1. Prescribing antipsychotics for children and adolescents
Topic 10a
Prescribing antipsychotics for children and adolescents
September 2010

2. Outline
Summary of the baseline findings of POMH Topic 10a audit – Prescribing antipsychotics for children and adolescents.
Clinical Background
Audit standards
Method
National findings
Trust level findings
Ward level findings
This presentation gives a summary of the baseline findings from the POMH Topic 10a audit – “Prescribing antipsychotics for children and adolescents”.
The slides that follow cover the clinical background, audit standards and method, followed by the main national and Trust level findings. Finally practice in each of the Trust’s wards is shown.

3. Clinical background
A recent survey of antipsychotic prescribing practice among child and adolescent psychiatrists in the UK found over 95% had prescribed antipsychotics in a 12 month period (Otasowie et al. 2010).
Almost all antipsychotics are unlicensed for use in children and adolescents, with a limited evidence-base of randomised clinical trials to support antipsychotic prescribing.
Children and adolescents appear to show greater sensitivity to a range of antipsychotic-related adverse events than adults, including extrapyramidal side effects (EPS), weight gain, obesity, and metabolic syndrome.
The full clinical background can be found in the baseline report, or in the POMH members area:

4. 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).

5. Method Participants: Data collected:
42 Mental Health Trusts participated
194 clinical teams
1,575 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-two specialist mental health Trusts participated in the audit, submitting data from 194 clinical teams for 1,575 children and adolescents who were prescribed one or more antipsychotics. Antipsychotic treatment had been initiated within the past three months in 380 patients; and initiated more than three months ago in 1,195 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

6. Key demographic characteristics
Patient demographic and clinical characteristics
Key demographic characteristics
Total sample
n %
Service
Inpatient CAMHS
Inpatient Paediatrics
Outpatient CAMHS
Outpatient Paediatrics
275 16
1138
146
18% 1%
72% 9%
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%
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
119
618
763 75 8%
39%
48% 5%
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%
16%
30%
28%

7. 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.
The most common clinical indications for antipsychotic prescribing
Treatment initiated within the past three months (n=380):
Treatment initiated more than three months ago (n=1,194):
43% Psychotic symptoms (61% of these patients have an F20-29 diagnosis)
34% Agitation/anxiety
22% Acute behavioural disturbance
19% Chronic behavioural disturbance with aggression
36% Chronic behavioural disturbance with aggression
33% Agitation/anxiety
26% Psychotic symptoms (62% of these patients have an F20-29 diagnosis)
18% Overactivity/hyperactivity
14% Acute behavioural disturbance
10% Chronic behavioural disturbance without aggression
10% Tics and related motor disturbance
Note that individual patients may have been prescribed antipsychotic medication for more than one indication.
Prescription initiated within the past 3 months
For four children and adolescents the indication for prescribing the antipsychotic medication was unclear. In relation to audit standard 1, this means that in 376 (99%) 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 18 children and adolescents the indication for prescribing the antipsychotic medication was unclear. In relation to audit standard 1, this means that in 1176 (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.

8. 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=970 (62%)
941 (97%)
29 (3%)
37 (4%)
Olanzapine
n=206 (13%)
174 (85%)
32 (15%)
41 (20%)
Aripiprazole
n=187 (12%)
169 (90%)
18 (10%)
5 (3%)
Quetiapine
n=128 (8%)
124 (97%)
4 (3%)
8 (6%)
Haloperidol
n=77 (5%)
41 (53%)
36 (47%)
60 (78%)
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.

9. National findings
Dosing details for the most five most commonly prescribed antipsychotics
Drug
Dose: median (range)
Oral
Oral PRN IM
IM PRN
Risperidone
1mg ( mg)
0.5mg ( mg)
n/a
Olanzapine
10mg (2.5-25mg)
10 mg (5-20mg)
10 mg (10-10mg)
15 mg (5-20mg)
Aripiprazole
5mg (0.5-30mg)
2.5mg ( mg) -
Quetiapine
200mg ( mg)
75mg (50-100mg)
Haloperidol
2mg (0.3-15mg)
15mg (2-30mg)
15 mg (2-30mg)
The median doses prescribed seem to be in keeping with the age of the clinical population and indications for use.

10. 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.

11. National findings Indication profile olanzapine
Note that olanzapine has a different indication profile to risperidone, for olanzapine the main indication is psychotic symptoms.
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.

12. 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.

13. National findings: < 3 months
Baseline physical health monitoring for patients prescribed antipsychotic medication for less than three months (n=380)
Evidence in the clinical records of physical health checks in the three months prior to antipsychotic treatment
No evidence of screening found
Some reference, but no result or value recorded
Test result or measurement is recorded
Full blood count
35%
15%
50%
Renal function tests
36%
49%
Liver function tests
38%
14%
48%
Thyroid function tests
44%
11%
43%
Baseline physical health monitoring may inform drug choice and allow clinicians to assess the impact of treatment emergent side effects. The tables below look at patients prescribed antipsychotic medication for less than three months (n=380), 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.

14. National findings: < 3 months
Baseline monitoring for patients prescribed antipsychotic medication for less than three months (n=380)
Evidence in the clinical records of screening in the three months prior to antipsychotic treatment
No evidence of screening found
Some reference, but no result or value recorded
Test result or measurement is recorded
Body weight
32%
10%
59%
Blood pressure
Pulse
35% 8%
57%
Blood glucose
48%
13%
38%
Lipid profile
51%
12%
37%
ECG
54%
36%
Plasma prolactin
63%
25%
Baseline physical health monitoring may inform drug choice and allow clinicians to assess the impact of treatment emergent side effects. The tables below look at patients prescribed antipsychotic medication for less than three months (n=380), 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.

15. National findings: Review
Review of medicines and side effects for patients prescribed antipsychotic medication for more than three months (n=1,194)
Documentation of decision at medication review conducted within the past 6 months.
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).

16. National findings : ≥ 3 months
Evidence in the clinical records of physical health checks in the past six months
No evidence of screening found
Some reference, but no result or value recorded
Test result or measurement is recorded
Full blood count
54%
16%
30%
Renal function tests
56%
15%
29%
Liver function tests
57%
28%
Thyroid function tests
64%
13%
23%
In relation to audit standard 2, this section 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 relevant for all patients. All patients should be monitored for metabolic side effects.

17. National findings : ≥ 3 months
Evidence in the clinical records of screening* in the three months prior to antipsychotic treatment
No evidence of screening found
Some reference, but no result or value recorded
Test result or measurement is recorded
Body weight
26% 9%
65%
Blood pressure
34% 7%
59%
Pulse
42%
51%
Blood glucose
62%
14%
24%
Lipid profile
63%
13%
ECG
68%
12%
20%
Plasma prolactin
73%
11%
16%
In the sample of children and adolescents prescribed antipsychotic medication for over three months, 4% (n=68) 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 physical health monitoring or side effect screening in the past six months.
The proportions 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, there was no evidence of blood glucose assessment in 56% of children and adolescents prescribed an antipsychotic for 4-6 months. This proportion rose to 59% when the antipsychotic had been initiated 7-12 months ago, and 65% where the antipsychotic had been initiated over a year ago. It may therefore be that clinicians are missing the chance to detect potentially harmful or distressing side effects.

18. 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.
Your Trust code is 40.

19. 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.

20. 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.

21. Trust level findings
Proportion of patients in each Trust for whom the continuing need for antipsychotic medication was reviewed in the past six months

22. 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).

23. 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
Trust 40
79% 6% 3%
TNS
74%
38%
37%
32%
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).

24. Team level findings
Analyses presented in this section were conducted for each clinical team from your Trust individually, for your total Trust sample and for the total national sample to allow benchmarking.
Data from each Trust clinical team are presented by code only.
Only the Local Project Team Lead (LPTL) for your Trust or organisation has the key to team codes. You should contact this person if you need to identify data for your own particular team

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

26. Team level findings
Proportion of patients in each team for whom the indication for antipsychotic prescribing is clearly documented
In this graph, and all subsequent graphs, the team(s) on the left hand side are closest to standard compliance, and the team(s) on the left are furthest. The bars on the extreme right show the Trust, and the 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.

27. Team level findings
Proportion of patients in each team for whom the continuing need for antipsychotic medication was reviewed in the past six months

28. Proportion of patients in each Trust with documented measure of:
Team level findings
Proportion of patients in each team 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
40.28
67% 0%
40.30
86%
14%
40.31
72% 6%
40.32
100%
Trust 40
79% 3%
TNS
74%
38%
37%
32%
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).

29. Team level findings
Proportion of patients in each team 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).

30. What happens next... Want to find out more?
Discussions within your Trust/team about your own practice.
POMH will develop bespoke change interventions including opportunities for sharing good practice between services.
A re-audit will be conducted in November 2011.
Want to find out more?
Ask to see a copy of the baseline report. 
The POMH lead for your Trust will have a paper and electronic copy of the full report.