Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.
BMJ Qual Saf. 2020 Aug;29(8):655-663. doi: 10.1136/bmjqs-2019-010033. Epub 2019 Dec 13.
Prescriptions for psychotropic medications to children have risen dramatically in recent years despite few regulatory approvals and growing concerns about side effects. Government policy and numerous programmes are attempting to curb this problem. However, the perspectives of practising clinicians have not been explored. To characterise the perspectives and experiences of paediatric primary care clinicians and mental health specialists regarding overprescribing and deprescribing psychotropic medications in children.
We conducted 24 semistructured interviews with clinicians representing diverse geographic regions and practice settings in the USA. Interview questions focused on clinician perspectives surrounding overprescribing and experiences with deprescribing. We transcribed audio files verbatim and verified them for accuracy. We analysed transcripts using a grounded theory approach, identifying emergent themes and developing a conceptual model using axial coding.
Analysis yielded themes within four domains: social and clinical contextual factors contributing to overprescribing, opportunities for deprescribing, and facilitators and barriers to deprescribing in paediatric outpatient settings. Most participants recognised the problem of overprescribing, and they described complex clinical and social contextual factors, as well as internal and external pressures, that contribute to overprescribing. Opportunities for deprescribing included identification of high-risk medications, routine reassessment of medication needs and recognition of the broader social needs of vulnerable children. Facilitators and barriers to deprescribing were both internal (eg, providing psychoeducation to families) and external (eg, parent and child preferences) to clinicians.
Our findings highlight a discrepancy between clinicians' concerns about overprescribing and a lack of resources to support deprescribing in outpatient paediatric settings. To successfully initiate deprescribing, clinicians will need practical tools and organisational supports, as well as social resources for vulnerable families.
尽管对副作用的担忧日益增加，且监管批准很少，但近年来儿童精神类药物的处方量却大幅上升。政府政策和众多计划正试图遏制这一问题。然而，实践临床医生的观点尚未得到探索。本研究旨在描述儿科初级保健临床医生和精神健康专家对儿童精神类药物过量处方和减药的观点和经验。
我们对来自美国不同地理位置和实践环境的 24 名临床医生进行了 24 次半结构化访谈。访谈问题集中在临床医生对过量处方的看法以及减药的经验。我们逐字转录音频文件并对其准确性进行验证。我们使用扎根理论方法对转录本进行分析，确定出现的主题，并使用轴向编码构建概念模型。
分析得出了四个领域的主题：导致过度处方的社会和临床背景因素、减药的机会以及儿科门诊环境中减药的促进因素和障碍。大多数参与者认识到过度处方的问题，他们描述了复杂的临床和社会背景因素，以及导致过度处方的内部和外部压力。减药的机会包括识别高风险药物、定期重新评估药物需求以及认识到弱势儿童的更广泛社会需求。减药的促进因素和障碍既有内部因素（例如，向家庭提供心理教育），也有外部因素（例如，父母和孩子的偏好）。
我们的研究结果突出了临床医生对过度处方的关注与支持门诊儿科环境中减药的资源不足之间的差距。为了成功启动减药，临床医生将需要实用工具和组织支持，以及弱势家庭的社会资源。
