'As required' medication for seriously mentally ill people in hospital

Review question

This review attempts to find evidence to find out whether the use of 'as required' medication is good clinical practice or not, when compared to the same drug given regularly, for people with schizophrenia who are in hospital. Searches for randomised trials investigating this question have been run by the Cochrane Schizophrenia Group in 2001, 2006, 2012 and 2013.

Background

Schizophrenia is a serious mental illness. People with schizophrenia often hear voices and see things (hallucinations) and have strange beliefs (delusions) that can be upsetting or frightening, or both. These symptoms of schizophrenia can cause agitation, aggression and distress. The main treatment for schizophrenia is antipsychotic drugs. However, these drugs usually take several weeks to work. In the meantime, for people in distress in hospital, other additional medication can be given when needed (if clinicians think it is appropriate), until regular antipsychotics start to work. This 'as required' medication is often used to help people feel less anxious and to reduce disturbed behaviour. 'As required' medication is usually written on the drug chart by the clinician so that nurses can administer it at their discretion and in the doctor's absence. Although there are many advantages to this practice, there are also potential disadvantages. For example, it may cause difficulty in knowing which medication (the prescribed medication or the 'as required' medication) has been effective and staff on the ward might use this additional medication too readily for individuals who are upset, rather than spending time with them or considering other approaches.

Study characteristics

The search only found trials that compared two different drugs, both of which were used 'as required'. The review authors found no trials that compared only giving additional medication when needed with regular doses of the same medication.

Key results

The review authors found no trials that could be included in the review. Although the practice of using medication 'as required' is common, there is currently no good evidence as to whether this is the best way of helping people when compared to them being given a regular dose of the same medication.

Quality of the evidence

The review authors found no trials that compared 'as required' with regular medication. 'As required' medication, though used widely, has not been evaluated scientifically. A well designed, conducted and reported randomised trial would help to gather more evidence.

Ben Gray, Senior Peer Researcher, McPin Foundation, http://mcpin.org/ (for the previous 'Plain language summary' please see Appendix 3).

Authors' conclusions: 

There is currently no evidence from within randomised trials to support this common practice. Current practice is based on clinical experience and habit rather than high quality evidence.

Read the full abstract...
Background: 

Drugs used to treat psychotic illnesses may take weeks to be effective. In the interim, additional 'as required' doses of medication can be used to calm patients in psychiatric wards. The practice is widespread, with 20% to 50% of people on acute psychiatric wards receiving at least one 'as required' dose of psychotropic medication during their admission.

Objectives: 

To compare the effects of 'as required' medication regimens with regular patterns of medication for the treatment of psychotic symptoms or behavioural disturbance, thought to be secondary to psychotic illness. These regimens may be given alone or in addition to any regular psychotropic medication for the long-term treatment of schizophrenia or schizophrenia-like illnesses.

Search strategy: 

We searched the Cochrane Schizophrenia Group's Trials Register, which is based on regular searches of MEDLINE, EMBASE, PubMed, CINAHL, BIOSIS, AMED, PsycINFO and registries of clinical trials, in November 2001, March 2006, July 2012 andOctober 2013.

Selection criteria: 

We aimed to include all relevant randomised controlled trials involving hospital inpatients with schizophrenia or schizophrenia-like illnesses, comparing any regimen of medication administered for the short-term relief of behavioural disturbance, or psychotic symptoms, to be given at the discretion of ward staff ('as required', 'prn') with fixed non-discretionary patterns of drug administration of the same drug(s). This was in addition to regular psychotropic medication for the long-term treatment of schizophrenia or schizophrenia-like illnesses where prescribed.

Data collection and analysis: 

We independently inspected abstracts and papers for inclusion. If trials had been found, we would have extracted data from the papers and quality assessed the data. For dichotomous data we would have calculated the risk ratios (RR), with the 95% confidence intervals (CI). We would have conducted analyses on an intention-to-treat basis. If data were available we would have completed a 'Summary of findings' table using GRADE.

Main results: 

We have not been able to identify any randomised trials comparing 'as required' medication regimens to regular regimens of the same drug. Our main outcomes of interest were important changes in (i) mental state, (ii) behaviour, (iii) dose of medication used, (iv) adverse events, (v) satisfaction with care and (iv) cost of care.

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