Abstract
DEAR SIR,
In response to the article by Walter et al.,[1] “Side effects of second generation antipsychotics: the experience, views and monitoring practices of Australian child psychiatrists”, we write to advise of the recent development of the Children, Youth and Women's Health Service (CYWHS) Antipsychotic Physical Health and Adverse Effect Monitoring Package. CYWHS is a state-wide health service in South Australia that includes the Women's and Children's Hospital (WCH). Within the WCH, the prescribing of antipsychotics occurs in the Boylan Ward (the psychiatric inpatient facility for children and adolescents) and the outpatient areas of the departments of psychological medicine, child development and general medicine. Prescriptions for antipsychotics are written by child and adolescent psychiatrists, developmental paediatricians or general paediatricians. In the community, prescriptions are written in the various Child and Adolescent Mental Health Services (CAMHS).
Antipsychotic drugs have a wide range of serious adverse effects, some of which may be irreversible.[2] Adverse effects include extrapyramidal side effects such as tardive dyskinesia, particularly with first-generation antipsychotics, and weight gain, diabetes, dyslipidaemia and an increased risk of cardiovascular disease particularly with second-generation antipsychotics. Hyperprolactinaemia and its associated problems, liver abnormalities, haematological abnormalities and cardiac problems may also occur. Compared to adults, children and adolescents appear to be more likely to experience some adverse effects such as weight gain and extrapyramidal side effects.3–6 It is of concern that antipsychotics are increasingly used in the management of child and adolescent psychiatric disorders in the absence of long-term safety and tolerability data.
In 2004, three consensus guidelines for physical health monitoring in adults prescribed antipsychotics for psychotic disorders were published.7–9 Since then, it has been observed that despite the availability of guidelines to monitor physical health in adults, many adults with schizophrenia receive little or no medical care, highlighting the existence of an evidence to practice gap.[10] It is well known that guidelines in isolation seldom result in improved care for patients and the development of implementation programs is required to achieve this goal.[10]
The stimulus for a joint project between the Pharmacy Department of the WCH and the Sansom Institute, University of South Australia, was that although the adverse effect profile of antipsychotics differs between adults and children, the monitoring needs of young people prescribed antipsychotics had not been considered. In 2005, a project team formed with the aim to produce a set of evidence-based recommendations for adverse effect and physical health monitoring for young people prescribed long-term antipsychotics in the range of CYWHS settings. A project advisory group of senior specialists within the CYWHS was assembled to guide the project.
Consistent with the requirements of any Quality Use of Medicines (QUM) endeavour, the project was undertaken in the QUM framework outlined in the National Strategy for Quality Use of Medicines. The QUM framework includes: (i) broad stakeholder consultation, (ii) a needs assessment, (iii) a multi-faceted implementation strategy, and (iv) evaluation.[11] In 2005, a thorough literature review was conducted examining the range of adverse events reported from antipsychotic use in young people and any associated monitoring recommendations. Published adult guidelines were also sourced. While monitoring is imperative, it was considered important to avoid unnecessary, time-consuming, invasive or traumatic interventions and coordinate where possible the simultaneous monitoring of different parameters. The outcome was the CYWHS Antipsychotic Physical Health and Adverse Effect Monitoring Package, which consisted of comprehensive monitoring guidelines, a monitoring chart, a brief guide to using the monitoring chart and a patient information leaflet. Furthermore, the package was specifically designed to aid in the efficient transfer of patient information along the continuum of care within the CYWHS or outside the service if the patient was followed up by private specialists or general practitioners.
In 2006, a pilot implementation trial of the CYWHS Antipsychotic Physical Health and Adverse Effect Monitoring Package was undertaken in a number of different settings where children and adolescents are prescribed antipsychotic medication. Doctors were recruited in both hospital and community settings and included child and adolescent psychiatrists, developmental paediatricians and general paediatricians. Several barriers to the implementation of the package were identified, including doctor or healthcare barriers, patient-related barriers and environmental barriers. A multifaceted intervention strategy was developed to overcome those potential barriers and optimize success of implementation of the antipsychotic monitoring package based on successful implementation methods reported in the literature. These included educational materials in the form of a monitoring support package and a patient resource kit as well as educational outreach visits, audit and feedback, and educational meetings.[12], [13] An article describing this project is currently in press.[14]
Outcomes of the 2006 pilot implementation trial were alterations to the monitoring chart to ensure it better met the needs of stakeholders, a second patient information leaflet on minimizing weight gain and a website which enabled all components of the monitoring package to be readily accessed by healthcare providers without access to our institution's intranet site.
In 2007, the CYWHS Antipsychotic Physical Health and Adverse Effect Monitoring Package was approved by the CYWHS Drug and Therapeutics Committee for use within our organization and can be accessed at www.wch.sa.gov.au/antipsychotic. This package is not directive, but designed to raise awareness, guide, prompt and educate health professionals to deliver best care for young people prescribed antipsychotics. We plan to audit and evaluate the package to carry on its evolutionary path of continual improvement and usability. The development of evidence-based guidelines is a time-consuming and expensive exercise. We hope that our package may be used by others to avoid ‘reinventing the wheel’. We hope that the process we have described will aid in the development of other programs to facilitate monitoring physical health and adverse effects in those prescribed antipsychotic medication, not just in children and adolescents.