Download Topic 12a slide set

POMH-UK QIP 12a
Prescribing for people with
a personality disorder
August 2012
Outline
Summary of the baseline findings of POMH Topic 12a
audit – Prescribing for people with a personality disorder.
• Clinical Background
• Audit standards
• Method
• National findings
• Trust level findings
• Team level findings
Clinical background
People with personality disorder (PD) have long-standing, pervasive
patterns of thinking, feeling and relating to others that lead to social
problems and poor mental health. Personality disorders are a
heterogeneous group of conditions which vary greatly in their
severity, but problems with inter-personal relationships are a defining
feature.
No drug treatments are currently licensed for personality disorder
and very few studies have been conducted to examine the risks
and benefits of drug treatment for most types of PD, except for
borderline PD.
Current UK guidelines state that, while it is important to treat co-morbid
mental health problems among people with PD, drug treatment should
not be used specifically for the treatment of antisocial or borderline PD
(National Institute for Health and Clinical Excellence, 2009).
Audit standards
1.There is a written crisis plan in the clinical records.
2.There is evidence that the patient’s views have been
sought in the development of the crisis plan.
3.A clinician’s reasons for prescribing antipsychotic
medication (i.e. target symptoms or behaviour) are
documented in the clinical records.
Treatment targets
1. Antipsychotic drugs should not be prescribed for more than four
consecutive weeks in the absence of a co-morbid psychotic illness.
Derived from NICE CG078 recommendation 6.12.1.2: Antipsychotic
drugs should not be used for the medium and long term treatment of
borderline personality disorder; and 3.12.1.3: Drug treatment may be
considered in the overall treatment of comorbid conditions.
2. Z-hypnotics should not be prescribed for more than four consecutive
weeks.
3.
Benzodiazepines should not be prescribed for more than four consecutive
weeks.
4. Medication prescribed for more than four consecutive weeks should be
reviewed, and such a review should take into account a) therapeutic
response and b) possible adverse effects, and also c) be documented in
the clinical records.
Method
Participants:
• 41 Mental Health Trusts participated
• 438 clinical teams
• 2,600 patients
Data collected:
•
•
•
•
•
Demographic, diagnosis, type of service
Antipsychotic(s) prescribed, duration
Clinical indications
Other medicines prescribed
Information about medication review
Key national findings
CRISIS PLAN
1.
Two-thirds (68%) of patients had a written crisis plan which was
accessible in the clinical records. For 72% of these plans there was
evidence that the patient had been involved in its development.
CLINICAL INDICATIONS
2.
The clinician’s reasons for prescribing the most recently initiated
antipsychotic were documented in the clinical records in 83% of
cases.
Key national findings
TREATMENT TARGETS
3. Just over half (55%) of patients without any co-morbid mental illness
were prescribed at least one antipsychotic and the vast majority of
these prescriptions were of at least 6 months duration.
4.
Z-hypnotics were prescribed in 20% of those patients without comorbid psychotic illness. Benzodiazepines were prescribed in 32%
of such patients.
5.
Eighty-two percent of patients were prescribed at least one
medication from the four drug groups (antipsychotics,
antidepressants, mood stabilisers and sedatives), of whom 67% had
evidence of a documented medication review.
Key national findings
REVIEW OF MEDICATION
5.
Of the patients who had evidence of a documented medication
review, there was evidence that the following had been considered:
therapeutic response (in 84% of cases), side effects/tolerability
(65%), patient’s views (74%) and adherence (54%).
6.
The outcome of the most recent medication review was documented
in 94% of cases.
100%
100%
80%
80%
60%
Patient has a crisis
plan and was involved
in its development
40%
20%
0%
TNS
T40
Proportion of patients
Proportion of patients
National and Trust level results for
Standards 1, 2 and 3
60%
Fully or partially
documented
40%
20%
0%
TNS
Standards 1 and 2
National and Trust level results for
Standards 1 and 2: proportion of all
patients with a crisis plan
T40
Standard 3
National and Trust level results for Standard
3: proportion of patients for whom the
clinical reasons for prescribing the most
recently initiated antipsychotic were
documented
National and Trust level results for
Treatment targets 1
Proportion of patients
prescribed antipsychotic
100%
80%
60%
Prescribed for
more than four
consecutive
weeks
40%
20%
0%
TNS
T40
Antipsychotics
Treatment target 1: proportion of patients with a PD diagnosis
alone (i.e. no co-morbid psychiatric diagnosis) prescribed
antipsychotics
National and Trust level results for
Treatment targets 2
Proportion of patients
prescribed z-hypnotic
100%
80%
Prescribed for
more than four
consecutive
weeks
60%
40%
20%
0%
TNS
Z-hypnotics
T40
Treatment target 2: proportion of patients with a PD
diagnosis alone (i.e. no co-morbid psychiatric diagnosis)
prescribed z-hypnotics
National and Trust level results for
Treatment targets 3
Proportion of patients
prescribed benzodiazepine
100%
80%
60%
Prescribed for
more than four
consecutive
weeks
40%
20%
0%
TNS
T40
Benzodiazepines
Treatment target 3: proportion of patients with a PD
diagnosis alone (i.e. no co-morbid psychiatric diagnosis)
prescribed benzodiazepines
National and Trust level
results for Treatment target 4
Treatment target 4: review of medication prescribed for more than four weeks
Proportion
prescribed
medication
for more
than four
weeks
Proportion of those
patients prescribed
medication for
more than four
weeks with
documented
evidence of a
medication review
TNS
82%
T40
80%
Proportion of medication reviews
considering:
Outcome of
medication review
documented
Therapeutic response
Side
effects/tolerability
Yes, clearly or
partially
documented
82%
84%
65%
94%
25%
100%
100%
100%
Patient demographics and clinical
characteristics
Key demographic characteristics
Gender
Ethnicity
Clinical setting*
Age
Female
Male
White/White British
Black/Black British
Asian
Mixed or other
Not specified or unknown
General adult – inpatient
General adult – outpatient
Specialist personality disorder service - inpatient
Specialist personality disorder service - outpatient
Forensic – inpatient
Forensic – outpatient
Forensic specialist personality disorder service - inpatient
Forensic specialist personality disorder service - outpatient
Other setting
Mean age in years (SD)
Min-max
16-25 years
26-35 years
36-45 years
46-55 years
56-65 years
66 years and over
Baseline
n
1533
1067
2281
81
57
46
135
199
1426
52
260
382
53
261
14
21
%
59%
41%
88%
3%
2%
2%
5%
8%
55%
2%
10%
15%
2%
10%
<1%
1%
39 (11.8)
18-78
402
651
749
564
180
54
16%
25%
29%
22%
7%
2%
Patient demographics and clinical
characteristics continued
Subtype of
personality
disorder
diagnosis: ICD10 category*
Other ICD-10
diagnoses*
Crisis plan in the
clinical records
Key demographic characteristics
F60.0: Paranoid personality disorder
F60.1: Schizoid personality disorder
F60.2: Dissocial personality disorder
F60.3: Emotionally unstable borderline personality disorder
F60.4: Histrionic personality disorder
F60.5: Anankastic personality disorder
F60.6: Anxious avoidant personality disorder
F60.7: Dependent personality disorder
F60.8: Other specific
F60.9: Personality disorder, unspecified
F61: Mixed and other personality disorders
Sub-type not yet determined
More than one personality disorder diagnosis
F00-F09: Organic, including symptomatic, mental disorders
F10-F19: Mental and behavioural disorders due to psychoactive substance use
F20-F29: Schizophrenia, schizotypal and delusional disorders
F21: schizotypal disorder subgroup n=54 (13%)
F30-F39: Mood (affective) disorders
F31: bipolar disorder subgroup n=135 (22%)
F40-F48: Neurotic, stress-related and somatoform disorders
F50-F59: Behavioural syndromes associated with physiological disturbances and
physical factors
F70-F79: Mental retardation
F80-F89: Disorders of psychological development
F90-F98: Behavioural and emotional disorders with onset occurring in childhood
and adolescence
F99: Unspecified mental disorder
None documented
Other
Yes
No
N
152
44
484
1776
44
29
102
73
33
141
140
78
356
18
%
6%
2%
19%
68%
2%
1%
4%
3%
1%
5%
5%
3%
14%
<1%
324
13%
406
16%
609
23%
266
10%
87
3%
107
29
4%
1%
64
3%
4
1054
49
1759
841
<1%
41%
2%
67%
32%
Crisis plan: across clinical settings
Audit standards
100%
Patient did not have
a crisis plan
80%
60%
Patient has a crisis
plan - but there is no
patient involvement
in its development
40%
20%
FSPD - OP
FSPD- IP
Forensic - OP
Forensic - IP
SPD- OP
SPD - IP
Adult - OP
0%
Adult - IP
Proportion of patients
1. There is a written crisis plan in the clinical records.
2. There is evidence that the patient’s views have been sought in the development
of the crisis plan.
Patient has a crisis
plan and was
involved in its
development
Clinical setting
Key: IP = inpatients, OP =outpatients, SPD= specialist personality disorder, FSPD = forensic specialist
personality disorder
Reference to medication in the
crisis plan
Proportion of patients
100%
Patient did not have a
crisis plan
80%
60%
Patient has a crisis
plan and but it does
not refer to
medication
40%
20%
Patient has a crisis
plan and it refers to
medication
FSPD - OP
FSPD- IP
Forensic - OP
Forensic - IP
SPD- OP
SPD - IP
Adult - OP
Adult - IP
0%
Clinical setting
Key: IP = inpatients, OP =outpatients, SPD= specialist personality disorder, FSPD = forensic specialist
personality disorder
Clinical reasons for prescribing
across the four groups of
medication – for PD alone
Antidepressant
n=1746
Antipsychotic
n=1720
Mood stabiliser
n=655
Sedative
n=1327
Personality disorder
alone
n=679
Personality disorder
alone
n=578
Personality disorder
alone
n=210
Personality disorder
alone
n=452
Affective/emotional instability
Aggression/hostility
Anxiety (including phobic anxiety and
panic)
Depressive symptoms
Distress
Disturbed sleep
Epilepsy
Impulsivity
21%
2%
41%
24%
71%
15%
8%
15%
25%
23%
7%
41%
71%
10%
12%
5%
10%
16%
11%
18%
1%
8%
2%
6%
13%
2%
22%
59%
5%
Known or suspected psychotic illness
0
7%
1%
<1%
Self harm; deliberate/repeated
Transient psychotic-like experiences
or symptoms
Patient request
Long-term treatment – reason
unclear
Other*
Not known
11%
18%
14%
7%
<1%
23%
2%
1%
4%
6%
3%
7%
7%
7%
4%
4%
13%
10%
17%
12%
8%
11%
10%
10%
Documentation of clinical reasons for
prescribing the most recently initiated
antipsychotic
Audit standard
3. A clinician’s reasons (i.e. target symptoms or behaviour) for prescribing antipsychotic medication
are documented in the clinical records.
Clinical reasons for
prescribing are fully
documented
17%
48%
Clinical reasons for
prescribing are
partially documented
34%
Clinical reasons for
prescribing are not
documented
Medications prescribed for
patients with co-morbid
psychotic or affective disorder,
or PD alone
No
medications
prescribed
Prescribed at
least one
medication
Antipsychotic
Antidepressant
Mood
stabiliser
Sedative
193
(18%)
861
(82%)
579
(55%)
679
(64%)
210
(20%)
452
(43%)
Any personality
disorder with
psychotic illness
n=485
10
(2%)
475
(98%)
457
(94%)
242
(50%)
220
(45%)
271
(56%)
Any personality
disorder with
affective disorder
n=606
12
(2%)
594
(98%)
411
(68%)
515
(85%)
199
(33%)
347
(57%)
Any personality
disorder diagnosis
only
n=1054
Medication review for patients
prescribed any medication for more
than four consecutive weeks
Proportion
with
documented
evidence of a
medication
review
1,744
(82%)
Evidence that medication review considered:
Outcome of medication review
clearly documented
Therapeutic
response
Side
effects/tolerability
Patient’s
views
sought
Adherence
Yes, clearly
documented
1,471
(84%)
1,135
(65%)
1,300
(74%)
947
(54%)
1,211
(69%)
Yes,
Not
partially
documented
documented
441
(25%)
92
(5%)
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.
Your Trust code is 40
Crisis plan
Audit standards
1. There is a written crisis plan in the clinical records.
2. There is evidence that the patient’s views have been sought in the development
of the crisis plan.
100%
80%
60%
Patient has a
crisis plan - but
was not involved
in its
development
40%
Patient has a
crisis plan and
was involved in
its development
20%
0%
12
19
62
93
11
40
80
9
16
89
73
25
59
99
92
42
90
3
17
66
74
5
27
81
18
20
29
94
21
84
82
98
56
22
72
68
31
50
79
83
95
TNS
Proportion of patients
Patient did not
have a crisis plan
Trust code
Reference to medication in
the crisis plan
Patient did not
have a crisis plan
80%
60%
Patient has a
crisis plan but it
does not refer to
medication
40%
20%
0%
12
93
62
19
42
25
27
11
90
82
9
89
31
72
17
5
80
84
16
40
92
73
59
29
94
3
99
56
98
66
74
20
81
18
68
22
21
79
50
83
95
TNS
Proportion of patients
100%
Trust code
Patient has a
crisis plan and it
refers to
medication
Documentation of clinical reasons for
prescribing the most recently
initiated antipsychotic
Audit standard
3. A clinician’s reasons (i.e. target symptoms or behaviour) for prescribing antipsychotic
medication are documented in the clinical records.
100%
80%
Partially
documented
60%
40%
Fully
documented
20%
0%
95
19
93
90
18
99
25
27
94
62
98
74
59
21
9
89
20
5
80
84
11
82
29
16
92
81
73
42
17
66
56
68
72
50
3
22
79
83
31
40
12
TNS
Proportion of patients
in the TNS
Not documented
Trust code
Proportion of patients prescribed
any medication for more than four
weeks and documented evidence
of a medication review
Treatment target
4. Medication prescribed for more than four consecutive weeks should be reviewed
No, there is no
medication
review
documented in
the clinical
records
80%
60%
40%
Yes, there is
documented
evidence
20%
0%
72
21
12
22
11
18
74
5
90
9
31
80
98
59
40
25
99
50
29
27
16
84
93
62
81
92
68
73
17
20
94
42
56
83
66
95
79
3
19
82
89
TNS
Proportion of patients
in the TNS
100%
Trust code
Patients with personality disorder alone
prescribed at least one antipsychotic
and length of prescription
Treatment target
1. Antipsychotic drugs should not be prescribed for more than four consecutive weeks
in the absence of a co-morbid psychotic illness.
Not prescribed for
more than four
consecutive weeks
80%
60%
Duration of
prescription
unknown
40%
20%
Prescribed for
more than four
consecutive weeks
0%
12
31
90
17
95
22
27
11
94
16
66
5
99
18
72
20
25
29
93
9
21
59
50
56
98
62
89
42
73
92
80
68
19
84
83
82
74
3
79
81
TNS
Proportion of patients
with PD only
100%
Trust code
Patients with personality disorder
alone prescribed at least one zhypnotic and length of prescription
Treatment targets
2. Z-hypnotics should not be prescribed for more than four consecutive weeks.
Not prescribed for
more than four
consecutive weeks
80%
60%
Duration of
prescription
unknown
40%
20%
Prescribed for
more than four
consecutive weeks
0%
12
83
95
31
50
80
68
21
94
99
27
22
18
59
84
5
93
17
25
73
56
62
11
66
72
9
82
29
89
92
98
20
16
42
74
19
90
3
79
81
TNS
Proportion of patients
with PD only
100%
Trust code
Patients with personality disorder alone
prescribed at least one benzodiazepine
and length of prescription
Treatment targets
3. Benzodiazepines should not be prescribed for more than four consecutive weeks.
Not prescribed for
more than four
consecutive weeks
80%
60%
Duration of
prescription
unknown
40%
20%
Prescribed for
more than four
consecutive weeks
0%
12
95
18
31
27
22
89
11
93
29
94
92
68
90
5
74
80
16
50
66
9
17
21
19
72
98
56
99
20
59
73
25
84
83
42
3
62
82
79
81
TNS
Proportion of patients
with PD only
100%
Trust code
Team level findings
Analyses presented in this section were
conducted for each clinical team from your Trust
individually, for your total Trust sample and for
the total national sample to allow benchmarking.
Data from each Trust clinical team are
presented by code only.
Only the POMH Lead for your Trust or
organisation has the key to team codes. You
should contact this person if you need to identify
data for your own particular team.
Crisis plan and patient
involvement
Patient did not
have a crisis plan
80%
60%
Patient has a crisis
plan - but was not
involved in its
development
40%
20%
Team code
TNS
Trust 40
0%
40.047
Proportion of patients
100%
Patient has a crisis
plan and was
involved in its
development
Reference to medication in the
crisis plan
Patient did not
have a crisis plan
80%
60%
Patient has a
crisis plan but it
does not ref er to
medication
40%
20%
Team code
TNS
Trust 40
0%
40.047
Proportion of patients
100%
Patient has a
crisis plan and it
ref ers to
medication
Documentation in the clinical
records of reasons for prescribing
the most recent antipsychotic
medication
80%
Not
documented
60%
Partially
documented
40%
20%
Fully
documented
Team code
TNS
Trust 40
0%
40.047
Proportion of patients
100%
Proportion of patients prescribed any
medication for more than four weeks and
documented evidence of medication review
in the clinical records
No, there is no
medication
review
documented in
the clinical
records
80%
60%
40%
20%
Yes, there is
documented
evidence
Team code
TNS
Trust 40
0%
40.047
Proportion of patients
100%
Patients with personality disorder
alone prescribed at least one
antipsychotic and length of
prescription
None prescribed
Patients with personality
disorder alone prescribed at least
one z-hypnotic and length of
prescription
None prescribed
Patients with personality disorder
alone prescribed at least one
benzodiazepine and length of
prescription
None prescribed
What happens next...
• Discussions within your
Trust/team about your own
practice.
• Trust action planning – a
template is included in the
report.
•POMH will develop bespoke
change interventions including
opportunities for sharing good
practice between services.
•A re-audit will be conducted in
October 2013