Prescribing guidelines for patients with a first episode psychosis

A critical component of optimal early treatment for patients with first episode psychosis includes appropriate and effective use of medications.

There is no clear guidance for prescribing antipsychotics for patients suffering with a first episode of psychosis however. We wanted to develop clear guidance for prescribers to show when treatment should be started, what should be prescribed, and for how long. NICE guidelines clearly states that the choice of antipsychotic medication should be chosen by the service user and healthcare professional together, taking into account the likely benefits and possible side effects of each drug.

NICE guidelines also provides clear information on baseline investigations, reviews of treatment including side effects, and physical health monitoring required. However, there is no specific guidance as to what medication choices are best, or in what order medication should be trialled. We wanted to provide prescribers with clear guidance to ensure that NICE guidance was adhered to, as well as minimising side effects to this vulnerable group of patients.

Before the project started there were no prescribing guidelines for prescribing in first episode psychosis across Avon and Wiltshire Mental Health Partnership Trust (AWP). AWP serves a population of approximately 1.8 million people.

Psychosis affects 1-3% of the population, which is higher than diabetes in young people. A patients’ experience of medication in the first stages of treatment can have a lasting impact on future attitudes towards medication, compliance and outcome. Patients with a first episode psychosis are more likely to suffer side effects from antipsychotics.

If a patient suffers side effects they are more likely to discontinue treatment, leading to a potential relapse of symptoms, which are harder to treat, possibly leading to an inpatient stay. This is detrimental to the patient's care and quality of life. Prescribing for first episode psychosis is therefore a critical time to optimise medical treatments and maximise the chance of a positive outcome for the patient. We set up a working group to develop prescribing guidelines and improve prescribing guidelines.

An initial baseline Trust-wide audit showed that practice around first episode prescribing varied greatly. We found that patients were not being included in prescribing decisions, first generation antipsychotics were sometimes used (with detrimental side effects), medication was not being given a trial for an adequate period of time, and Clozapine was not being offered when it was clinically appropriate to do so. Looking at the most up-to-date research, we put together a prescribing guideline to help prescribers make the best decisions for their patients.

We sought feedback from prescribers across the Trust, including our inpatient colleagues, developing the guidelines with the help of our Trust Quality Improvement team and pharmacists and AWP's Medicines Optimisation Group. We presented this to the Trust-wide Medical Advisory Group, as well as to the South West Regional Early Intervention in Psychosis Network.

We were keen to develop guidelines which would be appropriate for use for all patients presenting with a first episode psychosis, whether that be in the community or in an inpatient setting. We therefore spent time presenting our work around the Trust, as well as consulting colleagues across the South West Regional Early Intervention in Psychosis Network, and the Royal College of Psychiatrists Early Intervention Network.

At each step, we collected feedback and refined the guidelines so they would reflect best clinical practice. One particular challenge was engaging our inpatient colleagues. There is invariably pressure to stabilise a patient's mental state, treat quickly, and discharge back to the community as quickly as possible due to bed pressures within mental health. We presented our work to the Trust Medical Director who endorsed our project, taking steps to ensure that bed pressures did not come in the way of our treatment guidelines.

As well as working closely with inpatient colleagues to develop the guidelines, we also produced teaching sessions and presented the guidelines and rationale at each locality across the Trust to raise awareness and promote good prescribing practice following NICE guidance. The project did not incur any costs and actually proved to be cost saving for the Trust. (Our first-line recommended treatment, Aripiprazole, was shown to save the Trust nearly £3,000 over the course of the patients’ treatment).

Through presentations and consultations both within the Trust and externally, we were able to produce prescribing guidelines which incorporate NICE guideline recommendations, as well as providing prescribers with evidence-based treatment options. This therefore means that patients are correctly assessed (including a treatment-free period), and where appropriate, started on low dose, second-generation antipsychotics, with specific recommendations made, which builds on the relevant NICE guidelines.

Trust prescribing information shows that prescribing for antipsychotics is on a down-ward trend overall. Second generation antipsychotics are now primarily prescribed. There has been a move away from prescribing antipsychotics such as olanzapine, with its associated detrimental cardiometabolic long-term consequences for patients. Medication is given an increasingly fair trial. Physical health monitoring is also improving.

Patients have welcomed more choice in their treatment options, and we have received excellent feedback regarding information provided about the different medication options available. With patients more involved in prescribing decisions, compliance has increased and cessation of medication due to side effects has reduced. As a result, it is likely that this will have an impact on reducing rates of relapse, and thus a reduction in time spent in hospital. Not only have the prescribing guidelines benefited patients, but prescribers across the Trust have welcomed these guidelines. In addition, other Trusts are also adopting the guidelines.

The key to the success of our project has been the involvement of all prescribers through an extensive consultation period. For the prescribing guidelines to be adopted, all prescribers needed to be made aware of the benefits to patients and latest evidence-based treatments.

The involvement of our Trust Medicines Optimisation Group, Trust-wide Medical Advisory Group and endorsement of our Medical Director has been key. Close working relationships with inpatient colleagues and prescribers across other mental health teams has been essential in taking this forward, as prescribing is often initiated by them. Teaching and training has been helpful, with discussion and early identification of any issues.

A prescribing guideline for all patients with a first episode psychosis cannot be too prescriptive, but a fine balance can be achieved to ensure the best possible outcomes for this vulnerable group of patients.