Family Practice Vol. 20, No. 2, 126-128
© Oxford University Press 2003
Clinical Research |
The needs of patients receiving depot antipsychotic medication within primary care
Academic Centre, St Bernard’s Wing, Uxbridge Road, Middlesex UB1 3EU and
a Department of Psychiatry, Imperial College School of Medicine, London, UK.
Correspondence to Michael Phelan; E-mail: michael.phelan{at}wlmht.nhs.uk
Phelan M and Mirza I. The needs of patients receiving depot antipsychotic medication within primary care. Family Practice 2003; 20: 126–128.
Received 23 April 2002; Revised 23 August 2002; Accepted 4 November 2002.
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Abstract |
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Background. Depot antipsychotic medication is a vital treatment for many people with schizophrenia. Many patients receive this medication from primary care, and have little or no contact with specialist mental health services.
Objective. The aim of the present study was to compare the characteristics and needs of patients receiving depot medication within primary care with those receiving their medication from specialist mental health services.
Methods. A total of 58 patients were identified from four primary care teams. Data were collected from medical records, and staff interviews were conducted using standardized interview schedules.
Results. Patients receiving medication from primary care had more than twice as many health and social needs compared with those receiving medication from specialist services.
Conclusions. There are advantages for patients to receive depot medication from primary care, but the needs of the patients must be reviewed regularly, and primary care staff must have easy access to specialist mental health services.
Keywords. Depot antipsychotic, needs assessment, schizophrenia.
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Introduction |
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The needs of patients with schizophrenia depend on the severity of their disorder, but they often require a range of health and social care over many years. The closure of long-stay psychiatric hospitals has resulted in people with a severe mental illness being more dependent on community-based mental health services and primary care teams.1
Although some patients with schizophrenia have little or no contact with primary care, most are frequent attenders,2 and staff do have an opportunity to play an important role in their management.3 In the UK, around a quarter of people with schizophrenia have no contact with specialist mental health services, and are only seen in primary care.4 From the patients’ perspective, primary care has the potential to offer an accessible, non-stigmatizing service, as well as continuity of care. A proportion of psychotic patients receive depot antipsychotic medication from primary care staff; the number who do so, and the arrangements for how the medication is administered vary between practices.5
The aim of this study was to examine the characteristics and needs of patients receiving depot medication within primary care, and compare them with similar patients who were administered the same type of medication from specialist mental health services.
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Methods |
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Four general practices in west London agreed to participate in the study. We identified all patients registered with the practices who were (i) currently receiving depot antipsychotic medication and (ii) had a clinical diagnosis of an enduring psychotic illness defined in ICD-10 group F20–29 (which includes schizophrenia, schizotypal and delusional disorders). Diagnostic, socio-demographic and treatment data were obtained from written patient records. Staff who administered the depot medication were then interviewed. For the primary care group, this was a practice nurse, except for three patients where it was the GP. For the other group, it was a community psychiatric nurse (CPN), attached to the local mental health team. The interview consisted of checking data from written notes, and two standardized interview schedules, designed for use with people with severe mental illnesses: (i) The Global Assessment of Functioning Scale (GAF), which provides a measure of psychological, social and occupational functioning, on a 0–90 scale;6 and (ii) The Camberwell Assessment of Need Short Appraisal Schedule (CANSAS), which records met and unmet needs in 22 areas of basic, health and social needs.7
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Results |
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Twenty-seven patients receiving depot medication from primary care staff were identified and group matched (age within 5 year range, sex and diagnosis) with 31 patients who were registered at the same practices, but received depot medication from local mental health teams.
The groups were similar in terms of age, sex, diagnosis, marital status, children and residence. The majority of the patients were single, lived alone and had schizophrenia. There were no statistically significant differences in reported levels of global functioning, measured by the GAF [median case versus control 60 versus 50, odds ratio (OR) 1.63, 95% confidence interval (CI) 0.51–5.18, P = 0.64], number of past psychiatric admissions (median case versus control 6 versus 4, OR 7.2, 95% CI 0.74–70.2, P = 0.14) and amount of antipsychotic medication in chlorpromazine equivalents per day (median case versus control 100 versus 100, OR 1.16, 95% CI 0.39–3.43, P = 0.40). Patients receiving depot antipsychotic medication from specialist mental health services were more likely to have regular psychiatric reviews (chi-square 13.8, 2 df, P = 0.00).
The main difference between the two groups was that staff identified more than twice the number of health and social needs in the primary care patients, compared with the mental health service group. This was statistically significant for met need, and there was a trend in the same direction for unmet need. Amongst individual items on CANSAS, there were significant differences between the two groups for 16 of the 22 items.
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Discussion |
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The main findings of this study were that patients receiving depot antipsychotic medication from primary care were similar in terms of their global functioning to patients receiving their medication from specialist mental health, and were receiving a similar amount of medication. However, the primary care patients had more health and social needs (total of met and unmet), and more met needs than the patients in contact with specialized mental health services.
This study was conducted across four primary care teams, but the teams were all located in an inner city area, and the findings cannot necessarily be generalized to other areas. The measurement of patient need was based entirely on staff assessments. Although both patient and staff perceptions of need are valid, their views can differ.8 It is possible that the results would have been different if patients had rated their own needs. The greater levels of need perceived by staff in the primary care group may be due, at least in part, to primary care staff having a greater awareness of patients’ needs, compared with the mental health staff. As the control group was matched for age, we cannot exclude the possibility that there were significant age differences between the two populations, and this may in turn have influenced the results. Finally, there may be other small differences between the groups, which have not been detected because of the power of the study.
Levels of patient need and disability do not appear to be a significant factor in determining whether any particular patient receives his or her medication from primary care or specialist services. We would suggest that patient choice, historical patterns of care and the willingness of primary care teams to be engaged in the treatment of the severely mentally ill are more significant factors.
Burns et al.9 have highlighted that practice staff may lack confidence or training in administering depot medication. If they are responsible for vulnerable patients, it is important that they receive back-up from specialist mental health services in the form of training, regular liaison and immediate support. Primary care staff should review their arrangements for depot administration to ensure that patients are reviewed regularly, and that their many needs are being addressed, especially now that many patients may benefit from newer atypical antipsychotic drugs.
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Acknowledgments |
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IM’s post was funded by the Priory Group of Hospitals.
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References |
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1 King M. Management of patients with schizophrenia in general practice.Br J Gen Pract 1992; 42:310–311.[Medline]
2 Nazareth I, King M, Haines A. Care of schizophrenia in general practice. Br J Gen Pract 1993; 307:910.
3 Kendrick T, Burns T, Freeling P et al. Provision of care to general practice patients with disabling long-term mental illness: a survey in 16 practices.Br J Gen Pract1994; 44:301–305.[Web of Science][Medline]
4 Leary J, Johnson EC, Owens DGC. Social outcome in disabilities and circumstances of schizophrenic patients—a follow up study. Br J Psychiatry 1991; 159 (Suppl 19):13–20.
5 Mirza IQ, Phelan M. Variations in administration of depot antipsychotic medication within primary care: a cross-sectional survey of practices in the North Thames Region. Primary Health Care Res Dev 100; 1: 147–151.
6 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd edn, Revised. Washington DC: American Psychiatric Association, 1987.
7 Slade M, Thornicroft G, Loftus L et al. CAN: Camberwell Assesment of Need. London: Gaskell Press, 1999.
8 Slade M, Phelan M, Thornicroft G, Parkman S. The Camberwell Assessment of Need (CAN): comparison of assessments by staff and patients of the needs of the severely mentally ill. Soc Psychiatry Psychiatr Epidemiol 1996; 31:109–113.[CrossRef][Web of Science][Medline]
9 Burns T, Millar E, Garland C et al. Randomized controlled trial of teaching nurses to carry out structured assessments of patients receiving depot antipsychotic injections. Br J Gen Pract 1998; 48:1845–1848.[Medline]
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