Impact of the COVID-19 pandemic on antipsychotic prescribing in individuals with autism, dementia, learning disability, serious mental illness or living in a care home: a federated analysis of 59 million patients' primary care records in situ using OpenSAFELY

Abstract

Background: The COVID-19 pandemic affected how care was delivered to vulnerable patients, such as those with dementia or learning disability.

Objective: To explore whether this affected antipsychotic prescribing in at-risk populations.

Methods: With the approval of NHS England, we completed a retrospective cohort study, using the OpenSAFELY platform to explore primary care data of 59 million patients. We identified patients in five at-risk groups: autism, dementia, learning disability, serious mental illness and care home residents. We calculated the monthly prevalence of antipsychotic prescribing in these groups, as well as the incidence of new prescriptions in each month.

Findings: The average monthly rate of antipsychotic prescribing increased in dementia from 82.75 patients prescribed an antipsychotic per 1000 patients (95% CI 82.30 to 83.19) in January-March 2019 to 90.1 (95% CI 89.68 to 90.60) in October-December 2021 and from 154.61 (95% CI 153.79 to 155.43) to 166.95 (95% CI 166.23 to 167.67) in care homes. There were notable spikes in the rate of new prescriptions issued to patients with dementia and in care homes. In learning disability and autism groups, the rate of prescribing per 1000 decreased from 122.97 (95% CI 122.29 to 123.66) to 119.29 (95% CI 118.68 to 119.91) and from 54.91 (95% CI 54.52 to 55.29) to 51.04 (95% CI 50.74 to 51.35), respectively.

Conclusion and implications: We observed a spike in antipsychotic prescribing in the dementia and care home groups, which correlated with lockdowns and was likely due to prescribing of antipsychotics for palliative care. We observed gradual increases in antipsychotic use in dementia and care home patients and decreases in their use in patients with learning disability or autism.

Keywords: COVID-19; adult psychiatry; delirium & cognitive disorders; impulse control disorders.

Figure 1

Monthly rate of patients issued an antipsychotic between January 2019 and December 2021, stratified by at-risk group. Solid coloured lines represent the monthly rates for each group with shaded colours areas representing 95% CIs. Vertical grey lines represent the start of the first two national lockdowns. Note each plot has a separate y-axis scale thus plots should be considered separately.

Figure 2

Monthly rate of patients newly issued an antipsychotic between January 2019 and December 2021stratified by at-risk group. Solid coloured lines represent the monthly rates for each group with shaded colours areas representing 95% CIs. Vertical grey lines represent the start of the first two national lockdowns. Note variation in each plot has a separate y-axis scale thus plots should be considered separately.

Figure 3

Clinical characteristics.

Figure 4

Monthly rates of care home and patients with dementia newly issued an antipsychotic (red line), excluding patients who had died within 2 weeks of being prescribed an antipsychotic (one indicator of palliative care) (green line) and who had also recently been prescribed midazolam (a drug frequently prescribed in palliative care) (blue line).