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Accessible summary: What is known on this subject?: The physical health of people with serious mental illness (SMI) is an issue of growing concern in New Zealand and internationally.Metabolic syndrome is prevalent among people with severe mental illness and increases the likelihood of developing cardiovascular disease and diabetes.No previous international research has investigated rates of metabolic monitoring in specialist mental health services and in primary care. What this paper adds to existing knowledge?: Rates of metabolic monitoring are low in this specialist mental health service and in primary care.Primary care nurses are positive in their views of their role in providing care for people with mental illness, and would value further education in this area. What are the implications for practice?: Services need to consider ways in which nurses can be supported to improve rates of metabolic monitoring.Guidelines may have a role to play in improved monitoring but need service‐level support in order to be effective. Introduction: People with serious mental illness experience significant disparities in their physical health compared with the general population. One indicator of health impairment is metabolic syndrome, which increases the likelihood of developing cardiovascular disease and diabetes. No international studies have reported both primary care and mental health nurses' rates of metabolic monitoring among people with serious mental illness, and no New Zealand studies have investigated rates of metabolic monitoring. Aim: To evaluate metabolic monitoring practices within one of New Zealand's 20 district health board regions. Method: An audit of clinical records in primary care (n = 46) and secondary care (n = 47) settings and a survey of practice nurses were conducted. A survey was sent to 127 practice nurses with a response rate of 19% (n = 24). Data were analysed using descriptive statistics. Results: Rates of metabolic monitoring were low in both services. Survey participants expressed positive views towards physical health monitoring and confidence in relating to mental health consumers. Rates of treatment of metabolic abnormalities were low, and communication between primary and secondary services was limited. Conclusion: Despite existence of guidelines and protocols, metabolic monitoring rates in both primary and secondary health services are low. Incorporating metabolic monitoring systems into service delivery, supported by appropriate tools and resourcing, is essential to achieve better clinical outcomes for people experiencing mental illness. [ABSTRACT FROM AUTHOR]

The paper describes the Antipsychotic Medication Management Fidelity Scale and its psychometric properties, including interrater reliability, frequency distribution, sensitivity to change and feasibility. Fidelity assessors conducted fidelity reviews four times over 18 months at eight sites receiving implementation support for evidence-based antipsychotic medication management. Data analyses shows good to fair interrater reliability, adequate sensitivity to change over time and good feasibility. At 18 months, item ratings varied from poor to full fidelity on most items. Use of the scale can assess fidelity to evidence-based guidelines for antipsychotic medication management and guide efforts to improve practice. Further research should improve and better calibrate some items, and improve the procedures for access to information. Trial registration: ClinicalTrials.gov Identifier: NCT03271242. [ABSTRACT FROM AUTHOR]

Individuals experiencing a first episode of psychosis are likely to respond well to treatment with antipsychotic medications. Of those treated for a first episode of schizophrenia, three out of four can expect to achieve remission. The question of how long antipsychotic medication should be continued has been a topic of heated debate in the field. Longitudinal studies of individuals diagnosed with a first episode of psychosis have reported that as many as 30% may be able to come off of medications without relapsing while treatment discontinuation studies have found that very few patients remain in remission off of medication. This paper reviews the literature on relapse rates following a first episode of schizophrenia and identifies factors that contribute to the discrepancies in the rates reported. These factors include sampling considerations, the distribution of psychiatric diagnoses, the duration of follow-up, the rate of medication discontinuation and the criteria used to define illness recurrence. We propose that individuals for whom the diagnosis of their first psychotic episode is determined with ongoing follow-up to be due to schizophrenia are at extremely high risk of relapse and should be advised to continue antipsychotic medication for the long-term. Those whose first episode of psychosis is determined to be due to other causes are also at high risk of illness recurrence off medications. Recommendations for maintenance treatment should be tailored to reflect the risk of relapse and sequelae of relapse associated with specific causes of first episode psychosis. [ABSTRACT FROM AUTHOR]

Antipsychotic medication has been the mainstay of treatment for psychotic illnesses for over 60 years. This has been associated with improvements in positive psychotic symptoms and a reduction in relapse rates. However, there has been little improvement in functional outcomes for people with psychosis. At the same time there is increasing evidence that medications contribute to life shortening metabolic and cardiovascular illnesses. There is also uncertainty as to the role played by antipsychotic medication in brain volume changes. Aim: The primary aim of the study is, in a population of young people with first‐episode psychosis, to compare functional outcomes between an antipsychotic dose reduction strategy with evidence‐based intensive recovery treatment (EBIRT) group (DRS+) and an antipsychotic maintenance treatment with EBIRT group (AMTx+) at 24‐months follow‐up. Methods: Our single‐blind randomized controlled trial, within a specialist early psychosis treatment setting, will test the whether the DRS+ group leads to better vocational and social recovery than, the AMTx+ group over a 2‐year period in 180 remitted first‐episode psychosis patients. Additionally, we will examine the effect of DRS+ vs AMTx+ on physical health, brain volume and cognitive functioning. This study will also determine whether the group receiving DRS+ will be no worse off in terms of psychotic relapses over 2 years follow‐up. Results: This paper presents the protocol, rationale and hypotheses for this study which commenced recruitment in July 2017. Conclusion: This study will provide evidence as to whether an antipsychotic dose‐reduction recovery treatment leads to improved functioning and safer outcomes in first‐episode psychosis patients. In addition, it will be the first‐controlled experiment of the effect of exposure to antipsychotic maintenance treatment on brain volume changes in this population. [ABSTRACT FROM AUTHOR]

Sexual dysfunction is one of the most frequently occurring side-effects of antipsychotic medication, impacting both quality of life and adherence to treatment. Despite this, limited evidence-based guidance on treatment options is available. To synthesize and analyze the evidence on management of antipsychotic-related sexual dysfunction, specifically taking note of the more recently developed antipsychotics that have been incorporated in studies over the past decade. EMBASE, Medline, and PsychINFO databases were searched using search terms related to sexual or erectile dysfunction, treatments, and antipsychotics. 2 reviewers independently assessed papers for the inclusion criteria for randomized controlled trials (RCTs) of treatments for antipsychotic-related sexual dysfunction, including adjunctive medications and a switch of antipsychotic. Studies were excluded if participants did not have recorded sexual dysfunction at baseline. The primary outcome measure was any change in sexual function. 6 RCTs were identified, all of which investigated different interventions; hence, it was not possible to synthesize the data quantitatively. Results were overall limited by small sample size, brief treatment duration, and the potential for bias. 2 studies, one assessing adjunctive sildenafil and the other adjunctive aripiprazole, reported a reduction in antipsychotic-related sexual dysfunction. Due to the lack of high-quality data, no clinical recommendations can be made. A comprehensive search strategy was used with an extensive number of relevant search terms including "erectile dysfunction" and newer antipsychotics such as aripiprazole. In light of evidence that prolactin is not a reliable marker for sexual dysfunction, this review focused its inclusion criteria on participants presenting with sexual dysfunction rather than with hyperprolactinemia, which should give its recommendations more validity. However, only 6 RCTs were identified, and results were overall limited by small sample size, brief treatment duration, and the potential for bias. Our findings highlight the paucity of high-quality research in this area, and conjecture that it may be difficult to recruit participants with antipsychotic-related sexual dysfunction. Future research may be necessary to unlock and address these difficulties. Furthermore, fully powered future studies should focus on the management of sexual dysfunction rather than the surrogate marker of hyperprolactinemia. Allen K, Baban A, Munjiza J, et al. Management of Antipsychotic-Related Sexual Dysfunction: Systematic Review. J Sex Med 2019;16:1978–1987. [ABSTRACT FROM AUTHOR]

Accessible summary: What is known on the subject?: In the United States, 15.5% of nursing home residents without qualifying diagnoses of schizophrenia, Huntington's' Disease, and/or Tourette Syndrome receive antipsychotic medications.Antipsychotic medications are used off‐label (i.e., used in a manner the United States Food and Drug Administration's packaging insert does not specify) to treat neuropsychiatric symptoms, often before attempting nonpharmacologic interventions, despite evidence that this drug class is associated with significant adverse events including death.Less than optimal staffing resources and lack of access to geropsychiatric specialists are barriers to reducing antipsychotic use. What the paper adds to existing knowledge?: Antipsychotic use occurred in 11.6% of nursing home residents without qualifying or potentially qualifying diagnoses (bipolar disorder and psychotic disorder); antipsychotic use was more prevalent in residents with a dementia diagnosis than those without.One additional registered nurse hour per resident day could reduce the odds of antipsychotic use by 52% and 56% for residents with and without a dementia diagnosis respectively. What are the implications for practice?: Given the influence of total staffing and professional staff mix on risk of antipsychotic use, nursing home administrators may want to consider aspects of facility operation that impact antipsychotic use.More stringent Unites States' survey and certification standards for dementia care implemented in 2017 demand proactive person‐centered care that promotes maximal well‐being and functioning without risk of harm from inappropriate psychoactive medications.Mental health nurses have requisite training to provide expert person‐centered care to nursing home residents with mental illness and geropsychiatric disorders. Introduction: Antipsychotic use in nursing homes varies widely across the United States; inadequate staffing, skill mix, and geropsychiatric training impede sustained improvement. Aim: This study identified risk factors of antipsychotic use in long‐stay residents lacking qualifying or potentially qualifying diagnoses. Method: This secondary analysis used 2015 Minimum Data Set and cost report data from 458 Missouri nursing homes. The full sample (N = 29,679) was split into two subsamples: residents with (N = 15,114) and without (N = 14,565) a dementia diagnosis. Separate logistic regression models were run. Results: Almost 15% of the dementia subsample and 8.4% of the nondementia subsample received an antipsychotic medication in the past week. Post‐traumatic stress disorder, psychosis indicators, behavioral symptoms, anxiety medication with and without anxiety diagnosis, depression medication with and without depression diagnosis, and nurse staffing were among the strongest predictors of antipsychotic use in both subsamples. Simulation analyses showed decreased odds of receiving an antipsychotic in both subsamples when registered nurse hours matched the national average. Discussion: Matching nurse staffing mix to the national average may improve antipsychotic use in nursing homes. Implications: Knowledge of antipsychotic use risk factors use can inform care planning and staff education to minimize use of these medications in all but severe cases. [ABSTRACT FROM AUTHOR]

Introduction: Data from the literature suggests that some first episode psychosis (FEP) patients may recover without antipsychotic medication. There is however no reliable way to identify them. In a previous paper we found, in a cohort of 584 FEP patients, that those consistently refusing medication had poorer pre-morbid functioning, less insight, higher rate of substance use and poorer outcome. However, some medication refusers, had a favourable outcome. The study aim was to identify predictors of good short term outcome despite non-exposure to medication.Methods: The Early Psychosis Prevention and Intervention Centre (EPPIC) admitted 786 FEP patients between 1998 and 2000. Data were collected from patients' files using a standardized questionnaire. Data on medication adherence was available in 584 patients. Among the 17.9% of patients who consistently refused medication over the entire treatment phase we compared patients who had a favourable symptomatic and functional outcome with those who did not.Results: Among patients who consistently refused medication, 41% achieved symptomatic remission and 33% reached functional recovery. Predictors of symptomatic remission were a better premorbid functioning level, higher education and employment status at baseline. Predictors of functional recovery were a shorter duration of the prodrome phase, less severe psychopathology at baseline and lower cannabis use.Conclusions: Despite limitations mainly linked to the fact that non-exposure to antipsychotic medication was based on patient's treatment refusal, this study identified some characteristics which may contribute to the identification of a sub-group of FEP patients who may have good short term outcome without antipsychotic treatment. [ABSTRACT FROM AUTHOR]

Background: In 2014, nursing home administration and government officials were facing increasing public and media scrutiny around the variation of antipsychotic medication (APM) prescribing across Ontario nursing homes. In response, policy makers partnered to test an academic detailing (AD) intervention to address appropriate prescribing of APM in nursing homes in a cluster-randomized trial. This mixed-methods study aimed to explore how and why the AD intervention may have resulted in changes in the nursing home context. The objectives were to understand how the intervention was implemented, explore contextual factors associated with implementation, and examine impact of the intervention on prescribing.Methods: Administrative data for the primary outcome of the full randomized trial will not be available for a minimum of 1 year. Therefore, this paper reports the findings of a planned, quantitative interim trial analysis assessed mean APM dose and prescribing prevalence at baseline and 3 and 6 months across 40 nursing homes (18 intervention, 22 control). Patient-level administrative data regarding prescribing were analyzed using generalized linear mixed effects regression. Semi-structured interviews were conducted with nursing home staff from the intervention group to explore opinions and experiences of the AD intervention. Interviews were analyzed using the framework method, with constructs from the Consolidated Framework for Implementation Research (CFIR) applied as pre-defined deductive codes. Open coding was applied when emerging themes did not align with CFIR constructs. Qualitative and quantitative findings were triangulated to examine points of divergence to understand how the intervention may work and to identify areas for future opportunities and areas for improvement.Results: No significant differences were observed in prescribing outcomes. A total of 22 interviews were conducted, including four academic detailers and 18 nursing home staff. Constructs within the CFIR domains of Outer Setting, Inner Setting, and Characteristics of Individuals presented barriers to antipsychotic prescribing. Intervention Source, Evidence Strength and Quality, and Adaptability explained participant engagement in the AD intervention; nursing homes that exhibited a Tension for Change and Leadership Engagement reported positive changes in processes and communication.Conclusions: Participants described their experiences with the intervention against the backdrop of a range of factors that influence APM prescribing in nursing homes that exist at the system, facility, provider, and resident levels. In this context, the perceived credibility and flexibility of the intervention were critical features that explained engagement with and potential impact of the intervention. Development of a common language across the team to enable communication was reported as a proximal outcome that may eventually have an effect on APM prescribing rates. Process evaluations may be useful during early stages of evaluation to understand how the intervention is working and how it might work better. Qualitative results suggest the lack of early changes observed in prescribing may reflect the number of upstream factors that need to change for APM rates to decrease.Trial Registration: ClinicalTrials.gov, NCT02604056. [ABSTRACT FROM AUTHOR]

Accessible summary What is known on the subject? The only previous quantitative study that examined nurses' use of assessment tools to identify antipsychotic medication side effects found that about 25% of mental health nurses were using assessment tools., No previous studies have examined factors that influence the manner in which mental health nurses assess antipsychotic medication side effects., What this paper adds to existing knowledge? One-third of the respondents were not aware of any antipsychotic medication side-effect assessment tool, and only one-quarter were currently using an assessment tool., 'Service responsibility' was significantly associated with ongoing use of antipsychotic medication assessment tools, indicating that respondents with more positive attitudes to their service were more likely to continue using antipsychotic medication assessment tools., What are the implications for practice? The low level of awareness and use of antipsychotic medication side-effect assessment tools indicates that nursing educational institutions should incorporate more detail about these tools in course content, and emphasize in particular the benefits that result from the use of these tools in clinical practice., Service processes contributed significantly to the use of antipsychotic medication assessment tools, which indicates that managers need to foster workplace cultures that promote routine use of these tools., Abstract Introduction Limited evidence suggests that only a minority of mental health nurses regularly use standardized assessment tools to assess antipsychotic medication side effects, but the factors that contribute to the non-routine use of these tools remain unknown. Aim To examine Australian mental health nurses' awareness of, and attitudes towards, side-effect assessment tools, and also identify factors the influence the use of these tools. Methods A cross-sectional survey was undertaken through distributing an online questionnaire via email to members of the Australian College of Mental Health Nurses. Completed questionnaires were received from 171 respondents. Linear regression was used to examine the relationship between the 'service responsibility' and 'personal confidence' scale scores, and awareness, previous use and ongoing use of antipsychotic medication assessment tools. Results Only one-quarter of the respondents (26.5%) were currently using an assessment tool. 'Service responsibility' was significantly associated with ongoing use of antipsychotic medication assessment tools ( Β = 3.26; 95% CI 0.83-5.69). 'Personal confidence' did not influence the ongoing use of assessment tools ( Β = −0.05; 95% CI −1.06-1.50). Implications for clinical practice Stakeholders can incorporate 'service responsibility' processes to foster increased use of assessment tools, which may enhance the identification antipsychotic medication side effects and improve the quality of care for service users. [ABSTRACT FROM AUTHOR]

Eliciting clinicians' views about antipsychotic medication side-effects may assist in understanding strategies that could enhance the identification and management of these side-effects. The present paper details the development and psychometric evaluation of a questionnaire that captures clinicians' perceptions about these issues. An initial item set was derived from a literature review, and then refined by an expert content validity panel that assessed the relevance of the items. The online questionnaire was distributed to Australian mental health nurses and 140 fully completed questionnaires were returned. Principal components analysis yielded two robust scales that conceptually tapped 'system responsibility' and 'personal confidence'. These scales may be used to advance knowledge about how mental health nurses' attitudes towards the assessment and management of antipsychotic medication side-effects influences their clinical behaviour. [ABSTRACT FROM AUTHOR]

Purpose - People with intellectual disability are subject to increased health morbidity when compared to the general population. This paper assesses the monitoring of metabolic syndrome in people with an intellectual disability who have been prescribed antipsychotic medication.Design/methodology/approach - A pre-audit analysis was followed by an audit of 32 patients. The height, weight and body mass index was recorded in 34 per cent prior to initiation, which decreased to 22 per cent at the three monthly follow up. Blood pressure was recorded in 6 per cent of the patients at baseline, but there was no record during treatment. The biochemical parameters including plasma glucose and plasma cholesterol were measured in 40 per cent of the patients on initiation which decreased to 33 per cent at three monthly follow up in the first year. In total, 21 per cent of patients received four monthly monitoring of the biochemical parameters, i.e. their height and weight, 25 per cent of the patients had an annual monitoring of all parameters.Findings - The results indicate inconsistent monitoring of metabolic syndrome in people with intellectual disability being treated with antipsychotic medication. While a proportion of patients may have been monitored in primary care, these data indicate the need for remedial action to improve the standard of metabolic syndrome detection in those people with intellectual disability receiving antipsychotic medication.Originality/value - This study highlights the inadequate monitoring of biochemical and physical parameters of metabolic syndrome in people with an intellectual disability who are prescribed antipsychotic medication. National criteria for monitoring the prescription of antipsychotic medication in people with intellectual disability who are prescribed antipsychotic medication is proposed. [ABSTRACT FROM AUTHOR]

Accessible summary • The attitudes of mental health professionals towards medication play a crucial and influential role in service users' uptake of treatments. Evidence suggests that when service users receive their medication via depot injection, compliance improves and relapse rates are reduced. It is vital that mental health service users are involved in decision making about the mode by which their antipsychotic medication is delivered. Despite this, few studies have investigated the attitudes and beliefs that healthcare professionals hold about depot medication. No reviews have looked at health professionals' attitudes towards depot medication alone. • Depots are seen as old fashioned, stigmatizing, causing side effects and being costly, and they are often not prescribed because of a presumed adherence to oral medication. • In the current study it has been found that research in this field is sparse, and studies have mixed quality. An issue that should be investigated when looking at prescribing of depot medication is that of non-medical prescribers, especially nurses. Nurses have a different relationship to the service users when compared with consultant psychiatrists, and this can have an impact on service users' choice of medication. Healthcare professionals are key providers of information about antipsychotic medication and may have a significant influence on the decisions that service users make about how their medication is delivered. This systematic review aimed to explore health professionals' attitudes and beliefs towards antipsychotic depot medication. A systematic search of AMED, BNI, CINAHL, EMBASE, HEALTH BUSINESS ELITE, HMIC, MEDLINE and PsycINFO was carried out, as well as hand searches of journals and citation searches. Studies were selected if the terms ‘attitudes/beliefs’ and ‘depot/injection’ were included in the title or abstract, if health professionals were participants in the study and if original data were included. The search strategy produced 131 papers. Eight relevant studies were then selected for the review. They included six cross-sectional surveys and two qualitative studies. It was shown that the research carried out is still very sparse. Depots are seen as old fashioned, stigmatizing, causing side effects and being costly, and they are often not prescribed because of a presumed adherence to oral medication. More research needs to be carried out to further explore these issues, to look at the role of non-medical prescribers and explore the relationship between health professionals' attitudes and those of service users. [ABSTRACT FROM AUTHOR]

There is considerable variation among the antipsychotic drugs in terms of their capacity to increase serum prolactin, but the clinical relevance of this to osteoporosis is unclear. This paper describes an audit of bone density measurement in a long-term psychiatric population specifically conducted to examine any association between prolactin level and use of antipsychotic medication. A sample of 31 female patients from one high security hospital underwent dual energy X-ray absorptiometry of their wrist bones. Information relating to risk factors for osteoporosis was collected by questionnaire from the patients, and the pharmacy department provided details of current medications. A logistic regression was carried out on the dependent variable of osteoporosis (i.e., osteopenia/osteoporosis and normal) as determined from the distal T score of the bone density measurement, with age at interview, smoking, length of time on antipsychotic medication, serum prolactin measurement, whether or not the patient was taking thyroxine, and body mass index all entered as independent variables. The only variable found to have a significant independent effect on osteopenia/osteoporosis was body mass index: the higher the body mass index, the higher the distal T score. This suggests that weight, rather than antipsychotic medication use, appears to influence bone density more than prolactin level, with obesity seemingly having a protective role. [ABSTRACT FROM AUTHOR]

Objectives: This paper gives an overview of studies on the association between dopaminergic neurotransmission and the subjective experience of patients with schizophrenia.Methods: We undertook a review of the literature.Results: Dopaminergic neurotransmission may be relevant for subjective experience. Higher striatal D2 receptor occupancy by typical and atypical antipsychotics is related to worse subjective experience, more severe negative symptoms, and depression. Individuals with lower baseline dopamine function are at an increased risk for dysphoric responses during antipsychotic therapy with dopaminergic-blocking drugs. There is preliminary evidence that a window of striatal D2 receptor occupancy between 60% and 70% is optimal for the subjective experience of patients. These occupancies are often reached even with low dosages of antipsychotic drugs.Conclusions: Reaching an optimal dopamine D2 receptor occupancy is clinically relevant, since subjective experience associated with antipsychotic medication is related to medication compliance. Antipsychotic drug dosages often need to be lower than levels in common use. [ABSTRACT FROM AUTHOR]

Summary The present paper documents a retrospective evaluation of a specialist challenging behaviour unit for individuals with severe learning disabilities according to two criteria: (1) its efficacy at reducing the frequency and severity of violent incidents; and (2) the level of reliance upon antipsychotic medication for behavioural purposes. The results were placed within the perspective of the specific approach to challenging behaviour adopted by the unit, which emphasizes communication as the fundamental tenet within the management and reduction of challenging behaviour. The results demonstrate a 92% reduction in incidents of violence towards others over the 6 years since the unit opened, alongside a 95% reduction in violence towards property. During the same period, the levels of antipsychotic medication used for behavioural purposes fell in the cases of three out of the four clients under examination. An attempt is made to highlight the predominant factors underlying this success as potential indicators for the development of services for those who exhibit challenging and violent behaviours. [ABSTRACT FROM AUTHOR]