Editorial

Psychiatry is possibly unique in modern medicine because prescribing practice for mental health conditions can often be said to be unsupported by robust data. This is rather kindly referred to as the ‘art’ of the practice of psychiatry: the triumph of clinical experience, or more often desperation, over evidence-based medicine. With antipsychotic prescribing, high-dose treatment and polypharmacy continue to be used despite a near absence of supporting literature. A handful of studies have attempted to improve prescribing practice in this area but few have succeeded. In this issue, my colleague, Shubhra Mace, and I describe a six-year programme of quality improvement aimed at reducing rates of non-evidence-based antipsychotic prescribing. Rates of antipsychotic polypharmacy and high dose prescribing were substantially and incrementally reduced over the audit period, against a background of little or no change at a national (UK) level. This important and sustained change was largely achieved by gaining agreement from all parties on the nonuse of antipsychotics as PRN (as required) medication; yet another prescribing practice without evidential support.

The futility of piling dopamine antagonist upon dopamine antagonist is ably, if indirectly, expounded by Hannah Steeds and her colleagues in their review of drug models of schizophrenia. In this piece, they show that the simple amphetamine/dopamine model is inadequate on a number of levels; not least that amphetamine-induced psychosis only partly mimics the spectrum of symptoms seen in schizophrenia. Other drug models (phencyclidine, ketamine, LSD, THC) are also individually inadequate but each in a different manner. What unites all of the receptor theories based on these drug models is, the authors contend, a shared effect on central glutamatergic function. This perhaps suggests that we have not such much been barking up the wrong tree as barking up only one branch of the right tree.

Dopamine antagonists are also used in bipolar disorder, of course, and quetiapine, a rather loose dopamine antagonist shows efficacy in all aspects of the condition: Andreas Carlbourg and coworkers describe their analysis of the use of two formulations of quetiapine (immediate release (IR) and extended release (XR)) in bipolar patients in Sweden. They showed that patients switched from IR to XR quetiapine had a higher degree of psychiatric co-morbidity and received higher daily doses of XR quetiapine (possibly reflecting better tolerability).

Jimmi Nielsen and colleagues report on another common outcome of antipsychotic use: prolongation of the cardiac QT interval. Sertindole is one of three antipsychotics (along with droperidol and thioridazine) to have been withdrawn or restricted because of QT problems. In this study, the authors confirm previous findings of substantial prolongation of QT but also of ratio of QT variability to heart rate variability: both findings reaffirming the cardiac toxicity of the drug.

Given the association between antipsychotics and other psychotropics with QT prolongation and other physical effects one might think that physical health monitoring would be a priority for people with severe mental illness. Not so; according to a survey of a mood disorders service in Southern England reported by David Baldwin and colleagues. Their study of 113 patients found that fewer than 5% of patients had even had their weight measured in the previous 12 months and less than a third had received physical monitoring of any sort.

Aripiprazole is one of a very few antipsychotics with no effect on QT interval and limited metabolic adverse effects. Like many other antipsychotics, it has other therapeutic uses. Saeed Shafti and Hamid Kaviani examined adjunctive aripiprazole or quetiapine in obsessive compulsive disorder. Response was seen with both drugs but quetiapine was clearly superior.

We also have two interesting case studies in this issue. Burton and Vanessa Tabaac describe an unusual case of pica (cardboard and paper) which responded completely to asenapine. Öncu and coworkers report on a case of methylphenidate-induced ejaculation. Their discussion of possible mechanisms and therapeutic uses is well worth a read, as, of course, are all the other papers in this issue.