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A Focus Group on Psychotropic Prescribing in Primary Care

A Focus Group on Psychotropic Prescribing in Primary Care

Results


The focus groups and participants are described in Table 1. The heads of the units were all female nurses without the right to prescribe drugs. The rest of the participants were physicians, who, in Sweden, have an unrestricted right to prescribe drugs. In the mixed group (focus group 3), there were 2 GPs and 3 GP interns. Three different themes emerged from the focus groups: Seeking care for symptoms; Lacking a framework, resources, and treatment alternatives; and Restricting or maintaining prescriptions. The latter had two subthemes: Individual factors and External influences. The themes and categories (in alphabetical order) are presented in Figure 1. The results describe the prescribing of psychotropic medication as a process, from patient care seeking to the actual prescribing. The first theme reflects the participants' understanding of why patients approach primary care, the second one the conditions for the physician-patient interaction, and the third one the physicians' internal decision making. All four focus groups contributed to all themes, but for four out of 21 categories there were contributions from only two or three focus groups. The presented quotes were chosen to represent a certain category, that is, to exemplify the discussions in the focus groups.



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Figure 1.



Factors of importance for psychotropic prescribing, resulting themes and categories.




Seeking Care for Symptoms


This theme contains categories describing factors of importance for the decision of the patient to seek care for psychiatric symptoms. According the participants, seeking care was not synonymous, for all patients, with wanting medication.

Demography and social factors were considered important for care seeking. Unemployment, divorce, and social problems were brought up as factors of importance. Age was also discussed and the participants meant that youth today cannot handle disappointments and they have high expectations on quick solutions.
"… young people who can't feel bad for 1 day, just have to get well the same day." (Focus group II, Head 1)
The participants discussed the importance of society and the media in terms of how mental diseases are less stigmatized today. The participants perceived that patients do not consider psychiatric symptoms to be as disgraceful as before, and they are more prone to try a psychotropic medication. They also mentioned that the media are contributing to the idea of antidepressants as "the happy pill" and that there is increased medicalization in society.
"… the main difference that distinguish psychotropics, and psychiatric diseases as well, is that psychiatric diseases have traditionally somehow, for both health care and patients, been kind of shameful. And that is disappearing to some extent." (Focus group IV, GP intern 4)
Other influences mentioned were positive or negative experiences of medication of friends and relatives, but also staff at nursing homes who may demand treatment for a patient who is considered problematic. The impact of knowledge (the well-informed patient) and attitudes of patients (e.g., a general skepticism against medication) were also discussed.
"So sometimes I meet people who are negative from the start and they are pretty difficult to convince. And sometimes they finally give in and try for a week. And then they go, All right, it didn't work. Even though I've explained that it may take 3 weeks." (Focus group III, GP 5)

Lacking a Framework, Resources, and Treatment Alternatives


The categories in this theme deal with the conditions of the physician patient consultation. Many of the factors mentioned were considered barriers to rational prescribing.

The category characteristics of mental illness included difficulties of psychiatric compared with somatic diseases, e.g., diagnosing, where the participants meant there may be a risk of imprecise diagnosing. Further, participants perceived problems in evaluating treatment. The problem of keeping psychiatric treatment evidence-based was also highlighted.
"…psychiatry is not a science like others, not as exact. And it leaves room for many interpretations." (Focus group I, GP 1) "It depends a lot on the individual, so it's hard to comply with general guidelines. Each time you have to manage by trial and error, I would say. And that applies to the drug, the selection, and the dosage as well." (Focus group IV, GP intern 5)
The patient physician process comprised the importance of communication skills, e.g. the ability of the physician to ask the right questions in order to make the right diagnosis. Further, the participants discussed patient factors, such as the patients' pre-understanding, or fear of adverse effects, as well as their expectations and desires concerning treatment.
"There are lots of people who expect that they have the right to feel well all their lives and that health care should sort it out for them." (Focus group I, GP 2)
Concerning economy and resources, the costs of medication and engaging locum physicians in primary care were mentioned. Further, the lack of time was discussed both with regard to the patient physician consultation and concerning patient follow-up.

Another category was technology. According to the participants, technical issues may increase the issue of renewing prescriptions without proper evaluation of the treatment.
"It's easy to press the button, to click accept." (Focus group I, GP 1)
(In the multi-dose drug dispensing system in Sweden (ApoDos), all drugs prescribed to an individual can be renewed simultaneously by performing "one click" on the computer. Ordinary prescriptions, on the other hand, need to be renewed one by one. Authors' comment)

Two organizational aspects were considered important for the prescribing of psychotropics; namely, level of care and differences between care units. Differences between care units concerned primarily different prescribing traditions at different units. The problem of indeterminate boundaries between psychiatry and primary care, the transfer to primary care of patients previously treated within psychiatric care implicating the inheritance of prescriptions from psychiatry, and the limited possibilities for follow-up in primary care were some of the subcategories of level of care.
"Because then you think, if they end up in the right place perhaps it'll be the right medication and you're more in control of things. And that's what it's all about. As for me, I feel that a lot of this is an organiza-, well, perhaps that's stretching it a bit, but to some extent anyway, that this is an organizational issue to a large extent, that there are lots of prescriptions." (Focus group II, Head 2)
The participants also discussed treatment alternatives from two perspectives, namely, effects/side-effects and availability. Based on the perceived effect of treatment, the choice between pharmacotherapy and psychotherapy is influenced by disease severity, as well as patient's background and age. Further, the participants suggested that limited access to psychotherapy can increase pharmacotherapy treatment.
"No psychoanalyst and no God to offer. We just have that security blanket, the pill, you know…" (Focus group IV, GP intern 6)

Restricting or Maintaining Prescriptions


The last theme describes how the prescribing behavior of physicians is influenced by Individual factors and External influences.

The category emotions comprised aspects such as the wish to be, or not to be, updated on new psychotropic drugs, not having the energy to say no to a patient, or the unease about changing drug treatment initiated by colleagues, e.g., specialists in psychiatry:
"It's much harder to withdraw a drug. And if someone else has started it, I feel, Hang on, I'm stepping on this colleague's toes." (Focus group III, GP 6)
Knowledge, or, rather, lack of knowledge, was another category described to influence the prescribing of psychotropics. The participants mentioned that primary care physicians do not have enough knowledge about new or specialized psychotropics to prescribe them or to evaluate their effect.
"…we've got problems getting help when we feel we're not quite, don't have the right competence…//…So I gather we all feel that our knowledge is not sufficient from time to time, for the prescribing we're doing." (Focus group I, GP 3)
Participants related the experience that a physician's past prescribing behavior may affect his or her future patient clientele. Participants mentioned that low prescribing of benzodiazepines makes those patients seek care elsewhere. Further, the experience of physicians makes them prescribe a small range of psychotropics, i.e., they have their own personal prescribing repertoire.

The impact of medical education was also discussed among the participants and many of the participating physicians had gone to medical school at the University of Gothenburg. They said it was their experience that in that academic environment, medication, rather than non-pharmacological treatment, was advocated.
"… those of us who studied in Gothenburg have had it thoroughly hammered in that it's the drugs that matter." (Focus group IV, GP intern 7)
Variability in prescribing between individuals was mentioned, with several examples of high prescribers given, that is, physicians that the participants had met in practice. Further, psychiatrists as a group were described as prescribing psychotropics to a higher extent and in higher doses compared to GPs. Participants also felt that the prescribing of psychotropics is often arbitrary.
"We just tinker about with the levels of different chemicals. And then we hope and keep our fingers crossed for it to work, and sometimes it's for the worse." (Focus group IV, GP intern 8)
External factors of importance are the pharmaceutical industry, colleagues, and the health care authorities.

The category health care authorities mainly concerned regional prescribing guidelines and the list of recommended drugs prepared by the drug and therapeutics committees. These publications were mostly regarded as trustworthy by the participants while some colleagues and, in particular, the drug industry were seen as less dependable.



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