Antidepressants: Quality prescribing - a guide for improvement
Background (age, sex, occupation, baseline function)
- 54-year-old male
- Recent loss of employment
History of presentation/reason for review
- Attended for review of his antidepressant started two months ago for first depressive episode
- Attends with a supportive friend who is concerned about him, as the individual has cancelled plans to meet and avoiding contact with others. Appears more socially isolated
- Signs of self-neglect
- Has lost over half a stone in weight due to reduced appetite
- Reports early morning wakening, increased rumination and a loss of motivation
Current medical history and relevant co-morbidities
- Depressive episode – started antidepressant therapy two months ago
- Asthma (diagnosed in childhood) currently well controlled
Current medication and drug allergies (include OTC preparation and herbal remedies)
- Citalopram 20mg tablets - one tablet daily
- Clenil® (beclomethasone) 100microgram MDI - two puffs twice a day
- Salbutamol 100microgram MDI - two puffs up to four times a day (two ordered in last 12 months)
- No known drug allergies
Lifestyle and current function (including frailty score for >65yrs) alcohol/smoking/diet/physical activity
- Recent loss of employment
- Supportive friend
- At review:
- Avoidant of eye contact and when asked becomes tearful reporting fleeting, occasional thoughts of ending his life. Whilst he has no active plan for suicide, he has disclosed he has thought about different ways of ending his life. Is adamant he would not act on these, citing his father and dog as protective factors
- He reports taking his citalopram as prescribed every day for eight weeks but little/no benefit
- Does not drink alcohol or use recreational substances
“What matters to me” (patient ideas, concerns and expectations of treatment)
- When asked about his goals he struggles to identify any, other than he wants to feel better but feels helpless as to how to change his situation
- Invited to complete the Patient Reported Outcome Measures (PROMs) prior to his review to identify any additional areas for discussion
Results e.g., biochemistry, other relevant investigations or monitoring
Note: local lab reference ranges may vary
- Recent bloods within normal range, including thyroid function tests
- During consultation indicates a worsening of symptoms. PHQ-9 score 14/27 eight weeks ago to 18/27 today (moderately severe depression)
Most recent relevant consultations
-
He is agreeable to a review of his medication and psychological supports are discussed. He was signposted to the NHS inform self-help guide at first presentation to the practice, which he had taken time to explore. He found understanding the links between his thoughts, feelings and behaviours helpful but would feel more comfortable if able to discuss this in person.
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
- Wants to “feel better”
- Wants to regain motivation and appetite
- Wants to walk his dog more often
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 identified as essential medicines
- Inhaled corticosteroids required for asthma control
- Consider the need for gradual withdrawal/ cross tapering with antidepressants where necessary
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
- Episode of depression, possibly related to loss of employment. Trial of citalopram 20mg daily – ineffective after two months
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
- Moderate severe depressive episode, worsening signs and symptoms, citalopram ineffective.
- Combination of:
- switch antidepressant as no effect at eight weeks of therapeutic dose. Should be reviewed two to four weeks after initiation.
- psychological intervention (e.g. cCBT)
- lifestyle interventions e.g. exercise such as walking
- Asthma well controlled
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
- Worsening symptoms and possible increasing self-harm/suicide risk
- Worsening symptom advice and out-of-hours numbers provided (e.g. NHS 24, Breathing Space).
- Follow-up review within one to two weeks, or sooner if considered appropriate
- Current medicines have low overdose fatality risk
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
- Formulary preferred options being prescribed
- Asthma well controlled, salbutamol ordering/use appropriate and inhaler technique checked
- Consider option of dry powder inhalers at a later consultation if suitable (prioritise depression management)
- Dispose of unwanted and expired medicines at community pharmacy
- Advised not to dispose of medicine via household or water waste
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
- Switch antidepressants: last dose of citalopram today, start sertraline 50mg daily tomorrow.
- Referral to adult mental health services for high intensity psychological interventions
- Safety information - suicide prevention advice, provide emergency contact telephone numbers for out-of-hours services for crisis support if required.
- Low intensity exercise recommended – e.g. walking his dog may help
- Friend attending with him is supportive, safety information provided as above
Key concepts in this case
- Ensure timely review of new antidepressant treatment to assess effectiveness
- Review following changes to antidepressant therapy to ensure effectiveness
- Potential medication side-effects: loss of appetite could be caused by both depression and/or antidepressants
- Ongoing symptoms of depression including suicidal thoughts, despite antidepressant, indicates the need for review of therapy
- Importance of non-pharmacological therapies, such as psychological interventions, cCBT, exercise
- Holistic review could include inhaler use and environmental sustainability. However, these may be more suitable for future discussions when depression has stabilised.
Click on the table image to view a PDF version of the full 7 steps table for case study 1.
