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Woodall A, Gampel A, Walker LE, Mair FS, Sheard S, Symon P, Buchan I. Antipsychotic management in general practice: serial cross-sectional study (2011-2020). Br J Gen Pract 2025; 75:e68-e79. [PMID: 39304310 PMCID: PMC11614393 DOI: 10.3399/bjgp.2024.0367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 09/11/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Long-term use of antipsychotics confers increased risk of cardiometabolic disease. Ongoing need should be reviewed regularly by psychiatrists. AIM To explore trends in antipsychotic management in general practice, and the proportions of patients prescribed antipsychotics receiving psychiatrist review. DESIGN AND SETTING Serial cross-sectional study using linked general practice and hospital data in Wales (2011-2020). METHOD Participants were adults (aged ≥18 years) registered with general practices in Wales. Outcome measures were prevalence of patients receiving ≥6 antipsychotic prescriptions annually, the proportion of patients prescribed antipsychotics receiving annual psychiatrist review, and the proportion of patients prescribed antipsychotics who were registered on the UK serious mental illness, depression, and/or dementia registers, or not on any of these registers. RESULTS Prevalence of adults prescribed long-term antipsychotics increased from 1.055% (95% confidence interval [CI] = 1.041 to 1.069) in 2011 to 1.448% (95% CI = 1.432 to 1.464) in 2020. The proportion receiving annual psychiatrist review decreased from 59.6% (95% CI = 58.9 to 60.4) in 2011 to 52.0% (95% CI = 51.4 to 52.7) in 2020. The proportion of overall antipsychotic use prescribed to patients on the serious mental illness register decreased from 50.0% (95% CI = 49.4 to 50.7) in 2011 to 43.6% (95% CI = 43.0 to 44.1) by 2020. CONCLUSION Prevalence of long-term antipsychotic use is increasing. More patients are managed by GPs without psychiatrist review and are not on monitored disease registers; they thus may be less likely to undergo cardiometabolic monitoring and miss opportunities to optimise or deprescribe antipsychotics. These trends pose risks for patients and need to be addressed urgently.
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Affiliation(s)
- Alan Woodall
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool; clinical lead for integrated care, Powys Teaching Health Board, Bronllys, Powys
| | - Alex Gampel
- Powys Teaching Health Board, Bronllys, Powys
| | - Lauren E Walker
- Centre for Experimental Therapeutics, University of Liverpool, Liverpool
| | - Frances S Mair
- General Practice and Primary Care, School of Health and Wellbeing, University of Glasgow, Glasgow
| | - Sally Sheard
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool
| | - Pyers Symon
- National Institute for Health and Care Research (NIHR) Mental Health Research for Innovation Centre, University of Liverpool, Liverpool
| | - Iain Buchan
- NIHR Mental Health Research for Innovation Centre, University of Liverpool, Liverpool; director, Civic Health Innovation Labs, University of Liverpool, Liverpool
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Woodall AA, Abuzour AS, Wilson SA, Mair FS, Buchan I, Sheard SB, Atkinson P, Joyce DW, Symon P, Walker LE. Management of antipsychotics in primary care: Insights from healthcare professionals and policy makers in the United Kingdom. PLoS One 2024; 19:e0294974. [PMID: 38427674 PMCID: PMC10906843 DOI: 10.1371/journal.pone.0294974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/26/2024] [Indexed: 03/03/2024] Open
Abstract
INTRODUCTION Antipsychotic medication is increasingly prescribed to patients with serious mental illness. Patients with serious mental illness often have cardiovascular and metabolic comorbidities, and antipsychotics independently increase the risk of cardiometabolic disease. Despite this, many patients prescribed antipsychotics are discharged to primary care without planned psychiatric review. We explore perceptions of healthcare professionals and managers/directors of policy regarding reasons for increasing prevalence and management of antipsychotics in primary care. METHODS Qualitative study using semi-structured interviews with 11 general practitioners (GPs), 8 psychiatrists, and 11 managers/directors of policy in the United Kingdom. Data was analysed using thematic analysis. RESULTS Respondents reported competency gaps that impaired ability to manage patients prescribed antipsychotic medications, arising from inadequate postgraduate training and professional development. GPs lacked confidence to manage antipsychotic medications alone; psychiatrists lacked skills to address cardiometabolic risks and did not perceive this as their role. Communication barriers, lack of integrated care records, limited psychology provision, lowered expectation towards patients with serious mental illness by professionals, and pressure to discharge from hospital resulted in patients in primary care becoming 'trapped' on antipsychotics, inhibiting opportunities to deprescribe. Organisational and contractual barriers between services exacerbate this risk, with socioeconomic deprivation and lack of access to non-pharmacological interventions driving overprescribing. Professionals voiced fears of censure if a catastrophic event occurred after stopping an antipsychotic. Facilitators to overcome these barriers were suggested. CONCLUSIONS People prescribed antipsychotics experience a fragmented health system and suboptimal care. Several interventions could be taken to improve care for this population, but inadequate availability of non-pharmacological interventions and socioeconomic factors increasing mental distress need policy change to improve outcomes. The role of professionals' fear of medicolegal or regulatory censure inhibiting antipsychotic deprescribing was a new finding in this study.
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Affiliation(s)
- Alan A. Woodall
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
- Powys Teaching Health Board, Bronllys Hospital, Powys, United Kingdom
| | - Aseel S. Abuzour
- Unit for Ageing and Stroke Research, School of Medicine, University of Leeds, West Yorkshire, United Kingdom
| | - Samantha A. Wilson
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
| | - Frances S. Mair
- General Practice & Primary Care, School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Iain Buchan
- NIHR Mental Health Research for Innovation Centre, University of Liverpool, Liverpool, United Kingdom
| | - Sally B. Sheard
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
| | - Paul Atkinson
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
| | - Dan W. Joyce
- NIHR Mental Health Research for Innovation Centre, University of Liverpool, Liverpool, United Kingdom
| | - Pyers Symon
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Lauren E. Walker
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
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