Antipsychotic Medication Reviews in Primary Care – Searching for best practice.

Lisa Grünwald is a PhD Student at the Division of Psychiatry, UCL, interested in antipsychotic medication management in primary care for people diagnosed with Severe Mental Illness. She previously worked on the RADAR study (Research into Antipsychotic Discontinuation and Reduction) – to find out more see https://www.ucl.ac.uk/psychiatry/research/epidemiology-and-applied-clinical-research-department/research-antipsychotic

Dr Nadia Crellin is a fellow at the Nuffield Trust and was previously programme manager for the RADAR study.

Prof Joanna Moncrieff is the RADAR Chief Investigator and a Professor in Critical and Social Psychiatry at UCL, as well as a community psychiatrist at North East London NHS Foundation Trust.

In the UK, little guidance is available on how mental health and the use of antipsychotic medication should be reviewed when patients no longer have access to a psychiatrist. Whereas the Quality Outcomes Framework mandates a yearly review, it is unclear what the review needs to cover exactly. Additionally, research is lacking as to whether GPs feel able to complete reviews in a comprehensive way, and about how patients feel about the treatment they receive. Increasing numbers of service users diagnosed with schizophrenia and/or psychosis are being discharged back to Primary care. Research found that currently up to 31% are under primary care only.¹ This number is likely to have increased due to the Covid-19 pandemic, as secondary care trusts have been asked to discharge up to 20% of their caseload.

What are the issues with antipsychotic medication?

Whereas a review might not seem a priority for those who are stable and on long term medication, increasing evidence of the severe and debilitating adverse effects associated with antipsychotics suggest that continuing medication indefinitely may not be the best option for some people.² Recognised adverse effects include drowsiness, weight gain, diabetes, tardive dyskinesia and sudden cardiac death, and potentially decreased brain volume and possible cognitive impairment.^3,4  People diagnosed with schizophrenia and/or psychosis also have a reduced life expectancy of, on average, 20 years in comparison to the general public, which may be partially attributable to antipsychotics.⁵ These adverse effects, combined with the fact that some people do not benefit from antipsychotics, mean that medication will need to be reviewed regularly and adapted as required.

Why is a review necessary?

The need for thorough review of antipsychotic medication in primary care is underlined by the finding that patients under primary care only are prescribed significantly more medication overall than people who are also seen in secondary care¹. Moreover, levels of polypharmacy are high and antipsychotics are frequently prescribed to people without a diagnosis of psychosis or severe mental disorder. Additionally, as the need for medication also changes across the lifetime, medication should to be reviewed on an ongoing basis. Guidance advises that older adults should be on lower doses. Which is particularly pertinent to primary care only patients, who are on average older, and have been diagnosed with schizophrenia/ psychosis for longer than people  still under secondary care¹. Barriers to completing thorough reviews exist, however: GPs report a lack of support from secondary care and a lack knowledge and confidence – not to mention the pressures of completing reviews in 10 minute appointments.

In summary, once people are discharged, GPs have increased responsibilities in the monitoring and prescribing of antipsychotic medication, yet may not feel fully equipped to manage these. Given that 1) an increasing proportion of people diagnosed with schizophrenia and/or psychosis are being discharged from secondary care 2) most people with this diagnosis are prescribed antipsychotic medication and 3) there are significant concerns regarding associated adverse effects of medication, it is important that medication is reviewed regularly and adapted as necessary.

A search for best practice – we need your help

Given the lack of guidance, GP practices are likely to have developed working practices of their own. In the search for best practice for those primary care only patients, research is urgently required on how this can best be achieved for patients who are only under primary care. We have therefore set up a short online survey for GPs practicing in the UK to gain further insights on their views and working practices on the topic. Please complete this anonymous, 10 minute online survey on your views on medication reviews in primary care. The study has ethical approval (University College London [19059/001]) and can be accessed through https://opinio.ucl.ac.uk/s?s=70230

References

1. Reilly, S., Planner, C., Hann, M., Reeves, D., Nazareth, I., & Lester, H. (2012). The role of primary care in service provision for people with severe mental illness in the United Kingdom. PloS one, 7(5), e36468.
2. Murray RM, Quattrone D, Natesan S, van Os J, Nordentoft M, Howes O, Di Forti M, Taylor D. Should psychiatrists be more cautious about the long-term prophylactic use of antipsychotics? Br J Psychiatry. 2016 Nov;209(5):361-365. doi: 10.1192/bjp.bp.116.182683. PMID: 27802977.
3. Moncrieff, J., & Leo, J. (2010). A systematic review of the effects of antipsychotic drugs on brain volume. Psychological Medicine, 40(9), 1409–1422. https://doi.org/10.1017/S0033291709992297
4. Husa, A. P., Moilanen, J., Murray, G. K., Marttila, R., Haapea, M., Rannikko, I., Barnett, J. H., Jones, P. B., Isohanni, M., Remes, A. M., Koponen, H., Miettunen, J., & Jääskeläinen, E. (2017). Lifetime antipsychotic medication and cognitive performance in schizophrenia at age 43 years in a general population birth cohort. Psychiatry research, 247, 130–138. https://doi.org/10.1016/j.psychres.2016.10.085
5. Ralph, S. J., & Espinet, A. J. (2018). Increased All-Cause Mortality by Antipsychotic Drugs: Updated Review and Meta-Analysis in Dementia and General Mental Health Care. Journal of Alzheimer’s disease reports, 2(1), 1–26. https://doi.org/10.3233/ADR-170042

Featured photo by Joshua Coleman on Unsplash