Antipsychotic management in general practice: serial cross-sectional study (2011-2020)

Abstract

AbstractBackgroundLong-term use of antipsychotics confers increased risk of cardiometabolic disease. Ongoing need should be reviewed regularly by psychiatrists.AimTo explore trends in antipsychotic management in general practice, and proportions of patients prescribed antipsychotics receiving psychiatrist review.Design and SettingA serial cross-sectional study using linked general practice and hospital data in Wales (2011-2020).MethodParticipants were adults (≥18 years) registered with general practices in Wales. Outcome measures were prevalence of patients receiving ≥6 antipsychotic prescriptions annually, proportion of patients prescribed antipsychotics receiving annual psychiatrist review, and proportion of patients prescribed antipsychotics registered on UK Serious Mental Illness, Depression and/or Dementia registers, or not on any of these registers.ResultsPrevalence of adults prescribed long-term antipsychotics increased from 1.06% (95%CI 1.04 to 1.07%) in 2011 to 1.45% (95%CI 1.43 to 1.46%) in 2020. The proportion receiving annual psychiatrist review decreased from 59.6% (95%CI 58.9 to 60.4%) in 2011 to 52.0% (95C%CI 51.4 to 52.7%) in 2020. The proportion of antipsychotics prescribed to patients not on the Serious Mental Illness register increased from 50% (95%CI 49 to 51%) in 2011 to 56% (95%CI 56 to 57%) by 2020.ConclusionsPrevalence of long-term antipsychotic use is increasing. More patients are managed by general practitioners without psychiatrist review and are not on monitored disease registers; they thus may be less likely to undergo cardiometabolic monitoring and miss opportunities to optimise or deprescribe antipsychotics. These trends pose risks for patients and need to be addressed urgently.How this fits inAntipsychotics are effective treatments for serious mental illness, but long-term use increases the risk of cardiometabolic disease, therefore ongoing use should be reviewed regularly. There is increasing use of these medications for non-psychotic mental illness by psychiatrists who then discharge patients to sole care by GPs, often for patients who are not captured on disease registers that automate recall for cardiometabolic risk monitoring. This study demonstrates a rising burden of long-term antipsychotic prescribing in general practice, with nearly half of all adult patients not under annual psychiatrist review, and only 44% of long-term antipsychotic prescriptions being issued to patients coded on the Quality and Outcomes Framework (QOF) Serious Mental Illness register. This means many patients taking antipsychotics may be missed for cardiometabolic screening and expert review. Policy changes are required to ensure regular effective review and monitoring to prevent increasing morbidity and early mortality for patients prescribed long-term antipsychotics.