Primary care use of antipsychotic drugs: an audit and intervention study.
BACKGROUND
Concerns regarding the use of antipsychotic medication in secondary care suggested an examination of primary care prescribing.


OBJECTIVE
To audit and intervene in the suboptimal prescribing of antipsychotic drugs to primary care patients.


METHODS
Cross-sectional prevalence: subsequent open treatment intervention.


METHODS
Seven of the 29 practices in the Eastern Hull Primary Care Trust.


METHODS
Criteria for best practice were developed, against which prescribing standards were tested via audit. Patients identified as suboptimally prescribed for were invited to attend an expert review for intervention.


RESULTS
1 in 100 of 53,000 patients was prescribed antipsychotic treatment. Diagnoses indicating this were impossible to ascertain reliably. Half the regimes failed one or more audit criteria, leaving diagnosis aside. Few practices agreed to patients being approached: of 179 invitations sent, only 40 patients attended. Of 32 still taking an antipsychotic drug, 26 required changes. Mean audit criteria failed were 3.4, lack of psychotic disorder diagnosis and problematic side effects being most frequent. Changes were fully implemented in only 16 patients: reasons for complete or partial failure to implement recommendations included the wishes or inaction of patients and professionals, and worsening of symptoms including two cases of antipsychotic withdrawal syndrome.


CONCLUSIONS
Primary care prescribing of antipsychotic drugs is infrequent, but most is unsatisfactory. Intervention is hampered by pluralistic reluctance: even with expert guidance, rationalisation is not without risk. Use of antipsychotic drugs in primary care patients whose diagnosis does not warrant this should be avoided. HOW THIS FITS IN: This study adds to concerns regarding high levels of off-licence use of potentially harmful medication. It adds evidence of major difficulties in rationalizing suboptimal regimes despite expert input. Relevance to the clinician is that it is better to avoid such regimes in the first place especially if there is no clear 'exit strategy': if in doubt, seek a specialist opinion.
Mortimer
Ann M
AM
Foundation Chair in Psychiatry/Head of Department, The Department of Psychiatry, The University of Hull, Cottingham Road, Hull, HU6 7RX, UK. A.M.Mortimer@hull.ac.uk
Shepherd
Charles J
CJ
Rymer
Michael
M
Burrows
Alison
A