Gruenwald, Lisa Marie; (2022) Antipsychotic Medication Management In Primary Care - Using Realist informed synthesis To Develop Recommendations For Policy And Practice. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Introduction: Increasing numbers of service users with a severe mental health (SMI) diagnosis are discharged from secondary care services back to their General Practitioner (GP). Recent estimates suggest that this affects between 30-50% of people with a SMI diagnosis, most of whom are prescribed long term antipsychotic medication. Given the wide range of associated adverse effects, and lack of efficacy of antipsychotic medication in some people, this medication needs to be reviewed, and potentially adjusted, regularly. It is unclear to which extent antipsychotic medication reviews are completed in primary care and what potential barriers and facilitators may be, and what GPs and service users’ views and experiences of primary care reviews are. It is also unclear if service users in primary care have particular needs in comparison to those service users still under specialist secondary care services, which may have treatment implications. Method: A realist informed synthesis was conducted: An initial programme theory was developed as part of a realist review (Chapter 2). This was further refined through an analysis of Service User interviews (Chapter 3) and a GP survey (Chapter 4). Chapter 3 analyses quantitative and qualitative data from semi-structured interviews of N=269 service users from a range of secondary and primary care services. This allowed a between groups comparison on a range of demographic and clinical variables. It also explores service user views on long term antipsychotic medication, reducing and stopping antipsychotics. The data were analysed using univariate statistical tests and thematic analysis. The GP survey was developed based on the initial programme theory and included GPs (N=103) views on long term antipsychotics, primary care only medication reviews, and explores barriers and facilitators of medication reviews, with the GP – Service User relationship at its core. Results: The realist review identified 5 CMOCs, indicating why meaningful antipsychotic medication reviews may not occur for people with a SMI diagnosis in primary care. The literature suggests a lack of hope and trust between GPs and service users. This manifests in low expectations of recovery for service users with a diagnosis of SMI, for which the GP survey also provided some evidence. The review also suggested that Service Users are perceived as lacking capacity to understand and participate in medication reviews, linked with a lack of mutual information sharing regarding mental wellbeing and rationale for medication. Research also suggests that GPs may feel at risk in consultations, for which the GP survey also provided some evidence. The most pervasive evidence was collated on the topic of uncertainty. Uncertainty regarding antipsychotic dose and illness trajectory meant that reviews may not occur. Little published data was identified, however the service user interviews highlighted that primary care service users are more reluctant to reduce their medication, despite increased age, than secondary care service users. Primary Care service users were most concerned with fears of relapse. Key considerations included effects on employment if medication is changed, older age as a barrier to reduction, and it being part of their role to take medication lifelong. Similarly, GPs listed uncertainty regarding relapses, a lack of knowledge and confidence, paired with lack of secondary care support as their reason for not reviewing or reducing medication. GPs highlighted the lack of “exit plans” upon discharge, detailing the proposed strategy for antipsychotic medication dose adjustment in the long term. Conclusions: Meaningful antipsychotic medication reviews may not occur in primary care. This PhD identifies key considerations to help explain why this might be the case and summarises these in a list of recommendations, which carry important implications for policy and practice. Further research is required to identify evidence-based means of addressing these issues.

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