Setting

This audit is relevant in any service where a high proportion of patients are likely to be prescribed antipsychotic medication.

Background

Guidelines on antipsychotic medication produced by the National Institute for Health and Clinical Excellence (NICE) suggests that atypical antipsychotics are preferred to typical antipsychotics because of their lesser side-effect profile and higher propensity for compliance. National Health Service trusts have an obligation to ensure that appropriate atypical drugs with the lowest purchase costs are considered before a prescription is made.

Standards

Standards were obtained from National Institute for Health and Clinical Excellence 2009 guidance on the use of atypical antipsychotic medication in schizophrenia. Of particular relevance are the following:

ᐅ The choice of antipsychotic medication should be made jointly by the prescriber and the (properly informed) patient and/or carer.

ᐅ Second-generation antipsychotics should be considered as the first-line treatment.

ᐅ Second-generation antipsychotics should be considered for patients who show or report unacceptable adverse effects caused by first-generation agents.

ᐅ Clozapine should be considered if the patient is unresponsive to two different antipsychotic medications (at least one being a second-generation antipsychotic).

ᐅ Depot medication should be used where there are grounds to suspect that a patient may be unlikely to adhere to prescribed oral therapy.

ᐅ The drug with the lowest purchase cost should be prescribed.

ᐅ Advance directives regarding patients’ preference for treatment should be developed and documented.

ᐅ A comprehensive package of care should be considered.

ᐅ Second-generation antipsychotics and first-generation antipsychotics should not be prescribed together except during a changeover of medication.

ᐅ Justify reasons for dosages outside the range given in the BNF(Joint Formulary Committee, 2009).

Method

Data collection

A retrospective review of case notes and medication cards from all in-patients was used. It was helpful to use an audit pro forma based on the above standards.

Data analysis

The total percentage compliance with all the above standards was analysed using a computerised statistical package.

Resources required

People

This audit was conducted by two people to cover the entire in-patient population as well as to minimise bias.

Time

If data are collected by two clinicians, it is anticipated that no more than 6 hours will be required for this, and a further 4 hours for analysis and presentation.