1. POMH-UK QIP 12a Prescribing for people with a personality disorder August 2012

2. 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

3. 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).

4. 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.

5. 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. Treatment targets

6. 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

7. 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. 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.

8. 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 co- morbid 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. 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 co- morbid 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.

9. 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. 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. Key national findings

10. National and Trust level results for Standards 1, 2 and 3 National and Trust level results for Standards 1 and 2: proportion of all patients with a crisis plan 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

11. National and Trust level results for Treatment targets 1 Treatment target 1: proportion of patients with a PD diagnosis alone (i.e. no co-morbid psychiatric diagnosis) prescribed antipsychotics

12. National and Trust level results for Treatment targets 2 Treatment target 2: proportion of patients with a PD diagnosis alone (i.e. no co-morbid psychiatric diagnosis) prescribed z-hypnotics

13. National and Trust level results for Treatment targets 3 Treatment target 3: proportion of patients with a PD diagnosis alone (i.e. no co-morbid psychiatric diagnosis) prescribed benzodiazepines

14. 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 Proportion of medication reviews considering: Outcome of medication review documented Therapeutic response Side effects/tolerability Yes, clearly or partially documented TNS82% 84%65%94% T4080%25%100%

15. Patient demographics and clinical characteristics Key demographic characteristics Baseline n% Gender Female 153359% Male 106741% Ethnicity White/White British 228188% Black/Black British 813% Asian 572% Mixed or other 462% Not specified or unknown 1355% Clinical setting* General adult – inpatient 1998% General adult – outpatient 142655% Specialist personality disorder service - inpatient 522% Specialist personality disorder service - outpatient 26010% Forensic – inpatient 38215% Forensic – outpatient 532% Forensic specialist personality disorder service - inpatient 26110% Forensic specialist personality disorder service - outpatient 14<1% Other setting211% Age Mean age in years (SD) 39 (11.8) Min-max 18-78 16-25 years 40216% 26-35 years 65125% 36-45 years 74929% 46-55 years 56422% 56-65 years 1807% 66 years and over 542%

16. Key demographic characteristics N% Subtype of personality disorder diagnosis: ICD- 10 category* F60.0: Paranoid personality disorder 1526% F60.1: Schizoid personality disorder 442% F60.2: Dissocial personality disorder 48419% F60.3: Emotionally unstable borderline personality disorder 177668% F60.4: Histrionic personality disorder 442% F60.5: Anankastic personality disorder 291% F60.6: Anxious avoidant personality disorder 1024% F60.7: Dependent personality disorder 733% F60.8: Other specific 331% F60.9: Personality disorder, unspecified 1415% F61: Mixed and other personality disorders 1405% Sub-type not yet determined 783% More than one personality disorder diagnosis 35614% F00-F09: Organic, including symptomatic, mental disorders 18<1% Other ICD-10 diagnoses* F10-F19: Mental and behavioural disorders due to psychoactive substance use 32413% F20-F29: Schizophrenia, schizotypal and delusional disorders 40616% F21: schizotypal disorder subgroup n=54 (13%) F30-F39: Mood (affective) disorders 60923% F31: bipolar disorder subgroup n=135 (22%) F40-F48: Neurotic, stress-related and somatoform disorders 26610% F50-F59: Behavioural syndromes associated with physiological disturbances and physical factors 873% F70-F79: Mental retardation 1074% F80-F89: Disorders of psychological development 291% F90-F98: Behavioural and emotional disorders with onset occurring in childhood and adolescence 643% F99: Unspecified mental disorder4<1% None documented105441% Other492% Crisis plan in the clinical records Yes175967% No84132% Patient demographics and clinical characteristics continued

17. Crisis plan: across clinical settings 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. Key: IP = inpatients, OP =outpatients, SPD= specialist personality disorder, FSPD = forensic specialist personality disorder

18. Reference to medication in the crisis plan Key: IP = inpatients, OP =outpatients, SPD= specialist personality disorder, FSPD = forensic specialist personality disorder

19. 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 instability21%41%71%8% Aggression/hostility2%24%15% Anxiety (including phobic anxiety and panic) 25%23%7%41% Depressive symptoms71%10%1%2% Distress10%16%8%22% Disturbed sleep12%11%2%59% Epilepsy--6%- Impulsivity5%18%13%5% Known or suspected psychotic illness07%1%<1% Self harm; deliberate/repeated11%18%14%7% Transient psychotic-like experiences or symptoms <1%23%2%1% Patient request4%6%3%7% Long-term treatment – reason unclear 7% 4% Other*13%17%8%10% Not known10%12%11%10% Clinical reasons for prescribing across the four groups of medication – for PD alone

20. 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.

21. Medications prescribed for patients with co-morbid psychotic or affective disorder, or PD alone No medications prescribed Prescribed at least one medication AntipsychoticAntidepressant Mood stabiliser Sedative Any personality disorder diagnosis only n=1054 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%)

22. Medication review for patients prescribed any medication for more than four consecutive weeks Proportion with documented evidence of a medication review Evidence that medication review considered: Outcome of medication review clearly documented Therapeutic response Side effects/tolerability Patient’s views sought Adherence Yes, clearly documented Yes, partially documented Not documented 1,744 (82%) 1,471 (84%) 1,135 (65%) 1,300 (74%) 947 (54%) 1,211 (69%) 441 (25%) 92 (5%)

23. 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

24. 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.

25. Reference to medication in the crisis plan

26. 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.

27. 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

28. Treatment target 1. Antipsychotic drugs should not be prescribed for more than four consecutive weeks in the absence of a co-morbid psychotic illness. Patients with personality disorder alone prescribed at least one antipsychotic and length of prescription

29. Patients with personality disorder alone prescribed at least one z- hypnotic and length of prescription Treatment targets 2. Z-hypnotics should not be prescribed for more than four consecutive weeks.

30. 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.

31. 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.

32. Crisis plan and patient involvement

33. Reference to medication in the crisis plan

34. Documentation in the clinical records of reasons for prescribing the most recent antipsychotic medication

35. Proportion of patients prescribed any medication for more than four weeks and documented evidence of medication review in the clinical records

36. Patients with personality disorder alone prescribed at least one antipsychotic and length of prescription None prescribed

37. Patients with personality disorder alone prescribed at least one z-hypnotic and length of prescription None prescribed

38. Patients with personality disorder alone prescribed at least one benzodiazepine and length of prescription None prescribed

39. 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