Sunday, 10 August 2008


The folk over at Mental Nurse are discussing the art/science/craft of nursing and after baiting them (why do they never bite when I try and wind them up?) commented on the medics role of pushing drugs.

Got me thinking.

How many prescriptions for antipsychotics do I dish out and hope for the best. As Mr Zarathustra says :
"Writing a script for some olanzapine and hoping for the best is being a “highly trained professional” is it?"

So, having some time on my hands, I've been through my last weeks activity. I guess it's fairly representative of a typical working week in terms of activities, but with a change of junior doctor and inductions I was doing and teaching and PCT/other meetings and management stuff taking up several afternoons, the absolute numbers seen are lower than my weekly average. This week clinical activity included :
- meeting in-patients (of which I currently have about half a dozen) throughout the week on different occasions to talk with them
- a formal weekly review of in-patients, with ward staff, pharmacy, CMHT et al
- meeting daily with the CMHT to discuss their visits and day to day patient care (what's the point of having an MDT if we don't think through and have a voice in all patient care?)
- a formal weekly CMHT meeting
- an out-patient clinic seeing 4 follow-up patients (each for half an hour)
- 2 home visits (joint visits with with a CPN) to see new patients referred
- 1 home visit (joint visit with with a CPN) to see an urgent referral on an evening
- 1 case conference at a GP's surgery with a CPN, Consultant Physician and GP then a home visit by the CPN and me to convey outcomes
- 2 case conferences to discuss care with patients and families
- 5 early onset dementia patient reviews
- 2 formal Best Interest meetings with patients, families, social services, care staff, CPNs, care staff (and lengthy 'phone calls with the GPs who couldn't be there in person but being fair they knew the patients well and visited frequently)
- 3 home visits (joint visits with with a CPN) to follow up patients and discuss medication with them
- 1 home visit (joint visits with with a social worker) to follow up a patient
- 1 care home visit (joint visit with with a CPN) to see an urgent referral, one from police
- 1 care home visit (joint visit with with a CPN) to see an emergency referral from the police
- 3 care home visits (joint visits with with a CPN) to review care
- 4 liaison referrals from our neighbouring acute hospital Trust
- 1 section 136 assessment (joint visit with an ASW, ward nurse and a home treatment CPN)

Only 35-ish patients that I saw directly, with a similar number discussed. 70 patients whose care I influenced last week. That's a very different world from Primary Care.

Going through these patients, what prescribing decisions were made? Prescriptions :
- in-patients : 0 antipsychotics, 3 acetylcholinesterase inhibitors, 1 duloxetine, 4 lorazepam, 0 sedatives/sleeping tablets
- out-patients : 0 antipsychotics, 3 acetylcholinesterase inhibitors, 1 lorazepam, 0 sedatives/sleeping tablets
- community : 4 antipsychotics (trifuoperazine, amisulpiride, 2 olanzapine) continued, 1 atypical antipsychotic stopped (aripiprazole), 1 depot antipsychotic (fluphenazine) stopped, 5 acetylcholinesterase inhibitors, 1 citalopram continued and titrated to 40mg, 1 citalopram stopped, 1 mirtazepine, 3 lorazepam
- liaison : 3 haloperodol stopped, 2 acetylcholinesterase inhibitors, 1 mirtazepine, 1 lorazepam
- 136 assessment : 0 antipsychotics

Antipsychotics prescribed : 3
Antipsychotics stopped : 5

The 5 stopped were 3 inappropriate prescriptions for haloperidol, 1 depot that no longer seems necessary and 1 aripiprazole for BPSD that hasn't done anything tangible.

The trifluoperazine was continued in a lady who asked for it. She'd been on it since God was a lad, and after so many years and trying so many drugs she had confidence in it, wishing to take it 3 times a day. It's working for her, so we're running with it. No more hallucinations. Delusions that she's being spied on gone. No longer wanting to move house. All's good.

The amisulipride 300mg is a relatively low dose since it's for BPSD and is working, the husband can now take her to the shops with him and she's settled. All's good.

Olanzapine 20mg is for BPSD in someone who smokes. I know, I know, high risk (2% a year) of CVA. But smoking halves the amount of olanzapine available so effectively she's just on 10mg. And it's cured her symptoms of BPSD. No more wandering at night, no more physical hostility, no more paranoia about family that she's acting on. Still awfully muddled, still swears like a trooper. But family can manage her at home, now, and even after discussing risks are adamant that she's a new woman on this drug so wish to continue it. And I agree, it's in her best interests to be functioning better and less distraught. All's good.

The other olanzapine 20mg is for bipolar disorder and is working. From being on section 2 this Summer the lady's now back home, off lithium and off her depot and on just olanzapine. She's content/a touch high which is exactly where she likes to be. Lots of energy and motivation, lots of creativity, but insightful and able to manage her relationships with family (that're damaged when she's hypomanic). So she's stable and well. All's good.

So there we have it. In one week I've stopped more antipsychotics than I've prescribed, which is pretty typical. It's not too bad, is it?


InEx said...

I am all for anti-psychotics if they work - which is where you seem to be coming from. My Psychiatrist (who really is brilliant, kind and lovely) has tried me on quite a few, secretly I think he thinks I am better on them, but he supports my decision not to take them........I have forgotten what my point was.......Oh dear just goes to show you shouldn't let loons loose on a computer...........I know what my point is.......Why don't Doctors and Nurses just get on with it instead of getting all picky with each other.....Medicine and Nursing both still have a lot to learn and wouldn't it be better if you did it together in a mutually supportive environment.......but I guess it is more fun being picky...

Anonymous said...

Good work Shrink - but I am surprised the GPs still talk to you. You must command some respect.
Nice to see you stop a depot too.

My malcontent also covers all the symptomatic uses of anxiolytic, antideporessants or antispychotics too tho that aren't backed up with good interventions to remove/militate the underlying causes or problems or are prescribed off-label as a temp fix - and left for months or years.
I'd prefer a drug free treatment - for everything - even physical ailments. Would be nice eh? But then, just what would you do?

I note silvawingz comment too -
"Why don't Doctors and Nurses just get on with it instead of getting all picky with each other"
For me, personally, we gate-keep each other. My medics test me and question me on what I'm doing with my nursing team for the patient and keep me motivated and on my toes. And my medics will be thinking in the back of his/her mind that s/he better be able to justify himself from several angles or be prepared for a blast of 20 questions on why s/he determines one line of action over an other.
I am perhaps a little heavy some times tho, and my previous Consultant stopped coming to my nursing group ward rounds because I would not accept his rationale for treating anyone who didn't improve their behaviour to commence Clozapine - he argued they were treatment resistive - But I suggested they needed to have schizophrenia first to meet the criteria?!
So he passed the whole group over to a new Consultant who conveniently arrived.
He was far too political too and patients had decisions made over their care and placement on political grounds rather than treatment ones. Using patients as pawns in your own sick medico-political battles is not my idea of good care.
A little off-topic, excuse my rant :)

Spirit of 1976 said...

Why don't Doctors and Nurses just get on with it instead of getting all picky with each other.....Medicine and Nursing both still have a lot to learn and wouldn't it be better if you did it together in a mutually supportive environment.

To be honest, by and large we generally do. All this is just a bit of gentle mutual mickey-taking via the internet and shouldn't be taken too seriously. Certainly in my own clinic the doctors and nurses work extremely closely with each other and by and large get on very well.

The Shrink is certainly a welcome visitor to Mental Nurse, and we're all sure that if he studies hard and applies himself, then maybe one day he'll too have what it takes to become a nurse. ;)

ditzydoctor said...

sounds right :)

Unknown said...

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