‘Flattened, fattened, and forgotten’: the ‘dis-integrated’ care of patients prescribed antipsychotics in the UK

Rising antipsychotic burden in primary care

There is a growing problem with antipsychotic prescribing, that if the NHS is not careful, could become a new scandal in the making. Illnesses that require treatment with antipsychotics have increased risks for development of multimorbidity, polypharmacy, and premature mortality.¹ These medications — originally reserved for treatment of serious mental illnesses (SMIs), such as schizophrenia and bipolar affective disorder — can be lifesaving or transformative, and we value their appropriate clinical use. This editorial is not ‘anti-psychiatry’; nor do we advise patients to stop taking antipsychotics without expert review. However, antipsychotics cause weight gain, glucose dysregulation, and dyslipidaemia; these exacerbate the SMI-patient specific risks for obesity, diabetes, and cardiovascular disease, which contribute towards premature death around 10–20 years earlier than their peers.² People prescribed antipsychotics require proactive physical health monitoring, coordinated care, and early, sustained interventions to minimise risks. Central to these interventions are rational prescribing, lowering doses, or switching antipsychotics to those with lower cardiometabolic risk when possible. Sadly, the fracturing of NHS services is failing to address this need, often leaving patients ‘flattened, fattened, and forgotten’, as was poignantly summarised by Carolyn A Chew-Graham and colleagues, including the lived experience of GP David Shiers as the father of a patient.¹

The growing antipsychotic burden is fuelled by a triumvirate of factors. First, increasing antipsychotic prevalence is occurring in the UK and internationally, despite no significant increase in prevalence of psychotic illness, with the greatest burden of use in those who are most socioeconomically deprived.^3,4 Second, in the UK, antipsychotics are usually initiated by psychiatrists, but due to persistent underfunding of mental health services, pressure is placed on teams to discharge ‘non-SMI patients’ to primary care.⁵ It is easily understood why psychiatric services under pressure may use antipsychotics to manage patients as a stop-gap, enabling earlier discharge to general practice, when the alternative is patients waiting — often years — for psychological therapy; nearly half of all adults taking long-term antipsychotics are now discharged to primary care.^3,6 Sadly, due to lack of follow-up and barriers to service engagement, patients often never receive psychological therapy and remain on antipsychotics long-term. Finally, expanding ‘off-label’ antipsychotic use for non-SMI conditions such as mood disorders, insomnia, and for emotional and behavioural regulation, means these patients are ineligible for funded physical health monitoring, because the criteria for monitoring is based on an outdated diagnostic classification focusing on schizophrenia and bipolar disorder rather than antipsychotic use (as defined by the NHS Quality and Outcomes Framework [QOF] severe mental health register).⁷ We estimate that up to 500 000 patients may be affected in the UK, with over 50% of antipsychotic prescriptions being for non-SMI conditions that do not qualify for QOF-funded cardiometabolic monitoring.³

Fragmented care, fragmented lives

Psychiatric services are under-resourced and under extreme pressure; many teams lack access to physical health interventions, and some psychiatrists report feeling underskilled in their use, being told to refer back to the GP to arrange.⁵ GPs are equally overwhelmed with unfunded transfer of work from secondary care, of which psychiatry is only one of many. Few GPs have the expertise to adjust antipsychotic prescribing; many are reluctant to make changes that may risk disrupting a patient’s stability, further complicating care.⁵ Therefore, a growing cohort of patients may remain ‘trapped’ on antipsychotics without effective review, with little care coordination between services that struggle to communicate, share records, or arrange health interventions.^5,8 Further, across the UK, the QOF, which originally provided physical health surveillance for those with SMI, has been largely abandoned in Scotland and Wales, resulting in a diffusion of responsibility for cardiometabolic monitoring. Funding for this has supposedly been included in the GP core contract, but without external scrutiny it will largely be down to GPs to take the lead, with many competing pressures to ensure monitoring occurs. In 2016, Scotland abolished the QOF but continued collecting national performance data; after 3 years, a substantial reduction in mental health and cardiometabolic monitoring was observed.⁹ Fragmented provision now exists, and we suspect that Julian Tudor Hart’s inverse care law will apply, with patients in the most deprived areas, with the highest burdens of mental illness, being those least likely to receive specialist review. That this is continuing to happen, despite repeated warnings,¹ to some of the most vulnerable patients in the UK is shameful.

Avoiding a new healthcare crisis

Few clinicians can fail to be concerned about how benzodiazepines were overprescribed, causing millions of patients’ long-term harm, and rightly, much tighter regulation of these medications has been introduced, with national prescribing indicators to reduce inappropriate use. Data suggests an emerging problem with antipsychotics, as more are used off-label for their hypnotic and behavioural regulation properties. Quetiapine appears the most mis-prescribed, and yet even low doses may increase cardiovascular risks.¹⁰ A minority of care homes still pressure doctors into prescribing antipsychotics for patients with dementia who can be difficult to manage — 18% of long-term risperidone use is for patients with dementia despite known risks of harm^3,5 — possibly because it is difficult to retain skilled staff able to deploy behavioural interventions. It is, again, a shameful indictment of the insidious unintended effect of the UK’s profit-oriented care system; excessive use in some care homes needs to be addressed. Finally, the pharmaceutical industry is not without blame; the drive to extend product licences beyond SMI has been done without any evidence to assist in their safe deprescribing and withdrawal. Such studies must be funded and industry should share the cost.

Ending ‘dis-integrated’ care

There is a pressing need to reduce inappropriate antipsychotic prescribing. Urgent changes are needed to ensure that all patients prescribed antipsychotics receive annual cardiometabolic screening alongside regular psychiatric review with an aim to rationalise prescribing, and to ensure that options other than continued antipsychotic use have been explored. This must be supported by mechanisms to fund care that are genuinely integrated around the patient, rather than a buzz-word.

We propose the following actions:

1. a joint working party between the Royal College of Psychiatrists and Royal College of General Practitioners to narrow the ‘dis-integrated’ care gap;

2. guideline development specifically for antipsychotics that address using these medications long-term;

3. national prescribing indicators to address inappropriate long-term antipsychotic use; and

4. evidence syntheses from intervention studies that demonstrate safe ways to withdraw, reduce, or switch antipsychotics, and improve physical health especially for patients using antipsychotics for non-SMI conditions.

There is, however, hope on the horizon, with the development of AI-augmented decision support to assist prescribers in undertaking evidence-based prescribing optimisation, but these alone will not work without a national drive to better integrate care caused by services working in silos.¹¹ A learning systems approach, using evidence from real world data and involvement of patient experts, should be at the forefront of driving this change.¹² Let’s get ahead of this emerging ‘antipsychotic crisis’ now, before we face another psychotropic drug scandal that damages the credibility of our profession.

Provenance

Commissioned; not externally peer reviewed.

Competing interests

The authors have declared no competing interests.