A23 23..23

Two papers in the Journal this month examine patterns of prescribing practice. With established clinical guidelines for the management of individuals with treatment-resistant schizophrenia in mind, Howes et al (pp. 481–485) reviewed prescribing practices prior to commencement of clozapine for a sample of patients managed within one mental health service. The authors found evidence of a significant theoretical delay in initiation (mean 47.7 months). Antipsychotic polypharmacy and high-dose antipsychotic treatment were also identified as common in the pre-initiation period. In a linked editorial, Patel (pp. 425–427) argues that clinician hesitation to commence clozapine when indicated for those with treatment-resistant schizophrenia is often driven more by clinicians’ knowledge, attitudes and preferences than by good clinical reasoning. Of relevance to discussions about a need to change prescribing practices in the light of evidencebased clinical guidelines, the quality improvement programmes (QIPs) initiated by the UK Prescribing Observatory for Mental Health (POMH-UK), have thus far focused primarily on areas of practice related to antipsychotic prescribing (e.g. metabolic monitoring, polypharmacy). Evidence that positive change in clinical practice can be achieved as a result of such programmes is emerging but, as Barnes & Paton argue (pp. 428–429), progress is gradual, variable and moderate. On the basis of concern about individuals with mental illness receiving inferior treatment for physical conditions, Mitchell et al (pp. 435–443) conducted a meta-analysis focusing on prescribing practices. The authors found evidence that patients with severe mental illness were more likely to be prescribed lower quantities of several common medications for the treatment of physical conditions, particularly cardiovascular ill health or risk. The authors call for research focused on understanding patient and provider influences on received medication and a greater focus, both at a clinician and clinical organisational level, on optimising treatment of physical health comorbidities for those with mental illness. Mental health service capacity and treatment outcomes in LAMI settings