Dr Anne-Marie Grew

My name is Dr Anne-Marie Grew, I’m a ST5 higher trainee psychiatrist currently working in the Renfrewshire Drug Service in Paisley, Scotland. I am undertaking my higher training in General Adult Psychiatry.

My current year of working is as part of my endorsement year in Addictions Psychiatry. I have found working in Addictions Psychiatry particularly interesting as it marries up requirement and monitoring of Opiate Replacement Therapy along with the concurrent monitoring of patients’ mental state.

I have a particular interest in clinical governance and patient safety. This review of off-label prescribing was directed towards these management parameters.

I hope to continue work into promoting effective clinical governance and enhanced patient safety structures in my future working career.

Aim:

This review looks at the prescription of antipsychotic medication within the Renfrewshire Drug Service and the indications for commencement.

Method:

A service-wide computerised prescribing programme search was undertaken for any patients prescribed antipsychotic medication within the first six months of 2018.  Search parameters included prescriptions of:

Amisulpride

Aripiprazole

Haloperidol

Olanzapine

Pericyazine

Quetiapine

Risperidone

Patients ‘ CHI numbers were collated and each patient ‘s computerised outpatient letters were reviewed in order to ascertain when these antipsychotic medications were commenced and the reason for their prescription.

Results:

During the first six months of 2018, 173 patients were prescribed the above antipsychotic medication.  Of these, 100 patients (58%) received antipsychotic medication off-label. Twenty-seven of the fifty Olanzapine prescriptions (54%) were without a ‘ psychotic ‘ diagnosis and sixty-six of the eighty-eight Quetiapine prescriptions (75%) were in the absence of a confirmed psychotic diagnosis. Reasons for their prescription include; ‘ anxiety ‘, ‘ distress ‘, ‘ sleep ‘, ‘ paranoia ‘, non-psychotic ‘ voices/hallucinations ‘, ‘ anger ‘ and ‘ mood stabilisation ‘.

Conclusions:

This highlights the dilemma faced by many psychiatrists treating patients with substance misuse; that although there are less diagnoses of psychosis/psychotic illnesses than antipsychotic prescriptions, the benefit of sedative antipsychotics to reduce distress, promote sleep and settle some of the chaos in a harm reduction approach, does appear to outweigh the clinical aspect of off-label prescribing.

Medical staff however, should continue to balance the delicate line of substance misuse harm reduction strategies with regular reviews of the requirement for off-label antipsychotic prescriptions, and attempt to reduce and stop these as soon as is clinically possible.

Co-Authors

Dr Anne-Marie Grew, ST5 doctor, NHS Greater Glasgow and Clyde

Conflicts of interest:

No conflict of interest