Saturday, 8 May 2010

More on medication

Drugs have a really important role to play in mental health care. They can cure people. They can make symptoms disappear. They can keep people well for years, when without them their lives are in bits. I've seen this time and time again, with patients feeling they're doing well on medication and feeling/showing they're doing badly without.

Maybe it's because of this that use and review of drugs matters. It's not a simple "drugs are good" message. Medication is good, for some people, some of the time.

How do we know who it's good for? We don't. We guess. It's an informed guess, but it's still a guess. Sometimes it's pretty clear that medication can have a useful role to play (i.e. it is "indicated") but that's different from knowing it's going to work and should be continued.

How often does a patient continue medication over the long term? It's not meant as a rhetorical question. Really, I'm inviting you to speculate. In the teams that I lead and I'm the only doctor in them, so all prescribing decisions come through me, we have in the ballpark of 5000 direct face to face patient contacts/year. 96 a week. How many patients, each week, have medication put on repeat prescription? Take a moment and have a guess.

We did an audit on oral medication use over the last 3 months and it surprised me. It excluded depot antipsychotic injection, which is long term medication so I'll 'fess up that there are 5 patients on long term depot. But apart from these 5 folk who wish to continue on depot, how many of the 96 contacts/week result in repeat prescriptions of medication?

The thing with drugs is it's not all about just one thing. The indication needs to be right and as the posts below describe, "depression" isn't good enough. Nor's "clinical depression" or even a DSM-IV "Major Depressive Disorder" diagnosis. Because management is guided by accurate formulation. Presence or absence of somatic symptoms has major implications for whether an alerting (help get up from bed, have some energy) or sedating (help stop worrying and get some rest and restorative sleep) and on use of medications over time. Psychological factors and social factors impact on psychological and practical interventions.

Meaningful assessment takes some time. Quite a lot of time.

From this, if medication potentially has a part to play, it's offered and started and doses are fiddled with and it's reviewed. If it's not working it's stopped. If it is working and side effects/risks are absent/tolerable it's continued. It's continued by the GP, so all longer term management is prescribed through Primary Care.

Which takes me back to the audit. Rather than just a short term intervention that our service prescribes and I'm involved with through assessment/medication use/review, the number of patients having repeat prescription from the GP was audited. All activity for 3 months was reviewed. Many, many patients had trials of medication. Often it was stopped. Often it was fiddled with by me, so I kept prescribing since doses and drug combinations were constantly changeing.

So how many did pass back to the GP for longer term prescribing of a stable medication dose regimen?

Of the roughly 96 patient contacts/week, 1.92 patients/week had a repeat prescription. It's not that many. We spend so much time prescribing and fiddling with drugs and reviewing drugs, it's only on review of the big picture that we see that drugs aren't a major longterm feature for most.

That surprised me.


Mark p.s.2 said...

The rates for TD are astronomical. In otherwise physically healthy adults, 5%-8% per year will develop the disorder, with cumulative rates in the range of at least 15%-20% for the first three years. In the elderly, the risk of tardive dyskinesia accumulates at 20% or more per year. It is tragic that such damaging drugs are allowed to remain on the market.

Mel said...

This is partly reassuring and partly, frankly. scary.

After applying for DLA, and going to a tribunal, I've found out just how close I came to being prescribed anti-psychotics. And, as a mental health nurse in training, it scared me. A lot.

Sarah Quail said...

I guess I'm part of that lucky 2% then. I'm probably an outlier when it comes to private outpatients at least though (although definitely not public inpatients), what with a bidirectional mood disorder with a long history.