Australian and New Zealand Journal of Mental Health Nursing (2000) 9, 166–176

INTRODUCTION

The aim of this paper is to describe how theLiverpool University Neuroleptic Side-Effect

Rating Scale (LUNSERS) was used as part of a recently completed research study designed to enhance case managers’ skills in the assess-ment of antipsychotic medication side-effects.The emphasis here is on the potential use of thescale in clinical practice for assessing and moni-toring clients who are prescribed antipsychotic medication.

BACKGROUND

Neuroleptic medications continue to dominatethe list of options available for the treatment ofschizophrenia and other psychotic disorders. Anumber of recent studies have demonstrated the

FEATURE ARTICLE

The use of the Liverpool University neuroleptic side-effect rating scale(LUNSERS) in clinical practice

Correspondence: Paul Morrison, School of Nursing,University of Canberra, ACT 2601, Australia.Email: paul.morrison@canberra.edu.au

Paul Morrison, BA(Hons), PhD, RMN, RGN, PGCE,AFBPsS, CPsychol, MAPS.

Deanne Gaskill, RN, BAppSc, GradDipHSc, MAppSc. Tom Meehan, RN, BHlthSc, MPH, MSocSc, GDip(Data

Analysis), FANZCMHN. Paul Lunney, BDSc(Hons), GradDipAppFin, MBA. Gayle Lawrence, RPN, RN, BHSc(Nurs). Paul Collings, BA(Hons), PhD.Accepted May 2000.

Paul Morrison,1 Deanne Gaskill,2 Tom Meehan,2 Paul Lunney,2 GayleLawrence2 and Paul Collings2

1School of Nursing, University of Canberra, ACT 2601 and 2Centre for Nursing Research,Queensland University of Technology, Kelvin Grove Campus, Brisbane, Qld 4509, Australia

ABSTRACT: Forty-four mental health clients completed the Liverpool UniversityNeuroleptic Side-Effect Rating Scale (LUNSERS)—a self-rating scale to assess theprevalence and intensity of neuroleptic side-effects. In the month prior to the study,50% of the clients surveyed had experienced more than half of the side-effects outlinedon the 41-item scale. A prevalence profile allowed us to rank the frequency of individual side-effects across the sample. Some side-effects such as ‘difficulty con-centrating’, ‘difficulty remembering’, ‘tiredness’ and ‘restlessness’ were experiencedby most of the clients in the study while ‘unusual skin marks’, ‘difficulty passingwater’, ‘rashes’ were experienced by a few. A prevalence profile may be a useful guidein developing strategies for managing side-effects more effectively in small groupsof clients. In addition, the use of the LUNSERS in clinical practice would enablecase managers to establish baseline measures for individual clients and evaluatechanges in medication and other non-medical strategies for reducing unwanted side-effects. The identification and assessment of antipsychotic side-effects is animportant area for client and professional carer education.

KEY WORDS: antipsychotic medication, case manager, LUNSERS, side-effects.

role of antipsychotic medications in producingbetter outcomes for people with psychotic illness(Chen, 1991; Hirsch et al., 1996). While Chen(1991) noted the importance of psychosocial andvocational rehabilitation, case management andsupportive therapy in the care of seriouslymentally ill people, he highlighted the impor-tance of pharmacotherapy as the ‘mainstay’ oftreatment.

In a recent study into schizophrenic relapse,Hirsch et al. (1996, p. 49) found that ‘patientswho continued on regular medication had 80%less risk of relapse than those who had been with-drawn from medication either by choice or underdouble-blind controlled [research] conditions’.Compliance with medication following dischargefrom hospital in patients suffering from schizo-phrenia or bipolar affective disorder was alsofound to be ‘correlated significantly with longerstays in the community’ (Fernando, Velamoor,Cooper & Cernovsky, 1990, p. 72).

However, it is now clear that antipsychoticmedications can also produce a range of adverseeffects which impact on the patients’ quality oflife (Keks, 1996). For a number of patients theseadverse reactions and side-effects can cause evengreater levels of distress than the symptoms ofthe illness (Finn, Bailey, Schultz & Faber, 1990).Thus, the side-effects of antipsychotic medica-tion have been identified as a major determinantof non-compliance in many studies (see forexample: Brown, Wright & Christensen, 1987;Clary, Dever & Schweizer, 1992; Del Compo,Carr & Correa, 1983; Myers, & Calvert, 1973).In addition, several studies have exploredpatients’ reasons for non-compliance, and theside-effects of antipsychotic medication emergedas an important and recurring theme (David-hizar, 1985; Lund & Frank, 1991; Schwarz,Vingrano & Bezirgowan, 1988).

Prevalence of side-effectsRogers, Pilgrim and Lacey (1993) noted persis-tent side-effects with major tranquilizers in 73%of a sample of people with mental illness(n = 367). A majority (61.7%) of respondentsreported these side-effects as severe to verysevere (n = 313). Mitchell and Popkin (1982)

suggested that many side-effects of medicationsmay go unnoticed because patients do not reportthem and staff do not ask about the problemspatients experience. They also claimed thatwhen information is sought, patients frequentlyraise such problems. Keks (1996, p. 23) notedthat: ‘historically, clinicians have been guilty ofunder-emphasizing the side-effects of anti-psychotic medication’. It is clear, however, thateffective management of the side-effects ofantipsychotic medication is a vitally importantfacet of quality nursing care and good casemanagement. It has unfortunately been aneglected area of care.

Consequences of medication side-effectsAnti-psychotic drugs have a wide range of side-effects that may be debilitating and occasionallyfatal (Abbott & Loizou, 1986; Kellam, 1987;Warner, 1994). Moreover, the side-effects of anti-psychotic medication can impinge on the clients’sociability and relationships (Michaels & Mum-ford, 1989). In contrast, those clients reportingfewer medication side-effects often report a betterquality of life (Sullivan, Wells & Leake, 1992).

Some side-effects, such as postural hypo-tension, can cause serious injury through falls,especially in elderly patients. The majority areunpleasant, physically and/or socially disfiguring,frightening and emotionally damaging (Littrell,1996). While other side-effects, such as weightgain, may be underestimated as a cause of emo-tional distress and the management of weightgain has been identified as an important deter-minant of compliance (Wade & Weir, 1995).

Hindmarch (1994, p. 306) pointed out that ‘aswell as the physical toxicity and sometimes life-threatening adverse events it is also necessary toinvestigate behavioural toxicity if the completeimpact of a neuroleptic on an ambulant patientis to be assessed’. He cites aspects of safety(sedation, cognitive impairment, motor retarda-tion, the risk of induced accidents) and ofcounter-therapeutic effects (feeling of beingdrugged, memory problems, etc.). There is someevidence to suggest that the presence of side-effects may aggravate the original mental illness,or even give rise to an additional one:

ASSESSMENT OF ANTIPSYCHOTIC MEDICATION SIDE-EFFECTS 167

Although the relationship between akinesia anddepression remains incompletely understood,the possibility of an association should lead it tobe considered as a potential toxic drugeffect…Akathisia has been associated withdramatic exacerbations of psychosis and inextreme cases it appears to have triggered orcaused suicide and homicide’ (Gardiner-Caldwell Communications Ltd, 1993, pp.20–21).

It has been suggested that the side-effects ofantipsychotic medication, may affect a person’sbiological, psychological, sexual and social func-tioning, and may be a major factor in non-compliance (Hogan et al., 1983). Bebbington(1995) noted that non-compliance may occur in50% of patients with schizophrenia on neuro-leptics and even more frequently in youngerpeople. In contrast, a study by Bunn, O’Connor,Tansey, Jones and Stinson (1997) found a highlevel of compliance among people who hadschizophrenia for a long time. Green (1988)claimed that non-compliance with medicationwas a critical factor in 92% of multiple admissionsstudied. Donovan and Blake (1992) argued thatnon-compliance may be seen as a very rationalaction from the patient’s viewpoint, hence it isimportant for the professional helpers to reallyunderstand the patients’ experiences. The cost ofnon-compliance to sufferers, their relatives andsociety is immense (Bebbington, 1995).

While the literature indicates a growingconcern with the problems associated with side-effects, most attempts to improve the situationhave focused on providing other medications toreduce particular side-effects, altering the med-ication dose or changing to another medication.These strategies are contingent upon the abilityof those staff who have routine contact with consumers, to accurately identify side-effectsand to report these within a multidisciplinaryframework. In addition, when disabling side-effects are identified, the management emphasistends to be on medication with little or noemphasis on the potential of non-medical strate-gies for managing side-effects. However, theassessment problem is primary and is discussednext.

Assessment of side-effectsIt is clear that the pharmacological control of psy-chotic symptoms includes the identification andmanagement of adverse reactions. A smallnumber of studies have explored how nurses andcase managers assess clients for side-effects andfound that community nurses did not assessclients in a systematic manner and typically iden-tified only three or four side-effects per client(Bennett, 1991; Morrison, Gaskill, Meehan &Collings, 1998). The results suggest that despitethe community nurses’ claims to be monitoringthe side-effects of medication, their level ofknowledge about side-effects was poor, theylacked a systematic approach and this meant thattheir nursing care was inconsistent and variable(Bennett, Done, Harrison-Read & Hunt, 1995a;Bennett, Done, Harrison-Read & Hunt, 1995b;Michaels & Mumford, 1989).

These deficiencies are at variance with theprinciples of case management outlined by Ryan,Ford and Clifford (1991) who suggested that theassessment and management of medication wasa critical component of a client’s package of care.The subjective reports of symptoms by evenchronically ill patients must be ‘part of the continuing medication assessment process’(Michaels & Mumford, 1989, p. 97).

Scales for assessing side-effectsA number of neuroleptic side-effect assessmentscales are currently available (Bech et al., 1993,pp. 55–56; Bennett et al., 1995b; Bostrom, 1988;Munetz & Benjamin, 1988) and these vary intheir complexity and the amount of time neededto administer the instrument. It is notable thatmany of the scales used to assess side-effects weredeveloped originally as research tools and are nottherefore easily administered by clinicians andpractitioners. The most comprehensive scaledeveloped to assess the general side-effects ofneuroleptic medication is the 48-item UKUrating scale (Lingjærde, Ahlfors, Bech, Dencker& Elgen, 1987). The development of the scaleinvolved 50 hospitals and almost 2400 patientsreceiving neuroleptic medication. While thisscale has good psychometric properties, its use is

168 P. MORRISON ET AL.

limited by the need for specially trained investi-gators and the fact that it may take up to 60 minto complete (Day, Wood, Dewey & Bentall,1995).

The Liverpool University Neuroleptic Side-effect Rating Scale (LUNSERS) has been devel-oped from the UKU and a correlation for totalside-effect scores on the LUNSERS and totalscores on the UKU of 0.828 (P < 0.001) has beenreported (Day et al., 1995). In contrast to mostof the other scales designed to assess side-effects,the LUNSERS was designed to enable clients toreport their experiences of side-effects. In short,the ‘LUNSERS may be a useful tool for system-atically eliciting side-effect information frompatients, and as a brief and cost-effective measureof side-effects in research studies’ (Day et al.,1995, p. 653).

THE STUDY

In this study we examined the prevalence ofneuroleptic side-effects in a sample of clientsusing a recently developed self-rating assessmentschedule. This was one component of a largerstudy designed to explore the extent and impactof neuroleptic side-effects experienced bymentally ill people and how assessments of side-effects are undertaken by case managers. Inaddition, we developed and evaluated an educa-tional intervention designed to improve casemanagers’ assessment skills (Morrison et al.,1998; Morrison, Meehan, Gaskill, Lunney &Collings, in press).

METHOD

Data collectionThe LUNSERS is a 41-item self-rating scalewhich requires respondents to indicate howmuch they experienced each of the side-effectslisted in the last month. The LUNSERS hasestablished reliability and validity (Day et al.,1995; Day, Kinderman & Bentall, 1998).Responses are scored on a five point scale from0 (not at all) to 4 (very much). Day et al. (1995)claimed that the scale may be completed com-fortably within 5–20 min, even by acutely

disturbed clients. In addition, health care staffmay use the scale without special preparation andtraining.

In contrast to other scales designed to assessside-effects, the LUNSERS was designed toenable clients to report their experiences of side-effects. Clients are instructed to ‘tick off howmuch you have experienced the followingsymptoms over the last month’ for each of theLUNSERS items. The LUNSERS may providenurses and other case managers (and researchers)with an appropriate method for assessing side-effects. It is also in keeping with approaches tocare which acknowledge and give credence to the subjective responses expressed by patients(Awad, 1993).

SampleAn opportunistic sample was used. A stipulationfor ethical approval was that case managers hadto approach clients in the first instance to ascer-tain their willingness to take part in the study. Thecase managers then provided client contactdetails to the research team. Initially, 48 casemanagers from two health regions in theBrisbane area volunteered to take part in thestudy and were asked to identify two patientsfrom their case load who were currently takingantipsychotic medication. The case managerswere drawn from a range of professional disci-plines (general and psychiatric nursing, socialwork, occupational therapy and psychology).Most of the case managers (68.7%) were fromnursing while 45.8% held psychiatric nurse qual-ifications. The mean length of time as a casemanager was 48.5 months.

Case managers identified a total of 44 clientswho consented to take part in the study. A majorityof the clients selected were diagnosed with someform of psychotic disorder; the term most fre-quently used by case managers was ‘schizo-phrenia’. A smaller number were reported to havea diagnosis of ‘bi-polar disorder’ or ‘psychoticdepression’. They ranged in age from 17 to 70years (mean = 38.5 years) and 27 were male.

A majority of clients (60%) were prescribed‘typical’ antipsychotic medications (e.g. chlorpro-mazine) which were taken orally or by injection.

ASSESSMENT OF ANTIPSYCHOTIC MEDICATION SIDE-EFFECTS 169

The remainder (40%) was prescribed ‘atypical’antipsychotics (e.g. clozaril, risperidone). Theyhad been receiving antipsychotic medication forperiods of between four months to 20 years.Twelve clients (27%) were receiving anti-psychotic medication only, nine (20%) werereceiving antipsychotic and anticholinergic medi-cation, 10 (23%) were receiving antipsychoticand antidepressant/antianxiety agents, and 13(30%) were receiving antipsychotic medicationand some other medication (e.g. contraceptivepill, antacids).

It was not possible to select patients receivingantipsychotic medication only. Many patientswere already receiving other medications tocounteract side-effects or to manage othermedical or psychological problems. This high-lights the very real problems which patients face daily and presents a major dilemma forresearchers working in this area. Setting aside thelimitations of the opportunistic sample and therange of medication use, it is interesting to notethat the pattern of medication use by patients in this study (conventional and ‘atypical’ anti-psychotics, mood stabilisers) was similar to thatreported recently in a large Australian study(Jablensky et al., 1999).

ProcedureCase managers were approached, either individ-ually or at team meetings to provide them withinformation about the project. Each casemanager was asked to identify and contact twoclients from their case load who were currentlytaking antipsychotic medication. We also askedcase managers to select male and female clientsand clients from different age groups. Casemanagers also filtered the client sample to ensurethat clients who were acutely disturbed were notapproached.

Clients who agreed to take part in the studywere then contacted by a research assistant andan appointment was made to meet with them. Atthis initial meeting, the research assistant dis-cussed the project with each client and obtainedtheir written, informed consent. A mutuallyagreed upon date, time and venue was then negotiated with clients for administration of the

LUNSERS. The majority of clients asked to beseen at home while a few were seen in their community mental health clinic or hospital. Allparticipants were asked if they would like anotherperson to be present when they completed theLUNSERS. With only a few exceptions, clientsnominated to be on their own. Case managerswere present on five occasions and in sixinstances, relatives were present. On every occa-sion, verbal directions about how to complete thescale (e.g. ‘place a tick in the appropriate boxbeside each question’), and reinforcement that it was the client’s perception of how often eachside-effect had occurred, were given by theresearcher.

When items required clarification, theresearcher first read aloud the item and wherenecessary offered an explanation. The majorityof clients (approximately 30) sought clarificationabout the term ‘palpitations’ which was explainedas ‘thumping in the chest’ and about 10 askedwhat ‘climax’ meant; an alternative word such as‘orgasm’ was provided and this was usually suffi-cient to aid understanding. Males were informedthat two questions concerning menstruation didnot relate to them. The LUNSERS took between5 and 20 min to complete. Most clients com-pleted the scale in 10 min. Seven clients askedthe research assistant (a qualified psychiatricnurse) to complete the scale for them because ofpoor eyesight, impaired concentration or a senseof feeling ‘overwhelmed by the task’.

RESULTS

One member of the research team administeredthe scale on two occasions but only the findingsfrom the initial administration are reported inthis paper. The internal consistency or ‘mea-surement of the same concept by different scaleitems’ (Bowling, 1995, p. 292) revealed aCronbach’s alpha of 0.93 at time one and 0.90 at time two which indicate that the scale is areliable measure (Loewenthal, 1996). There wasa strong positive correlation for total side-effectscores between the first and second LUNSERSadministration (Spearman’s rho 0.67, P < 0.01).

170 P. MORRISON ET AL.

An overview of the prevalence of particularside-effects across the sample is provided inTable 1. Prevalence was calculated as the per-centage of clients who scored one or more on therelevant LUNSERS items. The prevalenceprofile indicates that 50% of clients had experi-enced more than half of the side-effectsdescribed in the LUNSERS in the previousmonth.

The cumulative impact of a range of side-effects also emerged. The group as a whole ratedmany of the side-effects on the low end of thescale—only three side-effects from the 41 listedon the scale received a mean rating of greaterthan two on the 0–4 scale. However, the meanrating for individual side-effects is deceptive andtends to disguise the potential impact of experi-encing several side-effects concurrently on thequality of a person’s life. Overall, the number ofside-effects experienced by individual clientsranged from 5 to 40 with a mean of 20.9(SD = 8.8).

We also calculated the total side-effect scorefor each client by summing the values on all ofthe items. The theoretical score range on theLUNSERS is 0–164, while the actual score rangefound in this study was 9–133. The total side-effect score trends are summarized into threecategories in Table 2.

In the original LUNSERS the authors suggestthat a total side-effect score of more than 20 maybe important clinically. In this study, only sevenfrom the 44 respondents (16%) scored less than20 on the LUNSERS. It is clear that side-effectscan have a cumulative impact on the individualand can be a major source of distress.

DISCUSSION

All of the people in our study experienced side-effects as a consequence of taking antipsychoticmedications. However, individuals varied in theirresponses to medication and the type of side-effects that affected them most. While someclients experienced relatively few side-effects,others experienced many. This highlights theneed for case managers to perform individualassessments with clients on an on-going basis.

The LUNSERS could be used to do this routinely.

While all of the side-effects mentioned havea negative impact on clients’ lives, the most fre-quently cited side-effects can have a disablinginfluence on the psychological and social dimen-sions of a client’s life. The inability to concentrate

ASSESSMENT OF ANTIPSYCHOTIC MEDICATION SIDE-EFFECTS 171

TABLE 1: Rank ordering of percentage prevalence ofantipsychotic medication side-effects

Side-effect Patient-rated prevalence (%)

Difficulty concentrating 86Difficulty remembering 84Tiredness 82Restlessness 75Tension 74†

Dry mouth 70Passing a lot of water 68Difficulty staying awake–daytime 66Depression 66Difficulty getting to sleep 66Sleeping too much 64Increased dreaming 60†

Reduced sex drive 59Blurred vision 57Putting on weight 57Shakiness 57Pins and needles 57Headaches 53†

Constipation 52Dizziness 52Lack of emotions 52Muscle spasms 52Feeling sick 50Slowing of movements 50Sensitivity to sun 50Itchy skin 50Drooling mouth 49†

Palpitations 48Muscle stiffness 45Increased sweating 45Body parts moving on their own 45Difficulty achieving climax 42†

Losing weight 35†

Increased sex drive 34Diarrhoea 32Unusual skin marks 27Difficulty passing water 23Rash 20Period problems 18Swollen or tender chest 16†

Periods less frequent 11

n = 44; †n = 43.

and remember things, the tiredness and rest-lessness, the feelings of tension and depression,for example, could seriously undermine attemptsto establish and maintain interpersonal relation-ships or undertake and complete work. Indeed,any one of the LUNSERS items could be con-sidered in terms of its ability to disrupt an individual client’s life and give rise to non-compliance.

There is clearly a need for case managers toassess and monitor medication side-effects moreeffectively in practice. There is also an urgentneed for training of staff in the assessment ofmedication side-effects. This is an importantissue in the day-to-day care of people who requireantipsychotic medication. Training may encour-age staff to keep clients better informed aboutside-effects. The early detection of rarer butserious side-effects like neuroleptic malignantsyndrome (a serious complication of anti-psychotic medication associated with suddenfever, rigidity, tachycardia, hypertension anddecreased levels of consciousness) or tardivedyskinesia (movement disorder characterized byrepetitive motions such as chewing or grimacing)is also likely to be enhanced with training(Bennett et al., 1995a; Michaels & Mumford,1989).

The application of side-effects scales inpractice may, of themselves, improve the level ofknowledge about medication and side-effectssimply by providing a reminder of what to lookfor as well as adding clients’ perceptions into thepicture (Bennett et al., 1995b). Assessment scaleslike the LUNSERS provide a structure for assess-ing side-effects and help to raise staff awarenessof the problems and the extent to which theyimpinge on clients’ lives. They can also, at leastin part, provide quality clinical information for

reviewing and monitoring clients’ progress overtime.

Legal considerations must also be taken intoaccount. Side-effects or toxic reactions to drugscannot be regarded as inevitable or disregardedas a necessary ‘cost’ of treatment. A number ofside-effects are in fact predictable and the legalrepercussions of poor management may be substantial (Dauner & Blair, 1990). More formalassessments of side-effects, which considerclients’ subjective experiences, may significantlyimprove the quality of professional care andreduce the risk of litigation.

However, there is some agreement that it isfairly difficult to arrive at an objective assessmentof the presence and impact of side-effects(Driscoll, 1985; Kopala, 1996), as it is difficult todistinguish between some side-effects andsymptoms of the illness. For example, Gardiner-Caldwell Communications Ltd noted that:

…the diagnosis of akathisia [restlessness,pacing, inability to concentrate] is, however,very difficult since the distinction between psy-chotic excitement and akathisia may be very finein severely agitated patients…in addition,patients may associate inner restlessness withanxiety, or restlessness may cause anxiety, andin these cases it is very difficult to disentangletrue anxiety from restlessness’ (Gardiner-Caldwell Communications Ltd, 1993, pp.10–11).

This highlights the need to take note of a‘symptom baseline’ prior to administering med-ication and reduce the risk that ‘the clinician maybe easily misled and the wrong diagnosis can leadto an increase rather than a decrease in neuro-leptic medication’ (Gardiner-Caldwell Com-munications Ltd, 1993, p. 11). A similar problemexists with the apathy and blunting associatedwith akinesia [poverty of movement], which canbe difficult to distinguish from the negativesymptoms of schizophrenia (Gardiner-CaldwellCommunications Ltd, 1993).

While acknowledging the difficulties associ-ated with accurately identifying side-effects, theuse of standardized rating scales for the assess-ment and monitoring of medication side-effectsis an important strategy in providing an effective,

172 P. MORRISON ET AL.

TABLE 2: Total side-effect score for clients divided intothree categories

Score range Category Score (%)

9–50 (low) 22 (50)51–92 (medium) 18 (41)93–133 (high) 4 (9)

n = 44.

customised service to clients (Bennett et al.,1995a,b; Gray & Howard, 1997; Michaels &Mumford, 1989). The assessment of medicationside-effects by mental health workers (even if itis an imperfect assessment), will increase clientsatisfaction and compliance with treatment andhelp to reduce unwanted side-effects (Bennettet al., 1995a,b; Gray & Howard, 1997). TheLUNSERS is time-effective—it does not take toolong to learn and use.

However, the practical reality of communitycase management often requires workers from avariety of disciplines to manage large case loadswith limited resources. In this context, the use ofassessment tools, which provide good data andare easy to use, become very important. Scalessuch as the LUNSERS also provide a ‘bench-mark…to determine the effectiveness of anyproposed changes in treatment’ (Gray & Howard,1997, p. 225).

Routine assessment of side-effects should bean integral part of case management for patientstaking neuroleptic medication. Ideally, theseassessments should be done before treatmentcommences and at regular intervals afterwards.This would enable case managers to draw up aclear side-effect profile for each client in theircare. Such assessments will be an importantaspect of the collaboration that is required toestablish and maintain a collaborative workingalliance between patients and case managers.Regular discussions should also address concernsabout the illness; the medication benefits andrisks (Munetz & Benjamin, 1988). Patients needto weigh up the risks of developing unwantedside-effects with the benefits of continued treat-ment (Wyatt, 1991). While some case managersmay feel that such open discussions will lead tonon-compliance with medication, this fear is notsupported in the literature (Munetz & Roth,1985).

LimitationsWhile the findings reported here have implica-tions for the management of clients prescribedneuroleptics, a number of limitations must benoted. First, the selection of clients was prob-lematic because it required the help of busy case

managers with limited time for research. Theresearch team was dependent on these indivi-duals to elicit interest for the project in the clientgroup, initially. This meant that our sample wasnon-random and relatively small (n = 44).

Second, it was not possible to select a sampleof clients receiving antipsychotic medicationonly. Many clients were already receiving othermedications to counteract side-effects or tomanage other medical or psychological problemsand these too may have side-effects. This latterdifficulty, however, reflects the very real problemswhich clients face daily and presents a majordilemma for researchers working in this area andfor clinicians.

Third, side-effects which disrupt cognitivefunction such as memory and concentrationcould also influence a client’s ability to completethe LUNSERS questionnaire successfully so it ishelpful to have someone on hand to help if thisproblem arises.

CONCLUSION

In spite of the limitations just mentioned, thefindings highlight vividly an important facet ofcare, which must be addressed by case managerand researchers. This descriptive study did notattempt to identify differences in side-effectprofiles between medications. Others have andare continuing to focus on that important issue.Instead we have emphasized the practical andeveryday experiences of clients prescribedantipsychotic medication. The identification andthe appropriate management of neuroleptic side-effects continues to present a challenging task forcase managers.

All case managers (whatever discipline) arerequired to assess and manage side-effects. Thecollection of clinical information about side-effects from the clients’ perspective using toolslike the LUNSERS provides case managers(even those with a non-nursing background) witha means for improving day-to-day practice. TheLUNSERS provides a structured framework for assessing side-effects and could be used successfully to evaluate the impact of manage-ment strategies designed to eradicate or reduce

ASSESSMENT OF ANTIPSYCHOTIC MEDICATION SIDE-EFFECTS 173

side-effects. The LUNSERS could also prove tobe a useful addition to the case manager’s toolboxfor collecting and evaluating clinical and researchdata. The ability to identify and deal with side-effects effectively is a vital aspect of patient andcarer education (Sane Australia, 1997; Weiden,Scheifler, Diamond & Ross, 1999).

ACKNOWLEDGEMENTS

We would like to thank the case managers, clientsand other health care staff who took part in orsupported the study which was funded by thePharmaceutical Education Program, Common-wealth Department of Health and FamilyServices (PEP Grant 172).

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