Literature Collection

BACKGROUND: Mental illness poses a large and growing disease burden worldwide. Its management is increasingly provided by primary care. The prescribing of psychotropic drugs in general practice has risen in recent decades, and variation in prescribing rates has been identified by a number of studies. It is unclear which factors lead to this variation. AIM: To describe the variables that cause variation in prescribing rates for psychotropic drugs between general practices. METHODS: A narrative review was conducted in January 2018 by searching electronic databases using the PRISMA statement. Studies investigating causal factors for variation in psychotropic prescribing between at least two general practice sites were eligible for inclusion. RESULTS: Ten studies met the inclusion criteria. Prescribing rates varied considerably between practices. Positive associations were found for many variables, including social deprivation, ethnicity, patient age and gender, urban location, co-morbidities, chronic diseases and GP demographics. However studies show conflicting findings, and no single regression model explained more than 57% of the variation in prescribing rates. DISCUSSION: There is no consensus on the factors that most predict prescribing rates. Most research was conducted in countries with central electronic databases, such as the United Kingdom; it is unclear whether these findings apply in other healthcare systems. More research is needed to determine the variables that explain prescribing rates for psychotropic medications.

The mental status examination relies on the physician's clinical judgment for observation and interpretation. When concerns about a patient's cognitive functioning arise in a clinical encounter, further evaluation is indicated. This can include evaluation of a targeted cognitive domain or the use of a brief cognitive screening tool that evaluates multiple domains. To avoid affecting the examination results, it is best practice to ensure that the patient has a comfortable, nonjudgmental environment without any family member input or other distractions. An abnormal response in a domain may suggest a possible diagnosis, but neither the mental status examination nor any cognitive screening tool alone is diagnostic for any condition. Validated cognitive screening tools, such as the Mini-Mental State Examination or the St. Louis University Mental Status Examination, can be used; the tools vary in sensitivity and specificity for detecting mild cognitive impairment and dementia. There is emerging evidence for the validity of cognitive screening performed during telemedicine visits, but it should not replace in-person evaluation of patients who have comorbidities that would preclude reliable testing via telephone or video. The workup after abnormal results of a mental status examination or cognitive screening tool is based on clinical judgment and primarily focuses on ruling out reversible causes of impairment and considering the need for further neuropsychiatric evaluation.