How can service users and practitioners collaborate to optimise medication in people living with severe mental illness (SMI)?

Problem

Medication is a key treatment for people living with SMI. Medication optimisation can be challenging and failing to optimise the regimen can have devastating consequences both untreated mental illness and medication-related side-effects which increases the risk of relapse and non-adherence. MEDIATE, an NIHR Programme Development Grant, used a realist approach to understand the complexities and identify potential solutions.The overall aim was to understand what works, for whom, in what circumstances, to optimise medication use with people living with SMI.

Approach

Medication optimisation with people living with SMI was conceptualised as a complex process with outcomes that vary by individual and context. Realist research is well suited to make sense of complexity. The review was supported by key stakeholder engagement via Lived Experience and Practitioner Group meetings (n=6 and n=5 respectively) to help contextualise findings and identify gaps in the evidence.The review was conducted over five stages: 1: Developing Initial Programme Theories: An explanation for what needs to be done, by whom, how and why, and in what contexts was developed. 2: Developing Search Strategy: The programme theory was refined with input from stakeholders. 3: Selection/Appraisal: Documents were screened against inclusion and exclusion criteria. 4: Data Extraction and Analysis/Synthesis: Data were analysed with a realist logic with contexts, mechanisms and outcomes identified. 5: Programme Theory Development: Refined programme theories were based on: key outcomes and strategies required to trigger outcomes.

Findings

Medication optimisation is possible, in SMI, within the context of shared decision-making between service users and practitioners. Early and ongoing positive experiences can help service users form trusting therapeutic relationships, openly discuss medication concerns with practitioners including honest conversations about the level of adherence and negotiate changes to medications based on the lifestyle needs of the service user. Conversely, negative contacts with healthcare services, such as coercive treatment practices, adversely influence future therapeutic relationships, and ultimately, impact medication optimisation. Service users frequently access additional sources of information about medication and their mental illness from the internet, family, friends and peer support workers. Peer support workers are an important, and untapped resource, to service users in relation to medication, given their lived experience with SMI.

Consequences

Shared decision-making is critical to medication optimisation with people living with SMI. Positive early and continuing encounters with healthcare services and practitioners are key to achieving this goal. Most service users are cared for in community settings by primary care. GPs, community pharmacists and others may not have the knowledge or skills to deal with complex queries or change medications. This can impact the therapeutic relationship potentially prompting service users to manage their medication in the absence of practitioner input which could increase the risk of withdrawal effects and relapse.