The purpose of this review was to establish whether the prescription of antipsychotic medication in HMP Low Newton was safe, rational and consistent with current best practice. A search of the electronic healthcare records was performed on 14 March 2018 to identify all the women in the prison who were prescribed antipsychotic medication, and then data were collected from the records.

A total of 46 out of 336 prisoners (13.7%) had been prescribed antipsychotic medications; 29 of the 46 patients (84.8%) were also prescribed other psychotropic medications at the same time. Quetiapine was the most frequently prescribed antipsychotic and was also the most likely to be prescribed for off-label indications. Less than one-third of all antipsychotic prescriptions were for psychotic disorders.

The rationale for prescribing all antipsychotic medication, especially for off-label indications, should be clearly documented and reviewed regularly within the prison by the mental health team and psychiatrist.

Off-label ketamine treatment has shown acute antidepressant effects that offer hope for patients with therapy-resistant depression. However, its potential for integration into treatment algorithms is controversial, not least because the evidence base for maintenance treatment with repeated ketamine administration is currently weak. Ketamine is also a drug of misuse, which has raised concerns regarding the target population. Little is known about which patients would seek ketamine treatment if it were more widely available.

To explore some of the characteristics of the patients actively seeking ketamine treatment.

An online survey containing questions about duration of current depressive episode, number of antidepressants used and other comments was completed by patients who were exploring the internet regarding the possibility of ketamine for depression.

Of the 1088 people who registered their interest, 93.3% reported depression, 64.3% reported a chronic course of their symptoms and in the past 10 years, 86.3% had tried at least two antidepressants. Desperation was a common theme, but this appeared to be competently expressed. A small minority (<8%) reported experience of illegal ketamine use.

It cannot be ruled out that patients with different degrees of treatment resistance and comorbidities will seek treatment with ketamine. This stresses the urgency to perform larger randomised controlled trials as well as to systematically monitor outcomes and adverse effects of ketamine, that is currently prescribed off-label for patients in need.

R.M. is consulting and is Principal Investigator for Janssen trials of esketamine and is consulting for Eleusis.