59 Metabolic monitoring of youth prescribed antipsychotics: the evidence gap widensin failing to provide reasonable standard of physical healthcare

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Abstract

Objectives

Prescription of second-generation antipsychotics (also called atypical antipsychotics) in youth and young people is rapidly increasing globally, despite the potential for significant adverse effects (metabolic syndrome, MS) and long-term health consequences. The adverse effects of atypical antipsychotics are more severe in youth and young people than in adults (in particular, obesity and diabetes). They can gain a significant amount of weight after taking antipsychotics even for a short period (weight gain observed within 8–12 weeks). Evidence suggests that screening strategies for MS are not effective and that implementation of guidelines and health policies is falling short of acceptable standards of care as a component of pharmacovigilance. There is significant evidence gap on monitoring strategies among youth and young people. Present research examined these factors through assessment of intervention studies that aimed at improving the rate of metabolic monitoring in this target population.

Method

A systematic review was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) protocol. Studies were identified through Medline/PubMed, EMBASE and CINAHL abstract databases from 2000 to December 2017. Search terms included metabolic monitoring, children, atypical antipsychotics, mental health, diabetes, adherence, barriers and facilitators. Experimental (randomised, quasi-randomised trials); and observational (cross-sectional clinical audits, drug utilisation evaluation studies) studies conducted among youth/young people (10–24 years of age) were included. Key outcome measures were the most and least likely strategies to improve the rate of metabolic monitoring and the barriers to monitoring. The strategies were then ranked based on the Strength of evidence recommendation taxonomy (SORT) ratings.

Results

A total of 7 studies met the inclusion criteria and were analysed. The studies primarily targeted adherence to metabolic monitoring by practitioners. Four studies included patients and/or carers. Barrier analysis identified prescriber related factors affecting poor rate. The common prescriber targeted intervention included behavioural change strategies such as PDSA (plan, do study, act) quality improvement framework, education (e.g. periodic seminars, workshop, drop-in sessions) and reminders (e.g. physical health check reminder card, one page monitoring chart embedded in the patient file). Patient focused strategies were limited to diabetes education and management assessing the feasibility of point-of-care testing for metabolic monitoring of antipsychotics. Consumer related barriers to metabolic monitoring include stigma to undergo monitoring, challenging and vulnerable age group with severe mental illness, troubled family/carers and lack of knowledge to undergo monitoring. A modest improvement in glucose testing monitoring was observed but couldn’t meet the guidelines recommendation.

Conclusions

This is one of the first studies that evaluated intervention studies to improve metabolic monitoring of youth/young people prescribed antipsychotics. The clinical audits targeted prescriber related factors. Patient and health service factors remains understudied. Significant evidence gaps exist on what youth and carers feel about medication reviews including potential regular blood tests, physical examination and remedial action to counter the effects of obesity. Reform of practice and health service monitoring behaviour needs to work in parallel with changes in consumer behaviour. Significant service gap exists in the physical care of mentally ill youth/young people on antipsychotic medication.

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