Off-Piste or Just Usual Prescribing in CAMHS? an Audit of Prescriptions and the Guidelines That Support Them

AIMS: The aim of this audit was to review the prescriptions in one community Child and Adolescent Mental Health Service (CAMHS) and to see whether these prescriptions were licenced for the prescribed indication and if the prescription was supported by national guidelines. METHODS: I reviewed the treatment of 77 patients who were assessed by the consultant psychiatrist in one CAMHS team between January 2020 and August 2022. : The name of the medication. The Indication. Child or young person's comorbidities. I then compared this with the licenced use on the Summary Product Characteristics (SPC), as well as the guidance available from (National Institute for Health and Care Excellence (NICE), British Association of Psychopharmacology (BAP) and British National Formulary for Children (BNFc)). RESULTS: In total there were 177 prescriptions for a variety of medication including antidepressants, antipsychotics, sedatives, and medication to treat ADHD. It was found that 25% of all prescriptions were prescribed according to the medication's licensed use, with 42%, 62% and 67% compatible with NICE guidelines, BAP guidelines and BNFc respectively. However, 12% deviated entirely from these guidelines, including prescriptions for mirtazapine (1), melatonin (9), quetiapine (6), risperidone (1) and olanzapine (4). These prescriptions were also associated with increased comorbidity with each child having at least one comorbid mental health problem. There was an 81% agreement between NICE and BAP guidelines, a 75% agreement between NICE and BNFc and 66% agreement between BAP guidelines and BNFc. CONCLUSION: This audit demonstrated that only a quarter of prescriptions were prescribed according to a licenced use, with the vast majority falling outside the product licence. This is important because the Joint Standing Committee on Medicines preference “an appropriate licenced preparation” over unlicenced prescribing. Furthermore, the defensibility of unlicenced prescriptions is increased when they are supported by published clinical guidelines which was the case in 88% of prescriptions that were reviewed. This leaves 12% of prescriptions that were not supported by either licencing or BAP, NICE or BNFc guidelines. There may be multiple causes for this, but it is likely that the high number is aggravated by the lack of NICE guidelines for common conditions such as anxiety as well as high levels of comorbidity in this population group which is not always reflected in clinical trials and guidelines.