Audit: Prescribing practices at Queen Elizabeth Central Hospital Psychiatric unit in 2011 Olive Liwimbi Trainee, MMed Psychiatry, College of Medicine Medical Officer, Ministry of Health, Q.E.C.H

background Limited resources & drug shortages Emergency and OPD services Comprehensive guidelines not in place Do current practices conform to WHO MhGAP intervention guidelines?

methodology January – February 2012 Data collection: patient files, health passports and patient / guardian Targeted conditions: psychosis, bipolar disorder and unipolar depression Selection of standards : MhGAP

results 969 patients seen in 2727 visits in patients audited

guidelineAudit results: psychosis Initiation haloperidol : mg CPZ : 75 mg Fluphenazine: 12.5mg 3 initiated all above standard dose Effective dose haloperidol 3 – 20 mg CPZ 75 – 300 mg Fluphenazine mg 27 of 33 Anticholinergic use Do not prescribe routinely Routine use in 12 of 33

Results: Medication use, psychosis Guidelines: One antipsychotic at a time Findings :

guidelineAudit results: Medication use, depression Starting dose Amitriptyline 50mg or 25mg in the elderly / medically ill 1 Initiated below standard dose Effective dose Amitriptyline mg none of 10 Combined therapy Combined antidepressants & antipsychotics should be done under supervision of a specialist. 9 of 10 on antipsychotics No consultant supervision Indications for use in 3 patients

guidelineAudit results Bipolar disorder Discontinue any antidepressants none on antidepressants Therapeutic dose: Carbamezapine mg none of 7 If no improvement after 6 weeks: consider switching to another medication, or combination therapy e.g. antipsychotic plus a mood stabilizer. All patients on carbamezapine and antipsychotics

Other findings Side effects Recorded : 2 (headache, Seizures) Non recorded : 2 (dizziness, impotence) Switching medicationsAbrupt ( 17 of 33) Cessation of therapy stable, cessation attempted : 1 Stable, cessation not attempted : 28 Unstable, no cessation attempts: 18 Cessation duration unmet: 4 Review by clinician4 Discrepancy between file and health passport 1

Conclusion & recommendation Need for establishment of guidelines /standards emphasis on rational prescribing Need for clinician support: - once yearly review Regular availability of psychotropics Re- audit

acknowledgments Dr R Stewart, Mr Maida & the psychiatric team at QECH