What are the challenges / barriers for GPs in prescribing cardioprotective medication to patients with severe mental illness (schizophrenia, bipolar disorder, major depression)? A qualitative study in Edinburgh and Glasgow health board areas.
Problem
People with severe mental illness (SMI) die 10-20 years sooner than the general population, partly due to increased cardiovascular disease (CVD) risk. Following heart attack, mortality and further vascular events are more likely. Data indicates poorer outcomes may be partly due to GPs lower prescribing rates of cardioprotective medication to SMI patients. To our knowledge, no previous study has investigated GPs’ views of SMI cardioprotective medication thus we explored their potential challenges.
Approach
15 semi-structured qualitative interviews were conducted via Teams in October-November 2022 with GPs in NHS Lothian and NHS Greater Glasgow & Clyde Health Board areas, recruited via our networks and study publicising. Qualitative data were audio-recorded, transcribed and analysed using NVivo software and thematic analysis.
Findings
Whilst GPs were aware that patients with SMIs had increased risks of CVD, reasons for lack of routine prescribing of cardioprotective medications in some of these patients were themed around: challenges/barriers, enablers and structural/contextual factors. Lack of funding and the general practice crisis has resulted in GPs being unable to optimally care for their SMI patients. They feel forced to ‘firefight’, managing only urgent health conditions, rather than using primary prevention.
Prescribing cardioprotective medication was viewed as dissonant with holistic medicine, as CVD risk was perceived as outwith SMI patients’ priorities. These patients are less likely to attend with overall diminished treatment engagement. Moreover, frequent unmet basic needs as well as multiple and complex needs require attempts at addressing first. Thus, GPs were highly concerned about concordance.
Structural/contextual barriers included general practice being currently severely under-funded with workforce shortfalls and recruitment and retention problems. Backlogs of COVID-19 untreated patients’ conditions played into an already weakened state of general practice. Resultantly, fostering the depth of doctor-patient relationship required to have ‘those really difficult but really important conversations’ and continuity of care is challenged. Severe problems with IT systems and technology for identifying at-risk patients and suitably screening and monitoring them was acute. Problems with integrated care and communication between physical and mental health teams were cited, as well as mental health services long waiting lists.
Many GPs aspire to initiating cardioprotective medication proposing potential solutions e.g. facilitating strong doctor-patient relationships via appropriate continuity of care and embedding key MDT staff such as mental health nurses and pharmacists. Addressing patients’ lifestyle factors as fundamental first before medication could, or should, be considered was salient.
Consequences
The findings fill a gap in a highly under-researched area and have implications for planning and delivery of improved, inclusive and integrated healthcare, especially for vulnerable, and often excluded, patient groups such as those with SMI. Future research in this area should explore experiences of SMI patients and other practitioners.