Research Article: Identifying potential prescribing safety indicators related to mental health disorders and medications: A systematic review

Date Published: May 24, 2019

Publisher: Public Library of Science

Author(s): Wael Y. Khawagi, Douglas T. Steinke, Joanne Nguyen, Richard N. Keers, Mojtaba Vaismoradi.


Prescribing errors and medication related harm may be common in patients with mental illness. However, there has been limited research focusing on the development and application of prescribing safety indicators (PSIs) for this population.

Identify potential PSIs related to mental health (MH) medications and conditions.

Seven electronic databases were searched (from 1990 to February 2019), including the bibliographies of included studies and of relevant review articles. Studies that developed, validated or updated a set of explicit medication-specific indicators or criteria that measured prescribing safety or quality were included, irrespective of whether they contained MH indicators or not. Studies were screened to extract all MH related indicators before two MH clinical pharmacists screened them to select potential PSIs based on established criteria. All indicators were categorised into prescribing problems and medication categories.

79 unique studies were included, 70 of which contained at least one MH related indicator. No studies were identified that focused on development of PSIs for patients with mental illness. A total of 1386 MH indicators were identified (average 20 (SD = 25.1) per study); 245 of these were considered potential PSIs. Among PSIs the most common prescribing problem was ‘Potentially inappropriate prescribing considering diagnoses or conditions’ (n = 91, 37.1%) and the lowest was ‘omission’ (n = 5, 2.0%). ‘Antidepressant’ was the most common PSI medication category (n = 85, 34.7%).

This is the first systematic review to identify a comprehensive list of MH related potential PSIs. This list should undergo further validation and could be used as a foundation for the development of new suites of PSIs applicable to patients with mental illness.

Partial Text

Mental disorders are one of the largest contributors toward the global burden of disease, being responsible for 21.2% of years lived with disability (YLDs) [1] and affecting approximately 1 in 5 adults within a given 12 month period and about 1 in 3 at some point in their lives. [2] However, the quality of care provided to patients with mental illness compared to those with physical health illnesses has been found to be inferior, and their care needs may often remain unmet [3], including the management of comorbid physical conditions [4].

In order to achieve the aim of this systematic review, we followed three stages (Fig 1); (1) identifying studies that reported prescribing indicators of any kind; (2) identifying and extracting mental health (MH) related prescribing indicators; and (3) selecting potential PSIs related to MH disorders and medications.

To our knowledge, this is the first systemic review conducted to identify and screen all known published prescribing indicators and inappropriate prescribing tools in order to extract potential prescribing safety indicators (PSIs) related to populations with mental illness, and indeed any broader type of mental health related prescribing quality indicators. An earlier systematic review [20] published in 2014 was limited to inappropriate prescribing assessment tools, and another review by Song et al. [19] published in 2017 was limited to quality indicators and did not include most of the inappropriate prescribing tools which means that these reviews missed many studies which we found to contain potential PSIs and broader mental health related indicators, such as Gurerriro et al. in 2007 [50], Dreischulte et al. in 2012 [73] and Wessell et al. in 2010 [39].

This is the first systematic review to identify a list of potential PSIs related to MH disorders and medications that may be used to assess the safety of prescribing. Examination of the included studies and the types of the identified potential PSIs extracted highlights the need for development of a suite of PSIs specific to patients with mental illness, and which covers all known areas of hazardous prescribing and drug monitoring in this patient group. The findings of this review should be used as a foundation for others across the globe to develop, validate and apply their own PSIs for patients with mental illness across different settings to monitor and improve patient care.




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