The AHSN Network Polypharmacy Programme is working with healthcare professionals to address problematic polypharmacy by supporting easier identification of patients at potential risk from harm from multiple medications. Our evidence-based polypharmacy Action Learning Sets (ALS) are being rolled out across England to support GPs, pharmacists and other healthcare professionals who undertake prescribing or medication reviews to understand the complex issues around stopping inappropriate medicines safely. To drive and accelerate changes in practice, delegates complete a quality improvement project to address problematic polypharmacy in their workplace. This poster summary, Mental health polypharmacy in 'non-coded' primary care patients, can be viewed here. For more information about the polypharmacy programme, please visit https://www.ahsnnetwork.com/programmes/medicines/polypharmacy/

1. Mental health polypharmacy in “non coded” primary care patients
Mental health (MH) polypharmacy
Mental health polypharmacy refers to the prescription of >1 same group (e.g. two anti-depressants) or >2 multigroup mental
health medications (e.g. anti-depressants, anti-psychotics) concurrently to a patient. It can also involve prescribing adjunctive
medications (e.g. to deal with side effects [SEs] of MH medications) or augmentation medications (e.g. Propranolol,
Pregabalin, Zopiclone). The prevalence in primary care is 13%-90%. It is commonly associated with increasing
SEs/interactions, increasing risk of co-morbid conditions or complicating pre-existing ones.
Most common reason a patient receives mental health polypharmacy is because the clinician determines that current
medication(s) is ineffective in adequately controlling the patient’s mental health symptoms.
Non-coded MH primary care patients (on anti-depressants) have currently no monitoring pathway in primary care.
Data/Results
Seventy-two non-coded patients were identified as >1 same group MH polypharmacy.
Medications included SSRIs (Sertraline, Citalopram, Escitalopram, Paroxetine, Vortioxetine), SNRIs (Venlafaxine,
Duloxetine), TCAs (Amitriptyline), α2 blockers (Mirtazapine) and serotonin modulators (Trazodone).
Patients have a number of MH diagnoses, including: mixed anxiety/depression (n=48), post-traumatic stress disorder (n=16),
obsessive compulsive disorder (n=6) and personality disorder (n=2).
Polypharmacy in this cohort were initiated by general practitioners (n=44) and psychiatrists (28).
Sixty patients agreed with plan for reducing effects of polypharmacy. Following initial consultation, forty six patients could
attribute some of their symptoms to SEs/interactions from polypharmacy.
PSDA 1, which involved dose reduction and attempt elimination of second anti-depressant (below) in sixty patients, showed
significant reduction. A similar case was seen in the average reduction in number of SEs/interactions per patient.
Waseem Jerjes, Daniele Ramsay, Harvey Stevenson
Process map
Aims/PSDA
Identify MH polypharmacy in non coded patients on >1 same group medications.
Examine their medications (anti-depressants, adjunctive and augmentation).
Review patient to enquire about possible SEs/interactions and discuss polypharmacy.
Make change (reducing dose or eliminating medication) to reduce irrational polypharmacy to improve patient care.
Conclusions/Lessons Learned
• Non-coded mental health patients in primary care do require monitoring to reduce effects of polypharmacy to reduce side effects
and medications interactions. This will lead to less co-morbid conditions and will not complicate existing ones. We hope to see
more change with the implementation of PSDA 2 and 3.
• Clinicians prescribing mental health medications should be aware of the existence and high prevalence of polypharmacy.
• Polypharmacy may be necessary and justified particularly when there are co-morbidities requiring more than one group of
medication or when monotherapy provides insufficient improvement.
• Education, proper clinical titration aided by guidelines are effective ways to avoid irrational polypharmacy
Waseem Jerjes
GP Partner with special interest in mental health
North End Medical Centre
Hammersmith and Fulham Partnership
Email Waseem.Jerjes@nhs.net
MH patient sees GP with worsening symptoms
Already on one medication
or two multi group
medications for MH
GP either increase dose of existing medication
or add a second same-group medication or
add augmentation medication
When symptoms are controlled, all
medication(s) will be on the repeat
prescription
Patient continues to take medication for years
MH polypharmacy will not
be re-examined
Patient suffer from polypharmacy problems
but rarely reports as MH is better
Side effects, interactions
Long-term: morbidities or compliance
Fishbone diagram
Initiating MH
polypharmacy
Failure to examine
the MH
polypharmacy
Prescribing
Follow-up
Examination
Psychology
service
Psychiatry
service
Community
services
Clinician
decision
Patient’s
agenda
Different
clinician
Patient’s
engagement
1
st
Compliance
2
nd
Symptom
control
No
appointments
Side
effects/interactions
Clinician’s
confidence
Patient’s
resistance
NEMC SMI = 342 CCMI = 92 Not coded = 667
>1 same group medication = 72
>2 multigroup medications = 12
Adjunctive medication(s) = 122
Augmentation medication(s) = 201
MH polypharmacy
Idea Plan Do Study Act
Identify MH
polypharmacy in >1
same group medication
Review patient to discuss
polypharmacy,
SEs/interactions
Reduce dose of one medication
to lowest possible dose or stop
Review adjunctive medication
Follow-up patient
to assess outcome
Check if change in
sustained
Support services
Review same group of
MH patients
Review MH, BMI, BP, HR,
smoking/drinking/social
Non pharmacological support
Review adjunctive /
augmentation medications
Follow-up patient
to assess outcome
Check if successful
change
Education: patients and
colleagues
Leaflet for patients
Tutorials for clinicians
Annual checks Review response Check if change is
manageable
0
0.5
1
1.5
2
2.5
3
3.5
4
Initial consultation End of month 3 End of month 6 End of month 9
Average number of MH medication per patient, including adjunctive and augmentation
Average number of same group MH medications (anti-depressants) per patient
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
Initial
consultation
End of month
3
End of month
6
End of month
9
Average number of SEs/interactions per patient
Headaches, nausea, dizzy spells, fatigue,
abdominal pain, myalgia, arthralgia, back pain,
weight gain, skin reactions, worsening anxiety and
sleep disturbances
CCMI/SMI
list
capping