This review set out to determine which factors influence antipsychotic medication reviews in primary care. Using realist review methodology, an extensive search of the literature identified documents including data that was used to develop several CMOCs. Taken together, the CMOCs indicate the ways in which prevalent stereotypes can impede antipsychotic medication reviews. These include:
1) low expectations of people with SMI and their recovery resulting in a lack of conversations started due to hopelessness,
2) the perception that SU lack the capabilities and “insight” required to manage their illness, leading SU to feel dismissed and not taken seriously in appointments.
3) a lack of information from both GPs and SU. GPs may not share sufficient information regarding medication risks and side effects due to fears of SU stopping medication. Equally, SU may not share all information regarding their current dose and symptoms due to fears of coercion and sectioning.
4) the perception that SU pose a risk, preventing a trusting GP – SU relationship to form and
5) mutual understandable concerns regarding antipsychotic medication changes, due to the potential for relapse and uncertainties regarding effects of dose reduction, resulting in avoidance of reviewing antipsychotic medication.
The evidence reviewed suggested several factors that are relevant to whether appropriate medication reviews are conducted with individuals with schizophrenia or psychosis. Firstly, it identified a lack of communication between SU and GPs in relation to antipsychotic medication. Attribution theory suggests that stereotypes held by clinicians and SU can change their behaviour towards each other (56,78). GP expectations of lack of capacity or “insight” for example can lead to paternalistic attitudes, which prevent properly informed discussions about treatment, and do not facilitate participation of the individual in the decision-making process. The review findings evidence this, as well as the need for aspects of the therapeutic relationship, like hope and trust, to counter some of those mechanisms. Increased trust has been associated with a better therapeutic alliance (38,49,55,57,79). Given that there are multiple types of antipsychotics and dosing options, varying responses to antipsychotic medication, and no guidelines on how to review and reduce medication (16), GPs and SU encounter many uncertainties. Managing these uncertainties together requires a trusting relationship between GP and SU (55,57). Any history of coercion or sectioning under the Mental Health Act can make developing and maintaining trust more difficult, but a trusting relationship is key to shared decision making (24,79). Given the power imbalance between SU and GPs, and often held view that “doctor knows best” (79) the onus might be on the GP to start the conversation.
Strength and Limitations
This review has benefited from the input of a diverse stakeholder group, including GPs, psychiatrists and a Lived Experience Advisory panel (LEAP). This input helped ensure that the views of these groups informed the focus of the review, and the development and refinement of the programme theory. The data included in this review was found in documents identified by a comprehensive literature search strategy, including sensitive searches in a wide range of databases and the inclusion of additional material via citation chaining. The review has been conducted and reported following the RAMESES standards (18,19).
The review’s findings are limited by the availability of data used to develop the CMOCs presented above. For example, no CMOCs were identified in relation to balancing risks of reducing versus continuing medication, or in relation to best methods for tapering medication (potentially important personal and clinical challenges with regards to medication), highlighting the need for further research in this area. Many of the included studies focused on specific contexts and outcomes, providing little data relating to mechanisms, or on why the outcomes they included were found. Although several included studies addressed the care of SU with a diagnosis of schizophrenia or psychosis in primary care specifically, none have researched a primary care only population. As a result, the findings are applied with caution to this population.
This review should be viewed as an initial model, which has identified several CMOCs which require further testing and refinement. The evidence found for this review reflects GPs and SUs self-reported actions and feelings, but whether is impacts their behaviour in a consultation is not clear (48). It is of course possible that even despite the above listed stereotypes, that practice is not affected, or affected in ways not described above.
The review also has a UK focus, and some findings may not apply to countries where GPs do not act as “gate-keepers” to secondary or specialist care.
Comparison with existing literature
The review did not identify any existing literature, practice guidelines or interventions assessing the treatment and care of SU who are under primary care only. Previous research found that when comparing patient records, primary care only SU are older, have fewer GP appointments and are on more medication overall (2,3). The content of antipsychotic medication reviews, as well as their feasibility in primary care, have not been investigated. A focus group study of SU diagnosed with SMI was conducted in primary care (27), however SU were not explicitly primary care only, therefore it is difficult to estimate their treatment experiences and expectations, since they may differ if they are no longer under secondary care. A recent systematic review also identified expectations of low capabilities, lack of trust and paternalism (including the decision to limit the amount of information regarding adverse effects shared and “doctor knows best” mentality; (80) as barriers to patient involved prescribing.
Previous literature cites negative symptoms like apathy and paranoia, as well as cognitive difficulties associated with a diagnosis of SMI, as a reason for lack of engagement with health services in this population (5,81). The above listed CMOCs offer additional explanations, alongside potential solutions to improve engagement in the future. A recent study on lifestyle interventions to reduce cardiovascular risk also found that primary care health professionals described people as “threatening or scary or difficult” (p7, (82). This prevented staff from offering interventions. These results align with the findings of this review and illustrate the impact stigma still has on service provision. Clearer guidance is needed to address issues around (perceived) risk management in this population.
More research is urgently needed to address this gap in knowledge regarding primary care only SUs’ individual needs and treatment, as well as how GPs can be better supported to look after a population estimated to include approximately 30% of all SU with a diagnosis of schizophrenia or psychosis (2,3). This research should include studies linking patient-level data from primary care with secondary care patient records, to establish exact numbers of primary care only SU, and compare the demographics and potentially unique needs of this population, as well as research exploring SU and GP views on receiving or providing antipsychotic medication reviews solely in primary care.
Implications for research and/or practice
Several recommendations for practice can be made on the basis of this review’s findings. Increasing GP knowledge regarding antipsychotic treatment could help GPs to develop their confidence to balance risks and benefits and make changes to medication, like reducing doses to improve side effect burden. Greater familiarity with the recovery agenda may help GPs to appreciate the possibilities of living a fulfilling life with and without medication, to counter some of the hopelessness identified in CMOC 1.
To combat some communication difficulties (as seen in CMOC 2), GPs need to enable SU to express their views (79,81) and take SU concerns seriously (39). This may also include structured assessments, as SU may not volunteer problems with their medication (2). SU complaints and queries regarding antipsychotic medication should be assumed to be justified and need proper consideration. Such ways of working are established best practice in consultation in primary care (83) but may be less common when working with individuals with psychosis. Conversations about medication should include sufficient information about antipsychotic medication (CMOC 3), and side effects as well as benefits. Increasing SU awareness of potentially severe side effects has been associated with increased trust between SU and GP (55,79) and allows SU to prepare for side effects and return to the GP for help if they persist or cause problems. Engagement with physical health monitoring may also increase, if SU are aware of the specific reasons for this (CMOC 3), which may tackle some health disparities between this population and the general population (66). This may also help to avoid SU discontinuing medication without consultation. Some evidence suggests that pharmacists can help to increase knowledge (70,84). This could ease the pressure of time limited appointments. Access to sufficient information could help to increase SU confidence to commence conversations about medication (57), improve adherence (62,68), patient safety (72) and facilitate Shared Decision Making (SDM; (58)). A more nuanced knowledge of risk would be beneficial (CMOC 4). Whereas there are certain risks associated with a SMI diagnosis, like higher rates of substances abuse, these are not as great as perceived by the general population (53), and SU have been found to be 14 times more likely to be victims of violent crime than being the perpetrator (85). A safe environment needs to be developed for GPs and SU alike.
Concerns about relapse are understandable (CMOC 5) but should not necessarily exclude attempts to reduce the dose of antipsychotic medication slowly and carefully to facilitate patient choice and minimise side effects and health complications. Continuity of care has been highlighted as a crucial factor for this population (49,79) as it can help GPs to potentially spot signs of relapse early and offer appropriate support, and is likely to be an important factor in facilitating a safe process of medication change. Continuity may also increase SU trust and encourage the start of conversations about medication. Trust could also facilitate safer prescribing (55), as SU may tailor their dose of medication, without necessarily consulting their doctor (84) and may be reluctant to disclose this due to fears of being sectioned/coerced.
Better guidance on safe reduction and discontinuation of medication(16), with a specific focus on whether this is achievable in primary care is needed, as well as better links between primary and secondary care services, as GPs do not seem to feel supported (5,26,86,87). Knowing that support is available may increase GP confidence.
Putting these recommendations in place could be a start to strengthening trust and commencing conversations, to enable appropriate and safe prescribing, whilst also maximising quality of life.