Audit of Antimanic Agents Monitoring in a High Secure Hospital

AIMS: Antimanic agents are effective in the management of mood disorders and other neuropsychiatric conditions such as epilepsy and aggression. These medications may cause serious side-effects and affect vital organs; hence, specific checks are recommended before initiation and for continuous use of these medications. The aim of the audit was to check compliance with monitoring of antimanic agents (lithium, valproate, and carbamazepine) and to compare with the 2018 audit. METHODS: Preliminary data of all patients on the antimanic agents at Rampton Hospital from 01 December 2020 to 30 November 2021 were obtained from records. Retrospective data were collected using a modified version of the 2018 audit tool. This includes patient hospital number, ward, medication initiation date, pre-initiation and monitoring tests. The tests were, depending on the medication; full blood count (FBC), thyroid function test (TFT), liver function test (LFT), electrolytes and urea (E&U), and electrocardiograph (ECG). The audit criteria were based on the recommendation of the Maudsley Prescribing Guidelines (14th edition). A total of 16 standards were assessed overall. RESULTS: A total of 98 patients were prescribed antimanic medications through the review period with valproate-59, lithium -32 and carbamazepine -7. Three patients on valproate and 3 on lithium had incomplete data and were excluded. Therefore, a total of 92 patients were included in the final audit (valproate-56, lithium-29 and carbamazepine-7). Pre-initiation compliance for LFT and FBC for valproate were 35.8% and 41.5% respectively, while the monitoring compliance within 6 months were 85.7% and 87.5% respectively. For lithium, pre -initiation compliance for ECG was 73.1%; TFT and U&E had 88.5% and 96.2% pre-initiation compliance respectively. There was 100% compliance with monitoring of lithium level at 3 months, and both U&E and TFT within 6 months. For carbamazepine, the pre-initiation and monitoring compliance was 50% and 100% respectively for three tests (LFT, FBC and U&E). There was improvement in all the standards when compared with the 2018 audit compliance except FBC monitoring for valproate within 6 months which dropped from 92% to 87.5%. CONCLUSION: Only 6 standards had 100% compliance with the guidelines. Lithium monitoring was generally higher than for other mood stabilizers; pre-initiation monitoring was poor for both carbamazepine and valproate. There was general improvement in the standards compared with the 2018 audit. The guidelines for monitoring mood stabilizers apart from lithium needs to be made popular especially pre-initiation monitoring for valproate and carbamazepine.