The Role of Trust and Hope in Antipsychotic Medication Reviews in Primary Care Settings: A Realist Review. 

Abstract Background: Increasing number of service users diagnosed with schizophrenia and psychosis are being discharged from specialist secondary care services to primary care, many of whom are prescribed long-term antipsychotics. It is unclear if General Practitioners have the confidence and experience to appropriately review and adjust doses of antipsychotic medication without secondary care support.Aim: To explore barriers and facilitators of conducting antipsychotic medication reviews in primary care for individuals with no specialist mental health inputDesign & Setting: Realist review in general practice settings. Method: A realist review has been conducted to synthesise evidence on antipsychotic medication reviews conducted in primary care with service users diagnosed with schizophrenia and/or psychosis. Following initial scoping searches and discussions with stakeholders, a systematic search and iterative secondary searches were conducted. Articles were systematically screened and analysed to develop a realist programme theory explaining the contexts (C) and mechanisms (M) which facilitate or prevent antipsychotic medication reviews (O) in primary care settings, and the potential outcomes of medication reviews.Results: Antipsychotic medication reviews may not occur for individuals with only primary care medical input. Several, often mutually reinforcing, mechanisms have been identified as potential barriers to carrying out meaningful reviews, including low expectations of recovery for people with severe mental illness, a perceived lack of capability to understand and participate in medication reviews, linked with a lack of information shared in appointments between GPs and Service Users, and perceived risk and uncertainty regarding antipsychotic medication and illness trajectory. Conclusions: The review identified reciprocal and reinforcing stereotypes affecting both GPs and service users. Possible mechanisms to counteract these barriers are discussed, including realistic expectations of medication, and the need for increased information sharing and trust between GPs and service users.