Literature Reviewed

Switching antipsychotics to support the physical health of people with severe mental illness: a qualitative study of healthcare professionals’ perspectives by Nash A, Kingstone T, Farooq S, et al. BMJ Open. 2021;11(2):e042497.

Original Abstract

Objective: The side effects of antipsychotic medications (APs) can increase the risk of developing physical health conditions. Some APs pose a higher risk than others. Evidence suggests switching to lower risk APs can support physical health outcomes. We sought to explore the views of healthcare professionals about switching antipsychotics to support physical health in people with severe mental illness (SMI)

Design: A qualitative study with semi-structured interviews conducted with general practitioners (GPs), psychiatrists and mental health nurses. The main focus was to explore participants’ views on the physical health of people with SMI, the impact of APs and decision-making about switching medication to support physical health. Data were analysed thematically using principles of constant comparison.

Settings: Participants recruited through primary care and one mental health trust in the West Midlands.

Participants: Interviews were conducted with 9 GPs, 10 psychiatrists and 4 mental health nurses.

Results: Awareness and knowledge of AP side-effects and risk profiles varied considerably between primary and secondary care clinicians. GPs reported limited awareness, while psychiatrists and nurses demonstrated a comprehensive understanding of AP risk profiles and side-effects. Mental health and control of symptoms were prioritised. Switching to promote physical health was considered as a reactive intervention, once side-effects or complications developed. There were a range of views over where responsibility lay for monitoring physical health and consideration of switching. Collaboration between primary and secondary care was identified as a way to address this.

Conclusions: This study presents multidisciplinary perspectives on awareness, decision making, perceived responsibility and barriers to switching APs to support physical health. Collaborative approaches that involve liaison between primary and secondary care, but tailored to the individual patient, may support switching and present an opportunity to intervene to address the physical health inequalities experienced by individuals with SMI.

Read the full paper.

Switching Antipsychotics: Commentary and Clinical Takeaways

This qualitative study by Nash et al utilizes perspectives from three different disciplines including general practice (GPs), nursing and psychiatry to provide a holistic account of perspectives on switching antipsychotic medications.3 Healthcare providers (HCPs) participated in a semi-structured interview conducted by Nash using a topic guide developed using existing literature in this area.3 (For more detailed information on the topic guide, please reference Box 1 in the original article.) Interviews were conducted with 9 general practitioners (GPs), 10 psychiatrists and 4 mental health nurses; interview times ranged from 44 minutes to 85 minutes.3

Risks of Switching Antipsychotic Medications

HCPs described the difficult challenge of balancing a patient’s mental health versus their physical health.3 Their concerns were making sure their mental health was taken care of, their symptoms were minimal, and that they tolerated their medications and viewed physical health as a later complication.  All participating clinicians were aware of physical health side effects caused by antipsychotics including the increased risk of cardiovascular disease, diabetes, and weight gain but some HCPs were unaware of the different risks between medications.3

Often, HCPs in this study would switch medication as a reaction to an emerging physical health problem or by prompting of the patient – not as a proactive intervention. Rather than switching antipsychotics, they would increase the dose or further add medications to combat the physical health problems along with diet and exercise.3

Antipsychotic Prescribing Responsibility

Additionally, the authors pointed out the differing opinions on whose responsibility is it to prescribe and make antipsychotic medication changes? Many GPs described “being willing to continue to prescribe medication initiated by specialists” but would contact the psychiatrist if they believed the underlying cause of the medical condition was due to their medications.3 Another discrepancy identified was who was responsible for patient education on their antipsychotic medication? Most of the GPs expected psychiatrists to inform the patient when the medication was started as they generally do not counsel and educate patients.3 This gap in communication could leave the patient unaware of potential side effects. Collaboration between patients and HCPs, along with resources and services, were identified as key to supporting patients with serious mental illness (SMI). Communication and educational materials often included discussions about switching medications, side effect management, and supporting patients who would like autonomy in their care to make a medication change suggestion.3

Overall, this paper provides multidisciplinary perspectives on the treatment of SMI, such as schizophrenia and bipolar disorder, with antipsychotics and the barriers experienced by healthcare providers, especially in regard to management of prescribing, mitigation of side effects, and identifying whose responsibility it is to manage which section of care. The need for collaborative care in treating patients with SMI is key to their success.

While pharmacists were not analyzed in the study specifically, they contribute to interdisciplinary care by helping providers choose medications based on patient factors. For example, a pharmacist can assist prescribers who are not as familiar with medication nuances by providing information on different receptor profiles and how they may impact certain side effects as well as efficacy. Clinical pharmacists can also help to ensure that patients understand their medications and respective side effects, reinforce healthy diet and exercise, and encourage regular follow up with GPs and other team providers.

Next Paper in the Literature Review: Antipsychotic Polypharmacy. Focus (Am Psychiatr Publ) by Foster A, King J. 2020.

Prior Paper in the Literature Review: Atypical Antipsychotics and Metabolic Syndrome: From Molecular Mechanisms to Clinical Differences by Carli M, Kolachalam S, Longoni B, et al. Pharmaceuticals (Basel). 2021.

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Last Updated: Sep 1, 2021