Antidepressants: Quality prescribing - a guide for improvement
Background (age, sex, occupation, baseline function)
- 24-year-old female
- Office administrator
History of presentation/reason for review
- Reports a 12-week history of increasing anxiety including worry, mild irritability, difficulties concentrating and marked sleep disturbance
- Increasingly difficult to control her worries which is having an impact on her work. She has been going in early and staying late as taking extra time to both complete and then check over her work due to concerns she may make a mistake
- Parents have noticed she is more on edge, restless and seems tired all the time
Current medical history and relevant co-morbidities
- No mental or physical health comorbidities
Current medication and drug allergies (include OTC preparation and herbal remedies)
- None
Lifestyle and current function (including frailty score for >65yrs) alcohol/smoking/diet/physical activity
- Single, no dependents
- Lives at home with her parents
- Social drinker
- Non-smoker
- Very supportive close group of friends, parents, and older brother that she has been able to talk to about her anxiety
“What matters to me” (patient ideas, concerns and expectations of treatment)
- Keen to reduce the time she spends worrying, improve sleep, and feel less tense
- Although she is experiencing some difficulties at work, she is keen to avoid time off and is still managing to go to the gym
- Keen to avoid medication
- Invite individual to complete questions to prepare for the review (PROMs)
Results e.g., biochemistry, other relevant investigations or monitoring
Note: local lab reference ranges may vary
- GAD-7 score 8 (mild-moderate anxiety). However, as the anxiety is affecting her daily tasks of living, she is experiencing moderate anxiety
Most recent relevant consultations
- Presents as very motivated, has clear goals that including reducing the time she spends worrying, improved sleep, and feeling less tense
- Caffeine intake assessed and discussed
- Medication options are explored alongside psychological options. Has avoided coming into the practice as she is keen to avoid medication however expresses an interest in accessing CBT which she has looked up online. Comfortable using computers, see this as a flexible way to receive support that she can manage around her work and social commitments
- Reports no family history of suicide. No plans or intent to harm herself or others
Agreed plan:
- Medication options will not be commenced at this stage. Sleep hygiene discussed and written information given
- Referral to Daylight, a cCBT package for Generalised Anxiety Disorder (GAD) with a review in the practice in four to six weeks’ time or if symptoms worsen
7 Steps: Person specific issues to address for case study
1. Aims: What matters to the individual about their condition(s)?
Review diagnoses and consider:
- Therapeutic objectives of drug therapy
- Management of existing health problems
- Prevention of future health issues, including lifestyle advice
- Ask individual to complete Patient Reported Outcomes Measures (PROMS) before the review
Person specific actions
- Motivated and keen to reduce anxiety and time spent worrying
- Improve focus at work
- Improve sleep
- Prefers to avoid medication
2. Need: Identify essential drug therapy
Identify essential drugs (not to be stopped without specialist advice*)
- Drugs that have essential replacement functions
- Drugs to prevent rapid symptomatic decline
* with advice from healthcare professional with specialist interest
Person specific actions
- None
3. Does the patient take unnecessary drug therapy?
Identify and review the continued need for drugs
- what is medication for?
- with temporary indications
- with higher than usual maintenance doses
- with limited benefit/evidence for use
- with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)
Person specific actions
- None
4. Effectiveness: Are therapeutic objectives being achieved?
Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives
- to achieve symptom control
- to achieve biochemical/clinical targets
- to prevent disease progression/exacerbation
- is there a more appropriate medication to achieve goals?
Person specific actions
- Medication options explored but not appropriate at present, interested and preference for cCBT and non-pharmacological management (e.g. sleep hygiene, physical activity, caffeine reduction)
5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?
Identify individual safety risks by checking for
- appropriate individual targets
- drug-disease interactions
- drug-drug interactions (see ADR table)
- monitoring mechanisms for high-risk drugs
- risk of accidental overdosing
Identify adverse drug effects by checking for
- specific symptoms/laboratory markers
- cumulative adverse drug effects (see ADR table)
- drugs used to treat side effects caused by other drugs
Medication Sick Day guidance
Person specific actions
- No current plans or intent to harm herself or others
- No family history of suicide
- Has good family and friends support network
- Prefers non-pharmacological treatment to start with
- Reducing the use of medicines that are not indicated or appropriate avoids the risk of ADRs
6. Sustainability: Is drug therapy cost-effective and environmentally sustainable?
Identify unnecessarily costly drug therapy by
- considering more cost-effective alternatives, safety, convenience
Consider the environmental impact of
- Inhaler use
- Single use plastics
- Medicines waste
- Water pollution
Person specific actions
- No medicines prescribed. Reducing the use of medicines that are not indicated or appropriate reduces the environmental impact from medicines
7. Patient centeredness: Is the patient willing and able to take drug therapy as intended?
Does the person understand the outcomes of the review?
- Consider teach-back
- Involve the adult where possible. If deemed to lack capacity, discuss with relevant others, e.g. welfare guardian, power of attorney, nearest relative if one exists. Even if adult lacks capacity, adults with Incapacity Act still requires that the adult’s views are sought. Ensure “Adults with Incapacity Documentation” in place
Ensure drug therapy changes are tailored to individual’s preferences. Consider
- is the medication in a form they can take?
- is the dosing schedule convenient?
- what assistance is needed?
- are they able to take medicines as intended?
Agree and communicate plan
- discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
- include lifestyle and holistic management goals
- inform relevant health and social care providers of changes in treatments across the transitions of care
Ask individual to complete post-review PROMS questions after their review
Agreed plan
- Medication options will not be commenced at this stage
- Sleep hygiene and non-pharmacological options discussed. Written information given with links to self-help resources
- Referral made to a cCBT program (e.g. Daylight) for GAD. Review in the practice planned for four to six weeks’ time
Key concepts in this case
- Moderate GAD
- Non-pharmacological option preferred by patient, and matches with stepped-care model as per NICE guidelines
- Online computerised CBT fits with individual’s preference, needs and ease of access
Click on the table image to view a PDF version of the full 7 steps table for case study 2.
