Practitioners' Perspective on Metabolic Monitoring of Second-Generation Antipsychotics: Existing Gaps in Knowledge,Barriers to Monitoring,and Strategies

Abstract

Introduction:

Prescription of second-generation antipsychotics (SGAs) in youth is rapidly increasing globally and in Australia. Lack of timely metabolic monitoring for potential adverse effects puts youth at greater risk for lifelong adverse health impact. Metabolic monitoring is recommended as best practice to prevent and/or manage SGA-induced weight gain/metabolic syndrome. The adherence to clinical guidelines remains suboptimal. It is crucial to gauge insight to challenges and strategies from the perspective of prescribers and to recommend strategies in promoting quality use of SGAs and adherence to pharmacovigilance standards.

Methods:

Psychiatrists participated through semistructured interviews within the community mental health clinics in the Queensland State of Australia. The interviews focused on barriers to monitoring and strategies to enhance rate of monitoring with key focus on practical strategies for future implications in community setting.

Results:

Ten participants completed the interviews. Barriers were specified such as lack of adequate resources to conduct monitoring, carers' disengagement in their youth's treatments, and patients' refusal to undergo blood tests. Strategies to enhance metabolic monitoring heavily relied on organizational support, provision of training, and education opportunities.

Conclusions:

Clinical recommendations require mental health providers to facilitate conduction of metabolic monitoring among youth prescribed SGA/s. However, they are not provided with enough support and there are challenges that prevent such care. It is crucial to understand the challenges in managing a complex and vulnerable patient cohort. This research has thrown light on these key aspects of existing gap between best practice standards and clinical practice in youth prescribed SGAs.

Introduction

Prescription rates of antipsychotics are increasing across the world and in Australia. The Australian Institute of Health and Welfare (AIHW) dispensing data reveals over 2.5 million prescriptions of psychotropic medication for youth aged 15–24 years (AIHW 2018). Similarly, a European study reported increased rates of youth prescribed antipsychotics in Denmark, Germany, The Netherlands, and the United Kingdom (Kalverdijk et al. 2017).

The U.S. Food and Drug Administration (FDA)-approved indications of antipsychotics are limited to the management of schizophrenia and bipolar disorder in children as young as 10 years of age. The FDA has approved risperidone and aripiprazole to treat irritability associated with autism. Other second-generation antipsychotics (SGAs) such as olanzapine, clozapine, and quetiapine are also commonly used in children in an off-labeled manner.

The use of SGAs is usually associated with metabolic adverse effects and most specifically significant weight gain (Correll et al. 2009). In addition, many studies reported that youth who are prescribed SGAs are two to three times more likely to develop type 2 diabetes than youth in the general population (Correll et al. 2009; Morrato et al. 2010; Rubin et al. 2015). Moreover, these medications are often being used in an off-label manner or even when not approved for some indications in this vulnerable population (Coughlin et al. 2018; Dharni and Coates 2018).

Early monitoring for SGA-induced metabolic adverse effects is considered best practice as it can lead to early management and/or potential prevention of long-term adverse outcomes (Meyer et al. 2008). Such monitoring facilitates safe and effective SGA use among children and youth. Unfortunately, despite the evidence-based recommendations by guidelines such as The Canadian Alliance for Monitoring Effectiveness and Safety of Second Generation Antipsychotics in Children (CAMESA) (Pringsheim et al. 2012), the rates of monitoring continue to be inadequate. Consequently, this can result in an unnecessary risk of developing cardiovascular adverse effects and long-term disease among this vulnerable population (Coughlin et al. 2018). Besides, there is minimal uptake of clinical guidelines in youth prescribed antipsychotic practice across various practice settings (Haupt et al. 2009).

Reasons for nonadherence to best practice are sparsely studied and there is only little evidence to understand psychiatrists' perception on metabolic monitoring in this cohort. Therefore, there is a need to understand the current problems, identify barriers to adherence to metabolic monitoring, and develop appropriate strategies to enhance uptake of evidence-based monitoring. A survey done by Rodday et al. (2015) among American psychiatrists reported inconsistent monitoring practices of youth prescribed SGAs, where factors such as years of work experience, comfort conducting physical examinations, and psychiatrists' personal beliefs about the risks of SGA-induced side effects have influenced psychiatrists' behavior regarding metabolic monitoring practices (Rodday et al. 2015). Furthermore, to our knowledge, there is a lack of evidence into understanding barriers to metabolic monitoring from the perspective of community child and youth psychiatrists in Australia.

Given the existing gap between best practice and prescribing behavior, the authors wanted to explore the barriers and reasons behind them through community mental health care providers' perspective.

Objective

This research aimed to investigate practitioners' perspective on metabolic monitoring of youth prescribed SGAs as well as the barriers and strategies to monitoring.

Methods

The researchers opted to utilize the qualitative research methodology that is highly successful in elucidating potential barriers and would be the best approach to answer complicated research questions in small samples (Rich and Ginsburg 1999; Crabb and Chur-Hansen 2009). Considering that the thematic analysis technique is the most common analytical technique (Kisely and Kendall 2011), as well as being flexible and accessible (Braun et al. 2019), we used this technique for data analysis. The framework for the interview questions was formed based on most recent and relevant evidence pertaining to the research phenomenon, which was piloted before the study.

The research was conducted between August 2018 and December 2018, across six Child and Youth Mental Health Services (CYMHS) in the Queensland State of Australia. Practitioners in this study comprised psychiatrists who work with children and youth at six community clinics. The psychiatrists were invited to voluntarily participate in the study and they were e-mailed the information sheet with the objectives, procedures, and other relevant information. A qualitative approach, through semistructured interviews, was facilitated for participants to share their narrative responses, and in addition, descriptive thematic analysis was utilized to analysis the data, that is, participants' responses. This form of analysis helped recognize the common themes across the participants' answers to our research questions (Vaismoradi et al. 2013).

Sample sizing in qualitative research tends to rely on the quality of the information gathered from the participants rather than the quantity of the sample (DeJonckheere and Vaughn 2019). Moreover, qualitative approaches aim to reach an in-depth and detailed understanding, usually utilize purposeful sampling, and seek to achieve data saturation (Malterud et al. 2016; DeJonckheere and Vaughn 2019). Data saturation is achieved when no new information is collected from participants anymore, but the research question has been adequately answered even when the sample size is small (DeJonckheere and Vaughn 2019; Guest et al. 2020).

Each clinic in our study has one psychiatrist and one trainee psychiatrist, and thus, the maximum number of participants who could have been recruited was 12. Therefore, the study sample size required to reach data saturation was guided by established evidence as well as pragmatic considerations, that is, the capacity of the study sites and participants' response rate (Guest et al. 2006; Carlsen and Glenton 2011; Vasileiou et al. 2018). This project was approved by the Children's Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC/17/QRCH/89) and the Griffith University Human Research Ethics Committee (HREC 2017/923).

Procedures

The interview guide was developed using the framework for semistructured interviews guided by Kallio et al. (2016) and based on the interview questions used by Ronsley et al. (2011) in a cognately similar cohort. Data were extracted through semistructured interview sessions that took ∼30 minutes. The interviews were audio recorded and conducted by one of the research team members. An informed consent form was provided to participants to describe the research process, confidentiality, and description of the interview session (also e-mailed before the interview session). Informed consent was obtained from all study participants before conducting the interviews. Prescribers were informed of the purpose of conducting the interview and that the interviews would be recorded and transcribed for data analysis. Data analysis was conducted by using NVivo software (QSR International Pty Ltd., 2018).

Data analysis

Transcripts were read and reread by the interviewer, to obtain a broad understanding of the interviewees' answers that were relative to the key questions. A coding guide was created to identify the key meanings provided by the interviewees. This was done by coding the messages provided by the participants and then by clustering them to create meta-themes, and these meta-themes reflected the key information provided by the prescribers. Subthemes were then developed to reflect further in-depth information within the meta-themes. To ensure consistency with data coding and theme and subtheme developing, another researcher who was not involved in the process of interviewing or transcribing the interviews conducted a consistency check.

Results

The semistructured interviews were conducted with 10 participants. Of these, nine chose to do the one-on-one semistructured interviews over the phone and one participant did the face-to-face interview.

The participants were 5 (50%) males and 5 (50%) females. All participants were psychiatrists who manage young patients up to the age of 18, with governance over the full range of all mental health disorders of severity and complexity. All the participating psychiatrists had at least 7 years of experience in child psychiatry.

The thematic analysis of the data revealed the following three meta-themes: (1) balancing mental health care and physical health care, (2) self-reported barriers to metabolic monitoring from psychiatrists' perspective, and (3) psychiatrists' miscellaneous and spontaneous suggestions to enhance rates of metabolic monitoring.

The representative quotes are coded with (Psy) to clarify that the participant was a psychiatrist, and the numeric values are indicators for the participants.

Meta-theme: balancing mental health care and physical health care

Participants were asked about balancing provision of mental health care and physical health care to young patients attending their clinics. All psychiatrists believed that balancing both mental health and physical health is their priority. This is driven by them taking responsibility of the SGA prescription as well as their medical background.

“…. I certainly do not want the treatment I instigate to be causing physical health problem, particularly for a child who has got long lifespan ahead of them and might have problems down the track.” (Psy 5)

Subtheme: provision of physical health care

Participants reported multiple reasons for considering provision of physical health care as their responsibility such as their medical background. Moreover, our participants indicated that their patients and carers do not engage with their general practitioners (GPs) to undergo physical measurements. On the contrary, these young patients seem to be more engaged with the psychiatrists at the mental health community clinics, providing more chances to enable physical health provision.

“I was once a general practitioner. It is always that health, mind and body and holistic endeavour.” (Psy 8)

“Lack of engagement is such a problem with these patients. We are the ones who have the best engagement, so I think we are best placed to do it actually.” (Psy 4)

However, three participants (30%) added that they also believe physical health care is a shared responsibility between the patients and their carers, the psychiatrists, and the GP.

“It is the families, the child and the GP's responsibility as well as the clinician's responsibility.” (Psy 3)

Subtheme: psychiatrists' challenges to balancing provision of mental health care and physical health care

In addition, participants also shared common challenges they usually face while balancing young patients' mental health care and physical health care, as shown in Table 1.

Table 1.

Common Barriers to Balancing Mental Health Care and Physical Health Care from Psychiatrists' Perspective

Barriers	n (%)	Representative quotes
Lack of time especially when the presenting case is complex	2 (20)	“I think when we prioritise any issue in a session, it is at the cost of other things that we could be dealing with.…” (Psy 1)
Lack of the proper equipment and resources	4 (40)	“Usually the biggest barriers having access to things like ECG machine and even things like the proper blood pressure cuffs and the room to examine people….” (Psy 10)
Lack of carers' engagement	4 (40)	“It is hard to make it with the parents because they often quite disenfranchised and not really active proponents of their own and their children's healthcare.” (Psy 4)
Lack of proper training to deal with physical health	4 (40)	“…. expertise and the education is not as great as it should be, so not always as confidant as I feel I should be.…” (Psy 6)
Lack of appropriate communication with allied health and general practitioners, GPs	4 (40)	“…. there is a kind of helplessness because we do not have the other allied health or other health professionals that could help us reinforce physical health change and reform.” (Psy 9)
The acuteness of young patients' mental health diagnosis	3 (30)	“The severity of the presentation, so you have kids ‘suicide, self-harm and complex relational and psychiatric presentation that requires a great deal of thought and reflection, and they will work with the family and systems, so between that finding an opportunity for physical healthcare is extremely challenging.” (Psy 3)
The fear of losing rapport with young patients if physical health checkups were mentioned, especially blood tests	3 (30)	“One barrier is rapport, so for example, for a young person to feel safe talking about what could be sensitive issues in terms of body weight or eating behaviour….” (Psy 1)
Carers' financial difficulties	2 (20)	“Financially, sometimes patients can struggle to access things that would be ideal, and we do not necessarily have these things in our service.” (Psy 6)

Meta-theme: self-reported barriers to metabolic monitoring from psychiatrists' perspective

There was a general consensus that requests to conduct metabolic monitoring tend to be difficult, especially blood tests. Participants were asked about the main issues they face in relation to metabolic monitoring. The barriers are summarized in Table 2.

Table 2.

Self-Reported Barriers to Conducting Metabolic Monitoring from Participants' Perspective

Barriers	n (%)	Quotes
Lack of proper resources (e.g., equipment, lack of electronic reminders, time, cost, and lack of proper guidelines that specifically target this vulnerable population).	10 (100)	“I think we failed to institute very clear and regular guidelines at the very beginning and if we did that there would always be a right time.” (Psy 9) “You have to do a room booking which is the tough part because we do share, and the clinic rooms here are not to a specific clinic. It is just a group of rooms and people book whatever.” (Psy 10)
Carers and young patients' disengagement and lack of insight into the importance of medication as well as the metabolic monitoring process.	7 (70)	“Lack of engagement is such a problem with these patients.” (Psy 4) “I mean the biggest most practical one is that good regular monitoring requires family to come and cooperate regularly.” (Psy 5)
Young patients' refusal to undergo blood tests, in particular.	7 (70)	“Large proportions of the children we are involved with absolutely refuse blood tests and the family give up on trying to get them there.” (Psy 5)
Multiple competing priorities reducing the capacity to conduct metabolic monitoring.	4 (40)	“…. the problem is pretty much most of the people that we see have complex trauma, so essentially their problems are influencing our metabolic monitoring issues.” (Psy 3)
Lack of commitment from mental health care providers.	3 (30)	“I personally feel that the biggest barrier is actually commitment from all mental health staff towards physical health, that includes both the clinician in the call phase in the front end to the senior executive on prioritising physical healthcare as a major priority result.” (Psy 3)
Young patients presenting to the clinic already prescribed unnecessarily high doses of SGAs.	3 (30)	“I think probably my primary difficulty with ATP is not the prescribing itself but it is how people come to us are on high doses with them, ……., and we tend to get it where everything goes wrong, and when it goes wrong, just prescribe one more and then getting more side effects and it does not really do anything whereas they would really benefit from an earlier assessment via menta health…” (Psy 10)
Difficulty getting the blood test results back.	3 (30)	“So there is no system that tells us the results have arrived and the results needed to be actioned.” (Psy 3)
Lack of clear role description and standardized methods for everyone to follow.	2 (20)	“We have a multidisciplinary team who also see children, adolescents who have metabolic problems and I think it is not really clear who has the primary responsibility for monitoring.” (Psy 9)
Difficulty communicating within the health care providers.	2 (20)	“There is not enough communication, so I do not know when the appointment is.” (Psy 4)

SGAs, second-generation antipsychotics.

One psychiatrist summarized the barriers to SGA metabolic monitoring:

“I think in all honesty the treatments on mental health problems are actually making their problems worse by adding side effects to their situation. So when we look at atypical antipsychotics, they have very slow grip on weight gain and this would worsen their vulnerability, so people with complex trauma, low socioeconomic status, they eat low quality food, they lack in recreation and sports, so all of that add to their risk and I think overall the benefits to the mental health does not seem to justify the damage to physical health sometimes.” (Psy 3)

Meta-theme: psychiatrists' miscellaneous and spontaneous suggestions to enhance rates of metabolic monitoring

Participants were then asked to share the strategies that they believe would be feasible in clinical practice, as tabulated under two major categories summarized in Table 3.

Table 3.

Suggestions to Enhance Metabolic Monitoring from Participants' Perspective

Category	Suggestions
Organizational support	• Continuous encouragement and supportive auditing of practitioners' performance in terms of metabolic monitoring. • Obesity management to be available in the public sector as well as GPs' knowledge of obesity management. • Create online access to laboratory results, which would be imbedded in the clinic's system. • Provide more education to patients and carers in the form of leaflets. • Create an alert popping reminder into the patients' files that shows that the blood results have arrived, and they need to be actioned. • The integration of physical and mental health care in the information system, so that there is clear accessibility and timely monitoring of this. • Develop an electronic monitoring system that includes tabs, which works as medical correspondence regarding the measurements and the results. • Set up the community clinic by adapting the one-stop shop concept, which would provide the patients with everything they need such as a GP, a dietitian, and an exercise physiologist.
Provision of training and education opportunities	• Provide better education and training for pediatricians and GPs who are often the first prescribers for antipsychotics. • All Queensland Health employees to undergo mandatory education and mandatory training in regard to the importance and the process of metabolic monitoring in children and youth. For instance, sharing videos about metabolic monitoring with the employees. • Provide proper education, training, and support to psychiatrists to improve their skills while dealing with sensitive or complex patients who refuse undergoing metabolic monitoring. • To prepare and train all team members and not just the ones with the medical background to be involved in the process of metabolic monitoring.

Discussion

This research addressed prescribers' needs, expectations, barriers, and experiences regarding the issues related to conducting metabolic monitoring in youth receiving SGAs. In addition, we explored their perception on strategies to enhance the rates of metabolic monitoring among youth prescribed SGAs and to adhere to best practice standards within the community practice setting.

It is worth noting the roles of community child and adolescent psychiatrists in our study sites:

Provide tertiary (via team or individual meetings) consultation or secondary consultation (i.e., see patient with treating clinician) or primary consultation (i.e., actively providing treatment, e.g., prescribe medication) and advice on diagnosis and management in the context of child-centered evidence-informed mental health care for children (between 5 and 18) and families attending public sector community clinics.

Where the child and adolescent psychiatrist is an active treatment agent, for example, prescribe medication, see the patient regularly, and carry out routine physical checks.

Within the context of their current role, the participating psychiatrists believed that it is their responsibility to balance both the physical health and mental health provision, especially if they are the ones initiating the SGA prescription. In a similar study that explored the views of primary care clinicians about metabolic monitoring in people prescribed antipsychotics, 80% of the psychiatrists held the same belief (Mangurian et al. 2019). This indicates that psychiatrists seem to be motivated and driven to conduct metabolic monitoring in addition to their main role of managing their young patients' mental health disorders, which is an essential element to provide optimum health care (Dieleman and Harnmeijer 2006).

Although study participants demonstrated responsibility and the confidence to conduct metabolic monitoring, they shared the many obstacles they face in a mental health community clinic setting.

Barriers to metabolic monitoring from psychiatrists' perspective

Psychiatrists reported numerous obstacles to delivering physical health care, including metabolic monitoring. For example, 40% of the participants cited shortage of equipment, lack of patients' and carers' engagement, lack of training and knowledge regarding physical health, and lack of proper communication with GPs. This was followed by 30% of the participants who mentioned the fear of losing rapport with the young patients as well as the severity of the mental health diagnosis (Table 1).

These obstacles are consistent with challenges specified by psychiatrists in other studies (Walter et al. 2008; De Hert et al. 2011; McLaren et al. 2017). For instance, 55% of the child psychiatrists in a survey study in Australia reported patient noncompliance as a major barrier (Walter et al. 2008). They also reported other obstacles such as patient inconvenience (40%), lack of time (35%), lack of appropriate resources (32%), and the belief that mental health care for psychiatric symptoms must be prioritized over management of physical health problems (28%) (Walter et al. 2008).

Similarly, a study focusing on providing physical health to patients with severe mental health disorders shared that the severity of mental health diagnosis, poor communication with patient and GPs, and complexity and time intensity of coordinating both medical and psychiatric medications were also barriers to balancing both physical health and mental health provision (De Hert et al. 2011).

The most common self-reported barrier to conducting metabolic monitoring as reported by all the psychiatrists in the present study was the lack of resources (Table 2). They noted that simple equipment, such as weight scales, waist measurement tapes, and blood pressure monitors, is lacking or difficult to access. For example, the equipment is usually located in a shared room that must be booked before use and psychiatrists have to share what is available during their consultations with the patients. Consequently, locating the equipment is time-consuming, which can negatively affect their ability to navigate the complexity of mental health care provision with added hurdle to metabolic monitoring within the treatment session. Furthermore, inadequate reminder systems as well as lack of clarity on delegation of responsibility for the monitoring were consistently highlighted.

This echoes findings from a Canadian survey in which only 9.1% of the participants (Ronsley et al. 2011) believed that there are proper reminding systems in place, and only 22.7% agree to the existence of systems for allocating responsibility for metabolic monitoring of the patients (Ronsley et al. 2011). Report by the World Health Organization (Dieleman and Harnmeijer 2006) specified that the shortage or lack of recourses and equipment can negatively affect the quality of health care administered by health care providers. This report also noted that the lack of equipment and resources can attribute to the lack of motivation to provide optimal health care. A similar finding by Kolehmainen-Aitken (2004) linked the performance of health care providers to their motivation and the availability of equipment.

The second common barrier reported by 70% of the participants was related to the lack of carers' and young patients' engagement with the treatment and the clinic (Table 2). Evidence reveals that the negative attitudes toward any treatment, lack of insight into the effect of the treatment, and lack of consistent family support are strong predictors for medication nonadherence (Quach et al. 2009). Carers play a significant role to enhance medication adherence through adequate engagement with health providers to achieve proper support for the young children and adolescents (Grover et al. 2014). A study by McFarlane (2016) found that family members' engagement in the management of the patients' mental health care led to less rehospitalization by 20%–50% over the period of 2 years. Other benefits include decreased psychiatric symptoms, improved social functioning, higher levels of participation in vocational therapy, and higher employment rates (McFarlane 2016).

However, there are many factors that might affect the carers' ability to look after their mentally ill children. Evidence revealed that some carers report emotional disturbances such as feelings of loss, anxiety, and distress (Kuipers 2010; Kuipers et al. 2010; Möller-Leimkühler and Wiesheu 2012; Stomski and Morrison 2021). In addition, providing care for such a vulnerable population can lead to social isolation, financial difficulties, family disruptions, and negatively affecting work productivity, which could also impact negatively on carers' quality of life (Kuipers 2010; Kuipers et al. 2010; Hayes et al. 2015; Morrison and Stomski 2018; Stomski and Morrison 2021).

Moreover, evidence linked higher rates of depression in carers of mental health patients, with caring for younger age, as well as lower levels of carer educational attainment (Smith et al. 1997; Kuipers et al. 2010; Rabinowitz et al. 2013). Hence, both engagement and insight of the patients and their carers seem to have a positive influence on compliance, which could lead to better adherence with medication and the treatment plan (Smith et al. 1997).

Participants also noted that they manage the whole range of mental health disorders in the community clinics. Therefore, a potential link between the young patients' diagnosis and the psychiatrists' capacity to manage their physical health has emerged, particularly for patients with complex trauma, unsettled family environment, and patients with psychosis (Table 2).

This is similar to the findings by Mangurian et al. (2019), where 60% of both psychiatrists and GPs had reported the severity of mental health diagnosis as one of the common barriers to conduct metabolic monitoring. The severity of patients' mental health diagnosis has been reported as a significant barrier to metabolic monitoring by psychiatrists in other studies (Mangurian et al. 2013; Parameswaran et al. 2013). Thus, greater attention needs to be directed toward investigating the influence of the severity of mental health diagnosis on the provision of optimum health care in community clinics.

Finally, young patients' refusal to undergo blood tests was reported by 70% of participants in our sample, as shown in Table 2. This is a common obstacle to psychiatrists while trying to achieve comprehensive metabolic monitoring recommendations in young patients receiving SGAs (Rodday et al. 2015; McLaren et al. 2017).

Suggestions to enhance metabolic monitoring among youth from psychiatrists' perspective

Participants suggested that to combat carers' lack of engagement, mental health providers need to receive adequate organizational support (Table 3), such as increased number of employed nurses and mental health professionals within the clinics. Psychiatrists then would be able to increase their focus on the individual needs of the families and be able to provide them with the optimal support. For instance, they can utilize the consultation time to be focused on discussions with the young patients and their carers, provide the families with detailed advice about access to disability and financial support services, and enhance their ability to explore carers' opinion regarding the quality of health care provided to their young children (Stomski and Morrison 2021).

In addition, Dunbar et al. (2010) stated that to increase carers' engagement with the service, providing extra education and potential outcomes of the treatment is crucial. It is advised that such education has to be provided while also avoiding technical and medical terms, and approaching sensitive information about adverse effects and disease from the cultural perspective of the young patients and their families (Dunbar et al. 2010).

Another suggestion by the participants was to provide formal training and education to all team members. This could be in the form of in-service training around conduct and interpretation of metabolic measurements, especially blood tests (Dunbar et al. 2010). Educational seminars and interactive lectures using persuasive communication can also be a useful tool to enhance psychiatrists' adherence to guidelines' recommendations (Hetricket al. 2010). Periodic reminders and follow up to frequency of metabolic monitoring could also assist in adherence to the guidelines (Ronsley et al. 2011).

The utilization of electronic metabolic monitoring forms was suggested as an intervention to help enhance rates of metabolic monitoring by the participating psychiatrists. According to Happell et al. (2016), the introduction of an electronic standardized metabolic monitoring form could be an important step in addressing the poor rates of metabolic monitoring (Happell et al. 2016). This process helped to improve the provision of physical health care for youth prescribed SGA/s.

Finally, participants suggested providing the staff within the community clinics with a standardized metabolic monitoring process. For example, staff have unified guidelines and a protocol in place, which they need to follow. Moreover, staff should have a clear role description in regard to who should monitor and what to monitor and a reminder system. This can be a tool to enhance the staff confidence in metabolic monitoring and could also ensure consistent and continuous care for the young patients (Ronsley et al. 2011). It is worth noting that we only interviewed practicing child psychiatrists with a small sample size. Thus, our results do not reflect the opinion of the other mental health providers such as psychologists and social workers.

In summary, our study participants shared a number of initiatives in the form of multilayered intervention to bridge the existing gap between best practice and current rate of metabolic monitoring. These strategies were informed by the infrastructure at the local clinical setting. Inputs from consumers on the likelihood of acceptance of multilayered strategies form the future course of research. Evidence (Pereira et al. 2022) highlights such strategies for successful uptake of clinical guidelines in challenging and complex therapeutic areas.

Conclusions

The best practice guidelines and clinical recommendation require mental health providers to facilitate conduction of metabolic monitoring among youth prescribed SGA/s. However, they are not provided with enough support. The lack of organizational support, as well as families' lack of engagement with the treatment plan and decision-making, contributes to the ongoing medication nonadherence in this cohort. Appropriate strategies are needed to improve adherence with SGA monitoring guidelines for both psychiatrists and families. This could allow developing a feasible multilayered intervention utilizing a range of behavior change approaches to tackle complex barriers. Such interventions should be codesigned in consultation with the clinical team and the consumers' representatives, and tailored to suit local clinical settings.

This research promotes the importance of assessment of the barriers from the perspective of mental health providers. As researchers it is crucial that we understand the challenges they face in managing a complex and vulnerable patient cohort as well as to consider strategies they suggest and perceive as likely to work. This research has thrown light on these key aspects of the existing gap between best practice standards and clinical practice in youth prescribed SGAs.

Clinical Significance

Evidence-based guidelines on metabolic monitoring of SGAs, for example, CAMESA provide recommendations and key parameters for metabolic monitoring of youth prescribed SGAs. However, the rates of monitoring continue to be inadequate and suboptimal for unknown reasons. Suboptimal monitoring pose a significant clinical service gap in provision of physical care for youth prescribed SGAs. To the best of our knowledge, studies exploring the reason for existing gap (from the perspective of healthcare providers) in Australian clinical settings are limited. Present study explored this research gap by identifying those barriers and providing implications of findings in a direction towards support of rational and safe prescribing of SGAs in this vulnerable cohort.

Footnotes

Authors' Contributions

N.A.: Conceptualization (lead), methodology (lead), writing—original draft (lead), formal analysis (lead), and writing—review and editing (lead).

S.K.: Conceptualization (supporting), methodology (supporting), formal analysis (supporting), and review and editing (supporting).

H.H.: Review and editing (supporting).

A.H.: Review and editing (supporting).

A.K.: Original draft (supporting) and review and editing (supporting).

W.B.: Conceptualization (supporting), methodology (equal), formal analysis (supporting), and review and editing (supporting).

Disclosures

No competing financial interests exist.

References

AIHW: Australian Institute of Health and

Welfare

. Mental health services in

Australia

, 2018. https://www.aihw.gov.au/reports/mentalhealth-services/mental-health-services-in-australia/report-contents/mentalhealth-related-prescriptions (accessed March 15, 2020 ).

Braun

, Clarke

, Hayfield

, Terry

: Thematic analysis. In: Liamputtong P (ed.) Handbook of Research Methods in Health Social Sciences. Springer, L. P. Singapore, 2019.

Carlsen

, Glenton

: What about N?. A methodological study of sample-size reporting in focus group studies. BMC Med Res Methodol, 11:11, 2011.

Correll

, Manu

, Olshanskiy

, Napolitano

, Kane

, Malhotra

: Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents. JAMA, 302:1765–1773, 2009.

Coughlin

, Goldie C

, Tregunno

, Tranmer

, Kanellos-Sutton

, Khalid-Khan

: Enhancing metabolic monitoring for children and adolescents using second-generation antipsychotics. Int J Ment Health Nurs, 27:1188–1198, 2018.

Crabb

, Chur-Hansen

: Qualitative research: Why psychiatrists are well-placed to contribute to the literature. Australas Psychiatry, 17:398–401, 2009.

De Hert

, Cohen

, Bobes

, Cetkovich-Bakmas

, Leucht

, Ndetei

, Newcomer

, Uwakwe

, Asai

, and Möller

: Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry, 10:138–151, 2011.

DeJonckheere

, Vaughn

: Semistructured interviewing in primary care research: A balance of relationship and rigour. Fam Med Community Health, 7:e000057, 2019.

Dharni

, Coates

: Psychotropic medication profile in a community youth mental health service in Australia. Child Youth Serv Rev, 90: 8–14, 2018.

10.

Dieleman

, Harnmeijer

: Improving Health Worker Performance: In search of Promising

Practices

. Geneva, World Health Organization, 2006.

11.

Dunbar

, Brandt

, Wheeler

, Harrison

: Barriers and solutions to implementing metabolic risk assessment in a secondary mental health service. Australas Psychiatry, 18:322–325, 2010.

12.

Grover

, Chakrabarti

, Sharma

, Tyagi

: Attitudes toward psychotropic medications among patients with chronic psychiatric disorders and their family caregivers. J Neurosci Rural Pract, 5:374–383, 2014.

13.

Guest

, Bunce

, Johnson

: How many interviews are enough?. An experiment with data saturation and variability. Field Methods, 18:59–82, 2006.

14.

Guest

, Namey

, Chen

: A simple method to assess and report thematic saturation in qualitative research. PLoS One, 15:e0232076, 2020.

15.

Happell

, Platania-Phung

, Gaskin

, and Stanton

: Use of an electronic metabolic monitoring form in a mental health service—A retrospective file audit. BMC Psychiatry, 16:109, 2016.

16.

Haupt

, Rosenblatt

, Kim

, Baker

, Whitehead

, Newcomer

: Prevalence and predictors of lipid and glucose monitoring in commercially insured patients treated with second-generation antipsychotic agents. Am J Psychiatry, 166:345–353, 2009.

17.

Hayes

, Hawthorne

, Farhall

, B. O'Hanlon andHarvey

: Quality of life and social isolation among caregivers of adults with schizophrenia: Policy and outcomes. Community Ment Health J, 51:591–597, 2015.

18.

Hetrick

, Álvarez-Jiménez

, Parker

, Hughes

, Willet

, Morley

, Fraser

, McGorry

, Thompson

: Promoting physical health in youth mental health services: Ensuring routine monitoring of weight and metabolic indices in a first episode psychosis clinic. Australas Psychiatry, 18:451–455, 2010.

19.

Kallio

, Pietilä

, Johnson

, Kangasniemi

: Systematic methodological review: Developing a framework for a qualitative semi-structured interview guide. J Adv Nurs, 72:2954–2965, 2016.

20.

Kalverdijk

, Bachmann

, Aagaard

, Burcu

, Glaeske

, Hoffmann

, Petersen

, Schuiling-Veninga

, Wijlaars

, Zito

: A multi-national comparison of antipsychotic drug use in children and adolescents, 2005–2012. Child Adolesc Psychiatry Ment Health, 11:55, 2017.

21.

Kisely

, Kendall

: Critically appraising qualitative research: A guide for clinicians more familiar with quantitative techniques. Australas Psychiatry, 19:364–367, 2011.

22.

Kolehmainen-Aitken

R-L

: Decentralization's impact on the health workforce: Perspectives of managers, workers and national leaders. Hum Resour Health, 2:5, 2004.

23.

Kuipers

: Time for a separate psychosis caregiver service?. J Ment Health, 19:401–404, 2010.

24.

Kuipers

, Onwumere

, Bebbington

: Cognitive model of caregiving in psychosis. Br J Psychiatry, 196:259–265, 2010.

25.

Malterud

, Siersma

, Guassora

: Sample size in qualitative interview studies: Guided by information power. Qual Health Res, 26:1753–1760, 2016.

26.

Mangurian

, Giwa

, Brosey

, Shumway

, Dilley

, Fuentes-Afflick

, Pérez-Stable

, Schillinger

: Opinions of primary care clinicians and psychiatrists on monitoring the metabolic effects of antipsychotics. J Am Board Fam Med, 32:418–423, 2019.

27.

Mangurian

, Giwa

, Shumway

, Fuentes-Afflick

, Pérez-Stable

, Dilley

, Schillinger

: Primary care providers' views on metabolic monitoring of outpatients taking antipsychotic medication. Psychiatr Serv, 64:597–599, 2013.

28.

McFarlane

: Family interventions for schizophrenia and the psychoses: A review. Fam Process, 55:460–482, 2016.

29.

McLaren

, Brunette

, McHugo

, Drake

, Daviss

: Monitoring of patients on second-generation antipsychotics: A national survey of child psychiatrists. Psychiatr Serv, 68:958–961, 2017.

30.

Meyer

, Davis

, Goff

, McEvoy

, Nasrallah

, Davis

, Rosenheck

, Daumit

, Hsiao

, Swartz

: Change in metabolic syndrome parameters with antipsychotic treatment in the CATIE Schizophrenia Trial: Prospective data from phase 1. Schizophr Res, 101:273–286, 2008.

31.

Möller-Leimkühler

, Wiesheu

: Caregiver burden in chronic mental illness: The role of patient and caregiver characteristics. Eur Arch Psychiatry Clin Neurosci, 262:157–166, 2012.

32.

Morrato

, Nicol

, Maahs

, Druss

, Hartung

, Valuck

, Campagna

, Newcomer

: Metabolic screening in children receiving antipsychotic drug treatment. Arch Pediatri Adolesc Med, 164:344–351, 2010.

33.

Morrison

, Stomski

: Carers' perspectives on mental health consumers' use of antipsychotic medication: A multidimensional scalogram analysis. Contemp Fam Ther, 40:99–109, 2018.

34.

Parameswaran

, Chang

, Swenson

, Shumway

, Olfson

, Mangurian

: Roles in and barriers to metabolic screening for people taking antipsychotic medications: A survey of psychiatrists. Schizophr Res, 143:395–396, 2013.

35.

Pereira

, Silva

, Carvalho

, Zanghelini

, Barreto

: Strategies for the implementation of clinical practice guidelines in public health: An overview of systematic reviews. Health Res Policy Syst, 20:13, 2022.

36.

Pringsheim

, Doja

, Belanger

, Patten

: The Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA) guideline group. Treatment recommendations for extrapyramidal side effects associated with second-generation antipsychotic use in children and youth. Paediatr Child Health, 17:22B–30B, 2012.

37.

Quach

, Mors

, Christensen

TØ

, Krarup

, Jørgensen

, Bertelsen

, Jeppesen

, Petersen

, Thorup

, Nordentoft

: Predictors of poor adherence to medication among patients with first-episode schizophrenia-spectrum disorder. Early Interv Psychiatry, 3:66–74, 2009.

38.

Rabinowitz

, Berardo

, Bugarski-Kirola

, Marder

: Association of prominent positive and prominent negative symptoms and functional health, well-being, healthcare-related quality of life and family burden: A CATIE analysis. Schizophr Res, 150:339–342, 2013.

39.

Rich

, Ginsburg

: The reason and rhyme of qualitative research: Why, when, and how to use qualitative methods in the study of adolescent health. J Adolesc Health, 25:371–378, 1999.

40.

Rodday

, Parsons

, Mankiw

, Correll

, Robb

, Zima

, Saunders

, Leslie

: Child and adolescent psychiatrists' reported monitoring behaviors for second-generation antipsychotics. J Child Adolesc Psychopharmacol, 25:351–361, 2015.

41.

Ronsley

, Raghuram

, Davidson

, Panagiotopoulos

: Barriers and facilitators to implementation of a metabolic monitoring protocol in hospital and community settings for second-generation antipsychotic-treated youth. J Can Acad Child Adolesc Psychiatry, 20:134, 2011.

42.

Rubin

, Kreider

, Matone

, Huang

Y-S

, Feudtner

, Ross

, Localio

: Risk for incident diabetes mellitus following initiation of second-generation antipsychotics among Medicaid-enrolled youths. JAMA Pediatr, 169:e150285, 2015.

43.

Smith

, Barzman

, Pristach

: Effect of patient and family insight on compliance of schizophrenic patients. J Clin Pharmacol, 37:147–154, 1997.

44.

Stomski

, Morrison

: Predictors of burden in Australian mental health caregivers: A cross-sectional survey. J Ment Health, 30:411–416, 2021.

45.

Vaismoradi

, Turunen

, Bondas

: Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nurs Health Sci, 15:398–405, 2013.

46.

Vasileiou

, Barnett

, Thorpe

, Young

: Characterising and justifying sample size sufficiency in interview-based studies: Systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol, 18:148, 2018.

47.

Walter

, Delaroche

, Soh

, Hunt

, Cleary

, Malhi

, Lambert

, Correll

, Rey

: Side effects of second-generation antipsychotics: The experiences, views and monitoring practices of Australian child psychiatrists. Australas Psychiatry, 16:253–262, 2008.