Quality improvement programme Prescribing antipsychotics for children and adolescents Re-audit, November 2011

Audit standards 1: For all children and adolescents prescribed antipsychotic medication the indication(s) for treatment with antipsychotic(s) should be documented in the clinical records. (good clinical practice point) 2: For all children and adolescents prescribed antipsychotic medication, the side effects of antipsychotics should be reviewed at least once every six months. This review should include, as appropriate, the assessment of body weight, blood pressure, blood glucose, plasma lipids and raised plasma prolactin, and examination for the presence of extrapyramidal side effects (EPS). (extrapolated from relevant recommendations in the NICE schizophrenia guideline CG82; 2009) The audit has two standards: 1: For all children and adolescents prescribed antipsychotic medication the indication(s) for treatment with antipsychotic(s) should be documented in the clinical records. (given that the use antipsychotic medication in children and adolescents is mostly outside of licence, the POMH Topic 10 expert advisory board felt it to be important that the indication(s) for treatment are clearly documented.) 2: For all children and adolescents prescribed antipsychotic medication, the side effects of antipsychotics should be reviewed at least once every six months. This review should include, as appropriate, the assessment of body weight, blood pressure, blood glucose, plasma lipids and raised plasma prolactin, and examination for the presence of extrapyramidal side effects (EPS).

Method Participants: Data collected: 40 Mental Health Trusts participated 203 clinical teams 1,628 children and adolescents Data collected: Demographic, diagnosis, type of service Antipsychotic(s) prescribed, dosage Clinical indications Other medicines prescribed Duration of current antipsychotic prescription less than three months: baseline monitoring three months or longer: physical health screening and side effect monitoring Information about medication review Forty specialist mental health Trusts participated in the re-audit, submitting data from 203 clinical teams for 1,628 children and adolescents who were prescribed one or more antipsychotics. Antipsychotic treatment had been initiated within the past three months in 337 patients; and initiated more than three months ago in 1,291 patients The following data were collected:  Demographic variables Psychiatric diagnoses Type of service providing care Information about antipsychotic(s) currently prescribed and the clinical indications Other medicines prescribed Duration of current antipsychotic prescription For children and adolescents who had been prescribed the current antipsychotic for less than three months, information about baseline monitoring was collected For children and adolescents who had been prescribed the current antipsychotic for three months or longer, information about physical health screening and side effect monitoring was collected Information about medication review

Key demographic characteristics Patient demographic and clinical characteristics Key demographic characteristics Baseline n % Re-audit n % Service Inpatient CAMHS Inpatient Paediatrics Outpatient CAMHS Outpatient Paediatrics 275 16 1138 146 18% 1% 72% 9% 260 1283 85 16% 79% 5% Who is currently prescribing the antipsychotic? Adult psychiatrist CAMHS psychiatrist Learning disability psychiatrist GP Paediatrician 35 975 9 369 152 2% 62% <1% 23% 10% 21 1057 77 376 50 65% 3% Age Mean age in years (SD) Min – max 10 years or under 11-15 years 16-18 years 19-21 years 15 years (2.8) 4-21 years 15 (2.8) 5-21 years 119 618 763 75 8% 39% 48% 127 670 744 87 41% 46% Documented psychiatric diagnoses: ICD-10* F20-F29 (schizophrenia spectrum disorder) F30-F39 (mood disorder - bipolar) F30-F39 (mood disorder - other) F70-F79 (learning disability) F80-F89 (autistic spectrum disorder) F90 (hyperkinetic incl ADHD) 301 101 150 259 475 443 19% 6% 30% 28% 335 121 171 382 585 359 21% 7% 11% 24% 36% 22%

Documented evidence of side effect assessment for patients in whom antipsychotic treatment was initiated more than three months ago at baseline and re-audit in the TNS

National level results Inpatient services Outpatient services n 260 1368 Diagnosis Early-onset mental illness Schizophrenia spectrum disorder 32% 18% Mood disorder – bipolar 7% 8% Mood disorder - other 135 10% Neurodevelopmental disorder Learning disability 21% 24% Autistic spectrum disorder 19% 38% Hyperkinetic (incl ADHD) 25% Tic disorders 2% 11% None of the above diagnoses 43% Age in years (median, range) 16, 8-20 15, 5-21 Antipsychotic prescribing initiated within the past three months 16% As might be expected, young people with a psychotic illness were disproportionally more likely to be inpatients

National level results Audit standard 1: For all children and adolescents prescribed antipsychotic medication the indication(s) for treatment with antipsychotic(s) should be documented in the clinical records. Clinical indications Prescribing initiated within past 3 months (n=337) Prescribing initiated more than 3 months (n=1291) Psychotic symptoms 39% (55% of these patients have a F20-29 diagnosis) 29% (65% of these patients have a F20-29 diagnosis) Agitation/anxiety 32% 31% Chronic behavioural disturbance with aggression 21% 37% Acute behavioural disturbance 14% 10% Self injurious or self harming behaviour Overactivity/hyperactivity 11% Depressive symptoms 8% Sleep difficulties 7% Manic symptoms 6% Tics and other related motor disturbances Other - Chronic behavioural disturbance without aggression Obsessive behaviours including rituals 5% Note that individual patients may have been prescribed antipsychotic medication for more than one indication. Prescription initiated within the past 3 months For one child/adolescents the indication for prescribing the antipsychotic medication was unclear. In relation to audit standard 1, this means that in 336 (99.7%) cases the rationale for initiating treatment with an antipsychotic within the past three months was clearly documented in the clinical records. Prescription initiated more than 3 months ago For 22 children and adolescents the indication for prescribing the antipsychotic medication was unclear. In relation to audit standard 1, this means that in 1275 (99%) cases the rationale for initiating treatment with an antipsychotic more than three months ago was clearly documented in the clinical records, which must be seen as a high standard of practice.

Patients prescribed drug in total national sample National findings Dosing details for the most five most commonly prescribed antipsychotics Drug Use n (%) Patients prescribed drug in total national sample Monotherapy Combination PRN Risperidone n=843 (55%) 843 (94%) 39 (3%) 41 (4%) Aripiprazole n=257 (16%) 230 (89%) 27(10%) 4 (2%) Olanzapine n=234 (14%) 194 (83%) 38 (16%) 37 (16%) Quetiapine n=204 (13%) 187 (92%) 17 (8%) 10 (5%) Haloperidol n=64 (4%) 22 (32%) 42 (66%) 51 (80%) The majority of antipsychotic prescribing was regular monotherapy, however haloperidol is more commonly used as part of a combination of antipsychotics, reflecting its use as PRN medication.

National findings Indication profile for risperidone With respect to risperidone, the main indication for prescribing is chronic behavioural disturbance with persistent aggression. Please note that indications are not mutually exclusive; i.e. one drug may be prescribed for more than one indication; and similarly, more than one drug may be prescribed to target a particular indication.

National findings Indication profile for aripiprazole Please note that indications are not mutually exclusive; i.e. one drug may be prescribed for more than one indication; and similarly, more than one drug may be prescribed to target a particular indication.

National findings Indication profile olanzapine

National findings Indication/target symptom profiles within the four most commonly documented diagnoses F80-89 (Autistic Spectrum Disorder) F70-79 (learning disability)

National findings Indication/target symptom profiles within the four most commonly documented diagnoses F90 (hyperkinetic including ADHD) F20-29 (schizophrenia) Please note that indications are not mutually exclusive; i.e. one drug may be prescribed for more than one indication; and similarly, more than one drug may be prescribed to target a particular indication.

National findings Proportion of patients in the total national sample prescribed additional medication (n=1628) Other medication prescribed in addition to an antipsychotic Total sample Antidepressant - SSRI 350 22% Melatonin 248 15% Methylphenidate 196 12% Benzodiazepine 144 9% Valproate 83 5% Atomoxetine 69 4% Carbamazepine 33 2% Lamotrigine 28 Anticonvulsant drug - Other 29 Dexamfetamine (or other amfetamine preparation) 10 1% Lithium 22 Antidepressant - Other 21 Clonidine 12 Antidepressant - TCA 6 <1% Other 154 10% Prescribed none of the above 623 38% Prescribed any of the above 1005 62%

Test result or measurement is recorded No evidence of screening found National findings: < 3 months Baseline physical health check for patients prescribed antipsychotic medication for less than three months (n=337) Evidence in the clinical records of physical health checks in the three months prior to antipsychotic treatment Baseline Re-audit Test result or measurement is recorded Some reference to screening or relevant observation made, but no result or value recorded No evidence of screening found Full blood count 50% 18% 32% Renal function tests 49% Liver function tests 48% 19% 33% Thyroid function tests 43% 44% 38% Baseline physical health monitoring may inform drug choice and allow clinicians to assess the impact of treatment emergent side effects. The tables refer to patients prescribed antipsychotic medication for less than three months (n=337), and show the proportion of patients who had no documented evidence of screening, some reference to screening, or a test result or measurement in the clinical records.   Suitable tests to be performed depend on the antipsychotic to be prescribed and its potential side effects; not all tests should be done on all patients.

Test result or measurement is recorded No evidence of screening found National findings: < 3 months Baseline screening for patients prescribed antipsychotic medication for less than three months (n=337) Evidence in the clinical records of screening in the three months prior to antipsychotic treatment Baseline Re-audit Test result or measurement is recorded Some reference to screening or relevant observation made, but no result or value recorded No evidence of screening found Body weight 59% 67% 10% 24% Blood pressure 8% 25% Pulse 57% 66% 26% Blood glucose 38% 42% 18% 40% Lipid profile 37% 19% 44% ECG 36% 34% 48% Plasma prolactin 31% 52% In the sample of children and adolescents prescribed antipsychotic medication for three months or less, 14% (n=47) had evidence of a test result or measurement documented for all of the above assessments. All patients had some reference to, or evidence of, at least one baseline physical health check or side effect screen in the three months prior to treatment.

National findings: Review Documentation of decision at medication review conducted within the past 6 months: baseline (n=1194) and re-audit (n=1291) The proportion of patients for whom a clinical medication review had been documented in the previous year is very close to the standard, and higher than that seen in general adult psychiatry (POMH 2008a).

National findings : ≥ 3 months Evidence in the clinical records of physical health checks in the past six months Baseline Re-audit Test result or measurement is recorded Some reference to screening or relevant observation made, but no result or value recorded No evidence of screening found Full blood count 30% 36% 23% 41% Renal function tests 29% 42% Liver function tests 28% 35% Thyroid function tests 20% 52% In relation to audit standard 2, this slide gives details about the prevalence of documented side-effect monitoring in the subgroup of patients who had been prescribed antipsychotic treatment for over three months. Suitable tests to be performed depend on the antipsychotic prescribed and its potential side effects; not all tests are indicated for all patients. All patients should be screened for metabolic side effects. EPS: (%) No documented evidence of assessment Statement side effect not present Statement side effect present Evidence of formal assessment Baseline (n=1194) 62% 28% 4% 6% Re-audit (n=1291) 50% 37% 3% 10%

Test result or measurement is recorded No evidence of screening found National findings : ≥ 3 months Evidence in the clinical records of screening* in the three months prior to antipsychotic treatment Baseline Re-audit Test result or measurement is recorded Some reference to screening or relevant observation made, but no result or value recorded No evidence of screening found Body weight 65% 10% 26% Blood pressure 59% 58% 32% Pulse 51% 55% 9% 36% Blood glucose 24% 31% 22% 47% Plasma lipid profile 30% 21% 49% Plasma prolactin 20% 28% 50% ECG 16% 14% 66% All patients had some reference to or evidence of at least one physical health check or side effect screen in the past six months.   The proportion of children and adolescents with documented physical health and side effect assessments in the past six months diminishes the longer the antipsychotic has been prescribed. For example, in children and adolescents prescribed an antipsychotic for 4-6 months there was some evidence of blood glucose assessment in 59%. For those prescribed an antipsychotic for 7-12 months or more than a year, the respective figures were 56% and 51%. It may therefore be that clinicians are missing the chance to detect potentially harmful or distressing side effects on longer term treatment.

Raised plasma prolaction National findings : ≥ 3 months Proportion of patients in the total national sample with documented side effect assessments by medication prescribed in the past six months Body weight Blood glucose Plasma lipids Raised plasma prolaction Risperidone 77% 50% 49% 48% Aripiprazole 73% 59% 56% 57% Olanzapine 75% 61% 60% Quetiapine 66% 52% 55% Early onset mental illness 67% 54% Neurodevelopmental disorders 51%

Data from each Trust are presented by code. 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.

Trust level findings Distribution of age groups by Trust and in the total national sample The Trusts with the highest proportion of patients aged 15 years and under are on the left hand side of the Figure and the Trust with the lowest proportion on the right. This Figure allows Trusts to compare the demographic characteristics of their sample of patients against the total national sample.

Trust level findings Proportion of patients in each Trust for whom the indication for antipsychotic prescribing is clearly documented In this graph, and all subsequent graphs, the Trust(s) on the left hand side are closest to standard compliance, and the Trust(s) on the left are furthest. The bar on the extreme right shows the total national sample (TNS) This Figure relates to audit standard 1: For all children and adolescents prescribed antipsychotic medication the indication(s) for treatment with antipsychotic(s) should be documented in the clinical records.

Trust level findings Proportion of patients in each Trust for whom the continuing need for antipsychotic medication was reviewed in the past six months This Figure relates to audit standard 2: For all children and adolescents prescribed antipsychotic medication, the continuing need for antipsychotic medication should be reviewed at least once every six months.    The Trusts with the highest proportion of patients having had the need for antipsychotic medication reviewed in the past six months are on the left hand side of the Figure and the Trust with the lowest proportion on the right. The diamond shows the proportion of patients at baseline that had documentation of a review in the last 6 months.

Trust level findings Proportion of patients in each Trust and the total national sample with documented evidence in their clinical records of assessment of EPS in the past six months. This Figure relates to audit standard 2: For all children and adolescents prescribed antipsychotic medication, the side effects of antipsychotics should be reviewed at least once every six months. This review should include, as appropriate, the assessment of body weight, blood pressure, blood glucose, plasma lipids and raised plasma prolactin, and examination for the presence of extrapyramidal side effects (EPS).

Proportion of patients in each Trust with documented measure of: Trust level findings Proportion of patients in each Trust and the total national sample with documented measurement of body weight, blood glucose, plasma lipids and raised plasma prolactin in the past six months Proportion of patients in each Trust with documented measure of: Trust code Body weight Blood glucose Plasma lipids Plasma prolactin TNS 74% 53% 52% 50% This Table relates to audit standard 2: For all children and adolescents prescribed antipsychotic medication, the side effects of antipsychotics should be reviewed at least once every six months. This review should include, as appropriate, the assessment of body weight, blood pressure, blood glucose, plasma lipids and raised plasma prolactin, and examination for the presence of extrapyramidal side effects (EPS).