Prescribing Responsibilities

Drug treatment is generally successful in treating positive symptoms, but up to a third of people derive little benefit and negative symptoms are notoriously difficult to treat. About half of people with schizophrenia do not adhere to treatment in the short term and the figure is even higher in the longer term.

Shared care guidelines are intended to provide clear guidance to GP’s and hospital consultants regarding the procedures to be adopted when clinical, and therefore prescribing responsibility for a patient’s treatment with a shared care drug is transferred from secondary to primary care.

Following the diagnosis of schizophrenia by a secondary care consultant a drug free assessment period may be initiated or use of sedating therapy prior to the commencement of an antipsychotic drug.

Prescribing should be continued by secondary care if the patient is attending for frequent review.

Prescribing can be transferred to the GP when the patient is stabilised and receives most of their care from the community based team. Patients are regarded as ‘stabilised’ for the purposes of shared care once they have responded to medication and there are not recognised problems with compliance, or significant acute risks of harm to themselves or others. They will usually have completed at least one month of treatment and be suitable for 28 day prescriptions. Some patients may require monitored dosage systems and supplies of less than 28 days duration.

GPs should enter into dialogue and discussion with the psychiatrist, on an individual case basis, in an effort to avoid a situation where they are unhappy to prescribe for any reason. To allow the safe transfer of prescribing responsibility, discussion between the psychiatrist and GP will be necessary for the following groups of patients:

• Patients receiving drugs prescribed outside the product license.
• Patients receiving more than one antipsychotic.
• Patients may be considered suitable for shared care prescribing providing:
• Suitable arrangements for community based care have been made
• The patient’s mental state has been stabilised
• The patient’s dosage has been stabilised and treatment is approved for shared Where drugs require routine blood monitoring this is the responsibility of the prescribing doctor.

Side Effect Monitoring

There should be a baseline assessment performed using the LUNSERS (Liverpool University Neuroleptic Side Effect Rating Scale) scoring system before patients are given their first dose of antipsychotic medication. It is difficult to be prescriptive about the frequency with which side effect monitoring should take place, as this will be patient specific. However, it should be done again within 2-3 weeks of the introduction of new medication, or when there has been a substantial increase in dose. Thereafter side effects should be monitored every six months.

Responsibility of the Psychiatrist

1. To assess the patient, establish the diagnosis and determine a management strategy.
2. To initiate drug therapy, monitor the patient and review their therapy at regular intervals.
3. To prescribe medication. It is the responsibility of the prescribing doctor to prescribe in light of the results of monitoring.
4. To ensure the patient is fully informed about their treatment.
5. Responsible for the baseline LUNSERS score before initiating treatment.
6. To provide the patients therapy whilst actively managing the acute illness. This includes if the patient is part of an assertive outreach programme or attending a day hospital.
7. Be available for advice if the patient’s condition changes and ensure that procedures are in place for the rapid re-referral of the patient by the GP if necessary. They will also continue to review the overall management of patients as necessary and notify the GP of any changes in drug therapy that may arise from future reviews.
8. Once ‘stabilised’ and if the patient is on a drug that has been identified as suitable for shared care to issue a request for a GP to take over prescribing.

The request should state:

• When the patient received their last supply of treatment (28 days supply) and when they will require their next supply
• GPs should be referred to the relevant drug information sheet if an atypical antipsychotic is being recommended
• For medications that require monitoring, the monitoring arrangements must be clearly documented
• Details of the patient’s management including the approximate date of their next outpatients visit Responsibilities of the GP

1. To seek the permission of the patient to refer the patient for specialist advice.
2. To review the patient in accordance with the requirements of the care pathway.
3. To manage general health issues of the patient.
4. To prescribe medication. It is the responsibility of the prescribing doctor to prescribe in light of the results of monitoring. Patients are recommended to receive a maximum of 28 days supply. Some patients may require monitored dosage systems and GPs are advised to provide weekly prescriptions for these patients.
5. To ensure the care coordinator monitors side effects of treatment.
6. To monitor compliance with drug therapies and alert the care coordinator of any compliance problems.
7. To inform the Mental Health Team of any prescribing changes that may affect the patient’s mental state.
8. To request a specialist reassessment of the patient if necessary.

Indications for reassessment or need for specialist advice include:

• Any spontaneous deterioration in mental state that cannot be managed by the GP
• Patient intolerance of adverse side effects including the development of extrapyramidal side effects
• Non-concordance, lack of efficacy or need for alteration of dose of antipsychotic therapy
• Specific prescribing circumstances e.g. pregnancy, initiation of concomitant medication that may interact with patient’s antipsychotic medication

Responsibilities of the Hospital and Community Pharmacists

1. To counsel the patient on appropriate aspects of selected drug therapy.
2. To provide information and support on psychotropic therapy for psychiatrists, GPs and CMHT.
3. To provide information and support to patients and carers.
4. To alert the care coordinator of any compliance problems.

Responsibilities of the Care Coordinator

1. To monitor the patient on appropriate aspects of selected drug therapy.
2. To check/remind patient and carers of the need to get blood tests done and facilitate this with the GP surgery or out-patient clinic as appropriate.
3. To ensure on-going monitoring of LUNSER score.
4. To provide liaison between patient, psychiatrist, GP and pharmacist.
5. To provide support to the patient and monitor compliance.