Mental Health Telephone Advice & Guidance, via Consultant Connect, has been available to clinicians in participating areas since October 2019. The service is answered by mental health specialists at South London and Maudsley NHS Foundation Trust (SLaM). We spoke with Dr Anne Connolly, Principal Pharmacist for Medicines Information, and Petrina Douglas-Hall, Medicines Information Manager, who answer calls for advice from clinical colleagues.
When a Primary Care clinician makes a medication advice call to SLaM, the patient benefits in many ways. Dr Connolly and Petrina outline the reasons why they think being able to speak directly to the clinician is so helpful:
‘Telephone Advice & Guidance gives clinicians rapid access to experts in 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 clinicians can speak to someone directly rather than via email or post. 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.
‘I can provide accurate and up-to-date medication information at the end of a phone line. I feel very strongly about the beneficial effects of Telephone Advice & Guidance, and feedback received from clinicians has been very positive as they receive quick access to practical advice to treat their patients effectively.’
– Petrina Douglas-Hall.
Dr Anne Connolly
‘A GP contacted me about the management of a complex psychotropic medication regimen and akathisia in a young man. The patient was taking Aripiprazole which he started for psychosis when using large amounts of illicit drugs. He was also taking Venlafaxine with different daily doses and possibly Quetiapine. Additionally, 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 currently using street drugs, but the GP said his speed was slurred on the phone. The patient had rung the surgery as he was concerned about his jumpy legs and feeling twitchy (akathisia), which had been ongoing since he came off using street drugs some 4-5 months previously. The patient had been adjusting his 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 him to reduce the dose to 5mg daily for one week and then stop. Aripiprazole can also cause akathisia, so I suggested withdrawal by reducing the dose to 10mg weekly to stop. I also advised that 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, so I informed the GP that it has a higher risk of metabolic effects than Aripiprazole, given his diabetes, but 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 Venlafaxine, erratic dosing can cause akathisia due to withdrawal effects, so I advised the patient to take the same dose daily. The maximum dose is 375mg for depression, usually 225mg for Generalised 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 GP was aware that the akathisia may be due to substance misuse.
‘The GP wanted detailed advice on managing the patient so she did not have to re-prescribe Benzodiazepines. The management plan was initiated, and this was 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.’
‘I was called by a GP who had a patient with depression. The patient was taking Sertraline but wanted to switch back to Mirtazapine because it helped them to sleep better. However, the GP was unsure how to handle the switching of medications.
‘I spoke to the GP, and together, we formulated a switching regime that was appropriate for the patient. This was a great result as the patient received rapid results and the best possible care. In this case, Telephone Advice & Guidance was important as the GP received rapid support when needed, and the patient remained in the community.’
What advice would you give to mental health clinicians who have yet to answer Telephone Advice & Guidance?
‘The technological set-up is handled by Consultant Connect, making starting the service much more straightforward. 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 everyone under extra pressure.
‘The work is also flexible to fit in with your current service demands.’
– Dr Anne Connolly.
‘We help Primary Care clinicians to formulate medication treatment plans for their most difficult-to-treat patients. Give it a try and find out for yourself!’
– Petrina Douglas-Hall.