Perspectives of clinicians on switching antipsychotics to improve the physical health of people with schizophrenia: a qualitative study

Problem

People with schizophrenia have an increased risk of diabetes mellitus (DM) and metabolic syndrome, and are at much greater risk of dying prematurely compared to the general population. The increased risk is multifactorial, including lifestyle factors such as diet, low levels of activity, and smoking. However, a major risk factor for metabolic syndrome and diabetes is the antipsychotic medication prescribed to control symptoms, and specifically the type of anti-psychotic, with some conferring a higher risk of metabolic syndrome compared to others.

An expert consensus statement on the management of metabolic syndrome associated with antipsychotic use recommended that switching to a low-risk drug is considered when a patient gains 7% of the initial weight or develops hyperglycaemia, hyperlipidaemia, hypertension or other clinically significant cardiovascular or metabolic adverse effect. There are, however, a number of challenges in implementing switching in clinical practice, including lack of knowledge in health care professionals (HCPs) about the potential benefits of switching, a lack of guidance on optimum switching practice, and unknown acceptability of switching for people with schizophrenia.

Approach

NHS ethics and HRA approvals gained.

A qualitative study involving semi-structured interviews with people with schizophrenia as well as HCPs from primary and secondary care [including psychiatrists, mental health nurses (Ns) and general practitioners (GPs)] in the West Midlands and North West England. A patient and public (PPI) advisory group contributed to the topic guides. Interviews were digitally recorded with consent and transcribed verbatim. Analysis was conducted by members of the research team, using the principles of constant comparison. The PPI advisory group will meet to discuss data analysis and plan dissemination.

Findings

Data generation is in progress. Initial analysis of transcripts of 3 Psychiatrists, 3 Ns and 2 GPs suggests the following themes: awareness of metabolic side-effects of antipsychotic drugs; lack of clarity over individual responsibility versus a team effort to suggest a change in medication; making the decision to switch versus maintaining the status quo; communicating the decision to switch. Barriers to switching included concern over the risk of relapse if medication was effectively treating mental health symptoms, absence of symptoms due to physical health problems, and the perception that patients are reluctant to change medication. Lack of a support network for the patient was perceived to influence treatment decisions. Clinician uncertainty was evident across the data-sets.

Consequences

Findings illustrate an interplay between uncertainty, understanding, responsibility and decision-making, resulting in reluctance to suggest making a switch to a lower-risk antipsychotic to improve physical health. This is made more complex by care across multiple interfaces. All clinicians suggested the need for the development of a protocol to guide switching.

Data generation is continuing, with recruitment of people with schizophrenia to explore their knowledge and experiences of switching.