluster 11 and 12. Data was then gathered on patient demographics, diagnosis, medications, indications, and regular monitoring. Afterward, the data were analyzed and discussed with a consultant psychiatrist and senior mental health pharmacist.

Outcome: 90% of the patients were on single antipsychotic, 4.45% of them were above BNF recommended maximum dose. 10% of patients on combined antipsychotics, 40% of them were above BNF recommended maximum dose. A total of 8% of patients were on above BNF recommended maximum dose. All the patients on high dose antipsychotics had a clear plan documented in the system. Documented monitoring of Full blood count was found in 75%, blood glucose in 50%, lipid in 75%, cardiac monitoring (ECG) in 0%, physical health monitoring in 0%.

Conclusion: The data showed areas of good practice as the majority of the patients were on monotherapy, and all the patients on a high dose or combined antipsychotics had clear management plans mentioned in their notes. However, the audit also highlighted areas that currently need improvements such as regular monitoring of the patients on a high dose and combined antipsychotics; it should also be clearly documented, recorded, and reviewed at intervals.