Psychotropic medication in inpatient mental health care for young people | Nursing Times

Introduction

In parallel with the increased prevalence of mental health problems reported by children and young people in England (NHS Digital, 2022), there has been an increase in the prescribing of psychotropic medications. These include medications such as antipsychotics, antidepressants, sedatives and hypnotics (Radojčić et al, 2023; Robinson, 2022; Jack et al, 2020). Much of the concern about this increase has focused on side-effects and whether such prescribing in younger people will have long-term effects on the developing brain. Weight gain with second-generation antipsychotics is thought to be greater, and the benefits less, in children and adolescents with psychosis than in adults (Stafford et al, 2015).

Solmi et al (2020) reviewed the relative efficacy and side-effects from randomised controlled trials of a wide range of psychotropic medications prescribed for children and young people and raised concerns about nausea/vomiting and discontinuation due to adverse events associated with antidepressants; sedation, extrapyramidal side-effects and weight gain with antipsychotics; anorexia and insomnia with anti- attention deficit hyperactivity disorder medications; and sedation and weight gain with mood stabilisers.

The prescribing of psychotropic medications for children and young people admitted to mental health wards or units has been poorly studied and guidance limited. The primary aim of this improvement programme was to enable inpatient units to receive information about their use of psychotropic medication benchmarked against other similar units, and to hear the views of both children and young people resident in the units and their parent carers.

Many of these units are small – typically 10-12 beds, with just 3-4 beds for high-intensity units – and in diverse locations. This improvement programme gave them an opportunity to compare their prescribing and practices with their peers in other parts of England.

Method

Three online tools were developed, in collaboration with a range of stakeholders. First was a medication census tool, so that provider clinicians could capture prescribing practices around psychotropic medication. The two other tools were questionnaires so that children and young people who were residents of the units, and their parent carers, could express their views. Censuses were completed on an agreed day in September 2022 and the questionnaires completed during the period of September/October 2022. Providers then received feedback about their prescribing benchmarked against other similar providers, as well as the overall results and findings.

“It is important for nurses to question the use of medication”

Results

Following a recruitment drive, 48 of the 63 providers of children and young people’s inpatient services known to NHS England (76%) signed up to participate. These providers were both from the NHS and the independent sector. Details of the psychotropic medication prescribed for 625 children and young people staying in 73 mental health units were recorded on one day in September 2022, and questionnaires from 142 children and young people and 75 parent carers were then submitted.

The main themes identified from the census were:

• Widespread prescribing of psychotropic medications – 545 (87%) of the 625 inpatients were receiving some kind of psychotropic medication. The most widely prescribed were:
  • Antihistamines and benzodiazepines as sedatives (65% of patients);
  • Antipsychotics (62%);
  • Antidepressants (54%);
  • Hypnotics (27%);
• Large variation of prescribing across similar units, both in the extent of prescribing of psychotropic medications and the administration of pro re nata (PRN) medications;
• Psychotropic medication polypharmacy – 57% were prescribed two or more regular psychotropic medications. Including PRN medications, that figure rose to 76%;
• Perceived little or no scope to reduce the load of psychotropic medications;
• The most widely prescribed and administered PRN medications were benzodiazepines and antihistamines as anxiolytics/sedatives (65%).
• Less often prescribed PRN were antipsychotics (10%) and hypnotics (8%);
• Antihistamines and benzodiazepines administered PRN during the two-week period before the census were used either for general management of behaviour or for rapid tranquillisation. Four units administered more than 60 PRN medication doses during the two-week period, while nine units administered none.

The main themes identified from the questionnaires were:

• Most children, young people, parents and carers said they were given information about medication from one or more source; 47% of the responses indicated that the source was the doctor or nurse, while 22% said they received information either directly from staff or via leaflets. Only 3% stated that they received no information:
• Most also said that they had someone to talk to if they had any questions;
• Nearly half of the children and young people found the provision of information about medication useful and the reasons for prescribing clear;
• There were mixed views about the value of the medications prescribed from both the children and young people and their parents and carers (Table 1);
• When asked to provide additional information about the use of psychotropic medications, both children and young people and their parent carers expressed concerns about weight gain, tiredness and disconnection from their environment; the potential long-term adverse effects on health, growth and development; and PRN medications.

Discussion

The findings of this programme demonstrated the extent of prescribing and the polypharmacy of psychotropic medication, both on a regular and PRN basis. It is important for nurses, particularly those working in the community who know their young people, to question the use of medication in the inpatient multidisciplinary team setting and to work closely with the medical team and specialist mental health pharmacist, if available, to ensure that medication use is necessary and appropriate.

The case study in Box 1 illustrates the need for good liaison about patients between teams and the importance of the local team maintaining oversight of the prescribing of medication.

This case study supports the recommendations made by James (2010), whose review proposed that the use of antipsychotics alongside psychosocial interventions can be recommended in certain disorders, provided there is careful monitoring. James recommended that antipsychotics should only be used as part of a comprehensive treatment plan, which involves psychoeducation, and consideration of psychological and psychosocial interventions.

A second key area of concern to nurses is the use of additional PRN doses and whether this amounts to a restrictive practice. The prescribing of psychotropic medications may be considered when looking to respond to the needs of children and young people who present with behaviours of concern. However, if medication is included in the management of such behaviours, then should it be considered as a form of restrictive practice? In this context it would be referenced as a form of chemical restraint.

The prescribing of medications as a response to behaviours of concern must be rights-respecting, and consideration must be given to children and young people’s rights under the Human Rights Act 1998. The application of a human rights-based approach can assist practitioners in their decision making by ensuring that they consider their legal, ethical and professional duties to the individual, including whether there is a need for a restrictive practice. It also gives them the opportunity to be clear around why such a practice is to be used, and the chance to establish whether a less restrictive approach can be chosen (Ridley and Hopes, 2022). Whatever the situation is, restrictive practices should never be used without a clear focus on preserving the person’s human rights, balancing risks and benefits, as well as preventing injury and harm for all involved (Health Information and Quality Authority, 2017).

According to the Restraint Reduction Network Training Standards (Ridley and Leitch, 2021), chemical restraint is defined as the involvement of medication, which is intended to restrict someone’s movement; this could be a regular prescribed medication or those which are prescribed PRN. The Mental Health Act 1983: Code of Practice (Department of Health (DH), 2015) specifies that where a restrictive practice is used, it should only be used for no longer than is necessary to prevent harm to the person or to others, it must be proportionate to the risk of harm presented, and it should be the least restrictive option.

Establishing whether a psychotropic PRN medication is needed, and what the level of risk may be to support a least-restrictive approach, must be supported by an assessment of the needs of the individual. The use of PRN medication should be considered proactively as part of planned therapeutic interventions that is in the best interest of the individual. Even where a form of restrictive practice such as psychotropic medication may be considered supportive and appropriate, it should continue to be reviewed with a view to ensuring that alternative approaches are considered and adopted, when possible.

Pereira and Walker (2024) propose many alternative strategies to managing aggression in mental health facilities. These include activity and engagement programmes, trained staff using verbal de-escalation techniques, time off the ward, providing one-to-one time, social interventions and environmental modifications. However, they restate the need to prioritise the least restrictive interventions to avoid possible consequences.

A third key area relevant to nurses arising from questionnaire responses was the availability of information about the medications prescribed.

The results lead us to consider better ways to share information about psychotropic medication and planned prescribing – including their use of and how best to provide opportunities for each child, young person and their parent or carer to ask questions, weigh up benefits and risks, and express their views and concerns in ways that are responsive to their needs.

Although the Mental Capacity Act 2005 does not apply to children under the age of 16, children have rights under the United Nations Convention on the Rights of the Child 1989, the Human Rights Act 1998, and the Children Act 1989 to be meaningfully involved in decision making and consent processes regarding their own healthcare needs, while being provided with appropriate information to aid their involvement. Children have more specific rights under the Mental Health Act 1983 and its Code of Practice (DH, 2015) relating to the necessity of understanding the rationale for treatment, including pharmacological intervention for their mental health disorder.

A question has to be raised about how much information a child and/or parent is provided with, so that they can make an informed decision. For example, should known long-term possible side-effects of antipsychotic medications be discussed with the child and/or parent, explaining that there is an increasing likelihood of metabolic disorder the longer the child is taking such medication (Ijaz et al, 2018)? Or should advice be given to children and parents about the off-label and unlicensed use of psychotropic medications (Royal Pharmaceutical Society (RPS), 2021), as most prescribing of psychotropic medication for children is both off label and unlicensed? There are no standards that determine the depth of information provided about prescribing psychotropic medications, which likely makes this intervention inconsistent at best. While the RPS (2021) advised that information is shared, the Nursing and Midwifery Council’s Standards of Proficiency for Nurse and Midwife Prescribers (2006) state, in section 18.1 c: “You should explain to the patient/client, or parent/carer, in broad terms, the reasons why medicines are not licensed for their proposed use”. Particularly when the rationale for prescribing for children with autism, the information shared with the child and/or parents needs to be clear.

When considering the prescribing of psychotropic medication, the child and parent should be involved in any decision about it to their fullest ability. This may mean, for some children, that they are able to consent to treatment. For others, this may mean they are able to contribute to the decision making but will not be able to consent to treatment and thus, the decision is consented to by parental consent, a best interests assessment or by the responsible clinician and second opinion approved doctor if the young person is detained under the Mental Health Act 1983.

The Mental Health Act: Code of Practice (DH, 2015) highlights the benefits of the use of independent mental health advocates and how they can support the child to understand the information provided about the medication. The code further demands that information needs to be provided to the child about the mental disorder they have and why the particular treatment option is appropriate, and how and when a second opinion approved doctor may be used.

Responsibility for ensuring the child has the right information in a way that is appropriate for their stage of development, in different forms, such as written and verbal, lies with the professionals caring for the child. While the child has a legal right to be involved in the decision-making and consent processes, including the parent is equally important where possible and appropriate, to reduce the risk of rupture in the care process (Cox, 2021) and ensure the parental rights are upheld under the Children Act 1989.

Spending time with the child and ensuring the relevant information is provided to support their knowledge around medication choice will ensure that the legal duties are upheld by professionals under the Mental Health Act 1983 and the Code of Practice (DH, 2015). It will also develop the child’s competence and understanding about psychotropic medication.

ISupport’s Rights-based standards for children having health care tests, treatments, examinations or interventions (ISupport, no date) are an internationally developed set of standards underpinned by the United Nations Convention on the Rights of the Child 1989 and are a helpful tool for all nurses and organisations, which ensure that children’s rights are upheld in healthcare settings, particularly around how children can be provided with information about medication in the right way for them. The standards support nurses eliciting children’s views and wishes about how they would like to be treated and how information should be provided for them. These standards are already being used in eating disorder guidance in the UK (NHS Elect, 2025). The increase in their use across mental health care settings will help ensure children receive the appropriate information to be involved meaningfully in their healthcare.

Conclusion

This improvement programme highlighted the widespread prescribing of psychotropic medications, multiple psychotropic medication prescribing, and the need for regular review. These results raise concerns about whether such prescribing is excessive and inappropriate for children and young people in inpatient mental health settings. Nurses involved in this area need to take a key role in ensuring that only those medications that provide benefit to the young person are used and continued, and that both the young person and their parents/carers are well informed about the medication prescribed and enabled to participate and give consent in decision making.