Objective: To highlight the pharmacological management of patients with Bipolar Affective Disorder and to evaluate whether the management meets the current standards as set up by recognised guidelines, especially those underlined by NICE guidelines.
Method: The audit data were collected from a patient population from the West patch of South Staffordshire and focussed on inpatients from the 2 adult units based at Stafford and a psychiatric ICU. It also included a minimum of 5 patients of both genders from all the community teams. The selection was random and not based on severity or duration of the disorder, co-morbidity or other accompanying diagnoses, for e.g, Personality disorder. The audit tool was devised by the clinical audit coordinator in conjunction with clinicians.
Results: Twenty of twenty-eight 28 patients (72%) were on mood stabilizers, either lithium or sodium valproate, with sodium valproate the more preferred drug. Twelve of twenty-eight (43%) were on antipsychotics. Three of seven (43%) patients, who did not respond to combination treatment, were started on lamotrigine. In 21/22 (95%) of the patients, antidepressants were stopped. Nine of the twenty-eight (32%) patients continued to be on antidepressants even after resolution of the depressive episode. The compliance of monitoring for physical side effects during the initial period of starting medications was not satisfactory with only:
19/24 (79%) monitored for renal disease,
18/24 (75%) monitored for diabetes,
15/24 (63%) monitored and advised about obesity and 15/24 (63%) drug levels checked regularly.
In 4/28 (15%), there was no documentation about any physical health monitoring.
Only in 50-60% of patients had the monitoring been done annually, but it was regardless of any recognised guidelines. In 19/26 (73%) the patient's preference of drug choices was recorded. In 21/28 (75%) patients, there was documentation about discussion of potential benefits and side effects of the medications. Five of twenty-eight (18%) patients who were prescribed valproate were of child bearing age; 4 were advised to use contraception and one had been sterilized.
Clinical implications: Monitoring cognitive function tests is often dependent on patient mental health, illness, age, and lack of side effects. Patient preference for drugs should be taken into consideration. Evidence should be documented regarding clinical need or history of risk on antidepressant medication. Evidence of long term treatment with antidepressants after resolution of a depressive episode should be documented in the patient notes. Annual check-ups of parameters should be documented by either the GP or Mental Health Team. However, weight and BP machines may not be available at clinic appointments. There is a need for closer understanding among clinicians about the responsibility for initiation and maintenance of close physical monitoring. Discussions should be held with women of child bearing age regarding contraception. Teams to monitor the need for referral to specialist Bipolar Units should be available, regardless of any cost implications.