Quality statement 6: Monitoring for side effects of antipsychotic medication

Quality statement

Children and young people with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication have their treatment monitored for side effects.

Rationale

Children and young people with bipolar disorder, psychosis or schizophrenia are particularly vulnerable to the adverse side effects of antipsychotic medication, including rapid weight gain and metabolic disturbances. This, combined with higher rates of smoking, leads to a higher risk of cardiovascular disease and metabolic disorders than the general population. Regular monitoring will allow antipsychotic medication to be adjusted so that side effects are minimised, and so that physical health interventions can be offered if needed.

Quality measures

Structure

Evidence of local arrangements to ensure that children and young people with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication have their treatment monitored for side effects.

Data source: Local data collection.

Process

a) Proportion of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication who have a record of baseline physical health investigations.

Numerator – the number in the denominator who have a record of baseline physical health investigations.

Denominator – the number of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication.

Data source: Local data collection. The Prescribing Observatory for Mental Health (POMH-UK) audit-based quality improvement programme on prescribing antipsychotics for children and adolescents includes data (for participating trusts) on documented tests and measures taken before starting antipsychotic treatment.

b) Proportion of children and young people with bipolar disorder, psychosis or schizophrenia newly prescribed antipsychotic medication who have a record of side‑effect monitoring 12 weeks after starting treatment.

Numerator – the number in the denominator who have a record of side‑effect monitoring 12 weeks after starting treatment.

Denominator – the number of children and young people with bipolar disorder, psychosis or schizophrenia newly prescribed antipsychotic medication.

Data source: Local data collection.

c) Proportion of children and young people with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication for more than a year with a record of side‑effect monitoring within the last 6 months.

Numerator – the number in the denominator with a record of side‑effect monitoring within the last 6 months.

Denominator – the number of children and young people with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication for more than a year.

Data source: Local data collection. The POMH-UK audit-based quality improvement programme on prescribing antipsychotics for children and adolescents includes data (for participating trusts) on a documented review of therapeutic response and side effects of antipsychotic medication at least once every 6 months.

Outcome

a) Obesity rates in children and young people with bipolar disorder, psychosis or schizophrenia.

Data source: Local data collection. Data on BMI values are included in the 'care.data' extract for the Health and Social Care Information Centre (not specific to children and young people with bipolar disorder, psychosis or schizophrenia).

b) Incidence of cardiovascular disease in people with bipolar disorder, psychosis or schizophrenia.

Data source: Local data collection. Data can be collected for adults with schizophrenia using the Royal College of Psychiatrists' National audit of schizophrenia Audit of practice tool, question 30.

c) Incidence of type 2 diabetes in people with bipolar disorder, psychosis or schizophrenia.

Data source: Local data collection. Data can be collected for adults with schizophrenia using the Royal College of Psychiatrists' National audit of schizophrenia Audit of practice tool, question 30.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP surgeries, community health services, child and adolescent mental health services and early intervention in psychosis services) ensure that systems and protocols are in place to monitor the side effects of antipsychotic medication for children and young people with bipolar disorder, psychosis or schizophrenia, and to share the results when the child or young person is in the care of primary and secondary care services.

Healthcare professionals (such as GPs, mental health nurses, and psychiatrists) monitor the side effects of antipsychotic medication for children and young people with bipolar disorder, psychosis or schizophrenia, and share the results when the child or young person is in the care of primary and secondary care services.

Commissioners (such as clinical commissioning groups and NHS England) commission services that monitor the side effects of antipsychotic medication for children and young people with bipolar disorder, psychosis or schizophrenia. They should also ensure that arrangements are in place to share the results of monitoring when the child or young person is in the care of primary and secondary services.

What the quality statement means for children, young people, parents and carers

Children and young people with bipolar disorder, psychosis or schizophrenia who are taking antipsychotic medication (medicine to help with psychosis) should see their healthcare professional regularly to check for side effects. This will include regular checks such as blood tests and measurements of their weight, height, waist, hip, pulse and blood pressure, to check for problems that may be caused by their medication (such as weight gain, diabetes, and heart, lung and breathing problems). The results of all health checks should be discussed with the child or young person and their parents or carers and shared between their GP surgery and mental health team.

Source guidance

Definitions of terms used in this quality statement

Baseline physical health investigations

Before starting antipsychotic medication, the following baseline investigations should be undertaken and recorded:

  • weight and height (both plotted on a growth chart)

  • waist and hip circumference

  • pulse and blood pressure

  • fasting blood glucose, glycosylated haemoglobin (HbA1c), blood lipid profile and prolactin levels

  • assessment of any movement disorders

  • assessment of nutritional status, diet and level of physical activity.

[Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.3.16 and Bipolar disorder (NICE guideline CG185) recommendation 1.10.5]

Monitoring for side effects of antipsychotic medication

Side effects of antipsychotic medication can be:

  • metabolic (including weight gain and diabetes)

  • extrapyramidal (including akathisia, dyskinesia and dystonia)

  • cardiovascular (including prolonging the QT interval)

  • hormonal (including increasing plasma prolactin)

  • other (including unpleasant subjective experiences).

The following should be monitored and recorded regularly and systematically throughout treatment with antipsychotic medication, but especially during titration:

  • efficacy, including changes in symptoms and behaviour

  • side effects of treatment, taking into account overlap between certain side effects and clinical features of schizophrenia (for example, the overlap between akathisia and agitation or anxiety)

  • the emergence of movement disorders

  • weight, weekly for the first 6 weeks, then at 12 weeks and then every 6 months (plotted on a growth chart)

  • height every 6 months (plotted on a growth chart)

  • waist and hip circumference every 6 months (plotted on a percentile chart)

  • pulse and blood pressure (plotted on a percentile chart) at 12 weeks and then every 6 months

  • fasting blood glucose, HbA1c, blood lipid and prolactin levels at 12 weeks and then every 6 months

  • adherence

  • physical health.

[Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.3.19 (key priority for implementation) and Bipolar disorder (NICE guideline CG185) recommendation 1.10.8]

Equality and diversity considerations

Healthcare professionals should take into account cultural and communication needs when explaining how the side effects of antipsychotic medication will be monitored.