Psychotropic drug debate misses big picture

The controversy over the use of psychotropic drugs in residential aged care masks broader structural problems and tackling the issue in isolation will not improve mental health care for residents, experts have warned.

The controversy over the use of psychotropic drugs in residential aged care masks broader structural problems and tackling the issue in isolation will not improve mental health care for residents, experts have warned.

The potential overuse of antipsychotic drugs may arise from the “wider systemic difficulty” in managing psychiatric illness in residential aged care, according to two psychiatrists with expertise in ageing.

Associate Professor Jeffrey Looi from the Australian National University and Associate Professor Stephen Macfarlane from Monash University say that sufficient “organisational and political will” is required to fund, study, design and implement interventions at a national level to improve mental health care for residents.

Writing in the Medical Journal of Australia, they said that while targeted pharmacological and non-pharmacological interventions may be effective, training and structural issues within aged care limited the ability of staff to implement them.

Providing pharmacological care in residential facilities was problematic as it relied on the support of medical professionals, many of whom experienced “significant barriers” to working in residential care.

Similarly, while there was growing evidence of the effectiveness of non-pharmacological strategies, the staffing levels in residential care and the mental health skills of most carers “may be inadequate to implement such strategies”.

Therefore, appropriate numbers of skilled nursing and allied health staff, such as psychologists and mental health nurses, were needed to meet the mental health needs of residents, the authors wrote.

Further, they proposed that improved models of care were necessary to provide effective medical and mental health care in residential care and these might best be nurtured by “embedding them within the standards of accreditation to ensure this becomes intrinsic to the culture of care.”

Dr Looi, who is a clinical neuropsychiatrist, said that when medical oversight was required to deliver a pharmacological intervention, GPs attending facilities often encountered difficulties such as a lack of appropriate consultation space and access to medical records.

“We also know, from the survey done by the AMA that the population of GPs visiting facilities is ageing; they’re gradually retiring and this is of concern because they are the main medical care providers in facilities,” Dr Looi told Australian Ageing Agenda.

Most residential aged care facility staff did not have the skills or training to provide the complex interventions that could prevent the need for use of medication, he said.

“For example, a facility trying to implement a plan designed by a psychologist to help someone who is wandering excessively will have to put in place some behavioural measures and that requires a consistency that might be hard for staff rotating in and out, and who don’t have the skill levels.”

Research

The experts also noted that while research into mental health interventions in residential aged care was growing, it required greater funding and rigour.

Expanding on this, Dr Looi said: “We should give credit to the nursing profession because many studies have been designed by nurses, but because they don’t get much funding and [the studies] are often embedded in particular facilities, the numbers of residents involved in these studies are small.”

He suggested greater support for researchers, particularly across a number of facilities.

Systemic response

The provision of effective mental health care and services would involve private and state healthcare, and “push-pull factors” based on service models and funding, the authors noted. “The state-federal divide in funding and responsibility is another complicating factor.”

When asked how governments could be encouraged to act, Dr Looi said these were issues the AMA and the Royal Australian and New Zealand College of Psychiatrists had raised with successive governments but had struggled to get on “the political radar”.

“These structural issues span several election cycles, so they just don’t seem to gain traction. The other factor we should not discount is the fact that these issues don’t fly with the mainstream media, and they’re not things social media pays attention to,” he said.

Psychotropic drug use in aged care facilities: a reflection of a systemic problem? was published in the MJA January 2014.

Tags: antipsychotic, anu, jeffrey looi, mja, monash, stephen macfarlane,

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