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Aim: Previous research has documented the widespread use of antipsychotic drugs by nursing staff with older persons, although less is known about the knowledge that nurses actually have about these drugs. The purpose of this exploratory, descriptive study was to survey a sample of UK gerontological nurses from different work settings on their knowledge of antipsychotic drugs.Methods: An exploratory descriptive study design was utilised, whereby a sample of nursing staff was given a questionnaire developed to determine knowledge about antipsychotic drugs and their use with older persons. Questionnaires were distributed to 100 nursing staff, including registered general nurses, registered mental nurses, state enrolled nurses, nursing assistants and care assistants. Of the 100 questionnaires distributed, 62 were returned and 57 were completed substantially enough for data analysis.Results: Descriptive statistics including frequencies and means were calculated for demographic variables and the questionnaire responses. Results indicated that the use of antipsychotic drugs within the psychiatric hospital setting was substantial, with 43.7% of patients receiving antipsychotic drugs, for an average length of time of 1.8 years. Conclusions: Nursing staff participants from all three work settings revealed a number of significant knowledge gaps, particularly with regard to appropriate indications for antipsychotic drugs with older persons and the side‐effects of antipsychotic drugs. Summary: This paper adds new information regarding the use of antipsychotic drugs in the nursing care of older people.

One in 14 people over 65 years suffer from dementia in the UK. Over 25 per cent are receiving antipsychotics, which cause increases in mortality and cerebrovascular events. The need for a reduction and the use of alternative supportive strategies has been advocated. Risperidone at six‐week intervals is the only antipsychotic licensed for treatment with regular review. The majority of management occurs at primary care level and in care homes. The purpose of this paper is to investigate antipsychotic prescribing practices and patient review in these settings.

In total, two surveys comprising questions addressing prescribing practices were developed and distributed electronically to all GP practices and care homes in Coventry and Warwickshire, West Midlands, England.

The majority of GPs (75 per cent) reported only “occasional” discontinuation of antipsychotics due to concerns at reducing drugs on their own, expectations of regulation from secondary care and resistance from care home staff. Poor reduction levels were reported in care homes, attributing low numbers to reluctance among GPs. History of cardiovascular risk factors did not appear to influence withdrawal. Only 40 per cent of GP practices maintained sole use of risperidone. At least six‐monthly reviews were reported by 63 per cent of GPs and 64 per cent of care homes, with very few conducting reviews at least three‐monthly. The importance of non‐pharmacological alternatives was emphasized, yet access was limited and highly resource‐dependent.

This study reveals the perspectives of staff delivering healthcare for people with dementia and behavioural and psychological symptoms of dementia (BPSD). Potentially inappropriate antipsychotic principles were reported. A lack of communication and uncertainty of roles was evident. The development of understandable guidelines for healthcare workers and care home staff managing behavioural issues in patients with dementia is necessary.

The use of pharmacological interventions in the treatment of forensic psychiatric patients constitutes an important part of the day‐to‐day practice of mental health professionals working in this important psychiatric sub‐speciality. It involves not just the prescription of specific drugs, but also the regular monitoring of their effects and possible side effects. Such monitoring involves the collaboration of professionals working in very different fields such as medicine, nursing, occupational therapy, physiotherapy and pharmacy.

This audit was conducted on acute psychiatric in‐patient wards with the aim of establishing if valproate prescribing in acute mania followed evidence‐based guidelines with particular emphasis on formulations used and whether accelerated valproate dosing was employed.

Case notes from 43 (42 percent male) patients admitted with mania and subsequently discharged on valproate were reviewed. Valproate formulation, weight measurement (necessary for dose‐calculation in accelerated dosing), initial valproate dose and increments, serum valproate monitoring and other prescribed psychotropic agents were noted.

Most (95 percent) patients received sodium valproate (epilim chrono/generic), the remaining received valproate semi‐sodium (depakote). All but one patient received antipsychotic medication in combination. Weight was recorded in only four (9 percent) patients. The mean valproate daily dose after the first week was 1,027 mg (sd=408). It took 29 (sd=42) days to reach the maximum daily dose (1,426 mg sd=467) from valproate initiation. Serum levels were monitored in 34 (79 percent) cases, but the mean period between valproate initiation to the first serum level test was 38 (sd=47) days. A significant positive correlation was found between days taken to reach maximum dose and hospital stay (Spearman's rho=0.41, n=43, p=0.006, two‐tailed).

Accelerated valproate dosing was not common practice, which may have resulted in suboptimal efficacy, probably leading to combination treatment.

This study highlights the need for adequate initial dosing and dose increments when treating manic patients and suggests current practice is not evidence‐based. Local prescribing policy and national guidelines' influence on practice are discussed.

Patients with severe mental illness (SMI) treated with antipsychotic medication are at increased risk of metabolic side‐effects like weight gain, diabetes mellitus and dyslipidaemia. This study aims to examine the feasibility of maintaining a physical health monitoring sheet in patients' records and its impact on physical health of patients with SMI, over a period of one year.

A physical health monitoring sheet was introduced in all the patients' records on a 15‐bedded male medium secure forensic psychiatric rehabilitation unit, as a prompt to regularly monitor physical health parameters. An audit cycle was completed over a one year period. The data between baseline and re‐audit were compared.

At baseline, 80 per cent of the patients were identified as smokers, 80 per cent had increased body mass index (BMI) and 87 per cent had raised cardiovascular risk over the next ten years. Appropriate interventions were offered to address the risks. At re‐audit, the physical health monitoring sheets were up to date in 100 per cent of patients' records. The serum lipids and cardiovascular risk over the next ten years reduced over time. No significant change was noted on the parameters including BMI, central obesity, high blood pressure and smoking status.

This was a pilot study and was limited by the small sample size, male gender only and the specific nature of the ward.

There is a need for improved access to physical health care in long‐stay psychiatric settings. A more robust lifestyle modification programme is required to positively influence the physical health parameters in this cohort of patients.

Introduction of a physical health monitoring sheet in patients' records led to regular screening of cardiovascular risks and subsequent increased prescribing of hypolipidaemic agents in individuals with severe mental illness.

Research has shown that academic detailing (AD), which includes repeated in-person educational messages in an interactive format in a physician’s office, is among the most effective continuing medical education (CME) forms for improving prescribing practices and reducing drug costs. The purpose of this paper is to investigate AD’s feasibility and acceptability as an educational tool among psychiatrists and its ability to facilitate positive changes in antipsychotic prescribing.

All psychiatrists practicing in Southwestern Ontario, Canada were invited to participate. Participants (32/299(10.7 percent)) were provided with two educational sessions by a healthcare professional. Participants evaluated their AD visits and completed a pre- and post-AD questionnaire measuring various prescribing practice aspects.

A total of 26 out of 32 (81.3 percent) participants completed the post-AD evaluation; most of them (61.5 percent, n=16) felt that AD gave noteworthy information on tools for monitoring side-effects and 50.0 percent (n=13) endorsed using these in practice. In total, 13 participants (50.0 percent) felt that the AD sessions gave them helpful information on tools for documenting polypharmacy use, which 46.2 percent (n=12) indicated they would implement in their practice. No significant differences were found between participants’ pre- and post-assessment prescribing behaviors.

There is great need for raising AD program’s awareness and improving physician engagement in this process locally, provincially and nationally.

To the authors’ knowledge, this is the first AD program in Canada to target specialists solely. Participant psychiatrists accepted the AD intervention and perceived it as a feasible CME method.

Clozapine is often considered the gold standard for the treatment of schizophrenia. Clinical guidelines suggest a gradual titration over 2 weeks to reduce the risks of adverse events such as seizures, hypotension, agranulocytosis, and myocarditis. The slow titration often delays time to therapeutic response. This raises the question of whether, in some patients, it may be safe to use a more rapid clozapine titration. The following case illustrates the potential risks associated with the use of multiple antipsychotics and rapid cloza-pine titration. We present the case of a young man with schizophrenia who developed life threatening neuroleptic malignant syndrome (NMS) during rapid clozapine titration and treatment with multiple antipsychotics. We were unable to find another case in the literature of NMS associated with rapid clozapine titration. This case is meant to urge clinicians to carefully evaluate the risks and benefits of rapid clozapine titration, and to encourage researchers to further evaluate the safety of rapid clozapine titration. Rapid clozapine titration has implications for decreasing health care costs associated with prolonged hospitalizations, and decreasing the emotional suffering associated with uncontrolled symptoms of psychosis. Clozapine is considered the most effective antipsychotic available thus efforts should focus on developing strategies that would allow for safest and most efficient use of clozapine to encourage its utilization for treatment resistance schizophrenia.

Integrated health care occurs when specialty and general care providers work together to address both the physical and mental health needs of their patients. The Substance Abuse and Mental Health Services Administration model of integration is broken into six levels of coordinated, co-located and integrated care. Our institution offers both co-located and integrated care among eight clinic sites. The care team is typically composed of the primary care provider, nurse and medical assistant, but other professionals may be introduced based on the patient’s medical and psychiatric conditions. The purpose of this prospective, quality improvement study was to compare the rates of adherence to long-acting injectable antipsychotics (LAIAs) between both types of integrated primary care settings at our institution. The comparison of the two settings sought to determine which environment provides improved outcomes for patients with serious psychiatric illnesses. Additionally, we aimed to assess the quality of medication-related monitoring and care team composition between care settings, and the ability of pharmacists to deliver interprofessional care team training and education on LAI use in clinical practice.

Subjects were identified and included in the study if they had received primary care services from our institution within the previous 12 months. Patient demographic and laboratory variables were collected at baseline and when clinically indicated. The rates of adherence between care settings were assessed at intervals that align with the medication’s administration schedule (e.g. every four weeks). Medication-related monitoring parameters were collected at baseline and when clinically indicated. The interprofessional care team completed Likert scale surveys to evaluate the pharmacist’s LAIA education and training.

There was not a statistically significant difference detected between integrated primary care settings on the rates of adherence to LAIAs. Additionally, there was not a statistically significant difference between rates of adherence to medication-related monitoring parameters or the effect of the patient treatment team composition. There was a statistically significant difference between pre- and post-session survey scores following interprofessional education and training provided by a pharmacist.

Because overall rates of adherence were low, both primary care settings were found to be equivalent. Our study may have been underpowered to detect a difference in the primary endpoint because of the small sample size. However, our study demonstrates that interprofessional education and training may lend itself to changes in practice, which is evident by the clinically significant relative increase in adherence. The Henry J. Austin Health Center network will be implementing a standard operating procedure regarding LAIA management within the primary care setting. Further studies are needed to assess a larger number of patients between both types of primary care settings, as well as the impact of the clinical psychiatric pharmacist as a member of the treatment team.

Since the development of antipsychotic drugs in the 1950s, a variety of studies and case reports have been published that suggest an association between exposure to typical antipsychotics and venous thromboembolisms (VTE). Therefore, when starting treatment with antipsychotics, especially low-potency typical antipsychotics and clozapine, health-care providers must account for the patient’s existing VTE risk factors.

In this case report, the authors describe the development of a pulmonary embolism associated with use of chlorpromazine in the treatment of an acute manic episode in a 51-year-old female patient with bipolar disorder type 1.

The patient was brought to the emergency room by the police on a legal hold for bizarre behaviors at a bus stop, which included incessantly yelling at bystanders. The patient was found to have disorganized thoughts, poor sleep, rapid speech, labile mood, distractibility, auditory hallucinations and grandiose delusions. During the course of her stay, the patient received extensive IM chlorpromazine for extreme agitation, in addition to chlorpromazine 200 mg IM Q8H, which was later decreased to chlorpromazine 100 mg chlorpromazine IM/PO Q8H. On day 4 of the treatment, the patient experienced difficulty breathing, hypoxia and tachycardia and was found to have bilateral expiratory wheezes. CT angiography showed sub-segmental pulmonary embolus and the patient was transferred to MICU service. The patient was then intubated and started on heparin by the medical team. Over the course of the next day, her respiratory distress resolved and the patient was extubated.

It is possible that chlorpromazine may indeed increase VTEs, and there are various physiological postulations regarding the mechanism of action. However, multiple confounding variables existed in the authors’ report, including venous stasis and the use of restraints, tobacco and valproic acid. Each of these variables has been shown to increase VTE occurrence. Further controlled studies are necessary to identify the true relationship between antipsychotics and VTEs.

Long‐term care is getting more attention these days due to its impact on the growth of overall healthcare cost. With the implementation of the Medicare Part D prescription drug plan, the incentives and payment dynamics have changed the long‐term care market. This paper seeks to focus on the pharmaceutical market in the long‐term care space and to identify a few characteristics for the stakeholders' strategies.

The study used the IMS data sets, complemented by the information and statistics available in the literature to isolate the long‐term care market with regard to pharmaceutical products, its characteristics and dynamics.

The analysis showed that the market for pharmaceutical products in the long‐term‐care space is characterized by a couple of therapeutic classes, concentrated in a rather few geographical area in the USA. The traditional institutional based care is declining but the home health care use is increasing.

Access to the IMS data makes the findings of the study unique. Given the government sponsored prescription drug plan for the elderly is expanding, it will be of significant value to document the impact of the Part D plan on the overall healthcare cost in a dynamic long‐term care market.