Table 5.

Barriers and facilitators to antipsychotic medication reviews

Barriers	Group	CMOC	Key quote	Facilitator
1. Low expectations	GP	Where GPs have low expectations regarding recovery for SU diagnosed with SMI(C), and rely on antipsychotics as a main treatment (C), then they may be left feeling hopeless (M), leading to little or no ongoing antipsychotic medication reviews (O).	“the most significant obstacles to the effective management of the chronically mentally ill are the prevailing negative attitudes and believes about them” [56] - author	Realistic expectations of what the medication can achieve [43, 62, 66], attempt to improving QoL [52, 63]
	Service users (SU)	Where GPs communicate hopelessness to SU (C), they may in turn feel hopeless (M), and therefore unlikely to commence a conversation about medication(O).	“When I approached my GP, he [..] said, ‘Well, you’ll be on these tablets for the rest of your life,[…] being told I’d never be able to work again, I’d never have an education, never have relationships, never have anything in my life. So, for a period of time I thought well, there’s no hope” [32] – SU focus group	Recovery orientated treatment [78]
2. Perceived lack of capabilities	GP	Where GPs perceive SUs to lack capabilities and/ or “insight” (C), despite years of stability (C), GPs may act in a paternalistic/authoritarian way (M) and dismiss medication queries (O) and a conversation regarding medication(O). Additional Context: 1) Where antipsychotic side effects are apparent in SU (apathy, cognitive impairment) 2) Where GPs feel pressure to prescribe 3) Diagnostic overshadowing (see Glossary)	GPs scepticism towards reliability and insight of people with psychosis may discourage clients themselves from help-seeking, with further negative effects on their health” [59] – author “I’ve had difficulty in getting full regular medical check-ups as every symptom is considered a sign for stress” [47] -SU interviews	See SU as capable; enable SU to discuss medication/ side effects; notion that medication queries are justified [43, 44, 82, 83] Commitment to Shared Decision Making (O)
	SU	In turn, experiencing a dismissal of their queries (C), particularly if SUs have a history of being coerced to take medication or being committed to treatment against their will (sectioning) (C), this will lead to decreased trust (M) in GPs, leading SU to not discuss medication with their GP (O) and covert medication changes (O).	I think it’s just a general disregard for they have for anything that people say, because they’re mentally ill therefore you know, anything they say is questionable [..] and they say, well, I have a problem with chlorpromazine or something, they might override that, rather than listen to what the consumer is saying” [84] – SU interview	Feel listened to, taken seriously, time to talk [44, 82]
3. Lack of information sharing	SU	Information about medication: Due to a lack of information (C), SU may be unaware (M) of the risk associated with antipsychotics and the need for check-ups, leading to no conversation (O) and lack of attendance at reviews (O).	55% [of patients] said that they were unaware of the potential metabolic side-effects of atypical antipsychotic medications [..]61% said that they had had no monitoring blood tests in the past year. 69% did not know that certain monitoring blood tests were recommended [33]. – SU response to survey	Provide more information [33, 43, 63, 71, 85]. Research required to established what constitutes sufficient information.
	GP	Information about side effects: Where GPs are aware of side effects (C),they may fear (M) that SU will discontinue their medication (O) and feel it is in the SUs interest (M) to not share more information regarding side effects (O).	“At one time … it was … if you tell patients about side effects, they won’t take the medication.” [74] – pharmacist interview	Increased information sharing can lead to higher adherence and facilitates trust [60, 84]
	SU	Due to lack of discussion about side effects (C), SU may in turn feel shocked (M) and loss of trust (M), where they experience side effects (C) which may lead them to alter or discontinue medication without further consultation (O). Distrust (M) is potentially amplified when SU access information elsewhere (C), like the internet, and realise that those are potentially common side effects.	“Lack of communication about antipsychotics was the contributing factor to my stopping attempt. I recall vividly when I was sitting on the couch, watching TV, and I looked down and I noticed my chest was wet, upon further inspection I realized that I was lactating. I was shocked, scared, and terrified. It was at that moment that I decided to quit.” [63]– SU interview	Access to sufficient information could help to increase SU confidence to commence conversations about medication [61]
4.Perceived risk	GP	Despite evidence to the contrary, GPs may consider SUs to be a risk to others (C), which can lead to fear in GPs (M), which may then lead to avoidance of medication reviews (O), or GPs taking a passive role (O).	A survey of GP attitudes to people diagnosed with schizophrenia found that they endorsed either “partially true” or “completely true” for: “people are frightened by them (93.9%) and ‘they would become dangerous if they stopped their medication’ (73.9%) [59].– GP responses to survey A survey of provider ratings of metabolic care barriers found that the most endorsed item in the category “primary care provider barriers” is “providers are scared of people with SMI” [76]– clinician responses to survey	Research needed to explore how to increase GPs feeling safe in appointments.
	SU	Where SUs have current/previous experience of being perceived as frightening (C), a good GP-SU relationship or open conversation is unlikely to occur (O). We were unable to elicit a mechanism here. Mechanisms were not identified in the literature, it is possible that a loss of trust or feeling disillusioned could play a role, however further research is required.	SU “felt their GP was scared of them, ending a consultation quickly and suggesting they find a different GP” [47] – SU interview	Feel comfortable at their GP practice, reassurance regarding risk of being sectioned.
5. Uncertainty regarding medication and illness trajectory	GP	Where there is a lack of guidance and (perceived) secondary care support (C), GPs may worry (M) about relapses and lack confidence (M) in changing medication and then they may be reluctant to change medication (O) even where SU are stable in mental health (C).	Many GPs are reluctant to reduce these without supervision, especially when the patient appears well. […] There is no clear agreement on the optimum frequency for reviewing maintenance treatment, nor is there consensus on what symptom-free period warrants consideration of discontinuation [1]. - author	Guidance on how to review and reduce (if indicated), secondary care support [1, 43]
	SU	SU may feel equally concerned (M) to start a conversation about medication (O), due to fears of relapse (M), especially for those who have a history of sectioning (C). SU may not even be aware that medication changes are possible (C)	“This dynamic [power imbalance] resulted in some participants feeling coerced into taking medication and out of control. [..]When the option to discontinue neuroleptic medication was not explicit, participants were left with uncertainty regarding the level of support they could expect from clinicians. […] All participants acknowledged the risks of withdrawing neuroleptic medication [43]. - SU interviews	Continuity of care; building of trusting relationship to enable discussion of medication changes and to identify and manage potential relapse [54, 60, 82]