Physician vs patient initiation of psychotropic prescribing in primary care settings: a content analysis of audiotapes

Initiation of new psychotropic prescriptions without a psychiatric diagnosis among US adults: Rates, correlates, and national trends from 2006 to 2015

OBJECTIVES

To estimate rates and national trends of initiation of new psychotropic medications without a psychiatric diagnosis and to identify demographic and clinical correlates independently associated with such use among US adults in outpatient settings.

DATA SOURCE

Data were gathered from the 2006-2015 National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of office-based U.S. outpatient care. The sample was limited to adults aged 18 or older who received a new psychotropic drug prescription (n = 8618 unweighted).

STUDY DESIGN

Using a repeated cross-sectional design with survey sampling techniques, we estimated prescription initiation rates and national trends. Multivariable-adjusted logistic regression analysis was used to identify correlates independently associated with initiation of new psychotropic prescriptions without a psychiatric diagnosis.

DATA COLLECTION/EXTRACTION METHODS

Data were publicly available, and we extracted them from the Centers for Disease Control and Prevention website.

PRINCIPAL FINDINGS

Altogether, at 60.4% of visits at which a new psychotropic prescription was initiated, no psychiatric diagnosis was recorded for the visit. Overall, the rate increased from 59.1% in 2006-2007 to 67.7% in 2008-2009 and then decreased to 52.0% in 2014-2015. Visits to psychiatrists were associated with very low odds of having no psychiatric diagnosis when compared to primary care visits (OR = 0.02; 95% CI, 0.01-0.04). Visits to non-psychiatric specialists showed 6.90 times greater odds of not having a psychiatric diagnosis when compared to primary care visits (95% CI, 5.38-8.86).

CONCLUSION

New psychotropic medications are commonly initiated without any psychiatric diagnosis, especially by non-psychiatrist physicians. Non-psychiatrists should document relevant diagnoses more vigilantly to prevent potentially inappropriate use or misuse.

When do doctors follow patients' orders? Organizational mechanisms of physician influence

Physicians, like other professionals, are expected to draw from specialized knowledge while remaining receptive to clients' requests. Using nationally representative U.S. survey data from the Community Tracking Study, this paper examines the degree to which physicians are influenced by patients' requests, and how physicians' workplaces may mediate acquiescence rates through three mechanisms: constraints, protection, and incentives. We find that, based on physicians' reports of their responses to patients' suggestions, patient influence is rare. This influence is least likely to be felt in large workplaces, such as large private practices, hospitals, and medical schools. We find that the protection and incentives mechanisms mediate the relationship between workplace types and physician acquiescence but more prescriptive measures such as guidelines and formularies do not affect acquiescence. We discuss these findings in light of the ongoing changes in the structure of medicine.

Clinically significant psychotropic drug-drug interactions in the primary care setting

In recent years, the growing numbers of patients seeking care for a wide range of psychiatric illnesses in the primary care setting has resulted in an increase in the number of psychotropic medications prescribed. Along with the increased utilization of psychotropic medications, considerable variability is noted in the prescribing patterns of primary care providers and psychiatrists. Because psychiatric patients also suffer from a number of additional medical comorbidities, the increased utilization of psychotropic medications presents an elevated risk of clinically significant drug interactions in these patients. While life-threatening drug interactions are rare, clinically significant drug interactions impacting drug response or appearance of serious adverse drug reactions have been documented and can impact long-term outcomes. Additionally, the impact of genetic variability on the psychotropic drug's pharmacodynamics and/or pharmacokinetics may further complicate drug therapy. Increased awareness of clinically relevant psychotropic drug interactions can aid clinicians to achieve optimal therapeutic outcomes in patients in the primary care setting.

What we talk about when we talk about depression: doctor-patient conversations and treatment decision outcomes

BACKGROUND

Efforts to address depression in primary care settings have focused on the introduction of care guidelines emphasising pharmacological treatment. To date, physician adherence remains low. Little is known of the types of information exchange or other negotiations in doctor-patient consultations about depression that influence physician decision making about treatment.

AIM

The study sought to understand conversational influences on physician decision making about treatment for depression.

DESIGN

A secondary analysis of consultation data collected in other studies. Using a maximum variation sampling strategy, 30 transcripts of primary care consultations about distress or depression were selected from datasets collected in three countries. Transcripts were analysed to discover factors associated with prescription of medication.

METHOD

The study employed two qualitative analysis strategies: a micro-analysis approach, which examines how conversation partners shape the dialogue towards pragmatic goals; and a narrative analysis approach of the problem presentation.

RESULTS

Patients communicated their conceptual representations of distress at the outset of each consultation. Concepts of depression were communicated through the narrative form of the problem presentation. Three types of narratives were identified: those emphasising symptoms, those emphasising life situations, and mixed narratives. Physician decision making regarding medication treatment was strongly associated with the form of the patient's narrative. Physicians made few efforts to persuade patients to accept biomedical attributions or treatments.

CONCLUSION

Results of the study provide insight into why adherence to depression guidelines remains low. Data indicate that patient agendas drive the 'action' in consultations about depression. Physicians appear to be guided by common-sense decision-making algorithms emphasising patients' views and preferences.

Pharmacovigilance: a worldwide master key for drug safety monitoring

Pharmacovigilance is like a sunshade to describe the processes for monitoring and evaluating ADRs and it is a key component of effective drug regulation systems, clinical practice and public health programmes. The number of Adverse Drug Reactions (ADRs) reported resulted in an increase in the volume of data handled, and to understand the pharmacovigilance, a high level of expertise is required to rapidly detect drug risks as well as to defend the product against an inappropriate removal. The current global network of pharmacovigilance centers, coordinated by the Uppsala Monitoring Centre, would be strengthened by an independent system of review. This would consider litigious and important drug safety issues that have the potential to affect public health adversely beyond national boundaries. Recently, pharmacovigilance has been confined, mainly to detect adverse drug events that were previously either unknown or poorly understood. Pharmacovigilance is an important and integral part of clinical research and these days it is growing in many countries. Today many pharmacovigilance centers are working for drug safety monitoring in this global pitch, however, at the turn of the millennium pharmacovigilance faces major challenges in aspect of better safety and monitoring of drugs. In this review we will discuss about drug safety, worldwide pharmacovigilance centers and their role, benefits and challenges of pharmacovigilance and its future consideration in healthcare sectors.

HEALTH SERVICES RESEARCH METHODS IN PHARMACY: Triangulation

There are many examples of studies in which pharmacy practice researchers have combined different types of data, methods and approaches within a single research project. Although a common practice in research across many disciplines, concerns have been expressed over combining methods underpinned by different philosophical assumptions and conceptual frameworks. The choice of methods made by pharmacy researchers is generally governed by practical considerations of the research and data requirements for fulfilling research objectives rather than these theoretical concerns. This review of the pharmacy practice research literature demonstrates how a wide variety of methods have been combined for different purposes and in a variety of study designs.

HEALTH SERVICES RESEARCH METHODS IN PHARMACY: Focus groups and observation studies

This paper reviews research undertaken in pharmacy practice and related settings employing focus groups and observation methods. The aim of the review is to identify the main methodological considerations of these approaches to enable pharmacy practice researchers to benefit from the experiences of their colleagues when conducting their own research. The paper is in two parts. Focus groups have become increasingly prominent in pharmacy practice and health services research. They are an attractive and effective alternative to individual qualitative interviews for particular problems in pharmacy research. In this paper, the use of focus groups by researchers in pharmacy practice and related settings is reviewed. Observation studies have been applied widely to address many research questions. They are a valuable method of obtaining data, documenting actual events and activities rather than relying on self-reports of behaviours and events. Observation methods have been used both as a sole method for a research study and in combination with other methods. In the pharmacy practice literature there are examples of participant and non-participant observation studies and both quantitative and qualitative approaches. Through the experiences of pharmacy practice researchers, the methodological and ethical issues that these studies present are identified and ways in which they have been addressed are explored.

The prevalence of benzodiazepine dependence among community-dwelling older adult users in Quebec according to typical and atypical criteria

BACKGROUND

Use of benzodiazepines, common among older people, may lead to substance dependence. DSM-IV-TR criteria for this iatrogenic problem may apply poorly to older persons following a physician-prescribed regimen. This study, first of its kind, aimed to determine the prevalence rate of benzodiazepine dependence in older persons according to DSM-IV-TR and other atypical criteria.

METHODS

Descriptive study based on face-to-face interviews conducted in the homes of 2,785 persons aged 65 years or older who were randomly selected from across the province of Quebec, Canada.

RESULTS

Use of benzodiazepines was reported by 25.4% of respondents. Among them, 9.5% met DSM-IV-TR criteria for substance dependence. However, 43% of users reported being dependent, and one third agreed that it would be a good thing to stop taking benzodiazepines.

INTERPRETATION

Benzodiazepine substance dependence is established at one tenth of community-dwelling older persons taking these medications, although a much larger proportion self-labels as dependent.

Measuring patient and physician participation in exchanges on medications: Dialogue Ratio, Preponderance of Initiative, and Dialogical Roles

OBJECTIVE

To identify, describe and characterize the patient and physician participation in content production in medication-related exchanges during primary care consultations.

METHODS

Descriptive study of audio recordings of 422 medical encounters. MEDICODE, a validated instrument was used to analyze verbal exchanges on medications. Two main indicators of participation were developed: Dialogue Ratio (DR), a 0-1 scale indicating extent of monologue/dialogue; Preponderance of Initiative (PI), a -1 to +1 scale for patient/physician initiative. Participation analyses were conducted by content theme and medication categories (New, Represcribed and Active).

RESULTS

We identified 1492 discussions of medications. Categorical analyses identified four communication roles patients and physicians adopted when participating in medication-related exchanges during consultations: (a) Listener, (b) Information Provider, (c) Participant, and (d) Instigator. The mean observed DRs and PIs indicated that monologues and physician initiation dominated medication-related exchanges.

CONCLUSION

Four factors are suggested to explain the communicational behaviors observed: (1) patient knowledge about medications, (2) physician expertise, (3) patient experience with the medication, and (4) the act of prescribing. Our data indicate a generally low level of dialogue when discussing medications during primary care encounters since physicians' monologues seem to be the rule rather than the exception, pointing to a lack of mutuality in exchanges on medications.

PRACTICE IMPLICATIONS

The proposed concepts offer a unique vocabulary and conceptual framework to help physicians master the necessary content and process skills required to discuss medications with patients.

Professional-patient communication in the treatment of mental illness: a review

The quality of the professional-patient relationship in the treatment of mental illness predicts patient outcome. Hence, we conducted a review of recorded professional-patient communication to identify existing research, methods, and findings. Sixteen studies focused on (i) how psychiatric symptoms are manifested in patient communication; (ii) the role of therapist communication in patient improvement; (iii) the influence of sociodemographic characteristics on doctor-patient communication; and (iv) how patients and professionals jointly construct therapeutic interactions. The findings were disparate and included (a) patient nonverbal communication is impaired in depression and schizophrenia; (b) the use of specific therapeutic skills led to improvement in depression; high expressed emotion (criticism and emotional over-involvement) in treating schizophrenia was a state rather than trait characteristic of therapists; (c) patient gender, income, and education influenced communication about depression, anxiety, and medication; and (d) psychiatrists' varying institutional agendas, which sometimes competed with patients' agendas, strongly shaped their consultations. Few studies investigated two-way professional-patient communication, with most focusing on either patient or therapist communication in isolation from the other. Finally, methodological advances in linking communication processes with treatment outcomes in large-scale observational studies and trials are a challenge for research on medical communication.

MEDICODE: an instrument to describe and evaluate exchanges on medications that occur during medical encounters

OBJECTIVE

To examine the psychometric properties of MEDICODE, a coding instrument developed to assess medication discussions during medical consultations.

METHODS

Inter-coder reliability, test-retest stability, and concurrent validity with the Roter Interaction Analysis System (RIAS) and predictive validity with the Medical Interview Satisfaction Scale (MISS) were calculated.

RESULTS

Inter-coder reliability and test-retest stability for medication class and status were both very good. Inter-coder agreement and test-retest stability for theme identification were mostly over 90%. Kappa values for theme identification varied from acceptable to excellent for 21 of the 29 and for 26 of the 37 Kappa coefficients that could be calculated. The mean percent agreement between MEDICODE and RIAS for medication class was of 96.8% and the mean Kappa value was 0.83. Although the mean percent agreement for the presence of a theme in MEDICODE and RIAS was 81%, the average Kappa coefficients were lower at 0.40. However, each of the four broad theme categories had its share of themes with robust Kappa values. We found significant positive correlations (p<0.05) between discussions of medication main effects and instructions with patient satisfaction.

CONCLUSION

With a reasonable amount of training, the coders were able to produce reliable and valid measures of discussions of medications during medical consultations.

PRACTICAL IMPLICATIONS

MEDICODE will facilitate the study of the impact of the nature and intensity of discussions about medications during consultations on patient medication knowledge, medication recall and compliance.

Nature and frequency of exchanges on medications during primary care encounters

OBJECTIVE

To describe the exchanges, related to discussion of all medications during primary care medical consultations.

METHODS

Descriptive study of audio recordings of 422 medical encounters. Coding was done with MEDICODE, a validated instrument developed to analyse verbal exchanges on medications. The unit of analysis is the medication.

RESULTS

An average of 3.9 medications (S.D.=2.8; range 1-21) are discussed per interview and 4.2 themes are broached for each drug (S.D.=2.6; range 1-17). "Active Discussed", "Represcribed" and "Newly Prescribed" drugs account for 43.1, 16.3 and 10.6%, respectively of all medications discussed. Themes most often discussed are Name, Instructions, Observed Main Effect, Class, Reasons for Taking the Drug, General Use of the Medication, Expected Effect on Symptoms, Form of the Medication, Indications Another Consultation Needed, and Alternative Medication. The least often discussed themes include clinically significant ones such as Possible Adverse Effects, Observed Adverse Effects, Expression of Attitudes and Emotions with regard to the medication, Compliance and Warnings. The average number of themes discussed differed between medications that were prescribed during the encounter, either New prescriptions or Represcribed drugs, compared to medications that were only discussed during the encounter.

CONCLUSION

Our results show that medication discussions are heterogeneous and vary with the status of the medication and the theme. Also, the nature and extent of the discussions about medications do not support the shared-decision making model.

PRACTICE IMPLICATIONS

Though it is too soon to make specific recommendations about discussions on medications, it seems clear that information-sharing about medications during medical encounters is a process that extends beyond any single encounter. Although communication skills are now part of most medical curriculums, there is an obvious need to put forth the concept of patient medication knowledge-building over multiple physician-patient encounters and to better prepare physicians to use the specific content and process skills necessary to revisit issues related to medications that seem necessary to support their patients' medication-taking practices.

Elderly women show neither a shortage of strategies nor an overreliance on drugs in handling aging and in dealing with minor health problems

Women 65 years old and over make up the fastest growing population segment in North America. They are, particularly among the underprivileged, known to be heavy consumers of prescribed and over-the-counter drugs. The objective of this study was to identify the role of medication in underprivileged elderly women's strategies for aging well and dealing with minor health problems. A qualitative study was conducted among 40 women aged 65 to 75. Results show that elderly women seldom mention resorting to medication to "age well" although they report using this strategy to deal with minor health problems. Overall, the elderly women mentioned a wide range of strategies to cope with aging and minor health problems, which suggests that they are well equipped to face the challenges of aging.

Parent resistance to physicians' treatment recommendations: one resource for initiating a negotiation of the treatment decision

This article examines pediatrician-parent interaction in the context of acute pediatric encounters for children with upper respiratory infections. Parents and physicians orient to treatment recommendations as normatively requiring parent acceptance for physicians to close the activity. Through acceptance, withholding of acceptance, or active resistance, parents have resources with which to negotiate for a treatment outcome that is in line with their own wants. This article offers evidence that even in acute care, shared decision making not only occurs but, through normative constraints, is mandated for parents and physicians to reach accord in the treatment decision.

Parents' perceptions of pediatric day surgery risks: unforeseeable complications, or avoidable mistakes?

A decline in people's trust of the US health care system has been documented. But do parents of pediatric patients have specific safety worries? If so, what are they? And what cultural factors inform them? To help answer these questions, in San Diego 35 English- and Spanish-speaking parents' (or guardians') self-reports of perceptions of their child's risk for experiencing a medical error during day surgery were collected using open-ended rapid assessment interviews, and analyzed using qualitative content analysis methods. (The innovative data collection and analysis protocol is described so as to be easily replicable in other settings for other types of highly focused quality improvement initiatives that rely on the inclusion of parent or patient perspectives and entail limited time and resources). Twelve key themes were identified. Anthropological discourse analysis techniques (modified for rapid use with rapidly collected interview data) were then applied to the transcripts in order to generate ideas regarding cultural factors underlying the themes. Discursive patterns of risk rationalization or refutation related to cultural expectations for parenting, children's bodies, and health care consumerism were found. Neither the (careful, loving, good) parent nor the (wisely chosen or well-reputed) care team was to blame for medical errors. Errors were cast as the inevitable results of latent, unanticipatable vulnerabilities inherent in the (defenseless) children undergoing surgery. The anxiety-generating potential of the surgical consent process also was noted. The implications of the findings for action as well as for theories of risk and vulnerability and of childhood and parenthood are discussed.

Unconventional indicators of drug dependence among elderly long-term users of benzodiazepines

A quarter of the elderly population is prescribed benzodiazepines (BZD). This has led to growing concerns about drug dependence and the validity of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for dependence to a substance. This study aimed to understand how dependence was experienced by long-term BZD users. Interviews were conducted with 45 elderly persons who had been using BZDs for an average of nine years. These users' comments suggest six indicators of dependence: self-identifying as a dependent user, invoking multiple stressors to justify BZD use, using BZD to cope with anticipated stressors, trivializing the dangers of BZDs, keeping a supply in reserve, having previously tried and failed to stop, and reducing the dosage. Our results stress the need to take a more elaborate, person-centered view of dependence.

The Subjective Experience of Youth Psychotropic Treatment

The psychotropic treatment of youth is increasing dramatically. This article examines child and adolescent psychopharmacological research and argues that social work practice and research must examine the complex relationships, social and psychological, in youth pharmacologic treatment. Regarding identity formation, this article explores the developmental consequences when youth adopt an illness narrative to make sense of everyday medication treatment. A conceptual framework for mapping the socio-cultural context of youth medication management is outlined. In the conclusion, youth psychotropic treatment is connected to a perplexing 'interpretive gap,' which highlights the subjective quality of medication treatment.

Hispanic ethnicity, physician-patient communication, and antidepressant adherence

The purpose of the study was to examine how Hispanic ethnicity influenced physician-patient communication about antidepressants and antidepressant adherence using a data set of audiotapes and transcripts of 98 medical visits and medical and pharmacy records. The data were collected in 1995 at the University of New Mexico's general medicine and family practice clinics. Physicians were more likely to state antidepressant information to non-Hispanic white patients than to Hispanic patients. Physicians were more likely to state information to patients who were prescribed new antidepressants. Physicians asked approximately one of five patients on continued therapy how well their antidepressants were working and only one of 10 patients if they were experiencing any side effects. Non-Hispanic white patients were significantly more likely to state information about their antidepressants than Hispanic patients. Younger patients and patients who were prescribed new antidepressants were more likely to ask questions about antidepressants. Hispanic patients and patients who were prescribed new antidepressants were significantly less adherent to their antidepressant therapy during the one hundred day period after their audio-taped visits than non-Hispanic white patients and patients on continued therapy.

The social grid of community medication management

Practitioners involved in case management at a community mental health center organized 5 elements of a psychotropic medication experience. Using case records, interview, and observational data, the authors examined an underresearched and especially problematic area of the management process: the interpretation of a medication's effect. They describe the divisions of labor, a grid of social relations, and spaces related to management, and they describe how the limits and potential of medications are realized in the intensity of monitoring and the knowledge produced in the day-to-day practices among all participants.

Participating in decisions about treatment: overt parent pressure for antibiotic medication in pediatric encounters

This article examines how parents and pediatricians negotiate antibiotic prescribing decisions in cases where parents overtly advocate this medication. Using the methodology of conversation analysis, this paper examines audio and videotaped acute care pediatric encounters and discusses four primary ways in which parents raise antibiotics in pediatric encounters. These formulations vary in their directness with indirect formulations being more common. The article argues that both parents and physicians are oriented to antibiotics as negotiable in and through their interaction. Finally, in contrast with existing research, this study suggests that overtly advocating for antibiotic treatment is relatively unusual; future research will need to incorporate an understanding of the effect of both explicit and implicit ways parents communicate pressure for prescription treatment.

Physician-patient communication about over-the-counter medications

The purpose of this study was to describe physician-patient communication about over-the-counter medications using a data set comprised of audio-tapes and transcripts of 414 primary care medical visits. The data set was collected during 1995 at the family practice and general medicine clinics at the University of New Mexico Health Sciences Center. Twenty-seven resident physicians and 414 of their adult patients participated. Fifty-seven percent of patients reported using one or more OTC medications during the past month. Analgesics, cold or allergy products, and antacids were the most commonly used OTC medications. White patients were significantly more likely to have reported using an analgesic in the past month than non-white patients. Female, white, and younger patients were more likely to have reported using a cold or allergy product in the past month than male, non-white, and older patients. Approximately 58% of patients discussed OTC medications with their physicians. Older patients and female patients as well as patients who reported using an antacid in the past month were significantly more likely to have discussed OTC medications with their physicians. Physicians asked questions about OTC medications during only 37% of encounters. Patients asked questions about OTC medications during 11% of encounters. Patient ethnicity did not influence physician or patient question-asking and information-giving about OTC medications. Male physicians were more likely to state information and ask questions about OTC medications than female physicians. Patients were more likely to ask male physicians questions about OTC medications. Physicians were more likely to state OTC information to and ask OTC questions of female and older patients. Physicians were more likely to ask less educated patients questions about OTC medications. Less educated patients were more likely to ask physicians questions about OTC medications. Despite the fact that more than half of all patients reported using OTC medications, physicians asked questions about OTC use during only approximately one-third of encounters. Of patients who reported using an OTC medication in the past month, 58% did not tell their physicians, yet only 14% of patients believed that it was not important for the physician to know about their OTC use. Physician-patient communication about OTC medications should be encouraged so that the patient becomes a collaborative partner in medication management.

Ethnicity and physician-older patient communication about alternative therapies

OBJECTIVES

The purpose of this study was to describe ethnic differences in physician-patient communication about alternative therapies, using a data set comprised of audiotapes and transcripts of primary care medical visits.

METHODS

The data set was collected during 1995 at the family practice and general medicine clinics at the University of New Mexico Health Sciences Center, Albuquerque, NM. Twenty-seven (27) resident physicians and 205 of their Hispanic and non-Hispanic white patients age 50 and over participated.

RESULTS

Almost 18 percent of patients reported using one or more alternative therapies during the preceding month. Herbal medicine was the most widely used therapy. Eighty-three percent (83%) of patients who reported using an alternative therapy in the previous month did not tell their physicians. Physicians asked one or more questions about alternative therapies during only 3.4% of encounters. Only 2% of patients asked their physicians one or more questions about alternative therapies. There were no ethnic differences in physician-older patient communication about alternative therapies.

DISCUSSION

Physician-patient communication could be improved to enhance physician understanding of the spectrum of interventions patients pursue to improve their health.

Pharmacist-patient relationship development in an ambulatory clinic setting

We investigated the pharmacist-patient relationship, conceptualizing its interpersonal constructs and dynamics using social exchange principles. The constructs of felt indebtedness (FI), collaborative willingness (CW), interpersonal relationship quality (IRQ), medication use beliefs (MUBs), and critical interpersonal incidents (CII) between pharmacist and patient were proposed, measured, and modeled. Patient responses were collected using interviews and mail surveys in 2 pharmacist-managed anticoagulation clinics. Higher IRQ levels predicted greater FI toward and CW with pharmacists (p < .01). MUBs predicted CW with IRQ mediating the association (p < .01). Patients reporting positive CII gave higher IRQ ratings and expressed greater FI (p < .05). Findings suggested that patients' perceptions of their pharmacists, and not their therapy, may lead to increased interpersonal exchange and patient collaboration in care.

The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes

OBJECTIVE

To evaluate the impact of regular multidisciplinary team interventions on the quantity and quality of psychotropic drug prescribing in Swedish nursing homes.

DESIGN

A randomized controlled trial.

SETTING

A sample of 33 nursing homes: 15 experimental homes and 18 control homes representing 5% of all Swedish nursing homes.

PARTICIPANTS

The sample consisted of 1854 long-term care residents with an average age of 83 years. Seventy percent of the residents were women, and 42% had a documented diagnosis of dementia. An additional 5% had a psychotic disorder, and 7% had a diagnosis of depression.

INTERVENTION

Experimental homes participated in an outreach program that was designed to influence drug use through improved teamwork among physicians, pharmacists, nurses, and nurses' assistants. Multidisciplinary team meetings were held on a regular basis throughout the 12-month study period.

MEASUREMENTS

Lists of each resident's prescriptions were collected 1 month before and 1 month after the 12-month intervention. Measures included the proportion of residents with any psychotropic drug, polymedicine, and therapeutic duplication and proportion of residents with nonrecommended and acceptable drugs in each psychotropic drug class, as defined by current Swedish guidelines.

RESULTS

Baseline results show extensive psychotropic drug prescribing, with the most commonly prescribed drugs being hypnotics (40%), anxiolytics (40%), and antipsychotics (38%). After 12 months of team meetings in the experimental homes, there was a significant decrease in the prescribing of psychotics (-19%), benzodiazepine hypnotics (-37%), and antidepressants (-59%). Orders for more acceptable antidepressants also increased in the experimental homes. In the control homes there was increased use of acceptable antidepressants, but there were no significant reductions in other drug classes.

CONCLUSIONS

There is excessive prescription of psychotropic drugs in Swedish nursing homes. Improved teamwork among caregivers can improve prescribing as defined by clinical guidelines.

A feminist model for women's health care

A feminist model of practice is grounded in feminist theories that are applicable to the health and health care of women. The goal of this model is to change how health care is delivered to individual women, but also to seek social transformation. Four major themes recur in this model: symmetry in provider-patient relationships, access to information, shared decision-making, and social change. This article describes ways in which clinicians can integrate these themes into practice. Suggestions for maintaining symmetry in the traditional power relationship include decreasing physical, social and personal barriers and attentive listening to patients' stories. Access to information involves creating an atmosphere that is conducive to teaching and learning, but also helping patients access other sources of information. Shared decision-making is central to feminist practice and is attainable when patients have been empowered and are knowledgeable about their healthcare needs. Social change entails the ever vigilant clinician who is familiar with the latest literature, both professional and lay, in order to critically analyse research studies, our colleagues' interpretations of those studies and how recommendations for practice are reached. Collectively, clinicians work with the public to strive for change within the healthcare system and society as a whole.