Self-harm
Most self-harm research has taken place in secondary care, although clearly primary care has an essential role in most cases. The Clinical Practice Research Datalink (CPRD) is an increasingly popular UK general practice data source and it was recently used to examine primary care clinical management following episodes of self-harm.1 Using data from 684 general practices, researchers identified 49 970 patients with a self-harm episode, of whom 41 500 had one complete year of follow-up. Among those with a year of follow-up, 62.8% were prescribed psychotropic medication and only 15% were referred to mental health services. Of concern, patients in the most deprived areas were 27.1% less likely to be referred than those in the least deprived areas. In addition, despite the guidance to avoid prescribing tricyclic antidepressants following self-harm because of their potentially lethal toxicity in overdose, 8.8% of patients in this cohort were issued a prescription in the subsequent year. With the recent political focus on improving mental health care across the country, the management of self-harm will be an important area for improvement and monitoring.
Repeat prescribing
Issuing repeat prescriptions is a complex process involving multiple members of the general practice team. As medication errors are an important target for national patient safety initiatives, repeat prescribing has recently gained much interest and was recently investigated by a UK general practice research team.2 Using a multi-site case study design, they studied eight practices in Scotland and England, gathering data between 2011 and 2014. Their fieldwork included analyses of protocols and patient leaflets, and they interviewed 62 members of (clinical and non-clinical) staff. Although GPs were formally responsible for authorising (and signing) each prescription, it was reception staff who were responsible for the initiation and overall coordination of the repeat prescribing arc of work. A range of intersecting hierarchies were noted between GPs and receptionists — receptionists typically being employees of the GP partnership and GPs considering themselves to have ‘overall authority’ for the patients. As the authors rightly state, the mundane, ‘routine’, and, most importantly, invisible nature of this work means it is rarely acknowledged and examined in depth.
Deprescribing
Safely reducing or discontinuing harmful medicines has significant benefits for the patient and the health system more broadly. However, there are lots of barriers including lack of time, guidance, and continuity of care.
A recent study from New Zealand involved interviews with GPs using a hypothetical profile of a multimorbid patient to initiate discussion about whether medications should be stopped.3 Opinions varied greatly among the participants, especially regarding preventive medications including statins, antiplatelet drugs, and bisphosphonates. Dilemmas about the most suitable management of reflux and insomnia also emerged. Of course, decisions about deprescribing (and, indeed, prescribing) should be taken with individuals and their relatives in a truly holistic way. This study surely supports the calls for more evidence and guidelines in this important area.
Worry
Worrying is generally reported as a negative experience and decades of research show it relates to a number of pathological conditions — both psychological and physical. It particularly seems to relate to subjective health complaints (SHCs) and a research team from the Netherlands recently tested an online intervention designed to reduce these complaints in the general population.4 Participants were instructed to register their worrying for 6 consecutive days and the intervention group was additionally instructed to postpone worry to a special 30-minute period in the early evening. In total, 361 participants completed the study and there was no difference between the control and intervention groups in SHCs, worry frequency, or worry duration. Although it would be wonderful to be able to offer interventions to reduce worry, I suspect we may be some way off finding a convincing treatment approach.
- © British Journal of General Practice 2016