Objectives In July 2021, the Essencial initiative ‘adding value to clinical practice’ from Catalonia (Spain) issued a do-not-do recommendation regarding patients with schizophrenia treated with at least three antipsychotic drugs (AP). In 2019, its prevalence in Catalonia was 10.8%. Within our de-implementation framework, one of the stages is the identification of causes and potential solutions. The objective is to explore the perceptions of mental health professionals (MHP) regarding barriers and interventions for antipsychotics polypharmacy (APP) prescription and to review the available literature on successful interventions to reduce unnecessary treatments.
Methods Firstly, using an intentional non-probabilistic sampling, we identified 30 mental health centres (MHC) from different regions and healthcare complexity, which had either the lowest or the highest adequacy results on APP. An online survey with open questions was sent to them, which included several issues regarding views on driving forces and specific interventions to avoid APP at local and regional levels.
Secondly, we conducted a rapid literature review on APP deprescription experiences to gain understanding of which were the most successful interventions.
Finally, 10 MHP leaders participated in a focus group to discuss their perceptions on APP causes and solutions. The main results of the previous survey and literature review were shared. Later, the participants prioritized and proposed three interventions that could effectively improve in terms of quality and safety of AP prescription.
Results Seventeen MHC answered the survey (57% response rate), and the main causes identified for APP were 1)using AP for insomnia to avoid benzodiazepines (N=12), 2)treatment-resistant patients (N=11), and 3)lack of HP’s knowledge (N=7). Regarding interventions, the most commented were 1)training HP and patients (N=14), 2)fostering clozapine prescription (N=6), and 3)periodic treatment review (N=4).
As for the literature review, we found 13 interventions and grouped them into three categories: interventions directed to MHPs (N=8), dosage adjustment (N=4) and national health policy (N=1). Barriers to change included MHPs’ and patients’ perceptions, fear of relapse and reluctance to discontinue AP once started.
During the focus group, MHPs did not consider that APP was a low-value practice. In terms of their perceptions, possible causes for APP were (i)that those patients were treatment-resistant and (ii)that healthcare organizational constraints (such as lack of visiting time and limited resources for lab tests) facilitated the use of more aggressive treatments. The three effective interventions prioritized to improve AP prescription were: MHP training, clozapine fostering and electronic prescription alarms.
Conclusions Overall, the barriers and solutions identified varied in nature, scale, complexity and size. They require tailored and multi-level interventions and the involvement of different stakeholders (MHPs, decision-makers and citizens). Nonetheless, this is a relevant task because APP affects patient’s safety, quality of life and it deals with long-term side effects. Efforts need to be made to raise awareness that APP is a low-value practice, in order to prevent its prescription. Solutions and strategies should be agreed upon and implemented to reassess patients with schizophrenia, and to deprescribe AP when indicated, in a safe manner.
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