The Pharmaceutical Journal
Vol 275 No 7377 p669
26 November 2005

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United Kingdom Psychiatric Pharmacy Group

Dealing with challenging behaviour

Roland Dix, a consultant nurse in psychiatric intensive care and secure rehabilitation in Gloucester, spoke on “Rapid tranquillisation outside the syringe”. He discussed the importance of considering the whole experience of rapid tranquillisation from the patient’s point of view. He described the process as an intrusive and degrading experience for all concerned, especially the patient, and explained that it should be done in such a way as to best protect the patient’s dignity and the safety of everyone involved. It was important to be aware of the likely psychological and emotional effects for the patient and how they would need to be managed, and it was necessary to learn from bad experiences. He said there should be a clear definition of what constitutes rapid tranquillisation and when it should be used.

Jane Byrne, senior lecturer at Wythenshawe Hospital, Manchester, considered the non-pharmacological treatment for behavioural and psychological symptoms in dementia (BPSD). She explained that there seems to be a lack of agreement regarding the definition of the core symptoms of BPSD and that there was a danger of treating the diagnosis and not the patient: it was important also to consider cultural and environmental factors. She discussed the evidence base for use of such treatments as psychological therapies, aromatherapy and bright light therapy and concluded that it is growing but that lifestyle factors, including diet and exercise, may be just as important in BPSD treatment.

Stephen Pereira, consultant psychiatrist at Pathways Psychiatric Intensive Care Unit, North East London Mental Heath Trust, discussed the National Institute for Health and Clinical Excellence clinical guideline on violence published in February 2005. He said that the evidence base of good quality studies in this area was poor and so formal consensus methods were often used to inform decisions. He said that the role of the specialist mental health pharmacist was to monitor and ensure safe use of medicines in rapid tranquillisation.

Roger Bullock, clinical lead in old age psychiatry in Swindon and director of the Kingshill Research Centre, considered the pharmacological management of BPSD. He said that, in terms of care-giver distress, the symptoms of dementia which most care-givers categorised as moderately or severely distressing included irritability, delusions, dysphoria, apathy and agitation. He discussed the issues of the current practice of widespread use of antipsychotics, which was often based on poor evidence, against a background of recent concerns about increased risk of cerebrovascular events. He said that studies showed a small benefit for the treatment of agitation with quetiapine and risperidone but that it was questionable whether the size of effect was clinically meaningful. No other antipsychotic had been shown to be effective. He advised that, when considering using antipsychotics, it was important to think about the consequences of extrapyramidal side effects in elderly patients.

Ethnicity issues in mental health

Harish Gadhvi, consultant psychiatrist at North East London Mental Health Trust, discussed the implications of ethnicity on both diagnosis of mental health disorders and treatment choices, demonstrating differences in Afro-Caribbean, Asian and Irish ethnic groups compared with the indigenous population in England. He said that mental health service-based studies in the UK showed that schizophrenia had a two to seven times higher incidence among Afro-Caribbeans and that this was unique to the Afro-Caribbean group resident in the UK. In addition, admission rates were higher and there was over-representation on secure units. In Asian service users some studies showed higher GP contact rates for problems such as depression and stress-related illness. There is also some evidence of high rates of self-harm in young Asian women and alcohol-related problems in Sikh men. Comparing Irish immigrants to the indigenous population, rates of schizophrenia and other psychoses are nearly twice as high, personality disorder is less common and the rate of alcoholism is nearly 10 times higher.

He suggested that these differences could be explained by genuine variation in illness between ethnic groups, reluctance to seek help, fears about confidentiality or being stigmatised, or, perhaps, lower detection rates.

He went on to examine the evidence for transcultural differences in pharmacodynamic and pharmacokinetic handling and, consequently the response to drug treatment. For instance, there are differences in the incidence of slow acetylators between ethnic groups. In the Caucasian population, 50 per cent are slow acetylators whereas in the Japanese population only 10 per cent are.

Genetic factors are major determinants in drug response. Phenotypes and genotypes of the cytochrome P450 enzyme system show clear individual and cross-ethnic variations which can influence the rate at which drugs are metabolised.

It is known that Chinese people are more sensitive to the sedative effects of benzodiazepines than Caucasians thereby requiring lower doses. Asians require lower doses of haloperidol than either Caucasian or Afro-Caribbean populations.

He concluded that it was important to consider ethnicity when prescribing and monitoring both the therapeutic effect and side effects of drugs.

Anne Connolly, principal pharmacist, medicines information, at the South London and Maudsley NHS Trust, gave an account of her research looking at antipsychotic prescribing quality in ethnic groups within the trust. She outlined the main outcome measurements which were doses used (mean maximum dose and high doses above 100 per cent maximum licensed dose), use of polypharmacy and type of antipsychotic prescribed. A total of 153 patients participated, 82 black and 71 white patients. All were in-patients at the trust who had been prescribed antipsychotics for longer than three weeks.

She explained that this study was designed to address the shortfalls of previous studies comparing prescribing practices in black and white patients. This was because comprehensive details of patient and clinical factors likely to influence prescribing had been collated. The results were statistically analysed to determine which variables were potentially confounding the association between ethnicity and antipsychotic prescribing. She outlined the main findings of the study:

· There was no significant difference in the prescribing of typicals and atypicals between black and white patients

· There was no evidence of an association between black patients and doses above maximum recommended

· There was no evidence of an association between black ethnicity and polypharmacy

· Black patients were found to be 2.5 times more likely than white patients to have medication costs higher than £150 per month, which was thought to be due to increased prescribing of high-cost risperidone long acting injection.

These results differed from previous studies which invariably show that black patients are treated with larger doses of antipsychotics, fewer are treated with atypical drugs and more are treated with depots at higher doses. The differences, she suggested, may be due to most other research being undertaken in the US where ethnic minorities do not have universal access to medical insurance. Also this study used percentage of maximum dose rather than chlorpromazine equivalents. It was planned to repeat the study with a larger sample size.