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

Drugs used to treat psychotic illnesses may take weeks to have an effect. Often, in the interim, additional, 'as required' doses of medication can be used to calm patients in psychiatric wards. 20 to 50% of people on acute psychiatric wards are written up for 'as required' doses of medication. In this situation, a doctor prescribes the frequency and upper limit of dose, and the drug is then given at the discretion of clinical staff.

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

The reviewers searched the Cochrane Schizophrenia Group's register of trials (November 2001). This register is compiled by methodical searches of BIOSIS, CINAHL, Dissertation abstracts, EMBASE, LILACS, MEDLINE, PSYNDEX, PsycINFO, RUSSMED, Sociofile and is supplemented with hand searching of relevant journals and numerous conference proceedings.

Relevant randomised control 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 is in addition to regular psychotropic medication for the long-term treatment of schizophrenia or schizophrenia-like illnesses where prescribed. The primary outcomes of interest were levels of disturbance, severity of psychiatric symptoms, dose of medication, and adverse effects.

Studies were reliably selected, quality rated and data extracted. For dichotomous data, relative risks (RR) would have been estimated, with the 95% confidence intervals (CI). Where possible, the number needed to treat statistic (NNT) was to have been calculated. Analysis would have been by intention-to-treat. Normal continuous data were to have been summated using the weighted mean difference (WMD). Scale data were to have been presented for only those tools which had attained pre-specified levels of quality. Tests of heterogeneity and for publication bias were to have been undertaken.

No randomised trials comparing 'as required' medication regimens to regular regimens of the same drug were identified.

This common current practice has no support from randomised trials. Current practice is based on clinical experience and habit rather than high quality evidence. Current practice, therefore, outside of a well designed, conducted and reported randomised trial, is therefore difficult to justify.