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

2. 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).

3. 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

4. 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%

5. 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

6. 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

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.
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.

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=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.

9. 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.

10. 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.

11. National findings
Indication profile olanzapine

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

13. 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.

14. 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%

15. 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.

16. 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.

17. 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).

18. 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%

19. 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.

20. 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%

21. 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.

22. 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.

23. 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.

24. 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.

25. 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).

26. 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).