Introduction
There is currently no available accurate number of 24-hour nurse-staffed community residences in Ireland, but a good estimate, based on previous inspections by the Inspectorate is 140 residences. These residences, previously designated as high support hostels, are located throughout Ireland and provide 24-hour nursing care for residents with long-term mental illness. Although many of these residents were transferred when traditional psychiatric hospitals closed, the age range of residents indicate that there is also a population of new long-stay residents. The policy document on provision of mental health services in Ireland, Planning for the Future (1984), recommended the provision of 25–33 places per 100 000 population in nurse-staffed community residences in areas where there was a ‘backlog’ of patients from a psychiatric hospital. Where there was no psychiatric hospital in the area, 15–20 places per 100 000 population were recommended (Planning for the Future 1984). In 2006 the policy document for mental health services, A Vision for Change (2006) stated there ‘would be a requirement for 30 places in large urban areas, with fewer required in areas with low deprivation levels’ (p. 109).
Residents in community residences live in homes where there is at least one nurse on duty 24 hours each day and suffer from a variety of illness, most commonly schizophrenia and affective disorders. One of the functions of the nursing staff is to administer medication. Psychotropic medication is prescribed by the treating psychiatrist and the objective of this survey was to review prescribing patterns in a sample of community residences located throughout Ireland.
There have been very few studies in the literature describing prescribing practices in psychiatric community residences. Most of the literature on prescribing has been conducted on in-patients in acute units (Waddington et al. Reference Waddington, Joussef and Kinsella1998; Patrick et al. 2006; Paton et al., Reference Paton, Barnes, Cavanagh, Taylor and Lelliott2008; Finnerty Reference Finnerty2011), patients attending outpatient facilities (Essock et al. Reference Essock, Schooler, Stroup, McEvoy, Rojas, Jackson and Covell2011; Howes et al. Reference Howes, Vergunst, Gee, McGuire, Kapur and Taylor2012; Grech et al. 2012) and community or residential care for elderly residents, often with a diagnosis of dementia (Kirby et al. 1999; Kogut et al. Reference Kogut, Yam and Dufresene2005; Fischer et al. 2011). The most comparable studies this author found was a study of a stable patient population in long-stay wards in a large psychiatric hospital in Newcastle in England (Clarke & Holden Reference Clarke and Holden1987) and Finnerty’s study of in-patients, which included a number of residents in long-stay units in Ireland in 2011. However, the residents in our study do not fit neatly into any of these categories.
Preliminary results from the 2011 data were published in the Annual Report of the Inspector of Mental Health Services in 2012.
Method
The Mental Health Act 2001 was enacted in Ireland in 2006. It stipulates that only facilities which are registered by the Mental Health Commission can provide in-patient psychiatric care. These facilities are designated as approved centres, defined as ‘a hospital or other in-patient facility for the care and treatment of persons suffering from mental illness or mental disorder’ (Mental Health Act 2001). All approved centres are inspected by the Inspectorate of Mental Health Services on an annual basis, as directed by the Mental Health Act (2001). In addition to these mandatory inspections, the Inspectorate carries out inspections of community facilities where mental health services are provided. These include community residences, day hospitals and day centres.
In the two years from 2011 to 2012, a total of 35 community residences were inspected. These residences were located in 18 different catchment areas (out of a total of 32 catchment areas) and from each of the four Health Service Executive regions. On the day of each inspection, inspectors obtained a photocopy of individual prescription kardexes or prescription sheet under powers granted by the Mental Health Act (2001), section 51(2)(c). This section permits the Inspector ‘to examine and take copies of, or extracts from, any record or other document made available to him or her as aforesaid or found on the premises’. Information was annonymised and provided to the author. Information on non-psychotropic medication was not considered in this survey. The survey reviewed the prescribing patterns of the following medications: benzodiazepines, hypnotics, antipsychotic medications, antidepressant medications and lithium. Analysis of antipsychotic prescribing included the use of polypharmacy and high dose prescribing. The definition used to calculate high-dose medication is described as a dose prescribed which is more than 100% of the BNF maximum adult daily dosage as published by the British Medical Association. When calculating total daily dose, only medication prescribed daily was counted; pro re nata (PRN) dosages were not included in assessing the total daily dose of medication taken.
Results
Prescription details were obtained for 428 residents (56% male, 44% female), with an age range from 20 to 87 years. Rehabilitation teams were responsible for the care of residents in 16 of these residences, whilst others were under the care of the community mental health team (CMHT) (17 residences), mental health of intellectual disability team (one residence) or had shared care between the CMHT and rehabilitation team (one residence). Rehabilitation teams focus on the needs of service users with long-term and complex mental health problems.
Eleven residents were not prescribed any psychotropic medication. Seven residents were prescribed an antidepressant only, five were prescribed a hypnotic only and three residents were prescribed a benzodiazepine only. In 12 residences, all residents were on antipsychotic medication.
Forty-nine per cent of residents were prescribed more than one antipsychotic concurrently. One hundred and ten residents (26%) were prescribed high-dose antipsychotic medication. Eighty-seven residents (20%) were prescribed clozapine. Just over a quarter of all residents were prescribed an antipsychotic long-acting injection and 41% were prescribed an antidepressant medication.
The findings are outlined in the tables below.
Medications prescribed
The most frequently prescribed antipsychotic medication was olanzepine, followed by clozapine and chlorpromazine. Seventy-five per cent of antipsychotics prescribed (424) were second-generation antipsychotics. Table 2 shows the antipsychotic medications used.
Of the 120 residents prescribed an antipsychotic long-acting injection, 99 (75%) were also prescribed an oral antipsychotic.
A wide range of antidepressants were used in the community residences. The most frequently prescribed was citalopram/escitalopram, followed by venlafaxine and mirtazapine. Fifty two per cent of prescriptions for antidepressants were for selective serotonin reuptake inhibitors (SSRIs), followed by 5-Hydroxytryptamine-N-acetylase (5HTNA) reuptake inhibitors (22%), presynaptic agonists (15%), tricyclics (6.6%) and priazolopyridine (3%). Table 3 shows the antidepressant medications used.
Medications prescribed
PRN, pro re nata.
Antipsychotic medication prescribed
Discussion
The standards set by the National Institute for Clinical Excellence (NICE) 2010 Guidelines, the Royal College of Psychiatrists, the Department of Health and Children (2002) and the College of Psychiatrists of Ireland EAP Position Paper, 2012 for the prescribing of psychotropic drugs including benzodiazepines, hypnotics and antipsychotic medications are well known. Guidelines issued by the NICE group recommend that benzodiazepines should not be used for more than 2–4 weeks, and in the non-benzodiazepine hypnotic group of medications, they should be only used for a maximum of between 2–4 weeks.
Antidepressant medication prescribed
One-quarter of residents were prescribed a benzodiazepine on a regular basis. The rate of prescribing benzodiazepines in acute in-patient units ranged from 20% to 52% in Scotland (Summers et al. 1998) to 51% in Ireland (Hallahan et al. Reference Hallahan, Murray and McDonald2009). In residents in long-stay wards in psychiatric hospitals or units in Ireland, the rate was 60% (Finnerty Reference Finnerty2009). In elderly populations in Ireland and Australia the rates were 17.3% (Kirby et al. 1999) and 16.6% (Jorm et al. Reference Jorm, Grayson, Creasy, Waite and Broe2000), respectively. Rates in the general adult population range from 7.7% in the United Kingdom (Dunbar et al. Reference Dunbar, Perra and Jenner1989), to 9.1% in a Swiss adult population (Petitjean et al. Reference Petitjean, Ladewig, Meier, Amrein and Wiesbeck2007). The results of this author’s study found a rate between those two populations of in-patients and people living in the community. It was not possible from the examination of the prescription kardexes or prescription sheets to determine what the duration or indications for use of benzodiazepines were.
Antipsychotic polypharmacy
Three hundred and eighty-five of the 428 residents were prescribed antipsychotic medication (90%) and almost half (209) were prescribed more than one antipsychotic medication concurrently. The issue of antipsychotic polypharmacy has been reported many times in the literature, with no real evidence that the concurrent use of two or more antipsychotic medications is an effective treatment (Waddington et al. Reference Waddington, Joussef and Kinsella1998; Patrick et al. 2006; Fischer et al. 2011; Paton et al. Reference Paton, Barnes, Cavanagh, Taylor and Lelliott2008). Yet, despite best practice guidelines by the Royal College of Psychiatrists and the NICE guidelines (Core interventions for Schizophrenia) which do not recommend the use of more than one antipsychotic drug at a time (except in exceptional situations), the use of polypharmacy is commonplace in the treatment of psychiatric illness. Reports of the prevalence of antipsychotic polypharmacy in the United States vary from 7% to ~50%, with most studies finding prevalence rates of between 10% and 30% (Correll et al. Reference Correll, Rummel-Klugr, Corves, Kane and Leucht2009). Vijayalakshmy et al. found a rate of 42% in a US state hospital in 2001, which fell to 31% in 2002 after a programme instituted to reduce this practice. In the UK, the POMH UK study of 3942 in-patients found a polypharmacy rate of 43%. An Irish study found that 29% of in-patients were on more than one antipsychotic (Finnerty) and in a long-stay unit in a Newcastle hospital in the United Kingdom, a rate of 76% of polypharmacy was found. Studies in an outpatient setting in the United States recorded a polypharmacy rate of 13% of antipsychotic prescribing (Essock et al. Reference Essock, Covell, Leckman-Westin, Lieberman, Sederer, Kealey and Finnerty2009) while a study of all patients (both in-patient and outpatients) just before commencing clozapine, found a rate of 36.2% (Howes et al. 2012). The figure of 49% of our residents on more than one antipsychotic concurrently must be considered high, given that these are patients who no longer require in-patient care and whose illness must be judged to be stable.
Polypharmacy is not without risk to the patient. Problems with overweight are commonplace and several studies have shown an increased risk for the development of diabetes and cardiovascular disease (Correll et al. Reference Correll, Rummel-Klugr, Corves, Kane and Leucht2009) with antipsychotic medication use. A study in Finland examining mortality in patients with schizophrenia who were taking neuroleptic medication (Joukamma et al. 2006) found that the number of neuroleptic drugs prescribed was related to the subsequent mortality of the subjects and posed the question whether ‘the high mortality in schizophrenia is attributable to the disorder itself or the antipsychotic medication’. Risk factors for mortality in schizophrenia, other than drug treatment include cardiovascular and respiratory disease, accidents and smoking (Brown 1997, Brown et al. 2010). Diabetes (Ryan et al. Reference Ryan, Collins and Thakore2003), unrelated to neuroleptic medication use has also been cited as contributing to the risk factors. In addition, a lack of exercise and unhealthy diet have also been considered as contributing to premature deaths in this cohort of patients (Connolly & Kelly Reference Connolly and Kelly2005). A report by Waddington et al. (1998) found that reduced survival was related to the greater number of antipsychotics prescribed.
In contrast, however, another Finnish study of patients with schizophrenia reported in The Lancet (Tiihonen et al. 2009) found that the long-term exposure to any antipsychotic medication was associated with lower mortality than no drug use.
The Consensus Statement of the Royal College of Psychiatrists (CR 138) states that the addition of a second antipsychotic to clozapine may be considered for people with treatment-resistant schizophrenia. In this study, 21% of residents were prescribed clozapine, but the number on combined clozapine and an additional antipsychotic accounted for only 22% of polypharmacy prescribing in the community residences.
High-dose antipsychotic prescribing
Another significant concern in patients on antipsychotic medication is that of prescribing high doses. The Maudsley Prescribing Guidelines state that ‘there is no firm evidence that high doses of antipsychotics are any more effective than standard doses’ (Taylor et al. p. 54). This view is confirmed by the Consensus statement on high-dose antipsychotic medication (CR138) published by the Royal College of Psychiatrists (2006) who go on to state that ‘it is self-evident that the risk and intensity of the majority of unwanted effects from antipsychotic drugs increase with dose’ (p. 16). Most studies on this topic have concluded that the main culprit in high dose prescribing was the use of antipsychotic polypharmacy (College Consensus statement CR 26, 1993; Harrington et al. Reference Harrington, Paton, Okocha, Duffett and Sensky2002; Noir Reference Noir2008; Paton et al. 2008; Paton et al. Reference Paton, Barnes, Cavanagh, Taylor and Lelliott2008; Barnes et al. Reference Barnes, Shingleton-Smith and Paton2009) and PRN prescribing (Paton 2008).
The Consensus Statement on high-dose antipsychotic medication published by the Royal College of Psychiatrists (2006) reported that 25% of in-patients were prescribed a high-dose of antipsychotic medication, which most often occurred in the context of antipsychotic polypharmacy. The group also commented that that ‘there are only limited data on the frequency of prescription of high-dose antipsychotics in psychiatric patients receiving care in the community’ (CR138). The POMH UK (2008) study of in-patients found a rate of high dose prescribing of 36%. A similar rate (34%) was reported in a study of outpatients just before commencing clozapine (Howes 2012). Other studies report lower figures than this: Kogurt et al. (2005) 6% in outpatients, Finnerty (Reference Finnerty2011), 10% in patients in long-stay wards, Connolly et al. (Reference Connolly, Rogers and Taylor2007), 16% in in-patients and Noir (Reference Noir2008), 24% in an in-patient setting in a secure hospital. In our study of residents living in the community, the rate of high dose prescribing of 26% must be considered high in light of the figures above.
Antipsychotic long-acting injections
Twenty-eight per cent of residents were prescribed a long-acting injection of antipsychotic medication. This rate was similar to that of an outpatient population with schizophrenia in the United Kingdom which reported a rate of between one-quarter and one-third (Barnes et al. Reference Barnes, Shingleton-Smith and Paton2009). Our study did not elicit information on diagnosis. Most residents who were prescribed a depot antipsychotic were also prescribed oral antipsychotics (75%). The use of both oral and long-acting antipsychotics contributes to polypharmacy and can be a factor in high dose prescribing.
Lithium
Lithium is an established treatment with bipolar affective disorder, although its use may be in decline. In a study, Baldessarini et al. (2007) found an initial prescription rate of lithium in patients with bipolar disorder of 7.5%. In a US study of outpatients with bipolar disorder, the authors found the rate of prescribing lithium declined from 50.9% between 1992 and 1995 to 30.1% between 1996 and 1999 (Blanco 2002). However, a UK study published by Lloyd et al. (2003) found that the rate of lithium prescriptions was remarkably similar when comparing prescribing patterns in outpatient populations with bipolar disorder in Manchester between 1994 and 1998 (51%) with patients in Newcastle between 2000 and 2001 (53%). Our study found a rate of lithium prescribing of 11% which was more in line with that of the US study, but as our study did not illicit any information on diagnosis, it is not possible to draw any conclusions from this figure.
Conclusion
Almost all residents of the 35 community residences in this study were on psychotropic medication. Over half were prescribed polypharmacy in relation to antipsychotic medication and 26% were prescribed high doses. As this level of prescribing of psychotropic medications was more in line with that of in-patient populations there must be some concern that perhaps much of this prescribing is historic in nature rather than currently clinically indicated. It is recommended that a more strident effort to review and reduce the level of prescribing of such medications be considered by treating teams particularly as many in this population are already elderly and face the concomitant health problems associated with this age group.
Acknowledgement
The author would like to thank Inspectorate colleagues for their help in gathering the data during the course of inspections and the Mental Health Commission for its support.
Conflicts of Interest
None.
