Facilitators And Barriers to the De-prescribing Of Benzodiazepines and Z-drug Hypnotics in patients under 65 on Adult Mental Health Wards: an exploratory qualitative study. (FABDOB Study)

Facilitators And Barriers to the De-prescribing Of Benzodiazepines and Z-drug Hypnotics in patients under 65 on Adult Mental Health Wards: an exploratory qualitative study. 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(FABDOB Study) Sonia Filmer, Ian Maidment This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6811205/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Nov, 2025 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version Abstract Background: There is a place for the use of benzodiazepines/z-hypnotics on adult mental health wards, but they are often continued beyond a length of time where they are beneficial. This can result in dependence and withdrawal effects if stopped. Timely deprescribing of these medicines is encouraged, but there is limited evidence available as to what can be a facilitator or barrier to the review of benzodiazepines/z-hypnotics on these wards. Method: Semi-structured interviews, with twenty-nine NHS healthcare professionals involved in the use of benzodiazepines/z-hypnotics on adult mental health wards, were conducted and recorded on Microsoft Teams and transcribed. Themes were generated via thematic analysis on NVIVO software, informed by a grounded, inductive approach, to identify similarities and differences in participants perceptions. Results: The four main themes identified from participants’ experiences were: · Culture · Patient factors · Practical measures to facilitate deprescribing of benzodiazepines/z-hypnotics on adult mental health wards · Primary/secondary care interface Deprescribing culture, rather than being led nationally, is more influenced by local factors. Some patient behaviour patterns can be a barrier to deprescribing but many of these can be overcome by promoting patient-centred care, allowing patients to feel involved and enabled to make informed decisions around their care. Access to non-pharmacological methods to de-escalate behaviour, promote wellbeing and improve sleep on adult mental health wards can support deprescribing. Cohesive multi-disciplinary team working aids deprescribing, but staff pressures can hinder this by reducing access to appropriately trained staff with the capacity to perform their role effectively. Effective discharge planning is important but not always achieved. Good communication post discharge can facilitate continued deprescribing. Conclusion: Overcoming the barriers and developing the facilitators identified could improve benzodiazepine/z-hypnotic deprescribing on adult mental health wards. Changes to national NHS culture and priorities are required to influence local culture. Otherwise, deprescribing practices will remain greatly influenced by local factors on individual wards. Good practice exists but further research and funding is needed to disseminate this throughout the NHS. Addressing underlying NHS pressures is essential to break the cycle of harmful polypharmacy and escalating patient behaviours. Health sciences/Health care Health sciences/Medical research Benzodiazepines hypnotics z-drugs deprescribing facilitator barrier EUPD NHS culture sleep hygiene de-escalation Figures Figure 1 Background Benzodiazepines (benzos) have been used for decades in the United Kingdon (UK) as anxiolytics and hypnotics on psychiatric wards 1 . Twelve benzodiazepines are licenced for use in the UK 2 . They slow down the central nervous system by acting as agonists at benzodiazepine receptors, enhancing the inhibitory effects of gamma-aminobutyric acid (GABA) 3 , resulting in calming and sedation. More recently, zopiclone and zolpidem (z-hypnotics), which also increase GABA transmission at these receptors, have emerged as alternative hypnotics 4 . Despite a decline in prescribing levels, in 2021-22, 1.8% of England’s population without learning disabilities were prescribed benzodiazepines, rising to 7.1% among those with learning disabilities 5 . During 2017-18, 2.3% of adults in England were prescribed Z-drugs 6 . Benzodiazepines/z-hypnotics have established roles in treating mania, alcohol withdrawal and short-term anxiety relief and insomnia on adult mental health (AMH) wards 7 , 8 . Nonetheless, they are often prescribed beyond their therapeutic window or inappropriately from the outset 9 . National Institute for Heath and Care Excellence (NICE) 9 guidelines recommend that benzodiazepines/z-hypnotics should not be prescribed for longer than 2–4 weeks to avert physical dependence and tolerance 2 . Between 15%-44% of chronic benzodiazepine users may face moderate to severe withdrawal symptoms when discontinuing 10 , 11 , such as sleep disturbance, irritability, increased anxiety, panic-attacks, tremor, sweating and nausea 9 . Z-hypnotics cause dependence like benzodiazepines 6 , 12 and withdrawal symptoms including insomnia, headaches, confusion, anxiety and restlessness 13 . NICE concluded z-hypnotics offer no distinct advantage over benzodiazepines for treating insomnia, 8 despite a perception of increased safety regarding tolerance 14 . Prescribers’ often overestimate their benefits, neglecting inherent risks 15 . Continued treatment beyond four weeks necessitates a careful withdrawal plan 1 , 16 , which may distress patients and destabilise their recovery, necessitating additional primary care input. Reviewing benzodiazepines/z-hypnotics regularly 17 can mitigate withdrawal symptoms. National Health Service (NHS) England’s guidance 18 recommends medication reviews with the patient, should happen every 2–3 days throughout admission. On AMH wards, benzodiazepines/z-hypnotics may be prescribed regularly or as-needed (PRN), with administration contingent upon nursing assessment of patients’ mental states. However, PRN administration practices reveal a lack of clarity and coherence 19 , 20 , with decisions often based on patient distress, safety concerns and requests. In some conditions, such as catatonia 21 , benzodiazepines/z-hypnotics are prescribed regularly. Compliance with NICE recommendations 9 necessitates regular reviews and ideally stopping these medications before discharge, if not a withdrawal plan post discharge should be established. Approximately 33% of patients are discharged from AMH ward on benzodiazepines/z-hypnotics 22 , with 20% continuing use 12 months post-discharge 5 . Public Health England has recognised the urgent need for further research into benzodiazepines/z-hypnotics dependence 6 . Evidence of efficacy of deprescribing, “the process of tapering or stopping drugs, aiming to minimise polypharmacy and improve patient outcomes” 23 is emerging from randomised controlled trials (RCT) and observational studies 24 . Challenges in the generalisation and transportability 25 of RCTs makes it difficult to apply this evidence in the personalised care of NHS mental health settings 26 and evidence is limited in AMH inpatient settings. Barriers to deprescribing stem from both clinician and patient perspectives, including prescriber confidence, communication issues and patient awareness 24 , 27 . Among primary-care prescribers, fears about consequences and workload concerns hinder action in patients under 65 24,28 . Procedural difficulties and perceived resistance are barriers with patients over 65 29,30,31 . There is more research into, and awareness of the benefits of, deprescribing of benzodiazepines/z-hypnotics in people over 65 32,33 than in the younger age group. Under 65s vary in recommended dosing levels and side-effect profile of benzodiazepines/z-hypnotics 2 . Researching barriers in younger populations is critical as they engage more actively in managing their medications 34 . Prescribers underestimate deprescribing enablers, including patients’ concerns and experiences of adverse effects, dislike of multiple medicines 24 , staff and patient education 35 , 36 , 37 , a multi-professional approach 37 , acceptability of non-pharmacological alternatives 38 and patient-centred care and shared decision making 38 . Person-centred care involves treating patients as individuals and as equal partners in their healing, meaning healthcare is coordinated, personalised and enabling 39 . Facilitators of benzodiazepines/z-hypnotic deprescribing on AMH wards include audit and feedback, increased clinical pharmacist input and placing limitations on prescribing 40 . New technologies may improve access to non-pharmacological treatments 8 . In summary, the need for research into reducing benzodiazepines/z-hypnotics dependence 6 is paramount, with limited evidence on deprescribing on AMH wards. This project aims to identify barriers and facilitators within deprescribing practices on AMH wards, setting the stage for future research and policy change that promotes effective management of these medications. Aims To identify barriers and facilitators to deprescribing of benzodiazepines/z-hypnotics on AMH wards. Objectives To interview healthcare professionals to investigate current practices in reviewing and deprescribing and identify barriers and facilitators associated with deprescribing benzodiazepines/z-hypnotics on AMH wards. Method This exploratory qualitative study involved remote interviews, adhering to the Consolidated Criteria for Reporting Qualitative studies (COREQ) guidelines 41 . (Appendix1) Ethics Ethical approval was secured from the Health Research Authority (IRAS number 322529) and Aston University’s Governance Committee. Additionally, capacity and capability approvals were obtained from Tees, Esk and Wear Valley NHS Foundation Trust. Clinical trial number: not applicable. All methods were performed in accordance with the relevant guidelines and regulations. Inclusion Criteria Healthcare professionals currently or recently (within the last 6 months) working on NHS AMH wards in the UK, with experience using or reviewing benzodiazepines/z-hypnotics in patients aged 18–65. Exclusion Criteria Healthcare professionals not working on NHS AMH wards in the UK within the last 6 month or lacking experience using or reviewing benzodiazepines/z-hypnotics in patients aged 18–65. Participants and recruitment A combination of convenience, snowball and purposive sampling techniques was employed to recruit participants through NHS contacts and professional networks. Pre-existing contacts promoted the study using an advertising flyer (appendix 2). Social media posts were shared through the College of Mental Health Pharmacists network. Participants were encouraged to disseminate information within their networks. Interview process and consent. Interviews took place from November 2023 to March 2024. Pilot interviews with two healthcare professionals were successfully conducted, with no modifications needed, and included in the final dataset. A participant information sheet (appendix 3) was sent out, along with consent (appendix 4) and demographic forms (appendix 5) to complete prior to interviews. The interviewees had the opportunity to ask questions and confirm their consent before beginning the interview. Semi-structured interviews were conducted online, recorded and transcribed using Microsoft Teams. This transcription was anonymised and accuracy checked. An interview guide (appendix 6) facilitated flexible discussions, allowing for spontaneous questions and in-depth participant reflections. This heuristic approach 42 enabled richer data collection while supporting systematic comparison across interviews. Data Analysis Transcribed interviews were coded and analysed using NVivo software, employing thematic analysis 43 with a grounded 44 , inductive approach. This allowed for open coding and opportunities to draw out meanings expressed by interviewees. Continuous data analysis enabled flexibility in interviews to explore emerging themes 42 , 45 whilst identifying data saturation 43 , 46 , which was achieved after 29 interviews, signalling an end to participant recruitment. Reflexivity and validation The researcher, a mental health pharmacist with over 25 years of clinical experience, remains mindful of her dual role as researcher and clinician. Reflexivity informed the analysis, ensuring participants’ views were conveyed accurately, accounting for potential biases from professional relationships 47 and experiences. Dissenting opinions were analysed and opposing views reported. Results Participant demographics are shown in the Table 1 below. Table 1 – Participant Demographics Participant ID Role Prescriber? Code for trust(s) worked in last 6 months Area of UK worked in Doctor1 Senior registrar Yes 1&3 Northeast England Doctor2 Consultant psychiatrist Yes 1 Northeast England Doctor3 Consultant psychiatrist Yes 3 Northeast England Doctor4 Senior registrar Yes 5 West Midlands England Doctor5 Consultant psychiatrist Yes 1 Northeast England Doctor6 Consultant psychiatrist Yes 1 Northeast England Doctor7 Senior registrar Yes 1 Northeast England Nurse1 Mental health nurse No 1 Northeast England Nurse2 Mental health nurse No 2 Wales Nurse3 Mental health nurse No 1 Northeast England Nurse4 Consultant nurse and approved clinician Yes 1 Northeast England Nurse5 Consultant nurse and approved clinician Yes 1 Northeast England Nurse6 Consultant nurse and approved clinician Yes 11 Yorkshire Pharmacist1 Clinical pharmacist Yes 1 Northeast England Pharmacist2 Clinical pharmacist Yes 2 Wales Pharmacist3 Clinical pharmacist No 3 Northeast England Pharmacist4 Clinical pharmacist Yes 4 East Midlands Pharmacist5 Clinical pharmacist No 3 Northeast England Pharmacist6 Clinical pharmacist No 3 Northeast England Pharmacist7 Clinical pharmacist Yes 6 Northwest England Pharmacist8 Clinical pharmacist No 4 East Midlands England Pharmacist9 Clinical pharmacist Yes 4 East Midlands England Pharmacist10 Clinical pharmacist Yes 7 Northwest England Pharmacist11 Clinical pharmacist No 7 Northwest England Pharmacist12 Consultant pharmacist Yes 8 Southwest England Pharmacist13 Clinical pharmacist No 4 East Midlands England Pharmacist14 Clinical pharmacist Yes 9 Wales Pharmacist15 Clinical pharmacist No 10 Northwest England Pharmacist16 Clinical pharmacist Yes 3 Northeast England 29 healthcare professionals meeting the inclusion criteria were interviewed from 11 different NHS organisations: average of 4 years in their current roles and 12.9 years’ experience in mental health. 79% identified White; 14% Asian: 3% mixed or from multiple ethnic groups; 3% as other ethnicities. 55% were female. Interviews lasted 20–50 minutes. Four main themes emerged: culture, patient factors, practical measures to facilitate deprescribing of benzodiazepines/z-hypnotics on AMH wards, and primary/secondary care interface. 1.Culture 1.1National and organisational culture and agenda. Clinicians felt isolated due to a lack of standardisation nationally leading to inconsistencies in prescribing cultures across different sites. “I’ve seen various strategies and good individual practices, but it’s not systematic or standardised enough. The right culture isn’t established yet.’(Doctor1) The Ashton Manual 48 and NICE document 9 were useful; awareness of the content of the latter was limited. Participants requested more accessible resources, compiling all necessary documentation necessary to create patient-specific deprescribing plans. Area-Prescribing Committee benzodiazepine/z-hypnotic withdrawal guidelines helped continuity of care between AMH wards and primary-care. Many were unaware if local guidelines existed in their organisation. Care Quality Commission (CQC) monitoring and national prescribing targets improved benzodiazepine/z-hypnotic deprescribing culture in some organisations. GPs and community mental health teams (CMHT) sometimes resisted taking on benzodiazepine/z-hypnotic prescribing when included in prescribing targets. “Some community teams emphasise they wouldn’t support patients on benzodiazepines, facilitating easier implementation.”(Doctor5). Subsequently, benzodiazepines/z-hypnotics were halted post-discharge unless the ward provided compelling rationale for their continuation. Leadership promoting integration of deprescribing into organisational culture, including encouraging incident reporting, audit and quality-improvement, aided by electronic prescribing systems (EPMA), incentivised change. “Leaders at trust strategic level must apply sufficient pressure to address existing problems,”(Pharmacist1) “I train primary-care pharmacists to incident report if hospitals persistently discharge people on benzos.”(Pharmacist10 .) “Good audit illustrates the absence of patient activity during evenings, correlating with self-harm and subsequent lorazepam use.”(Doctor4) Nationally, educating society on harms of long-term benzodiazepines/z-hypnotics use and altering cultural expectations may facilitate deprescribing. Smokefree culture in hospitals may contribute to continued benzodiazepine/z-hypnotic use, sometimes mitigated by proactivity around nicotine-replacement therapy. “Patients are already anxious and not sleeping. If anxious at home, they smoke…maybe thinking about smoking policy?”(Doctor1) Increased national legislation on prescribing and administration of benzodiazepines/z-hypnotics may support deprescribing. “They would be less utilised by staff members if treated like controlled-drugs… ”(Pharmacist9) 1.2 Ward culture Attitudes and actions of consultants, ward managers, nursing staff, and pharmacists shaped prescribing practices. “Different wards have different managers and different experiences.”(Pharmacist11) Consultants prioritising reviews helped deprescribing. Junior doctors’ training and confidence disproportionately affected the culture; over-prescribing on admission complicated later deprescribing. “Our current medics don’t have the same awareness around benzos and hypnotics. Once prescribed it’s difficult to say no.”(Pharmacist6) . Better defined indications for appropriate benzodiazepines/z-hypnotics and review/stop dates aided deprescribing. On-call prescribers often struggled using EPMA systems, leading to unnecessary continuation of PRN medication. “Nurses frequently wish to retain PRNs because there’s a problem with on-call medics using EPMA.”(Pharmacist12) . Collaboration and consistency among staff enhanced deprescribing culture. “Medication seeking patients ask staff members they know will give it. Everyone must be consistent.”(Nurse1) . Staff training and experience impacted this; inexperienced medics were reluctant to reduce benzodiazepines/z-hypnotics, inexperienced pharmacists did not challenge prescribing; inexperience nurses struggled to encourage non-pharmacological methods while confident nurses supported deprescribing. “Nurses question what patients want the meds for, do they actually need it?”(Pharmacist11) Conversely , doctors reported nurses discouraged deprescribing. “Nurses are clear to Junior Doctors they want prn’s prescribed just in case.”(Doctor1) Many staff relied on informal shadowing rather than formal training. “We’ve nothing formal in place. New members of staff shadow and follow us around.”(Pharmacist2) . 2. Patient factors 2.1 Patient Behaviour Increasingly violent, self-harming patient behaviours caused concerns about managing escalating behaviours without benzodiazepines/z-hypnotics hindering deprescribing. “The last three years has seen elevated violence, aggression and self-harm.”(Nurse5) Patients’ dependent on benzodiazepines/z-hypnotics showed reluctance to reduce them. “Patients like taking them as many use street Valium; prefer a prescription rather than buying it.”(Nurse2). Nurses struggled policing benzodiazepines/z-hypnotics in patient who abuse illicit drugs. “It would be easier stopped in patients who abuse them…then nurses don’t have to decide whether to give benzos or hypnotics, and patients cannot pressurise to have.”(Nurse1). Patients admitted with sleep-deprivation were sometimes reluctant to discontinue hypnotics when their sleep improved, fearing relapse. Disrupted daily routines and behaviour patterns interfered with hypnotic deprescribing “…patients often get a massive take away at 9pm. They’re not going to sleep easily after that. We aren’t allowed to stop that behaviour.”(Nurse1) Patients could be manipulative, which impacted deprescribing. “When the MDT deprescribe, patients discuss amongst themselves how to get medication. They know what to say to get it.”(Nurse1) 2.2 Past medical history and indication Some found deprescribing benzodiazepines/z-hypnotics easier in patients with clearly defined mental health diagnoses, facilitated by structured treatment pathways. Those prescribed higher, regular doses for conditions such as catatonia often experienced more managed deprescribing processes than those on PRN. The absence of alternative treatments hindered deprescribing, although promethazine was sometimes used. “…promethazine first line, having a tier option.”(Doctor 5) Deprescribing proved challenging in patients with emotionally unstable personality disorder (EUPD), especially with pre-existing polypharmacy, due to the perceived, and actual, risk of severe self-harm. “…tricky group of female EUPD patients…been there for months and collected multiple medications, including benzos. The self-harm with EUPD…has meant an overreliance on pharmacology.”(Pharmacist 12) . Previous alcoholism or severe agitation was also a barrier. Long admissions provided opportunity to support the patient to withdraw benzodiazepines/z-hypnotics. Conversely, if benzodiazepines/z-hypnotics were started during a long admission and dependence developed, then deprescribing was complicated by the need to slowly withdraw and fear over jeopardising recovery. 2.3 Person-centred care Shared-decision making is effective for deprescribing but requires comprehensive patient education and support. “I’ve seen prescribers stop it, but not explain it to the patient, who asks the nurse for it and it’s re-prescribed.”(Pharmacist 11) . Weekly multi-disciplinary team (MDT) ward rounds, including patient participation, enabled effective, actionable care-plans to be documented including de-escalation techniques. Strong relationships between nursing staff and patients helped reduce reliance on benzodiazepines/z-hypnotics. Person-centred care enabled prescribers build patient trust and understanding, facilitating deprescribing. Sometimes fear of damaging prescriber: patient relationships inhibited review. “You fear telling someone you’re going to stop their benzos in case you fracture the relationship.”(Doctor 3) 3. Practical measures to facilitate deprescribing benzodiazepines/z-hypnotics on AMH wards. 3.1 MDT working Good access to MDT professionals facilitated safe reduction of benzodiazepines/hypnotics. Higher nursing staff levels reduced reliance on benzodiazepines/z-hypnotics. “ …higher nurse: patient ratios so didn’t need to pharmacologically manage people in the same way.”(Pharmacist 13) Psychologists and Occupational Therapists supported deprescribing. “Psychologists are very useful in someone using lots of benzos. They speak to them.”(Pharmacist 11) Clinical pharmacists and non-medical prescribers (NMP) facilitated deprescribing. “ ….drawn upon pharmacists’ expertise to have conversations with patients about stopping benzodiazepines and hypnotics. ”(Nurse6). “It’s really positive having more non-medical prescribers in advanced roles on adult inpatient.”(Doctor1) Healthcare assistants, peer-support workers, experts-by-experience, activity coordinators and gym instructors lessened benzodiazepine/hypnotic reliance through non-pharmacological interventions such as exercise, especially in sectioned patients without unaccompanied leave. Staffing pressures constrained staff effectiveness. “If patients were busier with better ward activities and activity coordinators not used like taxi drivers, prn use would reduce.”(Doctor 1) . It was perceived staffing levels were worsening. “We’re running into problems post COVID with lack of staff. It’s an ongoing barrier.”(Pharmacist 10) This was compounded if multiple complex patients were on the ward. “When there’s high acuity on the wards and limited staffing, unfortunately PRN medication becomes the easier option.”(Doctor 2) Inconsistent staffing affected building strong patient relationships. Often benzodiazepine/hypnotic reviews were cancelled or key staff unavailable to take part. Staff availability for emergency response caused concern. “There isn’t the staff around on other wards to respond, so we reach for benzos, which is not necessarily inappropriate, if it keeps staff and patients safe.”(Pharmacist 12) Prescribing review meetings could help. “Other trusts should introduce prescribing reviews. It’s the main way we reduce benzos because we’ve got specific allocated time.”(Pharmacist 6) EPMA systems and utilising video conferencing, allowing remote working, enabled MDT review. Templates organising and recording MDT discussions added extra evidence to deprescribing decisions. 3.2 Non-pharmacological support Talking therapies, the talk-first initiative 49 and staff talking to patients, promoted verbal de-escalation and reduced PRN use. “talk-first initiative encourages use of verbal de-escalation instead of offering PRN first….the patient can be challenged and have boundaries set…..”(Pharmacist 5) Breathing exercises, distress tolerance, grounding techniques, mindfulness, distraction techniques, relaxation methods, muscle stimulation therapy and cognitive behavioural therapy helped reduce reliance on benzodiazepines. Anti-anxiety boxes containing craft items and sensory equipment, and calm cards identifying patient-led plans to reduce agitation prior to PRN, facilitated deprescribing. “…fidget spinners, watching cat videos, going for a walk…an individualised plan that helps staff know what they can do to support that patient.” (Pharmacist 15). Non-pharmacological methods should be individualised and agreed in advance with the patient. Sleep-hygiene leaflets/sleep-packs were not always given to patients or patients dismissed them as ineffective. “We will counsel people on sleep-hygiene. It generally doesn’t go down well, people feel they’re being patronised.” (Pharmacist 15) . MDT out-of-hours support facilitated effective sleep-hygiene. Some patients stayed up late drinking caffeinated and energy drinks, then requested hypnotics; many wards did not supply caffeinated drinks. Inpatient access to addiction services and support groups around benzodiazepines/z-hypnotics was lacking. “There’s no facility within substance misuse services, no support groups around prescribed benzodiazepines and z-drugs.” (Pharmacist 8) 3.3 Ward environment Facilities to support patients to use less benzodiazepines/z-hypnotics varied. “…ward’s got gym equipment as a way to de-stress rather than using the benzos.” (Pharmacist 11) A quiet room where people go to calm down was useful. “We’ve a snoozelum. It’s a relaxation room with nice lights and music on.” (Pharmacist 14) Many wards lacked sufficient private areas. “Our ward doesn’t have spaces for conversations about medications.” (Nurse 6) Wards could be unsettling environments for patients, due to noise and behaviour of other patients. “Reviewing benzos and hypnotics usually gets missed because of how chaotic the ward is. Patients get left on medication when the clinical need isn’t there.” (Nurse 3) A lack of “home-comforts”, uncomfortable beds and overnight staff observations disturbing sleep were barriers. Participants from one organisation felt their Sleep Well 50 scheme reduced hypnotic use by reducing disturbances overnight. 4.Primary/secondary care interface 4.1 Leave and Discharge planning Planning benzodiazepine/z-hypnotic tapering before or during patient leave was crucial for reinforcing deprescribing. “If the patient manages without benzos or hypnotics on leave, it breeds confidence they don’t need PRN's.” (Pharmacist 6) Lack of structured leave plans often resulted in patients continuing benzodiazepines/z-hypnotics unchanged during leave. Patient involvement seemed important. “Junior medics tend to do leave scripts; discussions aren’t always had between the wider team and with the patient. They go on leave with the prn’s they took on the ward.” (Doctor 7) Rushing deprescribing during discharge risked destabilising the patient or causing withdrawal symptoms. Implementing deprescribing treatment-plans prior to discharge helped, but patients were sometimes discharged in the middle of this plan, often because of bed-pressures or self-discharge. Benzodiazepine/z-hypnotic deprescribing may not be prioritised during discharge planning. “I don't think it’s considered. Priorities are suicide prevention planning or getting the patient food. Benzos are falling off the bottom of the list.” (Pharmacist 10) 4.2 Communication on discharge Effective discharge communication ensured ongoing deprescribing post-discharge. Discharge letters including a benzodiazepine/hypnotic reduction plan facilitated further management in the community. Oten discharge letters were inaccurate in recording benzodiazepine/z-hypnotic use, but pharmacy checks may improve this. “Benzos and hypnotics are started as an inpatient and intended for short-term use, but it’s not communicated well to GPs (General Practitioners), so inappropriately added on GP repeats.” (Pharmacist 13) Discharge counselling and discussing benzodiazepine/z-hypnotic prescribing in discharge meetings facilitated deprescribing. Usually only small quantities of benzodiazepines/z-hypnotics were provided on discharge. This should be explained to the patient and documented. Some organisations provided larger amounts, complicating deprescribing. Without a written plan, GPs sometimes lacked confidence to reduce medications. “GPs are reluctant to review or stop these meds as they were started by a specialist.” (Pharmacist 13). CMHTs struggled with capacity to support continued deprescribing. Participants felt one national healthcare computer system would facilitate communication between sectors. Discussion Summary Significant variation persists in the management of benzodiazepine/z-hypnotics on AMH wards. Local ward culture, rather than national guidelines, chiefly drives the approach to deprescribing, compounded by some patient behaviour patterns which can hinder this process. Adopting patient-centred care can alleviate many of these challenges. Access to non-pharmacological interventions aimed at de-escalating agitation, enhancing wellbeing, and improving sleep are crucial in supporting benzodiazepine/z-hypnotic deprescribing. Collaborative MDT efforts can bolster this initiative, although staff pressures are often a barrier. Effective discharge planning that prioritises safe deprescribing is vital but often overlooked due to bed pressures. If benzodiazepines/z-hypnotics are continued post-discharge; good communication with CMHTs/primary-care facilitates continued deprescribing. Detailed Discussion This research found the dominance of local culture influencing deprescribing of benzodiazepines/z-hypnotics on AMH wards leads to discrepancies in treatment pathways. Others have described deprescribing as "swimming against the tide" owing to patient expectation and entrenched medical norms and organisational constraints 51 . Clinician-centred medical culture has been highlighted as a barrier to deprescribing 38 . Although many clinicians referred to the Ashton Manual 48 for guidance, it’s focus is primarily on community settings, leaving a gap in support for inpatient scenarios. Brandt 52 highlighted inconsistencies and/or insufficiency of detail among deprescribing documents for benzodiazepines/z-hypnotics. Due to the individual nature of benzodiazepines/z-hypnotic deprescribing, resources need to be flexible so the patient can guide adjustments 9 . A national resource combining inpatient guidelines for benzodiazepines/z-hypnotics prescribing, withdrawal regimes, patient-information leaflets and non-pharmacological support could support the process. National resources are available in Wales 53 and Scotland 54 to support appropriate benzodiazepine/z-hypnotic prescribing, but not specifically for inpatients. Barriers to healthcare professionals accessing evidence-based guidelines include time constraints, lack of awareness, guideline complexity and disagreement 55 . Any new resources should be easy to use, with effective training and resource dissemination targeted to the AMH inpatient environment 53 . Initiatives such as Area Prescribing Committee guidelines can facilitate continuity of care, while the new NICE insomnia 8 guidelines may inform future practices, depending on their promotion and adoption. Multidisciplinary ‘deprescribing committees’ aid deprescribing in psychiatry 56 but motivation and training of MDT members affects successful deprescribing 31 . Capability barriers exist, especially among out-of-hours medical staff. Organisations need to ensure that on-call medical staff have the knowledge and IT skills required to safely prescribe and deprescribe. Simple educational strategies can reduce hypnotic prescribing rates and enhance staff confidence in insomnia management on mental health wards 22 . A dedicated team member, often a clinical pharmacist, overseeing the deprescribing process facilitated successful outcomes, mirroring findings elsewhere 57 , 58 . Hawkins 59 recommends using pharmacists to facilitate communication between prescribers, communicate risks to patients, and implement tapering/discontinuation plans. However, pharmacist confidence and capacity may impede effective implementation 60 . NMPs may enhance benzodiazepines/z-hypnotic management on AMH wards in a similar way to their role in primary care, by leveraging their detailed medication knowledge 61 and improving access to prescribers. The role of experts-by-experience in medicines optimisation has been documented 62 but research is needed into their role in deprescribing. Time pressures and pressures to discharge limit benzodiazepine deprescribing 31 . In 2024, CQC identified staffing shortages as one of the greatest challenges for the mental health sector, impacting quality and safety of care 63 . Reports from 39 UK mental health trusts, referencing staff shortages as a contributing factor to serious incidents, rose from 6,957 in 2019 to 11,073 in 2022 64 . There was an increase in restrictive practices on AMH wards associated with high staff sickness during the COVID pandemic 65 . Patients detained under the Mental Health Act may be denied escorted section 17 leave due to staff shortages 66 . Time away from the ward and exercise can be used to manage sleep-hygiene 8 and de-escalate aggression 49 . Poorly managed patient aggression negatively impacts healthcare workers’ psychological well-being and staffing levels 67 , causing a spiral where less staff are available to offer non-pharmacological management of aggression, resulting in less deprescribing of benzodiazepines/z-hypnotics. Staff fears over managing patient aggression without benzodiazepines/z-hypnotics is an example of fear contributing to deprescribing inertia, which is not easily allayed by limited evidence regarding safety and efficacy of deprescribing 68 . Patient-centred approach enables deprescribing 29 but often requires collaborative engagement among professionals 69 . Patients are more amenable to deprescribing conversations if they understand the rationale, are involved in developing the tapering plan, and offered behavioural advice. 31 , 70 Educating patients around deprescribing decisions prevents damaging patient/prescriber trust 71 . Staff following the safe wards model 49 reported increased confidence to use de-escalation skills before offering benzodiazepines/z-hypnotics. Trauma-informed care has been shown to reduce incidents of self-harm, seclusion and restraint on AMH wards 65 . Benzodiazepine/z-hypnotic deprescribing would be facilitated if further research highlighted which de-escalation techniques were most effective on AMH wards, resulting in national standardisation. Using EPMA systems to give prompts can aid deprescribing 51 however, existing systems may require adaption for diverse healthcare settings 72 . Contrary to the negative views around sleep-hygiene advice in this research, advising on sleep-hygiene has been associated with improved mental health outcomes 73 . Research is needed 74 into how to tailor this to the individual 75 as NHS patient-information leaflets are sometimes inaccurate, inconsistent and confusing 76 . Sleep-hygiene, when part of a larger quality improvement bundle, has been associated with a sustained reduction in hypnotic prescribing in general hospitals 77 . Although the negative effects of caffeine on sleep are well documented 78 and concern raised over the neurovegetative effects energy drinks 79 , further research is needed into their effect on insomnia and agitation on AMH wards. The Sleep Well programme 50 studied contributory factors to poor sleep on psychiatry wards; protecting sleep with reduced overnight checks personalised to the patient. Establishing and documenting clear rationale for initiating benzodiazepines/z-hypnotics is important as they are not always indicated 80 . The BNF 2 advises caution in initiating benzodiazepines/z-hypnotics in patients with a history of drug or alcohol abuse. If prescribed inappropriately, identifying the point at which deprescribing can be considered is made more difficult. Effective communication with patients can be impaired during admission, due to illness-related factors, acute intoxication and unwillingness to communicate 81 so a conversation on the short-term use of benzodiazepines/z-hypnotics may need to be delayed. Research has shown no difference between the genders in terms of aggression 82 , but more female patients are admitted with EUPD than male 83 . Peters 84 found being male significantly decreased the likelihood of receiving benzodiazepines at discharge from psychiatric inpatient treatment. Concern has been raised over the lack of evidence in prescribing in EUPD 83 ; resulting in a large burden of psychotropic polypharmacy 85 . Benzodiazepine prescribing in EUPD increased from 55.3% in 2014 to 58.6% in 2019 85 . At times of crisis, few patients with EUPD engage in psychotherapies 83 and specialist individualised services are required 83 . Future research should identify the support required for people with EUPD, on AMH wards, to reduce benzodiazepine/hypnotic use and to investigate if behavioural differences exist between the genders, or if it reflects therapeutic nihilism from ward staff. Promethazine was used as an alternative to benzodiazepines/hypnotics but is associated with several adverse-effects 2 and has little support in current NICE guidance 8 . NICE recently recommended daridorexant for chronic insomnia 8 . This novel hypnotic may facilitate benzodiazepine/z-hypnotic deprescribing by offering an alternative treatment 86 . Research on elderly wards concurred that long admissions facilitated deprescribing in patients admitted on benzodiazepines/z-hypnotics but acted as a barrier to deprescribing in patients started on these medications during admission 87 . Benzodiazepine/z-hypnotic deprescribing not being prioritised or completed at discharge mirrored previous research 88 . More research into discharge priorities from AMH wards could help us understand the priority given to benzodiazepine/z-hypnotic deprescribing. If deprescribing plans were put in place during initiation of benzodiazepines/z-hypnotics and well documented, then these plans could be included in the discharge communication. Primary-care/CMHT influencing deprescribing practices on AMH wards by applying additional barriers to discharging patients on benzodiazepines/z-hypnotics, follows the behavioural change wheel to implement evidence-based practice 89 . Mitchie 89 found motivation is one of the components of behavioural change and can take the form of incentivisation or coercion. Incentivising primary-care to reduce their benzodiazepine/z-hypnotic prescribing may have resulted in some coercion of secondary-care to encourage deprescribing. However, discontinuation post discharge should be discussed with the patient, and planned for early on in treatment, to prevent distress or withdrawal effects post-discharge. Keers 90 found discharge prescriptions issued by mental health NHS hospitals have high levels of prescribing, clerical and communication errors. Primary care clinicians may be hesitant to stop a medication started by a consultant psychiatrist as they do not feel responsible for the medication, because of professional hierarchy 24 . Direct communication between healthcare professionals when considering deprescribing is invaluable to resolve uncertainties, prevent conflicting instructions to patients, and ensure alignment of the therapeutic plan 91 . Creating a culture that values communication at discharge helps improve outcomes following hospitalisation 92 . Ensuring primary and secondary care have access to a universal patient note and prescribing system would aid deprescribing by passing information efficiently between sectors 93 . Strengths and Limitations The large numbers interviewed from multiple organisations may have helped ensure generalisability and is a strength of the study. Although participants were recruited throughout England and Wales, a large proportion were from the northeast of England, so regional differences may have skewed the results. Participants recruited via snowball effect from contacts of the researcher may not be representative of the population. Interviewees putting themselves forward for interview may have already had an agenda they wished to pursue on this topic or an interest in the subject, resulting in volunteer bias 94 . The researcher’s clinical role as a pharmacist on AMH wards may have affected the discussions with participants and interpretation of the results. To overcome interviewer bias 95 the researcher aimed to be transparent and reflexive throughout. Pharmacists were overrepresented in the demographics, with nurses being the least represented group. Future research should include a wider range of healthcare professionals and patients. A small number of interviewees worked directly with the researcher, which may influence the answers they gave. The researcher tried to avoid confirmation bias 96 by considering all data obtained while analysing and re-evaluating and discussing this with the chief investigator. Member checking of transcripts was not carried out, which may have led to misinterpretation during some of the transcribing. Implications for policy makers A strong national agenda is needed to drive a local culture of deprescribing benzodiazepines/z-hypnotics on AMH wards, including developing a national evidence-based resource which can support this. On-call medic cover on AMH wards should have the knowledge and IT skills to safely prescribe. EUPD treatment recommendations should be updated to provide more guidance on use of medication and access to specialist resources. Current staffing levels, and jobs descriptions of staff, on AMH wards should be reviewed to ensure benzodiazepines/z-hypnotic deprescribing can be supported safely. The ability of sectioned patients to access section 17 leave should be audited. Sharing of good practice between mental health trusts should be encouraged. Implications for future research Qualitative research into patient views around deprescribing benzodiazepines/z-hypnotics and research into factors which resulted in patients being discharged on these medications, would allow for triangulation. Qualitative research into the role played by various MDT members in deprescribing may identify changes in job descriptions and further training needs. Further research to identify the most effective de-escalation and sleep-hygiene techniques, would enable evidence-based national standardisation. Research is needed into the effect of energy drink consumption on insomnia and agitation on AMH wards. Further research is required to observe if gender differences exist in prescribing/deprescribing patterns of benzodiazepines/z-hypnotics in patients diagnosed with EUPD. Research into discharge priorities from AMH wards may indicate if deprescribing is considered during transfer of care. Conclusion Identifying facilitators and barriers to deprescribing benzodiazepines/z-hypnotics on AMH wards can alleviate the persistent issue of these medications being continued post-discharge, risking tolerance, dependence and withdrawal symptoms. While patient-specific barriers related to behaviour and motivation exist, they can be mitigated with non-pharmacological treatments and support from well trained staff. Maintaining adequate staffing across the full MDT is crucial. Changing national NHS culture is a major task but without promoting standardised practice, local factors on individual wards will continue to impact deprescribing efforts. This inconsistency can lead to unnecessary polypharmacy, distress for patients, and increased workload for the MDT. Although good practice exists, further dissemination, research and funding are needed to support all AMH patients in reducing inappropriate benzodiazepine/z-hypnotic use. Addressing underlying NHS pressures is essential to break the cycle of harmful polypharmacy and escalating patient behaviours. Abbreviations • Benzos benzodiazepines • UK United Kingdom • GABA gamma-aminobutyric acid • Z hypnotics-zopiclone / zolpidem • AMH adult mental health • NICE National Institute for Heath and Care Excellence • NHS National Health Service • PRN as-needed • RCT randomised controlled trials • COREQ Consolidated Criteria for Reporting Qualitative studies • CQC Care Quality Commission • CMHT community mental health team • EPMA electronic prescribing systems • EUPD emotionally unstable personality disorder • MDT multi-disciplinary team • NMP non-medical prescriber • GPs General Pratitioners Declarations Author information Sonia Filmer: Present address: Tees, Esk and Wear Valley NHS Trust, Lanchester Road, Durham, DH1 5RD, United Kingdom [email protected] Professor Ian Maidment Present address: Aston Pharmacy School, College of Health and Life Sciences, Aston University, Birmingham, B4 7ET, United Kingdom [email protected] Ethics Approval and consent to participate Approval for the study was obtained from the Health Research Authority (IRAS number 322529) and Aston University Governance Committee. Capacity and capability approval was obtained from Tees, Esk and Wear Valley NHS Foundation Trust, the researchers place of work. The protocol is available on request. Written informed consent was obtained from all participants, and copies of the patient information leaflet and consent form used are available on request. Consent for publication - not applicable Data Availability Statement (DAS) The qualitative data generated from this research project is not suitable for sharing as per ethical approval and the study protocol. If further information is required around the dataset, please contact [email protected] . Competing interests The authors declare that they have no competing interests Funding and disclaimer Sonia Filmer, grant reference number MH044 for the grant National Institute for Health Research School for Primary Care Research (NIHR SPCR) 2021-2026, is funded by the NIHR for this research project. The views expressed in this publication are those of the author and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care. Author’s contributions SF conceptualised and designed the work, performed the interviews, analysed and interpreted the data and was the major contributor in writing the manuscript as an MSc research study. IM was the academic supervision, guiding SF on all aspects of research, including ethical approval, study design, analysis and the final presentation of research. Both authors read and approved the final manuscript. Acknowledgements Dr Gemma Donovan supported SF in applying for funding to complete this project and provided technical help during the data analysis. Helen Ashton, librarian, and Hazel Betteney, medicines information pharmacist, who acted as proofreader, were both employed at Tees, Esk and Wear Valley NHS Trust, Co Durham at the time of the study . 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6811205","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":478292893,"identity":"d938e8e3-6668-4916-99e8-389c5564b5d4","order_by":0,"name":"Sonia Filmer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYJCCAwwMcjx8IFZCBUMCsVqMedhArAdnoFoOENZlzADSwviwjQgt8u29Bw/8YDCQYRM7fOxD4rw7efINvAcff8CjxeDMuYSDPQwGPGzSackzErc9KzY4wJdsgM8WA4kcgwM8DH+AWnKMGRK3HU7cwMBjJoHXYTNyDA7+AduS/5khcc7hxPkNPOY/8GlhuJFjcJgHrCWHmSGx4XBiwwEeM7zeNzhzxuCwjAHYL8YMCceADjvMYyxxBp/D2nuMP76pMLDnl05+zPijBuiw9h7DDxX4HAaxC5nDTFD5KBgFo2AUjAJCAADbHkw51OtOKAAAAABJRU5ErkJggg==","orcid":"","institution":"Tees, Esk and Wear Valleys NHS Foundation Trust","correspondingAuthor":true,"prefix":"","firstName":"Sonia","middleName":"","lastName":"Filmer","suffix":""},{"id":478292894,"identity":"c0d2dab0-eecf-47ee-9d24-7b4bc6d23a34","order_by":1,"name":"Ian Maidment","email":"","orcid":"","institution":"Aston University","correspondingAuthor":false,"prefix":"","firstName":"Ian","middleName":"","lastName":"Maidment","suffix":""}],"badges":[],"createdAt":"2025-06-03 12:23:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6811205/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6811205/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-25261-4","type":"published","date":"2025-11-21T15:58:58+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85776960,"identity":"6b3c2636-f333-49cf-94c7-52e51f1336f5","added_by":"auto","created_at":"2025-07-01 14:32:27","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":877528,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRepresentation of the findings: National Prescribing Culture Driving the Wheel of Benzodiazepine / Hypnotic Deprescribing\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6811205/v1/635ec95c0680966c649b549a.jpeg"},{"id":96650404,"identity":"5c00cddf-4f59-4e04-a2c7-15a476ff34ae","added_by":"auto","created_at":"2025-11-24 16:11:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":23581879,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6811205/v1/babc79f4-6c60-4a41-bb47-7669dca85db3.pdf"},{"id":85774880,"identity":"72c81ede-fdfa-4480-b81f-d58558a676b0","added_by":"auto","created_at":"2025-07-01 14:16:27","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":36257,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix16.docx","url":"https://assets-eu.researchsquare.com/files/rs-6811205/v1/d1e08507f5683cf0807c34d8.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Facilitators And Barriers to the De-prescribing Of Benzodiazepines and Z-drug Hypnotics in patients under 65 on Adult Mental Health Wards: an exploratory qualitative study. (FABDOB Study)","fulltext":[{"header":"Background","content":"\u003cp\u003eBenzodiazepines (benzos) have been used for decades in the United Kingdon (UK) as anxiolytics and hypnotics on psychiatric wards\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Twelve benzodiazepines are licenced for use in the UK\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. They slow down the central nervous system by acting as agonists at benzodiazepine receptors, enhancing the inhibitory effects of gamma-aminobutyric acid (GABA)\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e, resulting in calming and sedation. More recently, zopiclone and zolpidem (z-hypnotics), which also increase GABA transmission at these receptors, have emerged as alternative hypnotics\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite a decline in prescribing levels, in 2021-22, 1.8% of England\u0026rsquo;s population without learning disabilities were prescribed benzodiazepines, rising to 7.1% among those with learning disabilities\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. During 2017-18, 2.3% of adults in England were prescribed Z-drugs\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Benzodiazepines/z-hypnotics have established roles in treating mania, alcohol withdrawal and short-term anxiety relief and insomnia on adult mental health (AMH) wards\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Nonetheless, they are often prescribed beyond their therapeutic window or inappropriately from the outset\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eNational Institute for Heath and Care Excellence (NICE)\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e guidelines recommend that benzodiazepines/z-hypnotics should not be prescribed for longer than 2\u0026ndash;4 weeks to avert physical dependence and tolerance\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Between 15%-44% of chronic benzodiazepine users may face moderate to severe withdrawal symptoms when discontinuing\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, such as sleep disturbance, irritability, increased anxiety, panic-attacks, tremor, sweating and nausea\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Z-hypnotics cause dependence like benzodiazepines\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e and withdrawal symptoms including insomnia, headaches, confusion, anxiety and restlessness\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eNICE concluded z-hypnotics offer no distinct advantage over benzodiazepines for treating insomnia,\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e despite a perception of increased safety regarding tolerance\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Prescribers\u0026rsquo; often overestimate their benefits, neglecting inherent risks\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Continued treatment beyond four weeks necessitates a careful withdrawal plan\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, which may distress patients and destabilise their recovery, necessitating additional primary care input. Reviewing benzodiazepines/z-hypnotics regularly\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e can mitigate withdrawal symptoms. National Health Service (NHS) England\u0026rsquo;s guidance\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e recommends medication reviews with the patient, should happen every 2\u0026ndash;3 days throughout admission.\u003c/p\u003e \u003cp\u003eOn AMH wards, benzodiazepines/z-hypnotics may be prescribed regularly or as-needed (PRN), with administration contingent upon nursing assessment of patients\u0026rsquo; mental states. However, PRN administration practices reveal a lack of clarity and coherence\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, with decisions often based on patient distress, safety concerns and requests. In some conditions, such as catatonia\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e, benzodiazepines/z-hypnotics are prescribed regularly. Compliance with NICE recommendations\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e necessitates regular reviews and ideally stopping these medications before discharge, if not a withdrawal plan post discharge should be established.\u003c/p\u003e \u003cp\u003eApproximately 33% of patients are discharged from AMH ward on benzodiazepines/z-hypnotics\u003csup\u003e22\u003c/sup\u003e, with 20% continuing use 12 months post-discharge\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Public Health England has recognised the urgent need for further research into benzodiazepines/z-hypnotics dependence\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Evidence of efficacy of deprescribing, \u0026ldquo;the process of tapering or stopping drugs, aiming to minimise polypharmacy and improve patient outcomes\u0026rdquo;\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e is emerging from randomised controlled trials (RCT) and observational studies\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Challenges in the generalisation and transportability\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e of RCTs makes it difficult to apply this evidence in the personalised care of NHS mental health settings\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003eand evidence is limited in AMH inpatient settings.\u003c/p\u003e \u003cp\u003eBarriers to deprescribing stem from both clinician and patient perspectives, including prescriber confidence, communication issues and patient awareness\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Among primary-care prescribers, fears about consequences and workload concerns hinder action in patients under 65\u003csup\u003e24,28\u003c/sup\u003e. Procedural difficulties and perceived resistance are barriers with patients over 65\u003csup\u003e29,30,31\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere is more research into, and awareness of the benefits of, deprescribing of benzodiazepines/z-hypnotics in people over 65\u003csup\u003e32,33\u003c/sup\u003ethan in the younger age group. Under 65s vary in recommended dosing levels and side-effect profile of benzodiazepines/z-hypnotics\u003csup\u003e2\u003c/sup\u003e. Researching barriers in younger populations is critical as they engage more actively in managing their medications\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. Prescribers underestimate deprescribing enablers, including patients\u0026rsquo; concerns and experiences of adverse effects, dislike of multiple medicines\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e, staff and patient education\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e, a multi-professional approach\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e, acceptability of non-pharmacological alternatives\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e and patient-centred care and shared decision making\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e. Person-centred care involves treating patients as individuals and as equal partners in their healing, meaning healthcare is coordinated, personalised and enabling\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. Facilitators of benzodiazepines/z-hypnotic deprescribing on AMH wards include audit and feedback, increased clinical pharmacist input and placing limitations on prescribing\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. New technologies may improve access to non-pharmacological treatments\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn summary, the need for research into reducing benzodiazepines/z-hypnotics dependence\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e is paramount, with limited evidence on deprescribing on AMH wards. This project aims to identify barriers and facilitators within deprescribing practices on AMH wards, setting the stage for future research and policy change that promotes effective management of these medications.\u003c/p\u003e\n\u003ch3\u003eAims\u003c/h3\u003e\n\u003cp\u003eTo identify barriers and facilitators to deprescribing of benzodiazepines/z-hypnotics on AMH wards.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eTo interview healthcare professionals to investigate current practices in reviewing and deprescribing and identify barriers and facilitators associated with deprescribing benzodiazepines/z-hypnotics on AMH wards.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Method","content":"\u003cp\u003eThis exploratory qualitative study involved remote interviews, adhering to the Consolidated Criteria for Reporting Qualitative studies (COREQ) guidelines\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. (Appendix1)\u003c/p\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eEthical approval was secured from the Health Research Authority (IRAS number 322529) and Aston University\u0026rsquo;s Governance Committee. Additionally, capacity and capability approvals were obtained from Tees, Esk and Wear Valley NHS Foundation Trust. Clinical trial number: not applicable. All methods were performed in accordance with the relevant guidelines and regulations.\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eInclusion Criteria\u003c/h3\u003e\n\u003cp\u003eHealthcare professionals currently or recently (within the last 6 months) working on NHS AMH wards in the UK, with experience using or reviewing benzodiazepines/z-hypnotics in patients aged 18\u0026ndash;65.\u003c/p\u003e\n\u003ch3\u003eExclusion Criteria\u003c/h3\u003e\n\u003cp\u003eHealthcare professionals not working on NHS AMH wards in the UK within the last 6 month or lacking experience using or reviewing benzodiazepines/z-hypnotics in patients aged 18\u0026ndash;65.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and recruitment\u003c/h2\u003e \u003cp\u003eA combination of convenience, snowball and purposive sampling techniques was employed to recruit participants through NHS contacts and professional networks. Pre-existing contacts promoted the study using an advertising flyer (appendix 2). Social media posts were shared through the College of Mental Health Pharmacists network. Participants were encouraged to disseminate information within their networks.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInterview process and consent.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eInterviews took place from November 2023 to March 2024. Pilot interviews with two healthcare professionals were successfully conducted, with no modifications needed, and included in the final dataset. A participant information sheet (appendix 3) was sent out, along with consent (appendix 4) and demographic forms (appendix 5) to complete prior to interviews. The interviewees had the opportunity to ask questions and confirm their consent before beginning the interview.\u003c/p\u003e \u003cp\u003eSemi-structured interviews were conducted online, recorded and transcribed using Microsoft Teams. This transcription was anonymised and accuracy checked. An interview guide (appendix 6) facilitated flexible discussions, allowing for spontaneous questions and in-depth participant reflections. This heuristic approach\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e enabled richer data collection while supporting systematic comparison across interviews.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eTranscribed interviews were coded and analysed using NVivo software, employing thematic analysis\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e with a grounded\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e, inductive approach. This allowed for open coding and opportunities to draw out meanings expressed by interviewees. Continuous data analysis enabled flexibility in interviews to explore emerging themes\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e,\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e whilst identifying data saturation\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e,\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e, which was achieved after 29 interviews, signalling an end to participant recruitment.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eReflexivity and validation\u003c/h3\u003e\n\u003cp\u003eThe researcher, a mental health pharmacist with over 25 years of clinical experience, remains mindful of her dual role as researcher and clinician. Reflexivity informed the analysis, ensuring participants\u0026rsquo; views were conveyed accurately, accounting for potential biases from professional relationships\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e and experiences. Dissenting opinions were analysed and opposing views reported.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipant demographics are shown in the Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Participant Demographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant ID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRole\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrescriber?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCode for trust(s) worked in last 6 months\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eArea of UK worked in\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSenior registrar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026amp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNortheast England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant psychiatrist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNortheast England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant psychiatrist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNortheast England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSenior registrar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWest Midlands England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant psychiatrist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNortheast England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant psychiatrist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNortheast England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSenior registrar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNortheast England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMental health nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNortheast England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMental health nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWales\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMental health nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNortheast England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant nurse and approved clinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNortheast England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant nurse and approved clinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNortheast England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant nurse and approved clinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYorkshire\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNortheast England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWales\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNortheast England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEast Midlands\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNortheast England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNortheast England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNorthwest England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEast Midlands England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEast Midlands England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNorthwest England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNorthwest England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSouthwest England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEast Midlands England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWales\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNorthwest England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNortheast England\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e29 healthcare professionals meeting the inclusion criteria were interviewed from 11 different NHS organisations: average of 4 years in their current roles and 12.9 years\u0026rsquo; experience in mental health. 79% identified White; 14% Asian: 3% mixed or from multiple ethnic groups; 3% as other ethnicities. 55% were female. Interviews lasted 20\u0026ndash;50 minutes. Four main themes emerged: culture, patient factors, practical measures to facilitate deprescribing of benzodiazepines/z-hypnotics on AMH wards, and primary/secondary care interface.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e1.Culture\u003c/h2\u003e \u003cp\u003e \u003cb\u003e1.1National and organisational culture and agenda.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eClinicians felt isolated due to a lack of standardisation nationally leading to inconsistencies in prescribing cultures across different sites. \u003cem\u003e\u0026ldquo;I\u0026rsquo;ve seen various strategies and good individual practices, but it\u0026rsquo;s not systematic or standardised enough. The right culture isn\u0026rsquo;t established yet.\u0026rsquo;(Doctor1)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe Ashton Manual\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e and NICE document\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e were useful; awareness of the content of the latter was limited. Participants requested more accessible resources, compiling all necessary documentation necessary to create patient-specific deprescribing plans. Area-Prescribing Committee benzodiazepine/z-hypnotic withdrawal guidelines helped continuity of care between AMH wards and primary-care. Many were unaware if local guidelines existed in their organisation.\u003c/p\u003e \u003cp\u003eCare Quality Commission (CQC) monitoring and national prescribing targets improved benzodiazepine/z-hypnotic deprescribing culture in some organisations. GPs and community mental health teams (CMHT) sometimes resisted taking on benzodiazepine/z-hypnotic prescribing when included in prescribing targets. \u003cem\u003e\u0026ldquo;Some community teams emphasise they wouldn\u0026rsquo;t support patients on benzodiazepines, facilitating easier implementation.\u0026rdquo;(Doctor5).\u003c/em\u003e Subsequently, benzodiazepines/z-hypnotics were halted post-discharge unless the ward provided compelling rationale for their continuation.\u003c/p\u003e \u003cp\u003eLeadership promoting integration of deprescribing into organisational culture, including encouraging incident reporting, audit and quality-improvement, aided by electronic prescribing systems (EPMA), incentivised change. \u003cem\u003e\u0026ldquo;Leaders at trust strategic level must apply sufficient pressure to address existing problems,\u0026rdquo;(Pharmacist1) \u0026ldquo;I train primary-care pharmacists to incident report if hospitals persistently discharge people on benzos.\u0026rdquo;(Pharmacist10\u003c/em\u003e.)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Good audit illustrates the absence of patient activity during evenings, correlating with self-harm and subsequent lorazepam use.\u0026rdquo;(Doctor4)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eNationally, educating society on harms of long-term benzodiazepines/z-hypnotics use and altering cultural expectations may facilitate deprescribing. Smokefree culture in hospitals may contribute to continued benzodiazepine/z-hypnotic use, sometimes mitigated by proactivity around nicotine-replacement therapy. \u003cem\u003e\u0026ldquo;Patients are already anxious and not sleeping. If anxious at home, they smoke\u0026hellip;maybe thinking about smoking policy?\u0026rdquo;(Doctor1)\u003c/em\u003e Increased national legislation on prescribing and administration of benzodiazepines/z-hypnotics may support deprescribing. \u003cem\u003e\u0026ldquo;They would be less utilised by staff members if treated like controlled-drugs\u0026hellip;\u003c/em\u003e\u0026rdquo;(Pharmacist9)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Ward culture\u003c/h2\u003e \u003cp\u003eAttitudes and actions of consultants, ward managers, nursing staff, and pharmacists shaped prescribing practices. \u003cem\u003e\u0026ldquo;Different wards have different managers and different experiences.\u0026rdquo;(Pharmacist11)\u003c/em\u003e Consultants prioritising reviews helped deprescribing. Junior doctors\u0026rsquo; training and confidence disproportionately affected the culture; over-prescribing on admission complicated later deprescribing. \u003cem\u003e\u0026ldquo;Our current medics don\u0026rsquo;t have the same awareness around benzos and hypnotics. Once prescribed it\u0026rsquo;s difficult to say no.\u0026rdquo;(Pharmacist6)\u003c/em\u003e. Better defined indications for appropriate benzodiazepines/z-hypnotics and review/stop dates aided deprescribing. On-call prescribers often struggled using EPMA systems, leading to unnecessary continuation of PRN medication. \u003cem\u003e\u0026ldquo;Nurses frequently wish to retain PRNs because there\u0026rsquo;s a problem with on-call medics using EPMA.\u0026rdquo;(Pharmacist12)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eCollaboration and consistency among staff enhanced deprescribing culture. \u003cem\u003e\u0026ldquo;Medication seeking patients ask staff members they know will give it. Everyone must be consistent.\u0026rdquo;(Nurse1)\u003c/em\u003e. Staff training and experience impacted this; inexperienced medics were reluctant to reduce benzodiazepines/z-hypnotics, inexperienced pharmacists did not challenge prescribing; inexperience nurses struggled to encourage non-pharmacological methods while confident nurses supported deprescribing. \u003cem\u003e\u0026ldquo;Nurses question what patients want the meds for, do they actually need it?\u0026rdquo;(Pharmacist11) Conversely\u003c/em\u003e, doctors reported nurses discouraged deprescribing. \u0026ldquo;Nurses \u003cem\u003eare clear to Junior Doctors they want prn\u0026rsquo;s prescribed just in case.\u0026rdquo;(Doctor1)\u003c/em\u003e Many staff relied on informal shadowing rather than formal training. \u003cem\u003e\u0026ldquo;We\u0026rsquo;ve nothing formal in place. New members of staff shadow and follow us around.\u0026rdquo;(Pharmacist2)\u003c/em\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2. Patient factors\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e2.1 Patient Behaviour\u003c/h2\u003e \u003cp\u003eIncreasingly violent, self-harming patient behaviours caused concerns about managing escalating behaviours without benzodiazepines/z-hypnotics hindering deprescribing. \u003cem\u003e\u0026ldquo;The last three years has seen elevated violence, aggression and self-harm.\u0026rdquo;(Nurse5)\u003c/em\u003e\u003c/p\u003e \u003cp\u003ePatients\u0026rsquo; dependent on benzodiazepines/z-hypnotics showed reluctance to reduce them. \u003cem\u003e\u0026ldquo;Patients like taking them as many use street Valium; prefer a prescription rather than buying it.\u0026rdquo;(Nurse2).\u003c/em\u003e Nurses struggled policing benzodiazepines/z-hypnotics in patient who abuse illicit drugs. \u003cem\u003e\u0026ldquo;It would be easier stopped in patients who abuse them\u0026hellip;then nurses don\u0026rsquo;t have to decide whether to give benzos or hypnotics, and patients cannot pressurise to have.\u0026rdquo;(Nurse1).\u003c/em\u003e\u003c/p\u003e \u003cp\u003ePatients admitted with sleep-deprivation were sometimes reluctant to discontinue hypnotics when their sleep improved, fearing relapse. Disrupted daily routines and behaviour patterns interfered with hypnotic deprescribing \u003cem\u003e\u0026ldquo;\u0026hellip;patients often get a massive take away at 9pm. They\u0026rsquo;re not going to sleep easily after that. We aren\u0026rsquo;t allowed to stop that behaviour.\u0026rdquo;(Nurse1)\u003c/em\u003e\u003c/p\u003e \u003cp\u003ePatients could be manipulative, which impacted deprescribing. \u003cem\u003e\u0026ldquo;When the MDT deprescribe, patients discuss amongst themselves how to get medication. They know what to say to get it.\u0026rdquo;(Nurse1)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Past medical history and indication\u003c/h2\u003e \u003cp\u003eSome found deprescribing benzodiazepines/z-hypnotics easier in patients with clearly defined mental health diagnoses, facilitated by structured treatment pathways. Those prescribed higher, regular doses for conditions such as catatonia often experienced more managed deprescribing processes than those on PRN.\u003c/p\u003e \u003cp\u003eThe absence of alternative treatments hindered deprescribing, although promethazine was sometimes used. \u003cem\u003e\u0026ldquo;\u0026hellip;promethazine first line, having a tier option.\u0026rdquo;(Doctor 5)\u003c/em\u003e Deprescribing proved challenging in patients with emotionally unstable personality disorder (EUPD), especially with pre-existing polypharmacy, due to the perceived, and actual, risk of severe self-harm. \u003cem\u003e\u0026ldquo;\u0026hellip;tricky group of female EUPD patients\u0026hellip;been there for months and collected multiple medications, including benzos. The self-harm with EUPD\u0026hellip;has meant an overreliance on pharmacology.\u0026rdquo;(Pharmacist 12)\u003c/em\u003e. Previous alcoholism or severe agitation was also a barrier.\u003c/p\u003e \u003cp\u003eLong admissions provided opportunity to support the patient to withdraw benzodiazepines/z-hypnotics. Conversely, if benzodiazepines/z-hypnotics were started during a long admission and dependence developed, then deprescribing was complicated by the need to slowly withdraw and fear over jeopardising recovery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Person-centred care\u003c/h2\u003e \u003cp\u003eShared-decision making is effective for deprescribing but requires comprehensive patient education and support. \u003cem\u003e\u0026ldquo;I\u0026rsquo;ve seen prescribers stop it, but not explain it to the patient, who asks the nurse for it and it\u0026rsquo;s re-prescribed.\u0026rdquo;(Pharmacist 11)\u003c/em\u003e. Weekly multi-disciplinary team (MDT) ward rounds, including patient participation, enabled effective, actionable care-plans to be documented including de-escalation techniques.\u003c/p\u003e \u003cp\u003eStrong relationships between nursing staff and patients helped reduce reliance on benzodiazepines/z-hypnotics. Person-centred care enabled prescribers build patient trust and understanding, facilitating deprescribing. Sometimes fear of damaging prescriber: patient relationships inhibited review. \u003cem\u003e\u0026ldquo;You fear telling someone you\u0026rsquo;re going to stop their benzos in case you fracture the relationship.\u0026rdquo;(Doctor 3)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003e3. Practical measures to facilitate deprescribing benzodiazepines/z-hypnotics on AMH wards.\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.1 MDT working\u003c/h2\u003e \u003cp\u003eGood access to MDT professionals facilitated safe reduction of benzodiazepines/hypnotics. Higher nursing staff levels reduced reliance on benzodiazepines/z-hypnotics. \u0026ldquo;\u003cem\u003e\u0026hellip;higher nurse: patient ratios so didn\u0026rsquo;t need to pharmacologically manage people in the same way.\u0026rdquo;(Pharmacist 13)\u003c/em\u003e\u003c/p\u003e \u003cp\u003ePsychologists and Occupational Therapists supported deprescribing. \u003cem\u003e\u0026ldquo;Psychologists are very useful in someone using lots of benzos. They speak to them.\u0026rdquo;(Pharmacist 11)\u003c/em\u003e Clinical pharmacists and non-medical prescribers (NMP) facilitated deprescribing. \u0026ldquo;\u003cem\u003e\u0026hellip;.drawn upon pharmacists\u0026rsquo; expertise to have conversations with patients about stopping benzodiazepines and hypnotics.\u003c/em\u003e\u0026rdquo;(Nurse6). \u003cem\u003e\u0026ldquo;It\u0026rsquo;s really positive having more non-medical prescribers in advanced roles on adult inpatient.\u0026rdquo;(Doctor1)\u003c/em\u003e Healthcare assistants, peer-support workers, experts-by-experience, activity coordinators and gym instructors lessened benzodiazepine/hypnotic reliance through non-pharmacological interventions such as exercise, especially in sectioned patients without unaccompanied leave.\u003c/p\u003e \u003cp\u003eStaffing pressures constrained staff effectiveness. \u003cem\u003e\u0026ldquo;If patients were busier with better ward activities and activity coordinators not used like taxi drivers, prn use would reduce.\u0026rdquo;(Doctor 1)\u003c/em\u003e. It was perceived staffing levels were worsening. \u003cem\u003e\u0026ldquo;We\u0026rsquo;re running into problems post COVID with lack of staff. It\u0026rsquo;s an ongoing barrier.\u0026rdquo;(Pharmacist 10)\u003c/em\u003e This was compounded if multiple complex patients were on the ward. \u003cem\u003e\u0026ldquo;When there\u0026rsquo;s high acuity on the wards and limited staffing, unfortunately PRN medication becomes the easier option.\u0026rdquo;(Doctor 2)\u003c/em\u003e Inconsistent staffing affected building strong patient relationships. Often benzodiazepine/hypnotic reviews were cancelled or key staff unavailable to take part. Staff availability for emergency response caused concern. \u003cem\u003e\u0026ldquo;There isn\u0026rsquo;t the staff around on other wards to respond, so we reach for benzos, which is not necessarily inappropriate, if it keeps staff and patients safe.\u0026rdquo;(Pharmacist 12)\u003c/em\u003e\u003c/p\u003e \u003cp\u003ePrescribing review meetings could help. \u003cem\u003e\u0026ldquo;Other trusts should introduce prescribing reviews. It\u0026rsquo;s the main way we reduce benzos because we\u0026rsquo;ve got specific allocated time.\u0026rdquo;(Pharmacist 6)\u003c/em\u003e EPMA systems and utilising video conferencing, allowing remote working, enabled MDT review. Templates organising and recording MDT discussions added extra evidence to deprescribing decisions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Non-pharmacological support\u003c/h2\u003e \u003cp\u003eTalking therapies, the talk-first initiative\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e and staff talking to patients, promoted verbal de-escalation and reduced PRN use. \u003cem\u003e\u0026ldquo;talk-first initiative encourages use of verbal de-escalation instead of offering PRN first\u0026hellip;.the patient can be challenged and have boundaries set\u0026hellip;..\u0026rdquo;(Pharmacist 5)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eBreathing exercises, distress tolerance, grounding techniques, mindfulness, distraction techniques, relaxation methods, muscle stimulation therapy and cognitive behavioural therapy helped reduce reliance on benzodiazepines. Anti-anxiety boxes containing craft items and sensory equipment, and calm cards identifying patient-led plans to reduce agitation prior to PRN, facilitated deprescribing. \u003cem\u003e\u0026ldquo;\u0026hellip;fidget spinners, watching cat videos, going for a walk\u0026hellip;an individualised plan that helps staff know what they can do to support that patient.\u0026rdquo; (Pharmacist 15).\u003c/em\u003e Non-pharmacological methods should be individualised and agreed in advance with the patient.\u003c/p\u003e \u003cp\u003eSleep-hygiene leaflets/sleep-packs were not always given to patients or patients dismissed them as ineffective. \u003cem\u003e\u0026ldquo;We will counsel people on sleep-hygiene. It generally doesn\u0026rsquo;t go down well, people feel they\u0026rsquo;re being patronised.\u0026rdquo; (Pharmacist 15)\u003c/em\u003e. MDT out-of-hours support facilitated effective sleep-hygiene. Some patients stayed up late drinking caffeinated and energy drinks, then requested hypnotics; many wards did not supply caffeinated drinks. Inpatient access to addiction services and support groups around benzodiazepines/z-hypnotics was lacking. \u003cem\u003e\u0026ldquo;There\u0026rsquo;s no facility within substance misuse services, no support groups around prescribed benzodiazepines and z-drugs.\u0026rdquo; (Pharmacist 8)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Ward environment\u003c/h2\u003e \u003cp\u003eFacilities to support patients to use less benzodiazepines/z-hypnotics varied. \u003cem\u003e\u0026ldquo;\u0026hellip;ward\u0026rsquo;s got gym equipment as a way to de-stress rather than using the benzos.\u0026rdquo; (Pharmacist 11)\u003c/em\u003e A quiet room where people go to calm down was useful. \u003cem\u003e\u0026ldquo;We\u0026rsquo;ve a snoozelum. It\u0026rsquo;s a relaxation room with nice lights and music on.\u0026rdquo; (Pharmacist 14)\u003c/em\u003e Many wards lacked sufficient private areas. \u003cem\u003e\u0026ldquo;Our ward doesn\u0026rsquo;t have spaces for conversations about medications.\u0026rdquo; (Nurse 6)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eWards could be unsettling environments for patients, due to noise and behaviour of other patients. \u003cem\u003e\u0026ldquo;Reviewing benzos and hypnotics usually gets missed because of how chaotic the ward is. Patients get left on medication when the clinical need isn\u0026rsquo;t there.\u0026rdquo; (Nurse 3)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eA lack of \u0026ldquo;home-comforts\u0026rdquo;, uncomfortable beds and overnight staff observations disturbing sleep were barriers. Participants from one organisation felt their Sleep Well\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e scheme reduced hypnotic use by reducing disturbances overnight.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e4.Primary/secondary care interface\u003c/h2\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003e4.1 Leave and Discharge planning\u003c/h2\u003e \u003cp\u003ePlanning benzodiazepine/z-hypnotic tapering before or during patient leave was crucial for reinforcing deprescribing. \u003cem\u003e\u0026ldquo;If the patient manages without benzos or hypnotics on leave, it breeds confidence they don\u0026rsquo;t need PRN's.\u0026rdquo; (Pharmacist 6)\u003c/em\u003e Lack of structured leave plans often resulted in patients continuing benzodiazepines/z-hypnotics unchanged during leave. Patient involvement seemed important. \u003cem\u003e\u0026ldquo;Junior medics tend to do leave scripts; discussions aren\u0026rsquo;t always had between the wider team and with the patient. They go on leave with the prn\u0026rsquo;s they took on the ward.\u0026rdquo; (Doctor 7)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eRushing deprescribing during discharge risked destabilising the patient or causing withdrawal symptoms. Implementing deprescribing treatment-plans prior to discharge helped, but patients were sometimes discharged in the middle of this plan, often because of bed-pressures or self-discharge. Benzodiazepine/z-hypnotic deprescribing may not be prioritised during discharge planning. \u003cem\u003e\u0026ldquo;I don't think it\u0026rsquo;s considered. Priorities are suicide prevention planning or getting the patient food. Benzos are falling off the bottom of the list.\u0026rdquo; (Pharmacist 10)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e4.2 Communication on discharge\u003c/h2\u003e \u003cp\u003eEffective discharge communication ensured ongoing deprescribing post-discharge. Discharge letters including a benzodiazepine/hypnotic reduction plan facilitated further management in the community. Oten discharge letters were inaccurate in recording benzodiazepine/z-hypnotic use, but pharmacy checks may improve this. \u003cem\u003e\u0026ldquo;Benzos and hypnotics are started as an inpatient and intended for short-term use, but it\u0026rsquo;s not communicated well to GPs (General Practitioners), so inappropriately added on GP repeats.\u0026rdquo; (Pharmacist 13)\u003c/em\u003e Discharge counselling and discussing benzodiazepine/z-hypnotic prescribing in discharge meetings facilitated deprescribing.\u003c/p\u003e \u003cp\u003eUsually only small quantities of benzodiazepines/z-hypnotics were provided on discharge. This should be explained to the patient and documented. Some organisations provided larger amounts, complicating deprescribing. Without a written plan, GPs sometimes lacked confidence to reduce medications. \u003cem\u003e\u0026ldquo;GPs are reluctant to review or stop these meds as they were started by a specialist.\u0026rdquo; (Pharmacist 13).\u003c/em\u003e CMHTs struggled with capacity to support continued deprescribing. Participants felt one national healthcare computer system would facilitate communication between sectors.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eSummary\u003c/h2\u003e \u003cp\u003eSignificant variation persists in the management of benzodiazepine/z-hypnotics on AMH wards. Local ward culture, rather than national guidelines, chiefly drives the approach to deprescribing, compounded by some patient behaviour patterns which can hinder this process. Adopting patient-centred care can alleviate many of these challenges. Access to non-pharmacological interventions aimed at de-escalating agitation, enhancing wellbeing, and improving sleep are crucial in supporting benzodiazepine/z-hypnotic deprescribing. Collaborative MDT efforts can bolster this initiative, although staff pressures are often a barrier. Effective discharge planning that prioritises safe deprescribing is vital but often overlooked due to bed pressures. If benzodiazepines/z-hypnotics are continued post-discharge; good communication with CMHTs/primary-care facilitates continued deprescribing.\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eDetailed Discussion\u003c/h2\u003e \u003cp\u003eThis research found the dominance of local culture influencing deprescribing of benzodiazepines/z-hypnotics on AMH wards leads to discrepancies in treatment pathways. Others have described deprescribing as \"swimming against the tide\" owing to patient expectation and entrenched medical norms and organisational constraints\u003csup\u003e\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e. Clinician-centred medical culture has been highlighted as a barrier to deprescribing\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAlthough many clinicians referred to the Ashton Manual\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e for guidance, it\u0026rsquo;s focus is primarily on community settings, leaving a gap in support for inpatient scenarios. Brandt\u003csup\u003e\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u003c/sup\u003e highlighted inconsistencies and/or insufficiency of detail among deprescribing documents for benzodiazepines/z-hypnotics. Due to the individual nature of benzodiazepines/z-hypnotic deprescribing, resources need to be flexible so the patient can guide adjustments\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. A national resource combining inpatient guidelines for benzodiazepines/z-hypnotics prescribing, withdrawal regimes, patient-information leaflets and non-pharmacological support could support the process. National resources are available in Wales\u003csup\u003e\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e and Scotland\u003csup\u003e\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e to support appropriate benzodiazepine/z-hypnotic prescribing, but not specifically for inpatients.\u003c/p\u003e \u003cp\u003eBarriers to healthcare professionals accessing evidence-based guidelines include time constraints, lack of awareness, guideline complexity and disagreement\u003csup\u003e\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e. Any new resources should be easy to use, with effective training and resource dissemination targeted to the AMH inpatient environment\u003csup\u003e\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e. Initiatives such as Area Prescribing Committee guidelines can facilitate continuity of care, while the new NICE insomnia\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e guidelines may inform future practices, depending on their promotion and adoption.\u003c/p\u003e \u003cp\u003eMultidisciplinary \u0026lsquo;deprescribing committees\u0026rsquo; aid deprescribing in psychiatry\u003csup\u003e\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e but motivation and training of MDT members affects successful deprescribing\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Capability barriers exist, especially among out-of-hours medical staff. Organisations need to ensure that on-call medical staff have the knowledge and IT skills required to safely prescribe and deprescribe. Simple educational strategies can reduce hypnotic prescribing rates and enhance staff confidence in insomnia management on mental health wards\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA dedicated team member, often a clinical pharmacist, overseeing the deprescribing process facilitated successful outcomes, mirroring findings elsewhere\u003csup\u003e\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e,\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e. Hawkins\u003csup\u003e\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e recommends using pharmacists to facilitate communication between prescribers, communicate risks to patients, and implement tapering/discontinuation plans. However, pharmacist confidence and capacity may impede effective implementation\u003csup\u003e\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u003c/sup\u003e. NMPs may enhance benzodiazepines/z-hypnotic management on AMH wards in a similar way to their role in primary care, by leveraging their detailed medication knowledge\u003csup\u003e\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u003c/sup\u003e and improving access to prescribers. The role of experts-by-experience in medicines optimisation has been documented\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e but research is needed into their role in deprescribing.\u003c/p\u003e \u003cp\u003eTime pressures and pressures to discharge limit benzodiazepine deprescribing\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. In 2024, CQC identified staffing shortages as one of the greatest challenges for the mental health sector, impacting quality and safety of care\u003csup\u003e\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u003c/sup\u003e. Reports from 39 UK mental health trusts, referencing staff shortages as a contributing factor to serious incidents, rose from 6,957 in 2019 to 11,073 in 2022\u003csup\u003e64\u003c/sup\u003e. There was an increase in restrictive practices on AMH wards associated with high staff sickness during the COVID pandemic\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e. Patients detained under the Mental Health Act may be denied escorted section 17 leave due to staff shortages\u003csup\u003e\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e. Time away from the ward and exercise can be used to manage sleep-hygiene\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e and de-escalate aggression\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e. Poorly managed patient aggression negatively impacts healthcare workers\u0026rsquo; psychological well-being and staffing levels\u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e, causing a spiral where less staff are available to offer non-pharmacological management of aggression, resulting in less deprescribing of benzodiazepines/z-hypnotics. Staff fears over managing patient aggression without benzodiazepines/z-hypnotics is an example of fear contributing to deprescribing inertia, which is not easily allayed by limited evidence regarding safety and efficacy of deprescribing\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePatient-centred approach enables deprescribing\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e but often requires collaborative engagement among professionals\u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e. Patients are more amenable to deprescribing conversations if they understand the rationale, are involved in developing the tapering plan, and offered behavioural advice.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e Educating patients around deprescribing decisions prevents damaging patient/prescriber trust\u003csup\u003e\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e\u003c/sup\u003e. Staff following the safe wards model\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e reported increased confidence to use de-escalation skills before offering benzodiazepines/z-hypnotics. Trauma-informed care has been shown to reduce incidents of self-harm, seclusion and restraint on AMH wards\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e. Benzodiazepine/z-hypnotic deprescribing would be facilitated if further research highlighted which de-escalation techniques were most effective on AMH wards, resulting in national standardisation. Using EPMA systems to give prompts can aid deprescribing\u003csup\u003e\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e however, existing systems may require adaption for diverse healthcare settings\u003csup\u003e\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eContrary to the negative views around sleep-hygiene advice in this research, advising on sleep-hygiene has been associated with improved mental health outcomes\u003csup\u003e\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e. Research is needed\u003csup\u003e\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e\u003c/sup\u003e into how to tailor this to the individual\u003csup\u003e\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u003c/sup\u003e as NHS patient-information leaflets are sometimes inaccurate, inconsistent and confusing\u003csup\u003e\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e\u003c/sup\u003e. Sleep-hygiene, when part of a larger quality improvement bundle, has been associated with a sustained reduction in hypnotic prescribing in general hospitals\u003csup\u003e\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e\u003c/sup\u003e. Although the negative effects of caffeine on sleep are well documented\u003csup\u003e\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e\u003c/sup\u003e and concern raised over the neurovegetative effects energy drinks\u003csup\u003e\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e\u003c/sup\u003e, further research is needed into their effect on insomnia and agitation on AMH wards. The Sleep Well programme\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e studied contributory factors to poor sleep on psychiatry wards; protecting sleep with reduced overnight checks personalised to the patient.\u003c/p\u003e \u003cp\u003eEstablishing and documenting clear rationale for initiating benzodiazepines/z-hypnotics is important as they are not always indicated\u003csup\u003e\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e\u003c/sup\u003e. The BNF\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e advises caution in initiating benzodiazepines/z-hypnotics in patients with a history of drug or alcohol abuse. If prescribed inappropriately, identifying the point at which deprescribing can be considered is made more difficult. Effective communication with patients can be impaired during admission, due to illness-related factors, acute intoxication and unwillingness to communicate\u003csup\u003e\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e\u003c/sup\u003e so a conversation on the short-term use of benzodiazepines/z-hypnotics may need to be delayed.\u003c/p\u003e \u003cp\u003eResearch has shown no difference between the genders in terms of aggression\u003csup\u003e\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e\u003c/sup\u003e, but more female patients are admitted with EUPD than male\u003csup\u003e\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e\u003c/sup\u003e. Peters\u003csup\u003e\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e\u003c/sup\u003e found being male significantly decreased the likelihood of receiving benzodiazepines at discharge from psychiatric inpatient treatment. Concern has been raised over the lack of evidence in prescribing in EUPD\u003csup\u003e\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e\u003c/sup\u003e; resulting in a large burden of psychotropic polypharmacy\u003csup\u003e\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e\u003c/sup\u003e. Benzodiazepine prescribing in EUPD increased from 55.3% in 2014 to 58.6% in 2019\u003csup\u003e85\u003c/sup\u003e. At times of crisis, few patients with EUPD engage in psychotherapies\u003csup\u003e\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e\u003c/sup\u003e and specialist individualised services are required\u003csup\u003e\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e\u003c/sup\u003e. Future research should identify the support required for people with EUPD, on AMH wards, to reduce benzodiazepine/hypnotic use and to investigate if behavioural differences exist between the genders, or if it reflects therapeutic nihilism from ward staff.\u003c/p\u003e \u003cp\u003ePromethazine was used as an alternative to benzodiazepines/hypnotics but is associated with several adverse-effects\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e and has little support in current NICE guidance\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. NICE recently recommended daridorexant for chronic insomnia\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. This novel hypnotic may facilitate benzodiazepine/z-hypnotic deprescribing by offering an alternative treatment\u003csup\u003e\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e\u003c/sup\u003e. Research on elderly wards concurred that long admissions facilitated deprescribing in patients admitted on benzodiazepines/z-hypnotics but acted as a barrier to deprescribing in patients started on these medications during admission\u003csup\u003e\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBenzodiazepine/z-hypnotic deprescribing not being prioritised or completed at discharge mirrored previous research\u003csup\u003e\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e\u003c/sup\u003e. More research into discharge priorities from AMH wards could help us understand the priority given to benzodiazepine/z-hypnotic deprescribing. If deprescribing plans were put in place during initiation of benzodiazepines/z-hypnotics and well documented, then these plans could be included in the discharge communication.\u003c/p\u003e \u003cp\u003ePrimary-care/CMHT influencing deprescribing practices on AMH wards by applying additional barriers to discharging patients on benzodiazepines/z-hypnotics, follows the behavioural change wheel to implement evidence-based practice\u003csup\u003e\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e\u003c/sup\u003e. Mitchie\u003csup\u003e\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e\u003c/sup\u003e found motivation is one of the components of behavioural change and can take the form of incentivisation or coercion. Incentivising primary-care to reduce their benzodiazepine/z-hypnotic prescribing may have resulted in some coercion of secondary-care to encourage deprescribing. However, discontinuation post discharge should be discussed with the patient, and planned for early on in treatment, to prevent distress or withdrawal effects post-discharge.\u003c/p\u003e \u003cp\u003eKeers\u003csup\u003e\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e\u003c/sup\u003e found discharge prescriptions issued by mental health NHS hospitals have high levels of prescribing, clerical and communication errors. Primary care clinicians may be hesitant to stop a medication started by a consultant psychiatrist as they do not feel responsible for the medication, because of professional hierarchy\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Direct communication between healthcare professionals when considering deprescribing is invaluable to resolve uncertainties, prevent conflicting instructions to patients, and ensure alignment of the therapeutic plan\u003csup\u003e\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e\u003c/sup\u003e. Creating a culture that values communication at discharge helps improve outcomes following hospitalisation\u003csup\u003e\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e\u003c/sup\u003e. Ensuring primary and secondary care have access to a universal patient note and prescribing system would aid deprescribing by passing information efficiently between sectors\u003csup\u003e\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThe large numbers interviewed from multiple organisations may have helped ensure generalisability and is a strength of the study. Although participants were recruited throughout England and Wales, a large proportion were from the northeast of England, so regional differences may have skewed the results. Participants recruited via snowball effect from contacts of the researcher may not be representative of the population. Interviewees putting themselves forward for interview may have already had an agenda they wished to pursue on this topic or an interest in the subject, resulting in volunteer bias\u003csup\u003e\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe researcher\u0026rsquo;s clinical role as a pharmacist on AMH wards may have affected the discussions with participants and interpretation of the results. To overcome interviewer bias\u003csup\u003e\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e\u003c/sup\u003e the researcher aimed to be transparent and reflexive throughout. Pharmacists were overrepresented in the demographics, with nurses being the least represented group. Future research should include a wider range of healthcare professionals and patients. A small number of interviewees worked directly with the researcher, which may influence the answers they gave. The researcher tried to avoid confirmation bias\u003csup\u003e\u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e\u003c/sup\u003e by considering all data obtained while analysing and re-evaluating and discussing this with the chief investigator. Member checking of transcripts was not carried out, which may have led to misinterpretation during some of the transcribing.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eImplications for policy makers\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eA strong national agenda is needed to drive a local culture of deprescribing benzodiazepines/z-hypnotics on AMH wards, including developing a national evidence-based resource which can support this. On-call medic cover on AMH wards should have the knowledge and IT skills to safely prescribe. EUPD treatment recommendations should be updated to provide more guidance on use of medication and access to specialist resources. Current staffing levels, and jobs descriptions of staff, on AMH wards should be reviewed to ensure benzodiazepines/z-hypnotic deprescribing can be supported safely. The ability of sectioned patients to access section 17 leave should be audited. Sharing of good practice between mental health trusts should be encouraged.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eImplications for future research\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eQualitative research into patient views around deprescribing benzodiazepines/z-hypnotics and research into factors which resulted in patients being discharged on these medications, would allow for triangulation. Qualitative research into the role played by various MDT members in deprescribing may identify changes in job descriptions and further training needs. Further research to identify the most effective de-escalation and sleep-hygiene techniques, would enable evidence-based national standardisation. Research is needed into the effect of energy drink consumption on insomnia and agitation on AMH wards. Further research is required to observe if gender differences exist in prescribing/deprescribing patterns of benzodiazepines/z-hypnotics in patients diagnosed with EUPD. Research into discharge priorities from AMH wards may indicate if deprescribing is considered during transfer of care.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIdentifying facilitators and barriers to deprescribing benzodiazepines/z-hypnotics on AMH wards can alleviate the persistent issue of these medications being continued post-discharge, risking tolerance, dependence and withdrawal symptoms. While patient-specific barriers related to behaviour and motivation exist, they can be mitigated with non-pharmacological treatments and support from well trained staff. Maintaining adequate staffing across the full MDT is crucial. Changing national NHS culture is a major task but without promoting standardised practice, local factors on individual wards will continue to impact deprescribing efforts. This inconsistency can lead to unnecessary polypharmacy, distress for patients, and increased workload for the MDT. Although good practice exists, further dissemination, research and funding are needed to support all AMH patients in reducing inappropriate benzodiazepine/z-hypnotic use. Addressing underlying NHS pressures is essential to break the cycle of harmful polypharmacy and escalating patient behaviours.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; Benzos\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebenzodiazepines\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; UK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; GABA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003egamma-aminobutyric acid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; Z\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehypnotics-zopiclone / zolpidem\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; AMH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eadult mental health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; NICE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Institute for Heath and Care Excellence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; NHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Health Service\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; PRN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eas-needed\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; RCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003erandomised controlled trials\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; COREQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConsolidated Criteria for Reporting Qualitative studies\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; CQC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCare Quality Commission\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; CMHT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecommunity mental health team\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; EPMA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eelectronic prescribing systems\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; EUPD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eemotionally unstable personality disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; MDT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emulti-disciplinary team\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; NMP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003enon-medical prescriber\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; GPs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral Pratitioners\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSonia Filmer:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePresent address: \u0026nbsp;Tees, Esk and Wear Valley NHS Trust, Lanchester Road, Durham, DH1 5RD, United Kingdom [email protected]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProfessor Ian Maidment\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePresent address: Aston Pharmacy School, College of Health and Life Sciences, Aston University, Birmingham, B4 7ET, United Kingdom [email protected]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and consent to participate\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eApproval for the study was obtained from the Health Research Authority (IRAS number 322529) and Aston University Governance Committee. Capacity and capability approval was obtained from Tees, Esk and Wear Valley NHS Foundation Trust, the researchers place of work. The protocol is available on request. Written informed consent was obtained from all participants, and copies of the patient information leaflet and consent form used are available on request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e- not applicable \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement (DAS)\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe qualitative data generated from this research project is not suitable for sharing as per ethical approval and the study protocol. If further information is required around the dataset, please contact [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding and disclaimer\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSonia Filmer, grant reference number MH044 for the grant National Institute for Health Research School for Primary Care Research (NIHR SPCR) 2021-2026, is funded by the NIHR for this research project. The views expressed in this publication are those of the author and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSF conceptualised and designed the work, performed the interviews, analysed and interpreted the data and was the major contributor in writing the manuscript as an MSc research study. IM was the academic supervision, guiding SF on all aspects of research, including ethical approval, study design, analysis and the final presentation of research. Both authors read and approved the final manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDr Gemma Donovan supported SF in applying for funding to complete this project and provided technical help during the data analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHelen Ashton, librarian, and Hazel Betteney, medicines information pharmacist, who acted as proofreader, were both employed at Tees, Esk and Wear Valley NHS Trust, Co Durham at the time of the study\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSF is an advanced, clinical prescribing pharmacist with over 25 years of experience in primary and secondary care. For the past seven years she has worked on adult mental health wards at Tees, Esk and Wear Valley NHS trust. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAshton, H. \u0026lsquo;The treatment of benzodiazepine dependence. \u003cem\u003e\u0026rsquo; Addiction\u003c/em\u003e, 1535\u0026ndash;1541, 89 (1994).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHypnotics and Anxiolytics. In: Joint Formulary Committee: British National Formulary (Internet). London: British Medical Association and Royal Pharmaceutical Society of Great Britain; (Updated 2024; cited 2024 July 5). 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Medin (Eds.), Decision making from a cognitive perspective\u003c/em\u003e 385\u0026ndash;418 (1995).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Benzodiazepines, hypnotics, z-drugs, deprescribing, facilitator, barrier, EUPD, NHS culture, sleep hygiene, de-escalation","lastPublishedDoi":"10.21203/rs.3.rs-6811205/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6811205/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThere is a place for the use of benzodiazepines/z-hypnotics on adult mental health wards, but they are often continued beyond a length of time where they are beneficial. This can result in dependence and withdrawal effects if stopped. Timely deprescribing of these medicines is encouraged, but there is limited evidence available as to what can be a facilitator or barrier to the review of benzodiazepines/z-hypnotics on these wards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eSemi-structured interviews, with twenty-nine NHS healthcare professionals involved in the use of benzodiazepines/z-hypnotics on adult mental health wards, were conducted and recorded on Microsoft Teams and transcribed. Themes were generated via thematic analysis on NVIVO software, informed by a grounded, inductive approach, to identify similarities and differences in participants perceptions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe four main themes identified from participants’ experiences were:\u003c/p\u003e\n\u003cp\u003e· Culture\u003c/p\u003e\n\u003cp\u003e· Patient factors\u003c/p\u003e\n\u003cp\u003e· Practical measures to facilitate deprescribing of benzodiazepines/z-hypnotics on adult mental health wards\u003c/p\u003e\n\u003cp\u003e· Primary/secondary care interface\u003c/p\u003e\n\u003cp\u003eDeprescribing culture, rather than being led nationally, is more influenced by local factors. Some patient behaviour patterns can be a barrier to deprescribing but many of these can be overcome by promoting patient-centred care, allowing patients to feel involved and enabled to make informed decisions around their care. Access to non-pharmacological methods to de-escalate behaviour, promote wellbeing and improve sleep on adult mental health wards can support deprescribing. Cohesive multi-disciplinary team working aids deprescribing, but staff pressures can hinder this by reducing access to appropriately trained staff with the capacity to perform their role effectively. Effective discharge planning is important but not always achieved. Good communication post discharge can facilitate continued deprescribing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eOvercoming the barriers and developing the facilitators identified could improve benzodiazepine/z-hypnotic deprescribing on adult mental health wards. Changes to national NHS culture and priorities are required to influence local culture. Otherwise, deprescribing practices will remain greatly influenced by local factors on individual wards. Good practice exists but further research and funding is needed to disseminate this throughout the NHS. Addressing underlying NHS pressures is essential to break the cycle of harmful polypharmacy and escalating patient behaviours.\u003c/p\u003e","manuscriptTitle":"Facilitators And Barriers to the De-prescribing Of Benzodiazepines and Z-drug Hypnotics in patients under 65 on Adult Mental Health Wards: an exploratory qualitative study. 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