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ORIGINAL PAPER
A comparison between the UK and a Malaysian setting of antipsychotic
prescribing on forensic wards using Prescribing Observatory for Mental
Health-UK standards
Johnson D1 & Badi’ah Y2
1Newcastle
University Medicine Malaysia (NUMED), Nusajaya, Johor
Psychiatry, Hospital Permai, Johor Bahru, Johor
2Forensic
Abstract
Introduction: Clinical guidelines recommend the use of a single antipsychotic drug at
standard doses. In clinical practise high-dose and combined antipsychotics are common.
Methods: A clinical audit of antipsychotic prescribing for patients in a forensic ward in
a Malaysian hospital was undertaken using Prescribing Observatory for Mental HealthUK (POMH) standards and compared to POMH data. Result: The level of high dose
prescribing between Malaysian and the UK was comparable. There were low levels of
the use of ‘as required’ (PRN) medication in Malaysia compared to the UK. The use of
combined prescribing was more common in Malaysia. Discussion: Levels of high dose
antipsychotic prescribing are unsatisfactory across both jurisdictions. Specific quality
improvements in Malaysia need to centre on the use of combination antipsychotics.
Key words: forensic, antipsychotic, high dose
Introduction
The Prescribing Observatory for Mental Health-UK (POMH-UK) is a national quality
improvement programme open to all National Health Service (NHS), private and not-forprofit providers of mental health services (Healthcare Organisations; Trusts) in the UK.
POMH-UK facilitates a programme of topic-based audits. This audit compares data to a 12month re-audit for the POMH-UK Topic 3: Prescribing high-dose and combination
antipsychotics on forensic wards. A baseline audit was conducted in March 2007. The same
21 Trusts/organisations participated in the 12-month re-audit in March 2008, submitting data
for 1997 patients from 184 wards (72 high-secure and 112 medium or low-secure wards).
While there is considerable evidence for the effectiveness of antipsychotic drugs in the
treatment of psychosis1, there is no evidence to suggest that doses of antipsychotics higher
than the recommended dosages are more effective than standard doses2. This also appears to
hold true for cases where standard doses have failed to produce any benefit. The controlled
studies comparing very high doses of first-generation antipsychotics with standard dosage
regimens for treatment resistant schizophrenia all failed to show a significant advantage for
the high dosage 3, 4. Further, higher doses have a greater risk of dose-related side effects.
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Sometimes people receive more than one antipsychotic because they are switching from one
antipsychotic to another, and there is cross-tapering of the doses of both drugs in the
transition phase. Some people are prescribed a second antipsychotic drug ‘PRN’ for the
management of disturbed behaviour. For others, combined antipsychotics are prescribed
because a patient’s response to a single antipsychotic has proved less than satisfactory and it
is hoped that the addition of another will lead to an enhanced therapeutic effect. The literature
in this area suggests that the potential for harm may outweigh the potential for benefit; there
is no convincing evidence that symptoms improve 5, 6 and patients who are prescribed
combinations are more likely to receive a high total antipsychotic dose7 , experience side
effects and spend longer in hospital6. In the longer term, there is tentative evidence that
mortality may be increased8.
The primary driver for admission to secure care is violence. In people who have
schizophrenia, the risk of violence is increased by the presence of co-morbid antisocial
personality disorder9, and further increased by co-morbid substance misuse10. The potential
consequences of poorly controlled psychotic symptoms, possibly compounded by co-morbid
personality disorder and continued substance misuse, increase the risk of violence. Effective
interventions to reduce this risk, and thereby to allow transfer to a less secure setting, are a
priority. For many patients in tertiary settings, all evidence-based pharmacological
approaches may have been exhausted.
This study sought to examine the differences in prescribing practices of high dose
antipsychotics of forensic wards in Malaysian and the UK.
Method
A clinical audit of patient case notes and drug charts of current in-patients who had been
prescribed one or more antipsychotics was performed on a forensic rehabilitation ward in
Hospital Permai, Johor Bahru, Malaysia.
Audit standards were derived from the Consensus statement on the use of high dose
antipsychotic medication – Royal College of Psychiatrists (CR138) and the standards used in
the POMH-UK Topic 3: Prescribing high-dose and combination antipsychotics on forensic
wards and treatment guidelines.
The flowing standards were examined1. How many patients received high dose as calculated using the calculation matrix used
by POMH.
2. To what extent was this single or combination therapy or due to the use of PRN
medication
3. Where combination medication was been used was there evidence in the clinical
record stating a reason why?
4. Where any measures been taken to monitor those prescribed high dose medication?
No record was noted of ‘stat’ medication prescribed.
The following information was collected:- demographic variables (age, gender,); clinical
variables (diagnostic grouping, legal status, length of stay) and information related to the
standards set above. Data was collected and analysed in MS Excel. The audit data was
collected in September 2011.
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Results
In total 36 patients of a total of 57 were audited, all patients were male. Patients were selected
at random using a computer generated random number allocation. The only patients excluded
were those on no form of antipsychotic medication. No patients were needed to be excluding
using these criteria.
The average age was 42.75 years, with a median (middle value) of 41.0 years, and a mode
(most common value) of 35 years. There was a range of 44 years with a minimum age of 22
to a maximum of 66. All the patients were held under the Criminal Procedure Code (CPC) of
Malaysia. Twenty four (67%) patients were held under Section 348 and twelve (33%) under
Section 344.
The case note primary diagnosis was schizophrenia- 31 patients (86%), learning disability- 3
patients (8%), bipolar affective disorder -1 patient (3%) and organic- 1 patient (3%). The
average length of stay was 180 months.
With regard to the level of usage of different classes of antipsychotic medication, see figure 1
below.
Figure 1- Patient number and class of antipsychotic prescribed.
In ten (28%) patients high dose antipsychotic prescribing was noted. All those on high dose
medication were also on multiple antipsychotic medications. In another nine (25%) patients
antipsychotic were prescribed in combination but not in high dose. Of those prescribed high
dose antipsychotics, a clear reason for use was documented in the clinical record in 5 (50%)
cases.
With regard to investigations to monitor high dose anti psychotic use, 3 patients (33%) had
evidence of this in the clinical record. Two of these had an ECG in their notes and one had
evidence of blood monitoring.
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There was no use of PRN antipsychotic medication.
Discussion
The rate of high dose antipsychotic prescribing was comparable between the two jurisdictions
with 28% noted on the Malaysian forensic ward and 32% being the average from the POMS
re-audit in 2008 11. Of the Malaysian sample, 53% were on combination antipsychotic
medication compared to 40% in the POMS sample. Unlike the POMS sample, where most
combination prescriptions included PRN (71%), there was no use of PRN in the Malaysian
sample.
A number of limitations apply to this audit. Firstly what was measured was prescribed
medication, not administered medication. One cannot be certain that patients received what
was prescribed. The Malaysian data is based on limited numbers compared to the POMH data
with obvious implications for reliability. Also comparing data across two different
jurisdictions raises the issue of the validity of such a comparison. The results of a
retrospective review of patients admitted for violence to a forensic ward in Malaysia12 are
comparable to those of a U.K. forensic population13. However length of stay was not taken
into consideration. The patients assessed in Malaysia were on a forensic rehabilitation ward
for serious offenders with an average length of stay of 180 months. This contrasts with the
broader spectrum of mentally disordered offenders across a number of settings in the POHM
data where the average length of stay is considerably less13. This difference could the
comparison of the prescribing patterns.
Improvement in reducing the use of combination anti-psychotics along with increasing the
monitoring and documentation of a rationale behind its use in the Malaysian setting is a
priority. Feedback and local training will be the first stage in this. The use of the POHM
Ready Reckoner which is a simple tool for easy calculation of whether a single or combined
antipsychotic dose is within or greater than 100% of the BNF recommended maximum, could
be promoted within the Malaysian setting. Involvement of clinical pharmacists to monitor
this area in the face of stretched medical resources in Malaysia could also play a vital role.
Improvement in access to psycho-social interventions could represent another means to
reduce combination prescribing. Re-audit would play an obvious role though improvement
can be difficult to achieve14.
Why the low rates of use of PRN in Malaysia compared to the U.K.? The lack of use of PRN
could represent a cultural difference between the two jurisdictions, it could represent a
consequence of the use of alternate methods of dealing with acute disturbance such as deescalation skills or be related to the access of medical input given high patient to doctor ratio
in Malaysia compared to a UK setting.
Rates of high doses prescribing were similar in Malaysia and the U.K. Both jurisdictions have
challenges, though on different fronts, to improve this area of practice.
Acknowledgments
Dr S. Hafizah for her help in data collection.
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References
1. Lehmann, H.E. and Ban, T.A. The history of the psychopharmacology of
schizophrenia. Can J Psychiatr 1997; 42:152–156.
2. Lehman, A.F., Steinwachs, D.M. Translating research into practice: The
Schizophrenia
Patient
Outcome
Research
Team
(PORT)
Treatment
Recommendations. Schizophr Bull 1998; 24: 1-10.
3. Thompson, C. The use of high-dose antipsychotic medication. B J Psychiatry 1994;
164: 448-458.
4. Royal College of Psychiatrists. Revised consensus statement on high-dose
antipsychotic medication. Council Report 138. 2006 Available at
www.rcpsych.ac.uk/files/pdfversion/CR138.pdf Accessed 30th March 2012
5. Taylor, D., Mir, S., Mace, S. et al. Co-prescribing of atypical and typical
antipsychotics prescribing sequence and documented outcome. Psychiatric Bulletin
2002; 26: 170-172.
6. Centorrino, F., Goren, J.L., Hennen, J. et al. Multiple versus single antipsychotic. Am
J Psychiatry 2004; 161: 700-706.
7. Harrington, M., Lelliott, C., Paton, C. et al. The results of a multi-centre audit of the
prescribing of antipsychotic drugs for in-patients in the UK. Psychiatric Bulletin
2002; 26: 414-418
8. Waddington, J.L., Youssef, H.A, Kinsella, A. Mortality in schizophrenia.
Antipsychotic polypharmacy and absence of adjunctive anticholinergics over the
course of a 10 year prospective study. B J Psychiatry 1998; 173: 325-329.
9. Moran, P., Walsh, E., Tyrer, P. et al. Impact of co-morbid personality disorder on
violence in psychosis; report from the UK700 trial. Br J Psychiatry 2003; 182:129134.
10. Friedman, R.A. Violence and mental illness – how strong is the link? N Engl J Med
2006; 355: 2064-2066
11. Paton, C., Barnes, T.R.E., Brooke, D., Petch, E., and Shingleton-Smith, APrevalence
of, and rationale for, the prescription of high-dose and combined antipsychotics in
forensic settings in the UK. J Psychopharmacol 2008; 22(Supl): A44
12. Najwa Hanim, M.R., Abdul Kadir, AB., and Badi'ah, Y. Retrospective review on
patients admitted for violent crime in Permai Hospital, Malaysia. Malaysian Journal
of Psychiatry 2011, http://www.mjpsychiatry.org/index.php/mjp/article/view/130.
Accessed 25th April 2012.
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13. Coid, J., Kahtan, N., Gault, S., Cook, A., Jarman, B. Medium secure forensic
psychiatry services: comparison of seven English health regions. Br J Psychiatry.
2001; 178(1): 55-61.
14. Paton, C., Barnes, T.R.E., Cavanagh, M.R., Taylor, D. and Elliot, P. High-dose and
combination antipsychotic prescribing in acute adult wards in the UK: the challenges
posed by p.r.n. prescribing. Br J Psychiatry 1994; 192, 435-439.
Correspondence Address
Dr Dominic Johnson
Clinical Senior Lecturer in Mental Health Newcastle University
Medicine Malaysia (NUMED)
No.1, Jalan Sarjana 1 Kota Ilmu,
Educity@Iskanadar
79200 Nusajaya
Johor.
Direct: 07-5553824
H/P- 0127793356
Fax : 07-5553888
Email : dominic.johnson@newcastle.edu.my