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High-dose and combination antipsychotic prescribing in acute adult wards in the UK: the challenges posed by p.r.n. prescribing

Oxleas NHS Foundation Trust, Dartford

Thomas R. E. Barnes

Department of Psychological Medicine, Imperial College, London

Mary-Rose Cavanagh and David Taylor

South London and Maudsley NHS Trust, London

Paul Lelliott

Royal College of Psychiatrists Research Unit, London, UK, on behalf of the Prescribing Observatory for Mental Health project team

the POMH–UK project team

Correspondence: Carol Paton, Chief Pharmacist, Oxleas NHS Foundation Trust, Pinewood House, Pinewood Place, Dartford, Kent DA2 7WG, UK. Email: C.Paton{at}imperial.ac.uk

Declaration of interest

C.P., T.B. and D.T. have acted as consultants to pharmaceutical companies marketing antipsychotic medication; P.L., D.T. and T.B. have received funding from pharmaceutical companies for research studies. Other funding detailed in Acknowledgements.

Background

Clinical guidelines recommend the routine use of a single antipsychotic drug in a standard dose, but prescriptions for high-dose and combined antipsychotics are common in clinical practice.

Aims

To evaluate the effectiveness of a quality improvement programme in reducing the prevalence of high-dose and combined antipsychotic prescribing in acute adult in-patient wards in the UK.

Method

Baseline audit was followed by feedback of benchmarked data and delivery of a range of bespoke change interventions, and then by a further audit 1 year later.

Results

Thirty-two services participated, submitting data for 3942 patients at baseline and 3271 patients at the 1-year audit. There was little change in the prevalence of high-dose (baseline 36%; re-audit 34%) or combined antipsychotic prescribing (baseline 43%; re-audit 39%). As required (`p.r.n.') prescriptions were the principal cause of both high-dose and combined antipsychotic prescribing on both occasions.

Conclusions

The quality improvement programme did not have a demonstrable impact on prescribing practice in the majority of services. Future efforts to align practice with clinical guidelines need to specifically target the culture and practice of p.r.n. prescribing.

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