Psychotropic Medicines with a Focus on Antipsychotics

Following on from my presentation in the Learning Disability and Mental Health Theatre at the Southern Care Show, in this article I will be discussing psychotropic medicines with a particular focus on antipsychotic medicines.  I will begin by looking at what psychotropic medicines are, then take a more detailed look at their use in learning disability and autism, and finally look at how they are currently being used in care and nursing homes, and how data can be used to support staff to ensure these are used and managed appropriately.

What are psychotropic and antipsychotic medicines?

Psychotropic medicines are medicines that affect the mind, and include types such as antidepressants, antiepileptics, antipsychotics, anxiolytics and hypnotics.  Antipsychotics are a type of psychotropic medicine used to manage mental health problems with psychotic experiences such as hallucinations. 

Antipsychotics can cause many possible adverse effects such as weight gain, development of diabetes, movement disorders, heart conditions and disordered hormone levels leading to breast tissue enlargement and lactation. Therefore a careful assessment should be undertaken prior to starting these medicines, and the individual monitored closely for the development of any adverse effects. Some antipsychotic medicines also have drug-specific adverse effects.  For example there is a risk of serious blood disorders with clozapine and therefore this is recommended for use only when other management options have failed. 

These can be broadly grouped into two categories; first and second generation.  First generation antipsychotics and second generation antipsychotics work in different ways and therefore this affects the side effect profiles. First generation antipsychotics are more likely to cause movement disorders and sedation, while second generation antipsychotics are more likely to cause weight gain, high blood sugar levels and high cholesterol.

Psychotropic use in Learning Disability and Autism

Psychotropic medicines are often used “off-label” to help manage behaviours that challenge in learning disabilities and autism.  “Off-label” means that the medicine is being used for a reason different to the one it was initially intended for.  This means that there is a risk of the adverse effects associated with these medicines, with less certainty of benefiting from them.  Sometimes these medicines are beneficial and are being used in accordance to guidance – appropriate use.  However, this is not always the case.  Furthermore, it is important to ensure these medicines are monitored and reviewed regularly with the individual and their multi-disciplinary team (MDT). 

The Challenging Behaviour Foundation have created a medication pathway to support individuals and their carers to be involved in decision making around these medicines.  In the section I will take a more detailed look at some of the background included in Section B of this pathway.

What are the issues surrounding inappropriate medication use?

Acute awareness of inappropriate psychotropic use for behaviour that challenges was triggered by Winterbourne View.  This was a private hospital for assessment, treatment and rehabilitation of adults with learning disabilities and autism that was closed in 2011 following a BBC Panorama documentary showing abuse to the residents.  Reports following this found a high use of restraint and psychotropic medications. 

This led to the transforming care programme.  This is a joint commitment with NHS England, the Department of Health, Local Government Association, CQC & Health Education England.  It aims to improve quality of care, improve quality of life and reduce inappropriate hospital admissions and length of stay. This is still ongoing.

Multiple reports and studies were also formulated.  The NHS improving quality report describes the work of collaborations between NHS Improving Quality and project sites with the aim of ensuring safe, appropriate and optimized use of medication for people with learning disabilities with behaviour that challenges, in response to Winterbourne view

A Public Health England Report reviewed psychotropic medicine use using GP records in response to concerns over the use of psychotropic medicines for unlicensed indications.  For antipsychotics, this found that over 90% of these were prescribed long-term.  Almost ¼ of those prescribed an antipsychotic drug were also prescribed another psychotropic medicine.  Only around 2/5 had a potentially relevant indication recorded in their records.  An estimated 30,000 – 35,0000 adults with learning disability were taking an antipsychotic, an antidepressant or both without a licensed indication. 

A study by University College London looked at the medical records of over 30,000 individuals with learning disability or autism.  This found a greater proportion of individuals treated with a psychotropic drug than the proportion with a recorded mental illness.

A CQC survey looked at medication use for almost 800 individuals detained under the Mental Health Act between October 2012 and August 2013.  This found 86% were prescribed at least one antipsychotic drug to be given on a regular basis.  Of these, almost ½ had no recognized indication.  Meanwhile 28% had an increased likelihood of being administered a combined dose of antipsychotic medicines above the range recommended in the British National Formulary.

Finally, STOMP – stopping over medication of people with a learning disability, autism or both – is a national project to stop the inappropriate use of psychotropic medications in individuals with learning disability and autism.  It was launched in 2016 by NHS England, the Royal College of Nursing, the Royal College of Psychiatry, the Royal College of General Practitioners, the Royal Pharmaceutical Society and the British Psychological Society, and since this the number of partner organisations has grown.  It aims to encourage regular medicines reviews, involve the individual, their family, carers and the multi-disciplinary team in decisions about medicines and improve knowledge of other non-drug ways of supporting individuals to reduce the need for medication.

NICE guidance on use of antipsychotic medicines for behaviour that challenges in Learning Disability and Autism

NICE emphasise the importance of working with the individual and involve them as much as possible.  Initial assessment of behaviour that challenges should include a clear description of the behaviour, including severity, frequency, duration, impact on self and others, how personal or environmental factors are involved in developing or maintaining the behaviour and the role of other individuals during this process.  Behaviour that challenges often indicate unmet needs and attempts should be made to identify and address these.  Physical and mental health conditions should be considered, and risk assessment should be carried out including harm to self, harm to others and harm from others through abuse, neglect or exploitation.

This assessment should guide the creation of a behavioural support plan to attempt to prevent or reduce the occurrence of unsafe situations as a result of behaviours that challenge.  These proactive strategies are preferred over reactive strategies using interventions to make a person or situation safe as challenges occur.  Reactive strategies should only be used in combination with proactive strategies, as a last resort, and should be the least restrictive possible.  Risk assessments should be undertaken for these, particularly for the more restrictive measures such as physical restraint and as required medication use.

Antipsychotic medication should only be considered for behaviour that challenges if other interventions through the behavioural support plan have been unsuccessful within an agreed timeframe, treatment for coexisting mental or physical health problems has been unsuccessful or the risk to self or others is very severe.  They should initially be prescribed and monitored by a specialist.  Only a single medicine should be prescribed and this should be started on a low dose and built up if necessary.  Other interventions should be continued through the behavioural support plan alongside this. 

A clear reason should be given for why the antipsychotic medicine is prescribed – the target behaviour – and a clear way to measure its effectiveness.  There should be a clear plan on how long it should be taken for and strategy for review/withdrawal.  Its use should be reviewed at around 3 weeks and 6 weeks after starting to check for side effects and effectiveness.  If there has been no benefit by 6 weeks then the antipsychotic medicine should be withdrawn.  If there has been a positive response, its use should be reviewed with the individual and their multi-disciplinary team after 3 months, then at least every 6 months, alongside all other prescribed medication.

What can you do to help reduce inappropriate use of antipsychotics?

How are psychotropic medicines being used in care and nursing homes?

This sections looks at how these medicines are prescribed to individuals in care and nursing homes by examining non-archived medicines from a snapshot of electronic medicine administration records from Invatech Health’s ATLAS system.  It is worth noting that, as a limitation, this only considers medications listed under each individual and not how they are being administered.

Around 1/5 of individuals were prescribed an anxiolytic or hypnotic, or an antipsychotic.  15% were prescribed an antiepileptic and almost 30% an antidepressant.  The percentage prescribed these medicines was even higher for individuals in learning disability specialism homes compared to the average across all types of homes.

Looking at antipsychotic use, 20% were prescribed any antipsychotic medication in all homes - this is similar to findings of published research.  3% of these were prescribed levomepromazine.  This medicine is most commonly used in palliative care therefore has been filtered out from further analysis. Furthermore, of the approximately 1500 antipsychotics features on individuals lists of medicines, around 1/5 of these had not been administered in over a month - so it's not all bad.

There was significant variation in prescribing of antipsychotics between homes, from 2% to 81%.  The top 5 highest all had mental health listed as a specialism.  However, the highest of these without mental health as a specialism was a learning disability home, ranking at 6th with 71% of residents in the home prescribed an antipsychotic medication.  Average therapy length was 260 days, ranging from 14-1582 days.  For learning disability specialism homes, the average therapy length was higher and no individuals had been prescribed their antipsychotic medicine for less than 28 days.

With regards to type of antipsychotic medicines being used, the majority of prescriptions were for second generation antipsychotics.  There was very little difference in the split between the types of antipsychotics being prescribed for homes with mental health listed as a specialism and those compared to those without.  A very small number of individuals were taking clozapine, which is recommended as a last resort due to the risk of blood disorders.

Potential for Use of Data

Data has the potential to improve monitoring by giving real-time information in prescribing and administration.  Variation in use of antipsychotic medicines between homes may be a result of differing needs – appropriate medication.  However, the use of antipsychotic medicines should be closely monitored to ensure that individuals are not at risk of inappropriate antipsychotic use.  For example, individuals prescribed antipsychotic medicines for behaviour that challenges should have a behavioural support plan, an antipsychotic care plan and regular review with the multi-disciplinary team caring for them.  

Data could be used to help monitor the the use of these medicines against guidance.  Furthermore, it can be used to flag specific training needs – in homes with a high use of antipsychotic medicines it would be beneficial for staff to complete specialist training modules on these medicines.  Finally, predictive analytics could be used to predict the risk of adverse outcomes.  For example, many of these psychotropic medicines have been found to be a high risk for falls.  Techniques like machine learning could be used to predict this risk – These techniques have been shown to be more accurate than classic clinical risk scores, as described in the Topol review, the governments paper on their future vision for the use of technology and data in health and care.  

Summary

Psychotropic medicines are those that affect the mind.  They are often used "off-label" for behaviour that challenges in learning disability and autism.  If they are used for this, antipsychotic medicines should be reviewed regularly with the individual and their multi-disciplinary team alongside other medicines use.  Finally, data can be used to help monitor medicines use and other outcomes against guidance.

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