Identifying fallacious arguments in a qualitative study of antipsychotic prescribing in dementia

Background: Dementia can result in cognitive, noncognitive and behavioural symptoms which are difficult to manage. Formal guidelines for the care and management of dementia in the UK state that antipsychotics should only be prescribed where fully justified. This is because inappropriate use, particularly problematic in care-home settings, can produce severe side effects including death. The aim of this study was to explore the use of fallacious arguments in professionals’ deliberations about antipsychotic prescribing in dementia in carehome settings. Fallacious arguments have the potential to become unremarkable discourses that construct and validate practices which are counter to guidelines. Methods: This qualitative study involved interviews with 28 care-home managers and health professionals involved in caring for patients with dementia. Potentially fallacious arguments were identified using qualitative content analysis and a coding framework constructed from existing explanatory models of fallacious reasoning. Key findings: Fallacious arguments were identified in a range of explanations and reasons that participants gave in answer to questions about initiating, reducing doses of and stopping antipsychotics in dementia. The dominant fallacy was false dichotomy. Appeal to popularity, tradition, consequence, emotion, or fear, and the slippery slope argument was also identified. Conclusions: Fallacious arguments were often formulated to present convincing cases whereby prescribing antipsychotics or maintaining existing doses (versus not starting medication or reducing the dose, for example) appeared as the only acceptable decision but this is not always the case. The findings could help health professionals to recognise and mitigate the effect of logic-based errors in decisions about the prescribing of antipsychotics in dementia

What stops practitioners discussing medication breaks in children and adolescents with ADHD? Identifying barriers through theory-driven qualitative research

National and international guidelines on the treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents call for annual reviews to assess continuing need for medication by considering brief periods without medication, referred to as 'Drug holidays'. However, drug holidays are reactively initiated by families, or recommended by practitioners if growth has been suppressed by medication rather than proactively to check the need. There is little evidence of planned, practitioner-initiated drug holidays from methylphenidate. The aim of this study was to identify what stops practitioners from routinely discussing planned drug holidays from methylphenidate with children, adolescents, and their parents. Practitioners involved in shared-care prescribing for children and adolescents with ADHD in one UK County were included. Interviews with 8 general practitioners (GPs) and 8 Child and Adolescent Mental Health Service (CAMHS) practitioners were conducted. Transcripts were analysed qualitatively against the components of the Capability-Opportunity-Motivation-Behaviour (COM-B) model. Possible interventions for increasing prescribers' engagement with planned drug holidays were considered in response. Multiple barriers to practitioner engagement in planned drug holidays from methylphenidate were identified. Capability, in terms of knowledge and skills, was not a barrier identified for CAMHS practitioners but was for GPs. Opportunity was a main barrier for both groups, who reported lack of time and the absence of educational material about drug holidays. Motivation was more complex to define, with CAMHS practitioners questioning the need for drug holidays and GPs being more accepting due to worries about long-term medication side effects as well as cost savings. 'Education' and 'enablement' interventions were identified as key activities targeting all three components, which could feasibly increase uptake of practitioner-initiated planned drug holidays from methylphenidate. The application of the COM-B system identified a number of key barriers to practitioner engagement with drug holidays in children and adolescents with ADHD. Accordingly, a number of interventions could be developed to facilitate change. For example, educating and training GPs about ADHD management and drug holidays, and developing a decision aid to help families make informed decisions about whether or not to implement drug holidays could be used

‘The lesser of two evils’ vs ‘medicines not Smarties’: constructing antipsychotics in dementia

Background and Objectives: Because antipsychotics are associated with an increased risk of morbidity and mortality, they should only be prescribed in dementia in limited circumstances. But antipsychotics are prescribed to a large proportion of residents in formal care settings despite guidance and warnings to the contrary, justifying a study into how professionals define and in turn create realities about antipsychotic usage in dementia. Research Design and Methods: 28 professionals with a role in the care and management of patients with dementia in care homes were recruited and interviewed in this qualitative study. A gap in the literature about the social construction of antipsychotics in dementia prompted the use of critical discourse analysis methodology. Results: Antipsychotics were portrayed in two distinct ways; as ‘the lesser of two evils’ they were conceptualized as the less harmful or unpleasant of two bad choices and as ‘medicines not Smarties’ (a brand of sweets/candy) they were conceptualized as prescribed too frequently and indiscriminately. The first resource could be used to defend the prescribing of antipsychotics and uphold the prescribers’ privilege to do so while the second enabled the speaker to reject their own wilful involvement in overprescribing. Discussion and Implications: When prescribers draw on ‘the lesser of two evils’ paradigm to sanction the overprescribing of antipsychotics, implicit assumptions about these medications as being the best of bad choices should be recognized and challenged. Future studies should target specific normative beliefs about antipsychotic prescribing consequences, to change the lexicon of common knowledge which perpetuates bad practice

The utility of novel outcome measures in a naturalistic evaluation of schizophrenia treatment

A number of naturalistic studies have investigated paliperidone palmitate using proxy measures of effectiveness. An unexplored option is to examine the utility of the mental health clustering tool, because it is used in UK clinical practice, measures patient wellbeing and is linked to allocation of resources. This study evaluated the effectiveness of paliperidone palmitate using the mental health clustering tool, the health of the nation outcome scales and, for comparison, more conventional outcome measures. This was a naturalistic, one-year evaluation of paliperidone palmitate (n = 50) in schizophrenia, alongside a comparator antipsychotic drug group. Changes in the mental health clustering tool ‘cluster-score cost ranking’ and four ‘health of the nation outcome scales-derived factors’ were analysed using a mixed model statistical analysis to explore the utility of these measures. At one year, 30 patients (60%) continued paliperidone palmitate treatment. The mean ‘cluster-score cost ranking’ (-1.5) and Severe Disturbance factor scores (-1.1) were significantly lower [p-value (adj) = 0.0003, p-value (adj) = 0.002, respectively] after one year of antipsychotic treatment but no differences were found between paliperidone palmitate and the comparator antipsychotic drug group. Patients prescribed paliperidone palmitate were 1.8 times (95% CI 1.1−3.1) more likely to be discharged from hospital than those in the comparator antipsychotic drug group. Paliperidone palmitate’s continuation rate after one year made the study similar to existing evaluations, and it was possible to prospectively evaluate antipsychotic effectiveness using the novel measures although these did not discriminate between paliperidone palmitate and the comparator group. The investigation illustrates that in principle these novel measures are meaningful in naturalistic study designs

Knowledge, attitude and advice-giving behaviour of community pharmacists regarding topical corticosteroids

This study examines the relationship between community pharmacists’ knowledge, attitudes to information provision and self-reported counselling behaviours in relation to topical corticosteroids and adjunct therapy in atopic eczema. A mixed-methods approach was used whereby data from interviews with community pharmacists were used to design a structured questionnaire that a larger sample of community pharmacists completed anonymously. The questionnaire was completed and returned by 105 pharmacists (36% response rate). Pharmacists showed gaps in their knowledge on the use of topical corticosteroids in atopic eczema but had good understanding on the use of emollients. There was a significant correlation between pharmacists’ attitudes to information provision and their self-reported counselling behaviour for most themes except in relation to corticosteroid safety where less advice was given. Improving attitudes to information provision should correlate with increased counselling behaviour. However, for the theme of corticosteroid safety, further studies are needed to examine why in practice pharmacists are not providing patient counselling on this topic even though most agreed this is a topic patients should know about

Enhancing pharmaceutical packaging through a technology ecosystem to facilitate the reuse of medicines and reduce medicinal waste

The idea of reusing dispensed medicines is appealing to the general public provided its benefits are illustrated, its risks minimized, and the logistics resolved. For example, medicine reuse could help reduce medicinal waste, protect the environment and improve public health. However, the associated technologies and legislation facilitating medicine reuse are generally not available. The availability of suitable technologies could arguably help shape stakeholders’ beliefs and in turn, uptake of a future medicine reuse scheme by tackling the risks and facilitating the practicalities. A literature survey is undertaken to lay down the groundwork for implementing technologies on and around pharmaceutical packaging in order to meet stakeholders’ previously expressed misgivings about medicine reuse (’stakeholder requirements’), and propose a novel ecosystem for, in effect, reusing returned medicines. Methods: A structured literature search examining the application of existing technologies on pharmaceutical packaging to enable medicine reuse was conducted and presented as a narrative review. Results: Reviewed technologies are classified according to different stakeholders’ requirements, and a novel ecosystem from a technology perspective is suggested as a solution to reusing medicines. Conclusion: Active sensing technologies applying to pharmaceutical packaging using printed electronics enlist medicines to be part of the Internet of Things network. Validating the quality and safety of returned medicines through this network seems to be the most effective way for reusing medicines and the correct application of technologies may be the key enabler

Patient views about polypharmacy medication review clinics run by clinical pharmacists in GP practices

Background Polypharmacy can decrease medication adherence and increase the incidence of adverse drug reactions and drug-drug interactions, resulting in falls, hospitalisations and other complications especially in the elderly. Medication-related problems of polypharmacy can be prevented through patient-centred medication reviews but research in this area has been completed largely without examining patients' viewpoints. Objective The aim was to investigate patient views about a clinical pharmacist-led patient-centred polypharmacy medication review service completed within 17 English GP practices with those 75 years of age and prescribed 15 medications, during 415 consultations. Method A patient feedback questionnaire was constructed and face validated with two pharmacists then posted by a Clinical Commissioning Group pharmacist to all patients who had taken part in the service. Data from returned questionnaires were analysed using descriptive statistics and qualitative patient comments were analysed using thematic analysis. Results Of the 166 patients (40% response rate) who returned a feedback questionnaire 83% found the service helpful. Medication-related concerns of 94% who had a concern beforehand were addressed, and 80% understood their medicines better after the review. Patients appreciated pharmacists’ personal approach, advice and explanation. Conclusion Patients expressed broadly positive views about polypharmacy reviews by clinical pharmacists within GP practices. Impact of findings • Patients have views about their experience of polypharmacy medication review clinics which they can voice through a questionnaire • The patient feedback supports a shift towards employing clinical pharmacists within GP practice

Community pharmacy and COVID-19 – the unsung heroes on our high-streets?

Coronavirus Disease 2019 (COVID-19) is a transmittable infection caused by a new coronavirus. The virus has been transmitting in the community and within families, including in the UK, and was categorised as a pandemic on 11 March 2020. In the UK, the government’s aim has been to reduce the rate of virus transmission so that it takes place over months rather than weeks. This is to prevent the health services from becoming overwhelmed with multiple cases needing treatment all at the same time. The government’s meaning of ‘health services’ in this context, certainly at the start of the crisis, is the care given in hospitals by nurses and intensive-care specialists. And in the community, mitigating the impact of COVID-19 has to date focussed largely on general practitioners (GPs). This is unsurprising to those in the pharmacy profession who have long considered policy makers to overlook them. Yet, community pharmacists, a vital part of the health workforce and trusted by many people6, are also facing huge additional pressures because of COVID-19 and struggle to highlight their plight. This article considers the work pharmacists have been completing on their own, not necessarily with government support