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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.

There is a considerable disparity between clinical practice and recommendations based on meta-analyses of antipsychotic polypharmacy in clozapine resistant schizophrenia. For this reason, we investigated the clinical response to reducing the use olanzapine that had been previously added on clozapine treatment among seriously ill hospitalized patients. In a randomized controlled trial with crossover design, we studied volunteer patients (N=15) who had olanzapine added on to clozapine in a state mental hospital. Clozapine monotherapy was just as effective as clozapine-olanzapine therapy, according to results from Clinical Global Impression Scale and Global Assessment of Functioning as primary outcome measures. Polypharmacy is widely used in treating schizophrenia, and usually, add-on medications are started because of worsening of the clinical state. A major confounding feature of these add-ons is whether observed improvements are caused by the medication or explained by the natural fluctuating course of the disorder. The present study, in spite of its small size, indicates the necessity of reconsidering the value of polypharmacy in treating schizophrenia.

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.

Review of antipsychotic prescribing practices, rationale and follow-up using an internationally standardized audit can be an effective tool to encourage and monitor best practices. The purpose of this study is to audit the current prescribing pattern for people with intellectual disabilities and challenging behaviours in Qatar.

This study was based on the challenging behaviour management guidelines recommended by the Royal College of Psychiatrists. All current electronic medical records in the Mental Health Service-Hamad Medical Corporation were examined to identify patients with intellectual disabilities who received antipsychotics for challenging behaviour. Demographic variables, such as age, sex and nationality, were collected. In addition, details of psychiatric diagnoses, prescribed psychotropic medications and diagnoses of epilepsy were also collected. For patients who were prescribed antipsychotic medication, the clinical rationale for such medication was collected along with evidence of side effect monitoring to allow performance against the audit standards to be measured.

This is the first audit on prescribing practices in people with intellectual disability and challenging behaviour in the state of Qatar. The results of this study regarding the pattern of prescribing practices for patients with intellectual disability and challenging behaviour reflect the limitation in knowledge and experience among non-specialist practitioners within mental health service. The result may be helpful to support the development of specialist service provision to improve the care for such vulnerable group. The result may also help other medical centres and clinicians by providing an improved understanding of possible deviations from the best medical practices.

This is the first audit on prescribing practices in people with intellectual disability and challenging behaviour in the state of Qatar. The study is also noteworthy as, to the best of the authors’ knowledge, it is one of only a few studies on antipsychotic prescribing for patients with intellectual disability and challenging behaviour in the Middle East; therefore, it will be useful in raising awareness and promoting the best practices in the Middle East region. This study is also among the first few studies that were designed based on the four audit standards by the Royal College of Psychiatrists in this area.

In past years, Zuclopenthixolacetate as well as Flupentixoldecanoate have each proven to be reliable and efficient in the treatment of schizophrenic psychoses. In a specially implemented psychiatric treatment unit (PTU) we administered a high‐dose depot neuroleptic combination therapy initially consisting of both substances to seriously ill schizophrenic prisoners who exhibited highly aggressive behaviour (N = 20). We initially used both antipsychotics at the same time as a simple regimen in order to restore the prisoners’ health to enable them to return to their home prisons. A single coercive intervention was performed in 14 out of 20 prisoners which was followed by a second one in two cases according to Article 101 of the German Code of Criminal Procedure. On average, prisoners needed a treatment course of 30.4 days. Within this time PANSS global scores were reduced by approximately 40%. Side effects occurring as a consequence of neuroleptic treatment were negligible and could be dealt with.

The purpose of this paper is to describe a completed audit cycle of the assessment and documentation of antipsychotic side effects reported by patients in a secure hospital setting.

The initial audit was carried out in 2012. As a result of the findings clinicians were recommended to use a brief structured side effect monitoring guide (the Glasgow Antipsychotic Side-Effect Scale (GASS-m)). The audit was repeated in 2015.

Of the 41 patients notes included in the initial audit, for only one (2.4 per cent) was there evidence of a systematic and structured approach to monitoring antipsychotic side effects. In the repeat audit this figure (and use of the GASS-m) had increased to 21/45 (46.7 per cent). For all patients where the GASS-m had been used (n=21) the overall severity of side effects was in the “mild” range (0-21).

Sample size was modest and the study was conducted in an independent secure hospital so may not be generalisable to the NHS.

Use of structured tools/guides to monitor patients’ side effects is recommended so that emergent side effects can be readily recognised, tracked and managed and, relapses made less likely through improved compliance and thus patients’ quality of life improved. This is very important for forensic patients since relapses are likely to increase risk to others.

Previous audits have addressed physical health monitoring of patients on antipsychotics but not by asking them about side effects.

The purpose of this paper is to review the efficacy of atypical antipsychotics in combination with clozapine. Previous meta-analyses have assessed the use of both typical and atypical antipsychotics in combination with clozapine, combination treatment being withheld only for those patients deemed treatment resistant.

Outcomes assessed included: positive, negative and overall symptom score. The total numbers of participants (n=588) were scored using the Positive and Negative Symptom Scale/the Brief Psychiatric Rating Scale and effect sizes were used to judge the efficacy of the combination treatments. Data gained from the ten randomized, double blind, placebo controlled trials were analysed using the R statistical software.

The effect sizes gained from analysis showed a small benefit of combination therapy over clozapine monotherapy. Therefore, it is the recommendation of this analysis that alternative avenues be sought in order to treat patients who have a sub-optimal response to clozapine with a combination other than two second generation antipsychotics.

The initial trials search unveiled 1,412 studies. After the inclusion and exclusion criteria were applied, ten trials were used in this meta-analysis.

The recommendation of this analysis that alternative medications be sought in order to treat patients who have a sub-optimal response to clozapine with a combination other than two second generation antipsychotics. This route should only be used once all other treatment options have been exhausted.

This meta-analytical study looks specifically at the combination of atypical antipsychotics with clozapine in comparison to clozapine monotherapy. This work extends existing meta-analysis by incorporating data from more recent trials.

The purpose of this paper is to identify the training needs of the next generation of psychiatrists, and barriers in prescribing first-generation antipsychotics (FGAs), long-acting injectable (LAIs) antipsychotics and clozapine.

An electronic survey was sent to psychiatry residents (N= 75/288, 26 percent) at four Canadian residency programs in late December 2017. The survey was based on an instrument originally developed at the University of Cambridge and consisted of 31 questions in 10 content domains.

Nearly 80 percent of residents were aware that FGAs and second-generation antipsychotics (SGAs) have similar efficacy. However, extra-pyramidal symptoms and lack of training experience were the leading concerns associated with the prescribing of FGAs. Although over 90 percent of residents felt confident about initiating an oral SGA as a regular medication, only 40 percent did so with FGAs. Confidence with initiating LAIs and clozapine was 60 and 61 percent, respectively.

The survey highlights the need for better training in the use of FGAs, clozapine and LAIs. These medications can be effectively used in providing patients with the most appropriate evidence-based treatment options to improve treatment outcomes, while ensuring that these resources are not lost to the future generations of psychiatrists.

The survey may be the first of its kind to assess antipsychotic prescribing attitudes in Canadian psychiatry residents in multiple sites.

High‐secure hospital patients often have complex presentations that are marked by co‐morbidity, violence, histories of poor concordance with oral medication, and treatment resistance. The ability to give a long‐acting medication with a low propensity for extra pyramidal side effects is of potential value to clinicians treating these patients. Risperidone Long‐acting Injection (RLAI) is the first long‐acting atypical antipsychotic medication and may be potentially useful in this population. This paper aims to investigate this issue.

This was a retrospective, naturalistic study to investigate the use and effectiveness, using hard outcome measures, of RLAI in the four UK high‐secure psychiatric hospitals. Hospital pharmacy databases at Ashworth, Broadmoor, Carstairs and Rampton hospitals were used to identify all patients who had been prescribed RLAI. Anonymised data were then obtained from the pharmacy databases and case notes which were then pooled.

A total of 159 patients were prescribed RLAI, most of whom had schizophrenia. The mean length of treatment with RLAI was 65 weeks (range two to 260 weeks) and the mean maximum dose was 43.2 mg every two weeks (range 25‐75 mg every two weeks). No serious adverse effects were reported. In total, 42 per cent (67) patients responded to RLAI in as much as that they either remained on it in the long‐term or were discharged to conditions of lower security whilst taking it. As there was no control group, it is not possible to determine if RLAI was a significant factor in such discharges to conditions of lower security. Of those patients who failed to respond to RLAI, 44 per cent were subsequently treated with clozapine.

This pragmatic multi‐centre study of a small but complex patient group demonstrated that RLAI was effective in 42 per cent of patients and was well‐tolerated.

Use of off-license medicines in forensic mental health settings is common and unlicensed drugs are sometimes prescribed. Despite their responsibility for administering medicines little is known about how mental health nurses view these practices. The paper aims to discuss these issues.

In total, 50 mental health nurses working in low and medium secure adolescent and adult mental health wards were presented with a clinical vignette about administration of unlicensed and off-license medicines. Semi-structured interviews about their likely clinical response to, and feelings about, this practice were conducted. Interview data were subject to a thematic analysis.

Analysis revealed six themes: status of unlicensed/off-label medicines; legality of administering unlicensed medicines; professional standards around administering unlicensed medicines; finding out more about unlicensed medicines; trusting medical colleagues; and decision making in uncertain cases.

Forensic mental health nurses take a pragmatic approach to the practice of administering unlicensed medicines and most are aware of their professional responsibilities.

This study provides the first evidence to inform the development of training for forensic mental health nurses about an issue that is common in forensic mental health practice.