1. Use of antipsychotic medication in people with a learning disability
Topic 9:
Use of antipsychotic medication in people with a learning disability
Background, method and findings from the baseline audit
The Prescribing Observatory for Mental Health (POMH-UK) runs national audit-based quality improvement programmes open to all specialist mental health services in the UK. The aim is to help mental health services improve prescribing practice in discrete areas (‘Topics’).
This slide set contains the results of the baseline audit for Topic 9: Use of antipsychotic medication in people with a learning disability
POMH-UK is based at the Royal College of Psychiatrists Centre for Quality Improvement and does not receive any funding from the pharmaceutical industry.
Further information about POMH can be found on our website:

2. Background Topic background
Antipsychotic medications are prescribed “off label” for behavioural problems in people with a learning disability (LD).
The use of antipsychotics to manage behavioural problems which are not attributable to diagnosable mental illness, in people with LD is controversial.
A recent, influential, double-masked RCT called into question the role of antipsychotics for aggression of non-psychotic origin. No difference was found between the efficacy of haloperidol, risperidone or placebo (Tyrer et al, 2008).
A major consideration in LD prescribing practice is the capacity of people with LD and behavioural problems to participate in decisions about their treatment.
LD is a complex diagnostic entity. For an individual to be designated as having LD, three core criteria need to be met.
Evidence of significant intellectual impairment (i.e. IQ score 70 and below);
Problems in overall adaptive functioning that are a consequence of this impairment
An onset in childhood.
However, even within these bounds, and despite diagnostic subdivisions into ‘mild’, ‘moderate’, ‘severe’ and ‘profound’, people with LD constitute an extremely heterogeneous population encompassing a broad range of communicative, cognitive-perceptual, social, occupational, scholastic and self-actualising aptitudes and deficits.
The double-masked RCT by Tyrer and colleagues (2008) involving 86 participants (a small number for mainstream treatment trials but unusually large in LD where recruitment to research is notoriously difficult for ethical as well as practical reasons), could find no difference between the efficacy of haloperidol, risperidone or placebo used for aggression of non-psychotic origin.

3. Background
Why this Topic was selected?
POMH-UK member Trusts indicated their interest in benchmarking their prescribing practice in this area through participation in a quality improvement programme.
LD clinicians often feel they lack the guidance and support regarding best practice prescribing that is available in other clinical settings. This audit is the first time that national prescribing practice in LD psychiatry has been reviewed and benchmarked in this way.

4. Audit standards Audit standards
Whilst there is a lack of NICE guidance in this area, the literature has been reviewed and standards set in “Using medication to manage behaviour problems among adults with a learning disability” (Deb et al., University of Birmingham, September 2006).
The audit standards used in this report were derived from these, and the third standard is also supported by the NICE clinical guideline for the management of schizophrenia CG82 (2009).
The three audit standards used are shown on the next slide.

5. Audit standards Audit standards
The indication for treatment with antipsychotic medication should be documented in the clinical records (Deb, 2006).
The continuing need for antipsychotic medication should be reviewed at least once a year (Deb, 2006).
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, diabetes and dyslipidaemia (NICE clinical guidelines CG82, 2009).
The audit standards used in this report were derived from “Using medication to manage behaviour problems among adults with a learning disability” (Deb et al., 2006), and the third standard is also supported by the NICE clinical guideline for the management of schizophrenia CG82 (2009).

6. Sample Method Data collected
145 clinical teams from 39 mental health Trusts participated in the audit, submitting data for 2,319 patients, all of whom had a diagnosis of learning disability and were prescribed one or more antipsychotics.
This is the largest audit of antipsychotic prescribing in people with a learning disability that has been conducted to date.
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
Documented evidence of side effect monitoring
Documented evidence of formal review of medication
A copy of the questionnaire can be found in the audit report. The POMH lead for your Trust will also have a paper and electronic copy of this report.

7. Key findings Key findings: Part 1
For patients in whom antipsychotic treatment was initiated less than 12 months ago (n=328), the indication for treatment was clearly described in 93% of the clinical records.
The most common indications for antipsychotic prescribing in the total national sample (n=2,319) were comorbid psychotic disorder (42%), followed by anxiety and agitation (42%), and overt aggression (38%).
Of those patients in whom antipsychotic treatment was initiated more than 12 months ago (n=1,991), 96% had their continuing need for antipsychotic medication reviewed in the last year.
Overall, documentation of the rationale for prescribing an antipsychotic and for review of antipsychotic treatment was very good.
It is interesting that the most common reason for prescribing an antipsychotic is psychotic illness.
There were 8 key findings from the audit, these are presented over the next few slides.

8. Key findings Key findings: Part 2
Oral risperidone was the most commonly used antipsychotic, being prescribed for 40% of the total national sample. Olanzapine was prescribed for 20% of patients, and chlorpromazine, haloperidol and quetiapine for 10% each.
Only 4% of the total national sample were prescribed a high dose antipsychotic, and 15% were prescribed a combination of antipsychotics.
In addition to an antipsychotic, almost three quarters (73%) of patients were prescribed at least one other drug for the treatment of mental illness, behavioural problems or epilepsy.
The prevalence of prescribing of high-dose and combined antipsychotics is considerably less than is seen in general adult psychiatry.

9. Key findings Key findings: Part 3
For those patients in whom antipsychotic treatment was initiated more than 12 months ago (n=1,991), documented evidence of side effect assessment was as follows:
Blood glucose: 60% of patients (range across Trusts %)
Lipid profile: 57% of patients (12-100%)
Weight/BMI: 56% of patients (5-100%)
Extrapyramidal side effects: 41% of patients (0-100%)
Blood pressure: 37% of patients (0-100%).
Of the side effect assessments listed above, 19% of patients had no documented evidence of any of them being conducted in the last year. 14% of patients had evidence of 1 assessment, 16% had evidence of 2, and 52% had evidence of 3 or more.
The one area where practice could improve is the assessment of side effects. Given that people with LD may have difficulty with communication, there is a greater responsibility placed on clinicians to actively screen for side effects. Such screening can be difficult in some patients (for example physical examination or blood tests may be resisted or cause distress) but the variation in practice seen across participating services is very wide and unlikely to be explained by case mix alone.

10. Conclusions Conclusions
The indications for prescribing antipsychotic medication were clearly documented in the clinical records.
High doses and combinations of antipsychotics are prescribed less commonly than in adult mental health services.
The continuing need for antipsychotic medication was regularly reviewed and documented in almost all patients in this sample. The high proportion of patients having medicines changed at review suggests thoughtful and thorough practice in this area.
In just under three-quarters of patents, a general statement regarding side effects had been documented in the last year.
Documented evidence of systematic monitoring across a range of side effects was far less common. Potentially remediable physical health problems may therefore not be detected.
These are the conclusions drawn from the audit.

11. Indications* for antipsychotic prescribing:
National findings
Indications* for antipsychotic prescribing:
Initiated within the last 12 months (n=328)
Agitation and anxiety (n=142; 43%)
Co-morbid psychotic disorder (138; 42%)
Overt aggression (120; 37%)
Threatening behaviour (87; 27%)
Obsessive behaviour (37; 11%)
Initiated more than 12 months ago (n=1,991)
Co-morbid psychotic disorder (833; 42%)
Agitation and anxiety (826; 42%)
Overt aggression (754; 38%)
Threatening behaviour (609; 31%)
Self harm (266; 13%)
*Note that individual patients may have been prescribed antipsychotic medication for more than one indication.
Initiated within the last 12 months
In relation to audit standard 1, in 304 (93%) cases the rationale for initiating treatment with an antipsychotic was clearly documented in the clinical records.
There will be slides later showing the performance of your Trust and individual teams.
Initiated more than 12 months ago
For 95% of patients who started antipsychotic treatment over 12 months ago, a clear reason for prescribing antipsychotic treatment was documented in the clinical records.
Overall, the standard of practice in this area is very good.

12. Prescribing practice
Details for the 5 most commonly prescribed antipsychotics
Use: n (%)
Drug
Monotherapy
Combination
PRN
Risperidone
791 (86%)
134 (14%)
86 (9%)
Olanzapine
380 (81%)
91 (19%)
65(14%)
Chlorpromazine
143 (59%)
98 (41%)
112 (47%)
Haloperidol
117 (49%)
121 (51%)
110 (46%)
Quetiapine
183 (81%)
43 (19%)
25 (11%)
The table shows the five most commonly prescribed antipsychotics, and the way they were prescribed.
There are notable differences between drugs. For example, risperidone and olanzapine were primarily prescribed regularly as monotherapy whereas haloperidol and chlorpromazine were more often prescribed on a PRN basis in combination with another antipsychotic.

13. Prescribing practice
Dosing details for the 5 most commonly prescribed antipsychotics
Dose: Median (range)
Drug
Oral IM
Oral PRN
IM PRN
Risperidone
2mg
(0.5-14mg) -
1mg
(0.3-8mg)
Olanzapine
10mg
(2.5-30mg)
5mg
(2.5-20mg)
Chlorpromazine
100mg
( mg)
( mg)
125mg
(75-250mg)
Haloperidol
6mg
(0.5-30mg)
(6-15mg)
(0.5-20mg)
15mg
Quetiapine
250mg
(25-800mg)
(25-750mg)
This table shows the median doses prescribed of the five most commonly used antipsychotics.
The prevalence of high-dose and combined antipsychotic prescribing identified in this audit is notably lower than in general adult psychiatry Only 4% of the TNS were prescribed a high dose, and 15% prescribed a combination of antipsychotics.

14. Prescribing practice
Indication profiles for the most 5 most commonly prescribed antipsychotics
Co-morbid psychotic disorder
Overt aggressive behaviour
Threatening behaviour
General agitation/anxiety
Obsessive behaviour
Self-harming behaviour
Motor stereotypies
Inappropriate sexual behaviour
Oppositional or defiant behaviour
Social withdrawal
Other
Unclear
Only modest differences are seen between the indication profiles of risperidone, olanzapine, chlorpromazine, haloperidol and quetiapine. The majority of antipsychotic prescribing targets co-morbid psychotic disorder, anxiety and agitation, overt aggression or threatening behaviour.
Co-morbid psychotic disorder
Overt aggressive behaviour
Threatening behaviour
General agitation/anxiety
Obsessive behaviour
Self-harming behaviour
Motor stereotypies
Inappropriate sexual behaviour
Oppositional or defiant behaviour
Social withdrawal
Other
Unclear

15. National findings
Proportion of people with co-morbid diagnoses, across mild/borderline, moderate and severe/profound diagnostic subsamples (n=2,319)
The majority of patients overall had at least one co-morbid diagnosis. That the proportion was lower in those with severe/profound LD may partly reflect the diagnostic difficulties.
The five most frequent co-morbid diagnoses in the total national sample are listed below in order of frequency:
Mood [affective] disorders (F30-39): n=628; 27% of TNS
Schizophrenia, schizotypal and delusional disorders (F20-29): 615; 27%
Disorders of psychological development (F80-89): 481; 21%
Behavioural and emotional disorders with onset usually occurring in childhood and adolescence (F90-98): 201; 9%
Disorders of adult personality and behaviour (F60-69): 172; 7%

16. Medicine review in the last year
National findings
Medicine review in the last year
This slide shows performance against the standard; the clinical need for the continued treatment with an antipsychotic should be reviewed at least once a year. Within this review, the decision to either maintain the treatment or make a change to the drug/dose or frequency should be documented.
Of those patients receiving antipsychotic treatment for over 12 months (n=1,991), 1,913 (96%) had a documented medication review in the last year; in 99% of these cases there was a record of the clinical decision as to whether the medication was to remain the same or change.
For those with such a documented decision, the rationale for either keeping the medicine the same or changing was documented in 92%
Practice in this area overall is very good.

17. Side effect monitoring in the last year
National findings
Side effect monitoring in the last year
Borderline/mild
Moderate
Severe/profound
General statement that side effects are present
223 (24%)
120 (21%)
81 (17%)
General statement that side effects are not present
442 (48%)
271 (47%)
241 (50%)
No statement about side effects
260 (28%)
186 (32%)
167 (34%)
In relation to audit standard 3, 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 a year (n=1,991).
There is little difference across subgroups.

18. Data from each Trust are presented by code.
Trust level
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
Patients’ learning disability severity by Trust and in the total national sample
The Trusts with the highest proportion of patients with a borderline/mild learning disability 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 LD severity of their sample of patients against the total national sample.

20. Trust level
Proportion of patients in each Trust for whom the indication for antipsychotic prescribing is clearly documented
This Figure relates to audit standard 1: The indication for treatment with antipsychotic medication should be documented in the clinical records.
The Trusts with the highest proportion of patients with clear documented indications are on the left hand side of the Figure and the Trust with the lowest proportion on the right.

21. Trust level
Proportion of patients in each Trust for whom the continuing need for antipsychotic medication was reviewed in the last year
This Figure relates to audit standard 2: The continuing need for antipsychotic medication should be reviewed at least once a year.
The Trusts with the highest proportion of patients having had the need for antipsychotic medication reviewed in the last year are on the left hand side of the Figure and the Trust with the lowest proportion on the right.

22. Trust level
Proportion of patients in each Trust and the total national sample with documented evidence in their clinical records of a general assessment of side effects in the last year.
The following Figure relates to audit 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, diabetes and dyslipidaemia.
The Trusts with the highest proportion of patients with a documented general statement regarding side effects in the last year are on the left hand side of the Figure and the Trust with the lowest proportion on the right.
The variation across Trusts is marked.

23. Trust level
Proportion of patients in each Trust and the total national sample with documented evidence in their clinical records of assessment of EPS in the last year.

24. Trust level
Proportion of patients in each Trust and the total national sample with documented evidence in their clinical records of assessment of weight change in the last year.
Note that some antipsychotic drugs are associated with considerable weight gain.

25. Trust level
Proportion of patients in each Trust and the total national sample with documented evidence in their clinical records of assessment of blood pressure in the last year.
Note that people with psychotic illness are at increased risk of developing metabolic syndrome and that antipsychotic drugs contribute to this risk.

26. Trust level
Proportion of patients in each Trust and the total national sample with documented evidence in their clinical records of assessment of blood glucose in the last year.
Note that people with psychotic illness are at increased risk of developing metabolic syndrome (of which impaired glucose tolerance/diabetes forms part) and that antipsychotic drugs contribute to this risk.

27. Trust level
Proportion of patients in each Trust and the total national sample with documented evidence in their clinical records of assessment of lipid profile in the last year.
Note that people with psychotic illness are at increased risk of developing metabolic syndrome (of which dyslipidaemia forms part) and that antipsychotic drugs contribute to this risk.

28. Data from each Trust clinical team are presented by code only.
Team level
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.
The POMH-UK Central Project Team does not know the identity of individual teams.
Only the Local Project Team lead 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.

29. Team level
Proportion of patients receiving antipsychotic treatment for under a year (n=12) in each team for whom the indication for antipsychotic prescribing is clearly documented
This Figure relates to audit standard 1: The indication for treatment with antipsychotic medication should be documented in the clinical records.
The team with the highest proportion of patients with clear documented indications are on the left hand side of the Figure and the team with the lowest proportion on the right.
Each bar may only represent a small number or patients, please take note of the number stated in the title, and interpret with care.

30. Team level
Proportion of patients receiving antipsychotic treatment for over a year (n=9) in each team for whom the continuing need for antipsychotic medication was reviewed in the last year
This Figure relates to audit standard 2: The continuing need for antipsychotic medication should be reviewed at least once a year.
The team with the highest proportion of patients having had the need for antipsychotic medication reviewed in the last year are on the left hand side of the Figure and the team with the lowest proportion on the right.
Each bar may only represent a small number or patients, please take note of the number stated in the title, and interpret with care.

31. Team level
Proportion of patients in each team and the total national sample with documented evidence in their clinical records of a general assessment of side effects in the last year.
The following Figure relates to audit 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, diabetes and dyslipidaemia. Team level graphs showing team performance for these are available in the report.
The team with the highest proportion of patients with a documented general statement regarding side effects in the last year are on the left hand side of the Figure and the team with the lowest proportion on the right.

32. Proportion of patients in each team and the total national sample with documented evidence in their clinical records of assessment of EPS in the last year.

33. Proportion of patients in each team and the total national sample with documented evidence in their clinical records of assessment of weight change in the last year.

34. Proportion of patients in each team and the total national sample with documented evidence in their clinical records of assessment of blood pressure in the last year.

35. Proportion of patients in each team and the total national sample with documented evidence in their clinical records of assessment of blood glucose in the last year.

36. Proportion of patients in each team and the total national sample with documented evidence in their clinical records of assessment of lipid profile in the last year.

37. What happens next?
Your Trust’s Local Project Team Lead (LPTL) has a copy of the full report, please ask them for a copy to see these findings in more detail.
POMH will consider developing bespoke change interventions to be provided to each participating Trust, including opportunities for sharing good practice.
A re-audit will be conducted in January 2011.
If you have any questions, please ask your LPTL or POMH