Bradwell Community Hospital

BACKGROUND: People presenting with agitated or violent behaviour thought to be due to severe mental illness may require urgent pharmacological tranquillisation. Several preparations of olanzapine, an antipsychotic drug, are now being used for management of such agitation. OBJECTIVES: To estimate the effects of intramuscular, oral-velotab, or standard oral olanzapine compared with other treatments for controlling aggressive behaviour or agitation thought to be due to severe mental illness. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (Issue 1, 2002), The Cochrane Schizophrenia Group's Register (November 2004) and reference lists. We contacted authors of trials and the manufacturers of olanzapine. SELECTION CRITERIA: Randomised clinical trials comparing oral-velotab or intramuscular, or standard oral olanzapine to any treatment, for agitated or aggressive people with severe mental illnesses. DATA COLLECTION AND ANALYSIS: We reliably selected, quality assessed and data extracted studies. For binary outcomes we calculated a fixed effects Risk Ratio (RR) and its 95% Confidence Interval (CI) with a weighted Number Needed to Treat/Harm statistic (NNT/H). For continuous outcomes, we preferred endpoint data to change data and synthesised non-skewed data from valid scales using a weighted mean difference (WMD). MAIN RESULTS: Four trials compared olanzapine IM with IM placebo (total n=769, 217 allocated to placebo). Fewer people given olanzapine IM had 'no important response' by 2 hours compared with placebo (4 RCTs, n=769, RR 0.49 CI 0.42 to 0.59, NNT 4 CI 3 to 5) and olanzapine IM was as acceptable as placebo (2 RCTs, n=354, RR leaving the study early 0.31 CI 0.06 to 1.55). When compared with placebo, people given olanzapine IM required substantially fewer additional injections following the initial dose (4 RCTs, n=774, RR 0.48 CI 0.40 to 0.58, NNT 4 CI 4 to 5). Olanzapine IM did not seem associated with extrapyramidal effects (4 RCT, n=570, RR experiencing any adverse event requiring anticholinergic medication in first 24 hours 1.27 CI 0.49 to 3.26). Two trials compared olanzapine IM with haloperidol IM (total n=482, 166 allocated to haloperidol). Studies found no differences between olanzapine IM and haloperidol by 2 hours for the outcome of 'no important clinical response' (2 RCTs, n= 482, RR 1.00 CI 0.73 to 1.38) neither was there a difference for needing repeat IM injections (2 RCTs, n=482, RR 0.99 CI 0.71 to 1.38). More people on haloperidol experienced akathisia over the five day oral period compared with olanzapine IM (1 RCT, n=257, RR 0.51 CI 0.32 to 0.80, NNT 6 CI 5 to 15) and fewer people allocated to olanzapine IM required anticholinergic medication by 24 hours compared with those given haloperidol IM (2 RCTs, n= 432, RR 0.20 CI 0.09 to 0.44, NNT 8 CI 7 to 11). Two trials compared olanzapine IM with lorazepam IM (total n=355, 119 allocated to lorazepam). For the outcome of 'no important clinical response' , there was no difference between people given olanzapine IM and those allocated to lorazepam at 2 hours (2 RCTs, n=355, RR 92 CI 0.66 to 1.30) but fewer people allocated to olanzapine IM required additional injections by 24 hours compared with those on lorazepam IM (2 RCTs, n=355, RR 0.68 CI 0.49 to 0.95, NNT 10 CI 6 to 59). People receiving IM olanzapine were less likely to experience any treatment emergent adverse events, than those on lorazepam (1 RCT, n=150, RR at 24 hours 0.62 CI 0.43 to 0.89, NNT 5 CI 4 to 17) and over the same time period there were no clear differences in the use of anticholinergic medication between groups (1 RCT, n=150, RR 1.16 CI 0.38 to 3.58).No studies reported outcomes related to hospital and service use. Nor did any report on issues of satisfaction with care or suicide, self-harm or harm to others. No studies evaluated the oro-dispersable form of olanzapine. AUTHORS' CONCLUSIONS: Data relevant to the effects of olanzapine IM are taken from some studies that may not be considered ethical in many places, all are funded by a company with a pecuniary interest in the result. These studies often poorly report outcomes that are difficult to interpret for routine care. Other important outcomes are not recorded at all. Nevertheless, olanzapine IM probably has some value in helping manage acute aggression or agitation, especially where it is necessary to avoid some of the older, better, known treatments. Olanzapine causes fewer movement disorders than haloperidol and more than lorazepam. The value of the oro-dipersable velotab preparation is untested in trials. There is a need for well designed, conducted and reported randomised studies in this area. Such studies are possible and, we argue, should be designed with the patient groups and clinicians in mind. They should report outcomes of relevance to the management of people at this difficult point in their illness.

BACKGROUND: First generation 'typical' antipsychotics such as chlorpromazine and haloperidol have been the mainstay of treatment up until the introduction of the second generation 'atypical' antipsychotics such as risperidone and olanzapine. Typical and atypical antipsychotics do provide a treatment response for most people with schizophrenia, whether a reduction in psychotic episodes or a lessening in the severity of their illness. However, a proportion of people still do not respond adequately to antipsychotic medication. Additionally, atypical and especially typical antipsychotics are associated with serious adverse effects, which can often compromise compliance with medication and therefore increase the incidences of relapse. In this review we examine the effects of aripiprazole compared with placebo. OBJECTIVES: To evaluate the effects of aripiprazole compared with placebo for people with schizophrenia and schizophrenia-like psychoses. SEARCH STRATEGY: We searched the Cochrane Schizophrenia Group Trials Register (January 2008) which is based on regular searches of BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO. For this update, we carried out an initial search in May 2007 and a second search in August 2008. SELECTION CRITERIA: We included all randomised trials comparing aripiprazole with placebo in people with schizophrenia or schizophrenia-like psychosis. DATA COLLECTION AND ANALYSIS: We extracted data independently. For dichotomous data we calculated risk ratios (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based on a fixed-effect model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated mean differences (MD) again based on a fixed-effect model. MAIN RESULTS: Despite the fact that 2585 people participated in nine randomised aripiprazole studies, we were unable to extract any usable data on death, service outcomes, general functioning, behaviour, engagement with services, satisfaction with treatment; economic outcomes or cognitive functioning. In general, study attrition was very large for all studies over four weeks' duration. There was high attrition in most of the included studies. Fewer people left the aripiprazole group compared with those in the placebo group (n = 2585, 9 RCTs, RR 0.73 CI 0.60 to 0.87). Compared with placebo, aripiprazole significantly decreased relapse in both the short (n = 310, 1 RCT, RR 0.59 CI 0.45 to 0.77) and medium term (n = 310, 1 RCT, RR 0.66 CI 0.53 to 0.81). It also produced better compliance with study protocol (n = 2275, 8 RCTs, RR 0.74 CI 0.59 to 0.93). Aripiprazole may decrease prolactin levels below those expected from placebo (n = 305, 2 RCT, RR 0.21 CI 0.11 to 0.37). Insomnia (˜23%) and headaches (˜15%) were commonly reported in both groups, with no significant difference. AUTHORS' CONCLUSIONS: Aripiprazole may be effective for the treatment of schizophrenia. Aripiprazole has a lower risk of raised prolactin and prolongation of the QTc interval. Clearly reported pragmatic short-, medium- and long-term randomised controlled trials should be undertaken to determine its position in everyday clinical practice.

Aims and Method To report on the use of atypical antipsychotics in one health district by examining secondary care prescribing patterns for these medicines in North Staffordshire between 1994 and 2001. With one exception, these drugs were licensed solely for use in schizophrenia during the study period. Results A total of 502 patients were initiated on atypical antipsychotics in the study period. Of these, 297 (59.2%) had a diagnosis of schizophrenia (ICD–10 codes F20–29). Off-label prescribing was common, but psychiatrists were least likely to prescribe clozapine off-label (2.2%). Affective (18.4%) and organic disorders (12.4%) were the main disorders treated off-label. Olanzapine had the highest off-label use (44.5%). Clinical Implications The high off-label use of atypical antipsychotics has clinical and economic implications. Although off-label prescribing may be in the patient's best interests, they should be informed and give their consent. Commissioning bodies, such as primary care organisations, are basing their budgets on guidance from the National Institute for Clinical Excellence, which can have implications for funding this off-label use.

AIMS: To examine the long-term effectiveness of atypical antipsychotics in a naturalistic setting for patients with schizophrenia. METHOD: A retrospective analysis of atypical antipsychotic prescribing in one Health District between 1994 and 2001. Time to discontinuation of the first atypical antipsychotic prescribed was calculated using survival analysis. RESULTS: 253 patients were identified. Clozapine had a significantly lower discontinuation rate compared with olanzapine and risperidone (p = 0.018). Patients taking risperidone were 1.3 times more likely to discontinue than those taking olanzapine (p = 0.23). Older age (p = 0.0001), male sex (p = 0.016) and exposure to antidepressants (p = 0.014) significantly predicted compliance. CONCLUSIONS: Clozapine is an effective long-term schizophrenia treatment. The trend to superior effectiveness of olanzapine over risperidone in the long-term has not been reported before and warrants further investigation.

UNLABELLED: Too little, too late? Physical examinations performed by trainee psychiatrists on newly admitted psychiatric patients. OBJECTIVES: To assess the comprehensiveness of the physical examination carried out by psychiatric trainees on acute in-patient units. To quantify delays in undertaking physical examination on psychiatric inpatients. METHOD: A prospective case note study of 60 consecutive admissions to acute psychiatric wards in North Staffordshire. Information regarding demography, details of physical examination and routine blood investigations was collected. RESULTS: The case notes of 60 inpatients were studied. Mean age was 38.7 years and the sex ratio equal. A delay in performing a physical occurred in 17 (28.8%) patients. No explanation for a delay was given in six (10.0%) cases. The mean time to physical examination from admission was 61.8 h (range 0-612 h). The standard of physical examination was variable. The central nervous system (CNS) was reported as 'grossly intact' in six (10.2%) cases with only 34 (57.6%) of patients having a comprehensive CNS examination. CONCLUSIONS: Psychiatric patients are not receiving a comprehensive physical examination. Whilst the patient's ability to co-operate may account for a delay in the examination, it is unlikely to be the reason for the CNS being examined in just half the patients. Opportunities to reduce the physical morbidity associated with mental illness may be being lost. (MJ Psych Clin Pract 2004; 8: 57-60).

Aims and Method To describe Brunswick House, the first crisis house in North Staffordshire, and to assess the use of acute psychiatric wards and the local accident and emergency department by Brunswick House residents. A mirror design study compared the use of these facilities in the year before with the year after a resident's first admission to Brunswick House. Results Data collected on a cohort of Brunswick House residents between March 1999 and December 1999 showed a reduction in both the use of acute psychiatric wards and use of the accident and emergency department after the index admission to Brunswick House. Clinical Implications Brunswick House provides an alternative to NHS facilities for people in crisis.

AIMS and Method To investigate the interpretation of Section 136 of the Mental Health Act 1983 by Section 12(2) approved doctors and to describe a pathway that facilitates early assessment of people detained under Section 136. We surveyed a random sample of Section 12(2) approved doctors in the West Midlands. Results A response rate of 70% was achieved. Approximately 65% believe that it would be illegal to transfer a person under Section 136 from the police station to a further place of safety, such as hospital. Thirty-five per cent believed that this could be done legally or were unsure. Clinical Implications Ambiguity still remains about the legal interpretations of the provisions of Section 136 of the Mental Health Act 1983, which needs to be rectified.

A learning zone article helped Dominique Askey see the value of audit in ensuring quality of care

Purpose The purpose of the study is to undertake a formative evaluation of a young person's Smokebuster club and to examine how young people's experience of being a club member can be used to inform the club's future development. Design/methodology/approach After seeking and being granted Local Research Ethics Committee approval to undertake the study a postal survey was conducted of all the Smokebusters members ( n =2810). Findings The response rate achieved was 16 per cent ( n =438). Quantitative data analysis showed that the majority of club members who responded to the survey were white, non‐disabled females, aged between 13‐14 years old. The majority of young people surveyed said they had “never smoked and never will” (70.3 per cent, n =308). However, over 6 per cent ( n =28) of the young people surveyed said they “currently smoke but would like to give it up”. A wealth of qualitative data was also obtained that gives useful information on how the young people surveyed thought club provision could be improved. Practical implications The findings of this study are thought to be useful not only for future development of the Smokebuster club that is the focus of this evaluation but also for those who organise similar clubs. The findings are also of wider relevance to professionals engaged in smoking cessation initiatives for young people. Originality/value The value of this paper relates to issues surrounding engaging undertaking young people in such evaluation. Also reports of Smokebuster club evaluations are rarely given in the literature and therefore the findings of this study augment this limited information.

Antipsychotic Trials in Schizophrenia: The CATIE Project. Edited by T. Scott Stroup & Jeffrey A. Lieberman. Cambridge University Press. 2010. £75.00 (hb). 330pp. ISBN: 9780521895330 - Volume 198 Issue 6

The co-existence of physical and psychiatric illness in so much of the elderly population poses diagnostic and therapeutic problems for psychiatrists, geriatricians and general practitioners alike, with the presence of physical illness strongly influencing and sometimes limiting the options for treatment of the psychiatric illness. Recognition of this has resulted in the Section of Old Age Psychiatry of the Royal College of Psychiatrists recommending that senior registrar training in old age psychiatry should include a one month attachment to an approved geriatric medicine unit.

Aims and Method There are few descriptions in the literature of pharmacogenetic applications in psychiatry. We describe the relevance of pharmacogenetics to clinical psychiatry using a case-note review of the first 55 patients to have their cytochrome P450 (CYP2D6) status assessed in a general psychiatry clinic. Results The distribution of genotypes for CYP2D6 was the same as in the general population. A smaller number of reported side-effects ( P =0.01) and higher medication dosages ( P =0.001) were significantly associated with the extensive metabolism genotype. Clinical Implications This preliminary study suggests that CYP2D6 status may have an influence on medication dosage and adverse drug events reported by patients. Recommendations for further development are suggested.

Objectives People with severe enduring mental illness (SMI) are at least twice as likely to die from cardiovascular disease (CVD) than the general population, with 60% of excess mortality rate attributable to physical illness. Methods We report implementation in primary care of screening and intervention for cardiometabolic risk factors in SMI in Cheshire, UK. Data search was performed through the EMIS software provider. Results 453 patients (55.8% male 44.2% female) on the SMI Register in Cheshire, UK were screened for dysglycaemia (screening rate 57.3 %) and dyslipidaemia (screening rate 36.2%). There were no differences in BMI by gender, but a greater proportion of women (25% vs 20%) were obese (BMI ≥ 30 kg/m2). Fasting glucose was in the impaired fasting glycaemia range (6.1-6.9mM) in 6.5% of those screened and at or above the threshold for type 2 diabetes (7.0mM) in 17.3% of the group. Fasting serum cholesterol was high at >5mmol/L in 62.8% of those screened for whom the mean cholesterol was 6.2±0.8 mmol/L). Despite high rates of dysglycaemia and dyslipidaemia, systolic blood pressure was greater than 140mmHg in only 13% of those examined. 61% were active smokers. Multivariate linear regression analyses revealed a direct relation between fasting glucose levels and BMI (beta = 0.22, p< 0.001) independent of age, gender, systolic blood pressure and fasting cholesterol and triglycerides. Conclusion There is scope for cardiometabolic risk reduction in patients with severe mental illness. Measures to encourage weight reduction and smoking cessation would be vital in risk reduction strategies.