Mental Health Case Study

Dr Anne Connolly, a Principal Pharmacist for Medicines Information, describes how she answers Mental Health Medication Telephone Advice & Guidance calls.

“Telephone Advice & Guidance gives GPs rapid access to experts in the use of psychotropic medicines. This expertise has been established through research and clinical experience. In addition, clear, evidence-based information is provided immediately for most enquiries and primary care clinicians have the ability to speak to someone directly rather than to email or write for advice. When a patient’s referral to secondary care has been rejected, we can also give expert advice on the patient’s management.” Dr Anne Connolly

Mental Health Case Study

Dr Anne Connolly works at South London and Maudsley NHS Foundation Trust (SLaM) and has over 20-years experience of working in mental health. She is a Principal Pharmacist for Medicines Information and answers Telephone Advice & Guidance calls made through the Consultant Connect system alongside the rest of her team. This service has been in place with Consultant Connect since October 2019 and offers primary care clinicians across the country the chance to get specialist Mental Health Medication advice.

When a GP makes a medication advice call to SLaM, the patient benefits in many ways. Anne outlines the following reasons why she thinks being able to speak to the GP directly on the phone helps the patient.

“Telephone Advice & Guidance gives GPs rapid access to experts in the use of psychotropic medicines. This expertise has been established through research and clinical experience. In addition, clear, evidence-based information is provided immediately for most enquiries and primary care clinicians have the ability to speak to someone directly rather than to email or write for advice. When a patient’s referral to secondary care has been rejected, we can also give expert advice on the patient’s management.”

For areas where mental health clinicians have yet to answer Telephone Advice & Guidance calls, Anne comments on the ease of setting it up:

“The technological set up is handled by Consultant Connect so this makes starting the service much simpler.”

She continues that:

“We have found working with Consultant Connect a very positive experience. They have allowed us to be flexible with our service especially during the COVID-19 pandemic which has placed services, staff and patients under extra pressure.”

Anne also encourages mental health specialists to answer Telephone Advice & Guidance calls as:

“The work is also flexible so can fit in with your current service demands.”

It is not only secondary care colleagues who Anne recommends the use of Telephone Advice & Guidance to. In cases where a GP is unsure about making a call, she states that they should “give it a try”. She also asks them to speak to other people who have used this service to get Mental Health Medication Telephone Advice & Guidance and to obtain their feedback.

Anne has provided the following example of when a GP has contacted her through the Consultant Connect service.

“A GP contacted me about management of a complex psychotropic medication regimen and akathisia in a young man with antisocial personality disorder, anxiety and depression. The patient was taking aripiprazole which he started for psychosis when using large amounts of illicit drugs. He was also taking venlafaxine (different daily doses) and possibly quetiapine. In addition, he was on procyclidine, insulin and ramipril. His diagnosis was anxiety and antisocial personality disorder, ADHD (as a child) and illicit substance use. The patient said he was not on street drugs currently but the GP said he sounded slurry on the phone. He also had diabetes which was not well controlled. The patient had rung the surgery as he was concerned about his jumpy legs and feeling twitchy (akathisia) which had been going on since he came off street drugs 4 – 5 months ago. The patient had been adjusting his own medication – taking quetiapine on and off every few days. He did not find procyclidine helpful.

 

I recommended finding out the rationale for how and why the patient was on two antipsychotics and informed the GP that procyclidine does not treat akathisia and can be abused. Since the patient had a history of substance misuse and procyclidine can cause euphoria, I advised to reduce the dose to 5mg daily for one week and then stop.

 

Aripiprazole can also cause akathisia. I suggested withdrawal by reducing the dose by 10mg weekly to stop. I also advised the patient may stop abruptly as the long half life of this drug means it takes two weeks to be removed from the body after stopping.

 

Quetiapine is a drug that can be used for anxiety. I informed the GP that it has a higher risk of metabolic effects than aripiprazole given his diabetes but that it was a reasonable choice as it is a sedative agent. This drug is used in Parkinson’s disease so there is a very low risk of movement side effects like akathisia. The current dose being used was as an antipsychotic not as an anxiolytic.

 

With the venlafaxine, erratic dosing can cause akathisia due to withdrawal effects so advised that the patient took the same dose every day. The maximum dose is 375mg in depression and is usually 225mg in Generalized Anxiety Disorder (GAD).

 

If the patient needed crisis management, I instructed the GP to use promethazine when required, not benzodiazepines given the abuse potential (the caller said the patient was seeking benzodiazepines). They are a treatment for akathisia but it is better to do the above management first. The GP was aware that akathisia may be due to substance misuse.”

How Telephone Advice & Guidance helped:

“Benzodiazepines were not provided and the management plan above was initiated. The GP wanted detailed advice on management of the patient so she did not have to re-prescribe benzodiazepines.”

This is a great result for both the GP (who got the advice she needed quickly and efficiently) and the patient as a clear and thorough plan was constructed.

 

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