National standard for mindful prescribing of psychotropics

The new standard sets out how these medications should be used for all patients with cognitive disability and impairment.

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A new standard has been released nationally that aims to curb the inappropriate use and overprescribing of psychotropic medicines for managing the behaviour of children and adults with cognitive disability or impairment.

The Australian Commission on Safety and Quality in Health Care has designed the standard to encourage mindful prescribing of psychotropic medicines for these groups of people.

The standard contains eight quality statements that focus on specific areas of care where improvements will lead to better outcomes for people with cognitive disability or impairment. Three quality statements focus on appropriate assessment and the effective use of non-medication strategies and behaviour support plans when responding to behaviours of concern, while the remaining statements focus on person-centred care, informed consent, appropriate use of psychotropic medicines and effective communication at transitions of care.

The standard applies to all healthcare services provided to people of all ages with cognitive disability or impairment and is relevant in any setting where they receive care, including hospitals, aged care facilities and the community.

Psychotropic medicines include antipsychotics, antidepressants and anxiolytics.

The Commission’s chief medical officer, Conjoint Associate Professor Carolyn Hullick, told TMR it was important to be aware that this standard was not designed for all people taking psychotropic medications.

“This clinical care standard is only for people with cognitive disability or cognitive impairment,” she said.

“A lot of people have mental health conditions who are on psychotropic medications, medicines that are really important for them to take. This standard doesn’t cover people just with mental health illnesses.

“They are [psychotropic medicines] important drugs. And we don’t also want to send out a message that everyone should be stopping all these medications, and they shouldn’t be taken.

“We want to be supporting messages around safe and appropriate use of psychotropic medicines.”

Professor Hullick, who is also an emergency physician in Hunter New England Health NSW said the standard was a long-overdue recognition of the rights of people with cognitive impairment to safe and effective treatment options.

She said there was a role for psychotropic medicine use in people with cognitive disability or impairment, but this should be part of a behaviour support plan which also considered non-pharmacological interventions and other strategies.

GPs played a key role in identifying medical causes for a problem that might be helped by medication, especially in known patients where behaviours have changed suddenly or significantly, she said.

Patients should also be appropriately informed as part of any decisions around the use of medication or other behaviour interventions, along with carers, families and other health professionals involved with their care, including aged care facilities.

Any prescribing should include a plan for deprescribing, rather than a plan just to put a person on a psychotropic and leave them on it.

“We should be using it as a drug of last resort,” Professor Hullick told TMR.

“We’re not using it because there are not enough staff or difficult behaviours, but because we’ve actually gone through all the other things before we got to them [medication use].”

The commission revealed that Australia has seen a 60% rise in use of psychotropic medicines during the past 30 years.

While an increased awareness of the risks associated with using these medicines has led to a slight decline in antipsychotic prescriptions among older Australians, significant challenges persist.

According to the Commission, older people were particularly susceptible to adverse effects from psychotropic medicines, including worsening cognition and an increased risk of falls, stroke, and death.

In Australia, aged care residents had a 22% higher risk of death in the first 100 days when antipsychotics were prescribed. Around a third of people with intellectual disability are prescribed psychotropic medicines and also exposed to potential short and long-term adverse effects.

While psychotropic medicines play an important role in treating mental health conditions, they are also commonly used to manage behaviours of concern experienced by people with cognitive disability or impairment. This was despite the known harms of these medicines and the lack of evidence that they were effective for managing behaviours, which may include aggression, agitation, and sometimes self-harm.

The Royal Commission into Aged Care Quality and Safety and the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability revealed concerning trends in psychotropic medicines misuse and overuse in the aged care and disability sectors.

Professor Julian Trollor, director of the National Centre of Excellence in Intellectual Disability at the UNSW Sydney, advocated for greater support for prescribing practices for people with intellectual disability.

“When prescribing these medicines, it’s essential to have clear objectives and ways to measure their impact, including by collaborating with behaviour support practitioners to ensure that your prescribing has the intended response,” he said.

Geriatrician Professor Eddy Strivens, Clinical Director at the Cairns and Hinterland Hospital and Health Service, emphasised the need for coordinated efforts.

“This is a supportive standard for prescribers and clinicians. It provides practical information, encourages sharing information across care settings, and will help ensure that these agents are used least and last, rather than first and foremost,” he said.

The standard follows a joint statement released in March 2022 by the Commission, the Aged Care Quality and Safety Commission and the National Disability Insurance Scheme Quality and Safeguards Commission on the inappropriate use of psychotropic medicines to manage behaviours of concern in people with disability and older people. This statement highlighted the detrimental impact of the inappropriate use of psychotropic medicines in these groups of people.

The Psychotropic Medicines in Cognitive Disability or Impairment Clinical Care Standard and resources are available here.