Access to psychiatrists should be improved

BMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7047.1667b (Published 29 June 1996) Cite this as: BMJ 1996;312:1667
  1. Andrew F Tarbuck
  1. Consultant in old age psychiatry St Andrew's Hospital, Thorpe St Andrew, Norwich NR7 0SS

    EDITOR,—Inappropriate prescribing for elderly people remains a problem, and Alice McGrath and Graham Jackson have been successful in focusing media attention on the use of neuroleptic agents in nursing homes.1 The American legislation to which the authors refer has been criticised for penalising “incorrect” drug use while offering little guidance on alternative management.2 The American Geriatrics Society is concerned that the legislation may compromise the right to effective treatment for patients with serious mental disorders and dementia in nursing homes.3

    Although the legislation has reduced prescribing of neuroleptics, these reductions often cannot be maintained. For example, in the study quoted by the authors,4 neuroleptics were restarted or increased in 27-36% of cases because of a deterioration in the patient's mental state. In the same study, participating physicians were also encouraged to refer all patients taking neuroleptics for psychiatric review, which clearly has major resource implications. “Educational packages” have also been highly effective in reducing inappropriate neuroleptic use. They may be more effective than legislation.5

    In the United Kingdom the provision of care for elderly mentally ill people is changing rapidly. Many NHS continuing care beds for them have closed, and the imposition of “eligibility criteria” from 1 April 1996 may further restrict access to long term hospital care. Consequently, increasingly dependent and behaviourally disturbed elderly patients are entering nursing homes, placing an added strain on general practitioners who may have little experience or training in their management.

    Instead of considering legislation to restrict neuroleptic use, it would be better to increase levels of awareness and education in general practitioners and nursing home staff concerning the diagnosis and management of mental illness and behavioural disturbance in the elderly. Adequate staffing levels within nursing homes are vital in reducing inappropriate drug use, as is ready access to a multidisciplinary old age psychiatry service. Unfortunately, these can only be provided if sufficient resources are made available.

    The media have leapt on McGrath and Jackson's study with great enthusiasm, reporting stories of elderly people being “drugged up” inappropriately. Although misuse of neuroleptics is associated with adverse effects, when used correctly neuroleptics can be highly effective in reducing distressing symptoms and behaviours. It would be unfortunate if the perceived message from this research were that “neuroleptics are bad,” as this might adversely affect the rights of elderly severely mentally ill patients within nursing homes to receive adequate and appropriate treatment.


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