Severe mental illness and cardioprotective medication prescribing: a qualitative study in general practice

Background: Patients with severe mental illness (SMI) die 10–20 years earlier than the general population. They have a higher risk of cardiovascular disease (CVD) yet may experience lower cardioprotective medication prescribing. Aim: To understand the challenges experienced by GPs in prescribing cardioprotective medication to patients with SMI. Design & setting: A qualitative study with 15 GPs from 11 practices in two Scottish health boards, including practices servicing highly deprived areas (Deep End). Method: Semi-structured one-to-one interviews with fully qualified GPs with clinical experience of patients with SMI. Interviews were transcribed verbatim and analysed thematically. Results: Participants aimed to routinely prescribe cardioprotective medication to relevant patients with SMI but were hampered by various challenges. These structural and contextual barriers included the following: lack of funding for chronic disease management; insufficient consultation time; workforce shortages; IT infrastructure; and navigating boundaries with mental health services. Patient-related barriers included patients’ complex health and social needs, their understandable prioritisation of mental health needs or existing physical conditions, and presentation during crises. Professional barriers comprised GPs’ desire to practise holistic medicine rather than treating via cardioprotective prescribing in isolation, and concerns about patients’ medication concordance if patients were not prioritising this aspect of their health care at that particular time. In terms of enablers for cardioprotective prescribing, participants emphasised continuity of care as fundamental in engaging this patient group in effective cardiovascular health management. A cross-cutting theme was the current GP workforce crisis leading to ‘firefighting’ and diminishing capacity for primary prevention. This was particularly acute in Deep End practices, which have a high proportion of patients with complex needs and greater resource challenges. Conclusion: Although participants aspire to prescribe cardioprotective medication to patients with SMI, professional-, system- and patient-level barriers often make this challenging, particularly in deprived areas owing to patient complexity and the inverse care law.