Quality improvement programme Antipsychotic prescribing in people with a learning disability Supplementary audit July 2015

LD is formally classified with mental disorders and illnesses but it is nonetheless distinct from them and it is rare in contemporary practice for it to be thought of as a psychiatric disorder in and of itself. Despite this, mental illness, personality disorder and behavioural disorder requiring clinical intervention are overrepresented in this group As the severity of LD falls, diagnosing mental illness becomes increasingly difficult and clinicians become more inclined to consider clinical problems in diagnostic and descriptive ways, invoking the terms ‘challenging behaviour’ or ‘problem behaviour’. Although the use of antipsychotic medication for psychotic and related illnesses in people with a learning disability (LD) is relatively uncontroversial, their common use in the management of behavioural problems not attributable to diagnosed mental illness is not. Clinical background

Clinical practice standards 1. The indication for treatment with antipsychotic medication should be documented in the clinical records (Deb, 2006). 2. The continuing need for antipsychotic medication should be reviewed at least once a year (Deb, 2006). 3. Side effects of antipsychotic medication should be reviewed at least once a year. This review should include assessment for the presence of extrapyramidal side effects (EPS), and screening for the 4 aspects of the metabolic syndrome: obesity, hypertension, impaired glucose tolerance and dyslipidaemia (NICE schizophrenia guideline update CG82, 2009).

Compliance with NICE guidelines While the report for this supplementary audit was being prepared, NICE published a guideline entitled ‘Challenging behaviour and learning disabilities: prevention and interventions for people with learning disability whose behaviour challenges’ (NG11, May 2015). Practice standard 1 is consistent with recommendations and Practice standards 2 and 3 address aspects of NICE recommendations 1.8.4, and In addition, NICE recommends that treatment for co-morbid mental illness should be optimised (1.8.1) and that antipsychotic medication should only be considered if the risk to the person or others is severe, for example violence, aggression or self-injury (1.8.2). Where the data allow, we included tables or figures that showed clinical practice in relation to these recommendations.

The Winterbourne View report, published in 2012, raised concerns about the over- use of psychotropic medicines in people with learning disability. The report recommended (section 7.31) that 'health professionals caring for people with learning disabilities should assess and keep under review the medicines requirements for each individual patient to determine the best course of action for that patient.... Services should have systems and policies in place to ensure that this is done safely and in a timely manner and should carry out regular audits of medication prescribing and management...' For this supplementary audit, the eligibility criteria were therefore expanded to include all patients with a learning disability under the care of mental health services, regardless of whether or not they are prescribed antipsychotic medication. This allowed the prevalence of prescribing of different categories of psychotropic drugs to be benchmarked across services while also retaining the original focus of this QIP on the quality of prescribing of antipsychotic medication. The Winterbourne View report

Overprescribing in LD NHS England June 2015: Letter by Dr D Slowie and Dr K Ridge on behalf of NHS England and supported by RCPsych, RCN, RPS July In December 2012, the Department of Health (DH) publication “Transforming Care: A national response to Winterbourne View Hospital” stated that: “7.31 We have heard deep concerns about the over-use of antipsychotic and antidepressant medicines. Health professionals caring for people with learning disabilities should assess and keep under review the medicines requirements for each individual to determine the best course of action for that patient, taking into account the views of the person wherever possible and their family and/or carer(s)

Method Data were submitted for 54 Trusts 338 clinical teams 5,654 adult patients with a learning disability Audit data collected: Age, gender, ethnicity, severity of learning disability, co- morbid psychiatric diagnoses and care setting Diagnosis of epilepsy The dose of each oral/short-acting IM and depot/long- acting antipsychotic currently prescribed The main indications for antipsychotic prescribing Other medications for mental health, behavioural problems or epilepsy Evidence of side effect monitoring.

Practice standard 1: The indication for treatment with antipsychotic medication should be documented in the clinical records. Documentation in the clinical records of the reasons for prescribing antipsychotic medication within the last 12 months in the total national sample (TNS, n=465) and your Trust (n=28) National and Trust level results for practice standard 1

Practice Standard 1 Practice standard 1: The indication for treatment with antipsychotic medication should be documented in the clinical records. Common indications for prescribing Antipsychotic prescribing initiated within the last 12 months Antipsychotic prescribing initiated more than 12 months ago Baseline N=328 Re-audit N=334 Supplementary N=465 Baseline N=1,991 Re-audit N=2,053 Supplementary N=3, Agitation and anxiety 43%38%46%42%41%40% 2. Overt aggression37%41%38% 44%35% 3. Psychotic disorder42%43%35%42%39%42% 4. Threatening behaviour 27%23%25%31%27%30% 5. Self harm/self- injurious behaviour* 10%14%4% / 13%11%14%5% / 14% 6. Obsessive behaviour 11%7%9%13%9%

Common indications for prescribing Mild/borderline N=1,621 Moderate N=883 Severe/profound N=659 Psychotic disorder55%37%15% Agitation and anxiety32%48%51% Overt aggression27%42%48% Threatening behaviour28%35%28% Self harm/self-injurious behaviour* 4% / 7%3% / 15%8% / 31% Obsessive behaviour7%13%10% The most common indications for antipsychotic prescribing where this was initiated more than 12 months ago at supplementary audit by severity of LD (n=3,163)

Drugs prescribed Total sample n=5,654 Mild/ borderline n=2,973 Moderate n=1,531 Severe/ profound n=1,150 Antipsychotic 3,62864%1,87363%1,02267%73364% Antidepressant - SSRI 1,61629%95432%43929%22319% Antidepressant – other 5049%32611%1117%676% Carbamazepine* 69912%2518%19012%25822% Benzodiazepine* 79914%36212%22715%21018% Anticholinergic 58210%32311%1419%11810% Valproate* 1,12520%49317%31621%31627% Lamotrigine* 4057%1545%986%15313% The use of medicines to treat mental illness, behavioural problems or epilepsy

Proportion of patients in the total national sample prescribed antipsychotics and antidepressants with or without a relevant psychiatric diagnosis by severity of learning disability at supplementary audit.

Medicine review Practice standard 2: The continuing need for antipsychotic medication should be reviewed at least once a year. Figure 8: Documentation of decisions at medication review conducted within the last 12 months for those prescribed antipsychotic medication, and/or other psychotropic medication, for more than 12 months at supplementary audit.

Monitoring of side effects Practice standard 3: Side effects of antipsychotic medication should be reviewed at least once a year. This review should include assessment for the presence of EPS, and screening for the 4 aspects of the metabolic syndrome: obesity, hypertension, impaired glucose tolerance and dyslipidaemia. Figure 9: Nature of documented evidence in the clinical records of clinical assessment of side effects in the last 12 months in patients prescribed antipsychotic medication for more than 12 months at baseline, re-audit and supplementary audit.

Trust level findings Analyses presented in this section were conducted for each Trust individually and for the total sample to allow benchmarking. Data from each Trust are presented by code. Your Trust code is 102

Practice standard 1: The indication for treatment with antipsychotic medication should be documented in the clinical records. Proportion of patients in each Trust for whom antipsychotics were prescribed for less than 12 months and for whom the clinical reasons for antipsychotic prescribing is clearly documented: re-audit and supplementary audit. Trust-level results for practice standard 1

Practice standard 2: The continuing need for antipsychotic medication should be reviewed at least once a year. Proportion of patients in each Trust for whom antipsychotics were prescribed for more than 12 months and the continuing need for antipsychotic medication was reviewed: re-audit and supplementary audit. Trust-level results for practice standard 2

Practice standard 3: Side effects of antipsychotic medication should be reviewed at least once a year. This review should include assessment for the presence of EPS, and screening for the 4 aspects of the metabolic syndrome: obesity, hypertension, impaired glucose tolerance and dyslipidaemia. Proportion of patients in each Trust and the total national sample for whom antipsychotics were prescribed for more than 12 months with documented evidence in their clinical records of a general assessment of side effects at re-audit and supplementary audit. Trust-level results for practice standard 3

Summary for BCUHB Above average for standards 1 and 2 Below average for all aspects of standard 3 (side effect monitoring)

What happens next? 1.Clinicians are invited to reflect on their performance data and generate and implement action plans as appropriate. 2. Clinicians who do so, should be encouraged to submit evidence of this process as part of their CPD, to inform their appraisal and to support revalidation. 3. On the basis of the audit findings, POMH-UK will consider appropriate change interventions for provision to participating Trusts to support their local action plans.

Next in BCUHB Full results with team breakdown to be presented in LDS Governance group meeting and Consultant peer group Discuss and agree key practice points Re-audit with same/extended standards