This paper provides case study examples and personal accounts from specialist mental health pharmacists who played key roles in an NHS England-sponsored psychotropic medication improvement programme. The programme for providers of in-patient mental health services for children and young people enabled professionals and recipients of the services to actively participate in all aspects of improving the use of psychotropic medication.
The 2019 NHS Long Term Plan1 set out the priorities for expanding children and young people’s mental health services over 10 years. The subsequent NHS Mental Health Implementation Plan,2 which provides a framework to deliver this at a local level, aims to widen access to specialist mental health care that is based on a clearer understanding of young people’s needs and provided in ways that work better for them.
Funding for children and young people’s mental health services is scheduled to grow faster than both overall NHS funding and total mental health spending.
Data from NHS Digital on the prevalence of mental health problems for children and young people aged seven to 16 years showed rates rose from one in nine (12.1%) in 2017 to one in six (16.7%) in 2020.3
In parallel is an increase in the prescribing of psychotropic medications. Studies in the USA, Canada and the UK have shown the prescribing of psychotropic medications for children and young people to be rising significantly.4–6
A study of general practice in England showed the annual period prevalence of all antipsychotic prescriptions rose between 2000 and 2019 at an average of 3.3% per year (2.2%-4.9%), while the rate of first prescriptions also increased by 2.2% per year (1.7-2.7%).7
The authors postulated that the most likely indications of the first identified antipsychotic prescriptions were for autism spectrum disorder, non-affective psychosis, anxiety disorders, depression and conduct disorders. They also argued there was a trend towards longer treatments.
There are similar trends for antidepressants and hypnotics. The number of 12-to-17-year-olds in England prescribed antidepressants has risen sharply since 2005.8 In fact, an article published in the Pharmaceutical Journal in 2022 based on data from a freedom of information request revealed that the number of children prescribed melatonin has increased by 170% in seven years.9
Much of the concern about this increase in the prescribing of psychotropic medications has focused on antipsychotic side effects. Weight gain with second-generation antipsychotics is thought to be greater in children and adolescents than in adults.8 Excessive weight gain is associated with significant medical morbidity and mortality, including dyslipidaemia, diabetes mellitus, polycystic ovary syndrome, hypertension and sleep apnoea.
The increase in psychotropic prescribing has also resulted in greater involvement and appointment of specialist mental health pharmacists. Many of the posts are new and the units they serve are small (typically 10-12 beds for standard units and three to four beds for high-intensity units) and in diverse locations.
The NHS England-sponsored psychotropic medication improvement programme has enabled them a unique opportunity to compare the prescribing and the practices in relation to medication with their peers located in other parts of England.
Method
As part of the Psychotropic Medication in Children and Young People’s Mental Health In-patient Services improvement programme, three online tools were developed in collaboration with a wide variety of stakeholders.
First was a medication census tool to be completed by provider clinicians to capture prescribing practices around psychotropic medication. The other online tools were questionnaires that provided an opportunity for the children and young people and their parent carer to express their views of the medication.
Service providers received feedback in a variety of ways. An electronic dashboard provided data from their own service, comparisons with similar services and comparisons with the overall results from all services.
In addition, a series of webinars were provided for services which provided the total results relating to eating disorders services, general admission wards and the remaining ward types (psychiatric intensive care, medium secure, etc.). Participants were provided with an implementation guide and a technical guide to assist local reflection and development of improvement action plans.
A thematic analysis to identify themes was undertaken to aid reflection on current practices.
Results
Following a highly successful recruitment drive, 79% of providers of children and young people’s in-patient services known to NHS England signed up to participate. From those providers – including those in both the NHS and the independent sector – details of the psychotropic medication prescribed for 625 children and young people staying in 73 mental health units were recorded, and questionnaires from 142 children and young people and 75 parent carers were submitted.
A total of 12 themes were identified from the census and questionnaires. They included:
- Large variation of prescribing across similar units, both in the extent of prescribing of psychotropic medications and the administration as needed (pro re nata, or PRN)
- High levels of prescribing
- Psychotropic medication polypharmacy
- Variations in prescribing related to ethnicity, gender, a diagnosis of autism or learning disability
- Perceived little or no scope to reduce the load of psychotropic medications
- Views from both the children and young people and their families/carers about the value of the medications prescribed
- Concerns about weight gain, tiredness and disconnection and the potential long-term adverse effects on health, growth and development
- Whether the provision of information about medication was useful
- Unclear reasons for prescribing
- What the children and young people would like to do to help them achieve good health
- Prescribing and administration of PRN psychotropic medications
- The need to develop the evidence base and provide guidance on the prescribing of psychotropic medications for children and young people.
Reflections of participating specialist mental health pharmacists
- Case Study 1: Rachel Hogan, clinical lead CAMHS pharmacist and independent prescriber at Oxford Health NHS Foundation Trust, UK
Oxford Health NHS Foundation Trust provides two general admission units (GAUs) for children and young people and a high dependency unit (HDU). On the day of the medication census, there were 26 residents on the two units. Upon receipt of the results dashboards, I presented the Oxford Health data, alongside the national benchmarking data, at a variety of local meetings including the children and young people provider collaborative meeting.
The presentation included celebrating some positives, such as minimal psychotropic polypharmacy (defined as receiving more than one psychotropic medication), along with low levels of medication use in general when compared to the national picture.
Oxford Health’s results provide support to the benefits of the current model of specialist clinical pharmacists being active members of the multidisciplinary team (MDT), regularly attending ward rounds and being involved at the point at which decisions are made around medication use.
Some of the differences that were identified locally between the Trust’s two GAUs highlighted differing opinions about the benefits of olanzapine and about what stage in therapy it might be considered in those with anorexia nervosa, resulting in plans to produce a local guideline for the use of olanzapine to ensure consistency of approach across services in the Trust.
The differences noted between units in the rates of PRN prescribing of medications such as lorazepam prompted a discussion about the potential value of reviewing how each unit approaches the management of agitated behaviour, including at what point medication might be used, and the benefits of shared learning around incident management between the units.
Disappointingly, our Trust had minimal feedback from parent carers, so it is difficult to ensure we are meeting their needs when it comes to all aspects of medication use. Although I currently meet with inpatients on an as-needed basis, we plan to devise alternative methods of seeking such feedback on a routine and regular basis.
Recently, a new Oxford-based psychiatric intensive care unit (PICU) has opened. This unit offers a weekly wellbeing drop-in session for the children and young people, allowing easy access to various clinicians – including myself. Reviewing how well this is received, as well as seeking feedback, will help inform whether to extend this model of pharmacist accessibility to our other units.
Another big positive indirectly related to the project is the formation of a new Child and Adolescent Mental Health Services (CAMHS) Pharmacy Network. While CAMHS pharmacists are often working as part of a team of mental health pharmacists, they are often the only CAMHS pharmacist in their Trust or local area.
Being alone in a ‘specialty within a specialty’ can feel quite isolating and unsupported. The impetus to finally set up the CAMHS Pharmacy Network came about during one of the NHS England project feedback sessions and the Network now has more than 60 members with regular meetings and a discussion email forum.
The CAMHS Pharmacy Network aims to provide support by sharing learning, expertise, experience and ideas; to collaborate on the development of locally adaptable templates for guidelines and protocols relating to the use of medications for mental health conditions in children and adolescents; and to seek out and contribute to other collaborative opportunities, such as pharmacy research, in this specialist area.
- Case study 2: Christine Fyfe, advanced pharmacist practitioner at Cumbria, Northumberland Tyne and Wear (CNTW) NHS Foundation Trust, UK
CNTW provides five inpatient children and young people units in the north-east of England. At the time of the project in October 2022, these comprised two medium secure services, two GAUs and a PICU.
I worked as the specialist clinical pharmacist across all five units. My role in the project was to support the clinicians in completing the medication census and encourage completion of the questionnaires by the children and young people and their parent carers.
The project has led to several developments within our Trust:
- A review of promethazine prescribing within CNTW services was requested by the medicines optimisation committee. This has led to work on:
- A review of rapid tranquilisation processes
- Increased awareness and education for prescribers about use, risks and possible side effects
- Consideration given to annotation of all discharge/leave scripts specifying duration, i.e., expect this to be needed for a maximum of seven days
- How PRN prescribing is reviewed.
- A working group has been set up to produce prescribing and medication good practice guidance for children and young people with learning disabilities
- Active pharmacist involvement in the project had many positive outcomes for the pharmacy service. It enabled wider engagement not only with members of the MDT, including occupational therapists and social workers, but also with family ambassadors and peer support workers
- I was able to present the data at the ‘North Cumbria Together’ bimonthly meeting of professionals and service users across the region. I now attend the monthly family/carer days at one of the units, and the pharmacy team has started to attend community meetings on the ward when visiting the units at weekly visits
- There continue to be further opportunities to present CNTW-collated project data at various forums in 2024 and to follow up on issues still to be actioned.
On a personal level, this project has certainly made me reflect on my practice – am I ensuring that we are documenting appropriately and asking the necessary questions?
- Case study 3: Beryl Navti, clinical lead pharmacist for CAMHS at North East London NHS Foundation Trust (NELFT), UK
NELFT provides in-patient services for children and young people aged 12-18 across two GAUs.
The findings that children, young people and their parent carers were expressing concerns about side effects of psychotropic medication, wanting more information about the medication they are prescribed and wanting to understand reasons they were prescribed medication led us to consider:
- Best ways to share information about psychotropic medication and planned prescribing including the use of PRN
- Opportunities for each child, young person and their parent/carer to ask questions, weigh up benefits and risks, express their views and concerns in ways that are responsive to their needs, and consider how their views can inform prescribing and treatment
- How best to involve each child, young person and parent carer in decision-making about psychotropic medication use, alternative or additional treatments, and other ways to be healthy.
In response, CAMHS pharmacists are now ensuring that all medication changes are included in communications to parent carers and the young people weekly. Where they require further details, the pharmacist schedules a call to provide more information and information leaflets when required.
When prescribing psychotropic medication, pharmacists ensure that there is a discussion with the young person (where it is possible) regarding the rationale for initiating the medication and the intended outcomes. This allows their voice to be heard and encourages them to have input in their care.
We have also increased our pharmacy presence, actively making ourselves visible to the young people in the unit to encourage them to have conversations with us about their medication. Although the initial uptake was low, there has been an improvement with time.
A key barrier to engaging with children and young people on the units is the fact that pharmacist visits coincide with school hours. In our determination to overcome this, we have introduced pharmacist presence in the young people’s occupational therapy sessions. This informal environment allows young people to freely approach pharmacists to ask questions and request presentations on various psychotropic medications, their uses and side effects.
Additionally, the improvement project spurred us to incorporate into our practice the need to reduce medication load of young people where it is clinically appropriate, as polypharmacy can impact compliance and patient care greatly. All prescriptions for psychotropic medication including ‘when required’ are continually reviewed for appropriateness and efficacy.
The results of the improvement project have been discussed widely at MDT meetings in both units. To study change over time, we have replicated the data collection process in a snapshot review of prescribing within these units and shared the findings at our internal quality improvement summit.
At the national level, the results of the project were also disseminated to a multidisciplinary group of healthcare professionals at the first CAMHS symposium organised by the National Association of Psychiatric Intensive Care and Low Secure Units.
- Case study 4: Esther Njane, lead pharmacist for CAMHS, forensics, national & specialist services at South West London & St George’s (SWLStG) Mental Health Trust, UK
SWLStG Mental Health Trust has one ward for admissions, with 12 inpatient beds for young people aged 12-to-18-years-old experiencing serious mental health crises that require hospital admission.
Our participation highlighted the need for increased conversations with young people and parent carers about the medications prescribed. As the pharmacists actively participate in the MDT on the ward, they are well placed to contribute to medication decisions and facilitate discussions with the children and young people.
Conclusion
This improvement programme enabled providers of children and young people’s mental health in-patient services to receive feedback regarding the prescribing of psychotropic medication. Specialist mental health pharmacists played a key role in developing the programme and implementing change.
The improvement programme highlighted the necessity of ongoing medication reviews to ensure that prescribed medications have clinical evidence and that non-pharmacological therapies are considered before resorting to medications. There were active discussions on the review of medications and treatment choices during and after crises.
Potential further steps include:
- Continuous medication discussion groups on the ward, along with ongoing individual medication sessions for young people
- Post-discharge reviews of medications initiated in young people during crises would be beneficial, optimising medications and addressing patient concerns
- The need for similar scrutiny of psychotropic prescribing in a community setting.
Authors
David Branford
Independent pharmacy consultant (mental health and intellectual disabilities), contracted to Quality Transformation Team, NHS England, UK
Rachel Hogan
Clinical lead CAMHS pharmacist and independent prescriber, Oxford Health NHS Foundation Trust, UK
Christine Fyfe
Advanced pharmacist practitioner, Cumbria, Northumberland Tyne and Wear NHS Foundation Trust, UK
Beryl Navti
Clinical lead pharmacist for CAMHS, North East London NHS Foundation Trust, UK
Esther Njane
Lead pharmacist for CAMHS, forensics, national & specialist services South West London & St George’s Mental Health Trust, UK
Anne Webster
Lead – Psychotropic Medication in Children and Young People’s Mental Health Inpatient Services project; working on behalf of the Quality Transformation Team, NHS England, UK
Teresa Randon
Lived experience co-worker, children and young people, Learning Disability and Autism Programme, NHS England, UK
David Gill
Lived experience adviser, children and young people, Learning Disability Programme, NHS England, UK
Kirsten Peebles
Independent lived experience expert and co-chair of the Building the Right Support Advisory Group (representing families), NHS England, UK
References
- NHS. NHS Long Term Plan
- NHS. NHS Mental Health Implementation Plan 2019/20 – 2023/24
- NHS Digital. Mental Health of Children and Young People in England 2022 – wave 3 follow up to the 2017 survey
- Olfson M et al. National trends in the outpatient treatment of children and adolescents with antipsychotic drugs. Arch Gen Psychiatry 2006;63:679–85
- Doey T et al. Survey of atypical antipsychotic prescribing practices by Canadian child psychiatrists and developmental paediatricians for patients aged under 18 years. Can J Psychiatry 2007;52:363–8
- Olfson M et al. National trends in the mental health care of children, adolescents, and adults by office-based physicians. JAMA Psychiatry 2014;71(1):81–90
- Radojčić MR et al. Trends in antipsychotic prescribing to children and adolescents in England: cohort study using 2000–19 primary care data. Lancet Psychiatry 2023;10(2):119–28
- Jack RH et al. Incidence and prevalence of primary care antidepressant prescribing in children and young people in England, 1998–2017: A population-based cohort study. PLoS Med 2020;17(7):e1003215
- Robinson J. Insomnia: the great melatonin delusion. Pharm J 2022;309(7967)
- Correll C, Carlson H. Endocrine and metabolic adverse effects of psychotropic medications in children and adolescents. J Am Acad Child Adolesc Psychiatry 2006;45:771–91.
