Introduction

This chapter covers some of the key issues that may arise with people prescribed and administered antipsychotic medications. We begin with the issues surrounding the use of psychotropic medications for the management of behavioural emergencies followed by an exploration of PRN or ‘as needed’ medications, a medication route often prescribed in inpatient settings. An important aspect related to psychotropic medication outcomes is addressed under the heading adherence. Further issues related to the use of psychotropic medications such as depot preparations and polypharmacy are then examined, followed by a discussion of potential side effects that can have a significant impact on the consumer, such as metabolic syndrome and sexual dysfunction.

Behavioural emergencies and the use of psychotropic drugs

Agitation, a non-specific cluster of behaviours that is common in many psychiatric disorders, has the potential to readily escalate to aggression. This behaviour necessitates urgent intervention to reduce the likelihood of harm to the person and others in the environment. When managing these behaviours it is always preferable to use non-coercive treatments initially, such as de-escalation techniques (talk-down, clinical interview and environmental techniques). If these are ineffective or if the patient becomes combative, the implementation of more coercive interventions such as show of force, involuntary medication, physical restraint or seclusion may be required (Allen 2000). If psychotropic medication is selected as the best option available, the patient should be offered the choice of taking an oral medication initially. If this is refused, an intramuscular injection (IMI) is usually the next step. In situations where the oral medication is refused or where the behaviour is such that a rapid response is required, rapid tranquillisation with antipsychotics, benzodiazepines or other sedative drugs by IMI or intravenous injection (IVI) may be required (Rocca et al 2006). Rapid tranquillisation is the administration of a medication with the intent of calming or sedating an agitated or aggressive patient. The aim should always be to reduce patient distress, allow for improved communication and reduce the risks of injury to the patient and others (MacPherson et al 2005).

Evidence for the effectiveness of the pharmacological management of aggression is limited (refer to Table 8.1 for currently used options). The question of whether best clinical practice involves the use of first generation antipsychotics (FGAs) versus benzodiazepines versus a combination of both remains a topical issue. Meanwhile, the second generation antipsychotics (SGAs) have recently been introduced and, so far, there has been limited research undertaken to establish their effectiveness in the management of aggressive events (Yildiz et al 2003). FGAs used for the treatment of aggression include haloperidol and droperidol, found to be equally effective but with droperidol offering a more rapid effect coupled with a greater degree of sedation (Rocca et al 2006). Of the SGAs, oral risperidone (available as a dispersible oral dose) has been found to be equally as effective as haloperidol, and the new IMI formulations of olanzapine and ziprasidone now offer new treatment options for the management of aggressive incidents. Their broader efficacy and better safety profile, combined with the ease of transfer to oral maintenance after the initial episode, make them a better option than the FGAs (Yildiz et al 2003). Clozapine, an SGA, has been found to have a beneficial effect in reducing violence. Hence it has become a popular treatment option for forensic patients with a history of violence (Martin et al 2008). It is not, however, readily available in a parenteral form. Benzodiazepines such as clonazepam and midazolam are also popular choices for the management of aggressive and violent patients, either in combination with an FGA or on their own. Midazolam has been found to be more rapidly sedating than haloperidol (Rocca et al 2006). Care must be taken when using rapid tranquillisation, however, as serious drug interactions or over-sedation may result (see Clinical alert 8.1). Respiratory depression may occur with high doses of midazolam or droperidol, and cardiac arrhythmias with zuclopenthixol, so these medications must be used with caution. The patient must be closely observed following the administration of the medication and until full recovery has occurred.

Table 8.1 Pharmacological options for the management of aggression

The use of involuntary medications with psychiatric inpatients is, however, a controversial management practice. An injectable medication is likely to be perceived as a threat, assault or punishment, making the establishment of a therapeutic alliance more difficult. Therefore, it is clinically prudent to offer an oral medication first. If an IMI or IVI medication must be used, the clinicians must act in a respectful and non-judgmental way when dealing with the patient to ensure they do not cause any further distress or embarrassment. Removing the patient’s clothing and exposing their buttocks for an IMI medication is certainly an invasion of their privacy and has the potential to cause serious psychological consequences for the patient (MacPherson et al 2005). Hence, well experienced and trained staff, set procedures, briefing, debriefing and stress coping strategies are considered vital for the effective and safe management of agitated or aggressive inpatients (Rocca et al 2006) (see Thinking challenge 8.1).

Higher doses of psychotropics and polypharmacy are more commonly administered to aggressive patients. A recent study found an increased use of pro re nata (PRN) or as-needed psychotropic medication with aggressive patients, indicating they were generally more likely to receive a PRN than other patients. Continued administration of PRN psychotropic medications was also observed after an aggressive event (up to a further 36 hours), indicating the possibility that staff administered PRN in an attempt to reduce the likelihood of repeated aggressive episodes. The use of other somatic PRN medications was also increased during that period (Goedhard et al 2007). Further information of relevance to this section is contained below in relation to the prescription and administration of PRN psychotropic medications (see also Clinical alert 8.2).

PRN (pro re nata or as-needed) psychotropic administration

The existing PRN system enables nurses to respond efficiently to a consumer’s request to reduce agitation or distress or to respond rapidly to an aggressive event without the need to call the treating medical officer. It allows for a PRN medication to be administered at the request of the consumer or at the discretion of the nurse (Davies et al 2007). A common practice in psychiatric settings, especially in high dependency or intensive care units, the prescription and administration of PRN psychotropic medications is a frequently used adjunct to routine medications. Originally considered a viable alternative to restraint, it is now condemned by some as having merely replaced a physical restraint with a chemical one (Donat 2005). It has been suggested that, rather than being an independent decision of doctors, PRN prescription is the result of interactive dynamics between doctors and nurses (Craven et al 1987) where the nurses pressure the doctor to prescribe a wide range of medications available for PRN administration. Concerns have also recently been raised about PRN psychotropic medications being used as a ‘quick fix’ for the convenience of the organisation rather than for the benefit of the consumer (Davies et al 2007) and that they have become the primary intervention within acute care settings. Unfortunately, a recent study of inpatient charts indicated that alternative therapeutic interventions, such as de-escalation, talking or separating from the group, were not implemented as a first choice or even after the PRN event to prevent the need for further medication (Curtis et al 2007). Ideally, PRN psychotropic medication should only be implemented when alternative interventions have failed or the level of distress is so great that it is warranted. Alternatives to PRN psychotropic medication have, in fact, been trialled and found to be effective. A nurse-led activity-based intervention comprising of movement and games in the morning and relaxation sessions in the afternoon was shown to be successful in reducing the number of PRN medications administered in a psychiatric high dependency unit (Thomas et al 2006).

In general, antipsychotic medications and benzodiazepines are the main classes of medications prescribed for psychotropic PRN; however, antihistamines, anticholinergics, antimuscarinics and sedatives may also be prescribed and administered by this means. Internationally, within mental health settings, PRN medications have been reported to be prescribed to approximately 70–80% of consumers and administered to about 50% depending on the setting (Craven et al 1987, Thapa et al 2003, Geffen et al 2002, Dean et al 2006). Dean, McDermott and Marshall (2006) reported that almost three-quarters of a recent Australian sample were prescribed a PRN medication during their inpatient stay and approximately half were administered at least one dose of the medication. Another Australian study reported that 73.4% of their sample received a PRN on at least one occasion during the month of data collection (Curtis et al 2007). These findings are similar to the findings from earlier studies.

Psychotropic PRN medication is usually administered orally or by IMI and, although prescribed by a doctor, is a commonly administered nursing intervention. Usually given in the first few days after admission and most frequently during the evening shift, especially from 6 pm onwards, PRN medications are also frequently administered at weekends (Usher et al 2001). Peaks in PRN administration tend to coincide with regular medication administration and meal times (Gray et al 1996, Stratton-Powell 2001). Reasons given for administering a PRN medication include agitation, threatening behaviour, irritability, abusiveness, insomnia, disruptiveness, assault and at the request of the consumer (Usher et al 2001). Environmental influences have also been suggested as relevant to the administration of PRN psychotropic medications. The study by Usher, Holmes, Baker and Stocks (2007) proposed that the physical and psychological environment in which the consumers were cared for had an effect on the individual’s sense of security. Research has previously implicated the environment as a major factor in the creation of agitation and, hence, as an instigator of the need for PRN psychotropic medication. For example, consumers recently identified factors such as how the ward looks as well as feelings of safety and privacy as impacting on their sense of wellbeing within inpatient facilities (Brimblecombe et al 2007, Happell 2008). These factors may adversely affect a consumer’s mental health and indirectly lead to an increase in anxiety, agitation and frustration, and ultimately aggression, which in turn impacts on the need for staff to resort to administering a PRN medication.

The demographics of those who receive psychotropic PRN medications within inpatient settings are interesting. Although insufficient research has been conducted to confirm gender as a correlate of PRN administration, early studies do suggest that males are more likely than females to receive PRN psychotropic medication (Curtis & Capp 2003, Usher et al 2001). Similarly, Craven and colleagues (1987) reported age as a correlate, finding that consumers aged 50 or older were associated with more PRN prescriptions in total, and specifically the prescription and administration of more sedatives/hypnotics. Ethnic difference has also been found to be a predictor of PRN prescription and administration. Recent studies by Gudjonsson et al (2000) and Hales and Gudjonsson (2004) found that black American inpatients were more likely than white inpatients to be administered a PRN psychotropic medication. However they noted that many confounding variables, including the over representation of black patients within secure units, may have accounted for those findings. A recent Australian study found that, while nurses believed the Indigenous patients in the unit were administered a greater number of PRN medications, this was in fact not true. Interestingly, the study found that, while Indigenous inpatients were prescribed psychotropic PRN medications at a higher rate than non-Indigenous inpatients, the data revealed they were actually administered PRN medications less often than the non-Indigenous inpatients (Usher et al 2007). Alarmingly, this may indicate that mental health professionals are more likley to pathologise the behaviour of certain ethnic groups of people (Miranda et al 2002), including members of different Indigenous groups.

Despite the importance placed on the use of PRN medications within inpatient settings, little research has been undertaken to establish the clinical effectiveness of the intervention. In fact, it has been suggested that, in the past, the use of PRN psychotropic medications has been primarily based on clinical experience and habit rather than evidence (Whicher et al 2003) and has in many cases contributed to adverse reactions or excess sedation (Geffen et al 2002). The decision-making processes involved in the prescription and administration of PRN psychotropic medications are complex. Frequently, prescriptions include several medications and offer a dose range (for example 50–100 mg of a specific medication) from which the clinician must choose. Thus, even though they are prescribed by doctors, nurses are the ones most often charged with the responsibility of administering these medications and therefore have an important role to play in assessing the need for, and making the appropriate decisions around, administering psychotropic PRN medications (Usher et al 2003).

A recent study by Baker et al (2007a) in the UK has gone some way to unravelling the decision making that nurses engage in when faced with the administration of a PRN psychotropic medication. They found that nurses’ decisions to adminster the medications were influenced by safety, knowledge of the patient and levels of patient distress. They also found that nurses used PRN medication as a first rather than a last resort due to limited skills, fewer years of clinical experience, time pressures and low or inadequate staffing levels. The nurses in the study reported regularly using PRN medications as a first resort without any attempt to implement an alternative. A similar study conducted in Australia (Usher et al 2006b) found, in contrast, that nurses reported using alternatives to medication in many cases. However, some of the respondents in that study indicated that PRN medications were also used as an easy option for managing the ward. Even when nurses indicate that they have used alternatives to a PRN medication initially, there is little evidence to back this up in client inpatient files (Curtis et al 2007). Other factors that influenced the nurses’ decisions to administer a PRN psychotropic medication include the mental state of the patient, for example whether they assessed the person as being psychotic or agitated, and staffing levels, such as the lack of experienced staff or high levels of casuals on the ward (Usher et al 2007).

Perhaps the most serious problems associated with psychotropic PRN administration are the risks of severe side effects, pharmacokinetic drug interactions, higher than recommended drug doses and abuse by uninformed mental health staff (Ayd 1985, Bowden 1999). A recent study found that as many as one-fifth of reviewed consumer inpatient records contained prescriptions for drug combinations that were judged to have the potential to cause serious interactions (Davies et al 2007). This is alarming given that these potential interactions could be fatal. In many instances, large doses of antipsychotics can result in debilitating, potentially fatal side effects such as tardive dyskinesia, akathisia and parkinsonism. In a worst case scenario, a patient could display a side effect such as akathisia (restlessness, inner tension, emotional unease), which could be confused with a psychiatric problem; as a result, the patient may be given additional doses of antipsychotic agents that will only worsen the patient’s symptoms and lead to further hospitalisation. In situations such as these a large amount of responsibility is placed on the health professional, who must be able to distinguish between side effects and disturbances that are psychiatric in origin, and determine whether the combination of medications could have serious consequences for the consumer. This is even more of a concern when many PRN administrations occur during a time of emergency.

In the past, the drugs most often prescribed for PRN administration have been the FGAs, in particular drugs like haloperidol. There is now evidence to suggest that the benzodiazepines are just as effective as the FGAs in managing acute agitation and disturbed behaviour and should be the drug of choice when a PRN is considered the appropriate management of an adverse event or a distressed patient (Geffen et al 2002). The unwanted side effects of the antipsychotics, the FGAs in particular, make the benzodiazepine group the better alternative as these are generally better tolerated (Usher & Luck 2004). If an antipsychotic is to be prescribed, the SGAs, especially risperidone, ziprasidone and olanzapine, are considered the most effective for the purpose (Yildiz et al 2003). However, examination of current practice indicates that the FGAs continue to be used predominantly for PRN management of psychotic disturbance (Geffen et al 2002, Curtis et al 2007). This is a concern given the current information indicating this is not the best clinical option (see Thinking challenge 8.2). Wherever possible, PRNs should be administered at the lowest dose to avoid untoward side effects and, if needed, increased later. Best practice guidelines for the administration of PRN psychotropics were developed in the UK with the assistance of a panel of experts. They revealed four key themes: (i) service users should be more involved in all processes associated with PRN psychotropic medications; (ii) PRN medication must be administered for the purpose for which it was prescribed; (iii) prescriptions must be time limited, which encourages review; (iv) staff need to develop knowledge and awareness about potential side effects prior to administering them (Baker et al 2007b). See also Table 8.2 for a summary of decisions to be made when administering PRN psychotropic medication.