Prescribing for personality disorder: qualitative study of interviews with general and forensic consultant psychiatrists

Abstract

Aims and method To explore experiences of psychiatrists considering medication for patients with personality disorder by analysis of transcribed, semi-structured interviews with consultants.Results Themes show important relational processes in which not prescribing is expected to be experienced as uncaring rejection, and psychiatrists felt helpless and inadequate as doctors when unable to relieve symptoms by prescribing. Discontinuity in doctor-patient relationships compounds these problems.Clinical implications Problems arise from: (a) the psychopathology creating powerful relational effects in consultation; (b) the lack of effective treatments, both actual and secondary to under-resourcing and neglect of non-pharmaceutical interventions; and (c) the professionally constructed role of psychiatrists prioritising healing and cure through provision of technological interventions for specific diagnoses. There is a need for more treatments and services for patients with personality disorder; more support and training for psychiatrists in the relational complexities of prescribing; and a rethink of the trend for psychiatrists to be seen primarily as prescribers.

Qualitative systematic review of barriers and facilitators to patient-involved antipsychotic prescribing

“…Of the 30 studies, 13 were conducted in the UK, 27 , 28 , 30 , 33 , 36 , 37 , 41 , 44 , 46 , 47 , 49 , 51 – 53 ten in the USA, 20 , 29 , 31 , 32 , 34 , 38 , 39 , 43 , 48 , 50 four in Canada, 35 , 40 , 42 , 55 and one each in Norway 45 and Sweden 54 . Sixteen studies examined data from only patients' perspectives, 28 , 29 , 32 , 33 , 37 , 39 – 43 , 45 , 46 , 49 , 50 , 53 , 55 six from only health professionals' perspectives, 30 , 34 , 35 , 47 , 51 , 52 , 54 and only one from carers' perspectives. 36 The six remaining studies examined a combination of stakeholder perspectives, 27 , 31 , 38 , 44 two of these including carer viewpoints.…”

“…Of the 12 studies that included health professionals, 20 , 27 , 30 , 31 , 34 , 35 , 38 , 44 , 48 , 51 , 52 , 54 seven recruited a mixed sample of professionals such as psychiatrists, nurses, case managers and peer support specialists, 20 , 27 , 31 , 34 , 35 , 38 , 44 three recruited only psychiatrists, 30 , 47 , 51 , 52 one recruited only nurses 54 and one recruited only case managers. 48 …”

“…Sixteen studies recruited participants from a community care setting, 20 , 28 , 30 – 34 , 36 – 38 , 42 , 46 , 48 , 50 , 51 , 54 , 55 five from mixed settings, 27 , 29 , 35 , 39 , 47 one study each from an in-patient forensics ward, 53 primary care setting 44 and the readership of an alternative health magazine, 40 and five studies did not specify service setting. 41 , 43 , 45 , 49 , 52 …”

“…Twenty-one studies used individual interviews, 27 , 29 , 30 , 32 – 34 , 36 – 41 , 43 , 45 – 47 , 49 , 51 – 55 six used focus groups 20 , 31 , 35 , 42 , 44 , 50 and two used a mixture of both. 28 , 48 Twelve studies used thematic analysis 27 , 30 , 32 , 34 , 37 , 39 , 43 , 45 , 47 – 49 , 51 , 54 and five used grounded theory. 28 , 38 , 41 , 46 , 53 Seven used another type of analysis, e.g.…”

Drug-centred psychopharmacology: a non-diagnostic framework for drug treatment†

“…The relational aspects of prescribing are very powerful and may outweigh the pharmacological effects of medications in some situations. Martean & Evans (2014) illustrated these issues in their examination of prescribing for personality disorder. Consultant psychiatrists can feel helpless in the face of ongoing suffering and find denying medication stressful.…”