Depression with anxiety | Right Decisions

Background (age, sex, occupation, baseline function)

49-year-old female
Works two part-time jobs: school cleaner and dinner lady at different schools
Lives with adult daughter (currently pregnant) and daughter's partner
Two adult sons, one local, one lives further away
Very active helping others

History of presentation/reason for review

Contacted by the practice for review of her benzodiazepine

Current medical history and relevant co-morbidities

Mixed depression anxiety – 20 years
Asthma – 20 years
Dry eyes – 2 years

Current medication and drug allergies (include OTC preparation and herbal remedies)

Carbomer eye gel - as required
Clenil® (beclomethasone) 200 microgram MDI - two puffs twice daily
Hypromellose eye drops - as required
Diazepam 5mg tablets - two tablets three times a day
Paracetamol 500mg tablets - two tablets four times a day if needed
Salbutamol 100microgram MDI - one to two puffs four times a day if needed
Temazepam 20mg tablets – one tablet at night
Venlafaxine 150mg modified-release (MR) capsules – one capsule daily (prescribed for three years)

Lifestyle and current function (including frailty score for >65yrs) alcohol/smoking/diet/physical activity

Walks between jobs, does not drive
Smoker - 10 cigarettes per day
No alcohol
Number of episodes of deliberate self-harm, last overdose five years ago

“What matters to me” (patient ideas, concerns and expectations of treatment)

Main focus is being there for and able to help her family
At review agrees to reduce diazepam but not temazepam
Managing well with other medicines, reports:
- Asthma well controlled (Has ordered two salbutamol reliever inhalers over last 12 months). Demonstrates good inhaler technique
- Depression and anxiety mood stable, less depression symptoms over the last two to three years. PHQ-9 score 8 (mild depression). Denies thoughts of self-harm or suicide
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

Weight 52kg, height 1.6m, BMI 20 kg/m2
BP 134/84 mmHg
Normal blood results previously, including thyroid function tests

Most recent relevant consultations

Rarely attends GP. Last consultation 18 months ago for dry eyes

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

Wishes to maintain good control of depression and anxiety
Wondering what drops to use for her dry eyes

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

Asthma: Clenil® and salbutamol. Check inhaler technique and adherence to preventative therapy
Venlafaxine - mood currently stable

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

Currently on hypromellose and carbomer for dry eyes. Prefers carbomer. Stop hypromellose
Paracetamol – uses irregularly
Diazepam and temazepam prescribed for longer than four weeks and may worsen depression/anxiety symptoms

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

Total daily diazepam equivalent dose is 40mg. Diazepam reduction agreed

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 clear indication for long-term diazepam and temazepam
Previous history of self-harm

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

All medicines are local formulary choices
Prescribe carbomer in line with health board formulary
Venlafaxine MR to standard release considered inappropriate
Good asthma control, appropriate salbutamol use
Patient advised to dispose of medicines through community pharmacy
Advised patient to only order what is needed, do not stockpile 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

Low and slow reduction of benzodiazepines. Start to reduce diazepam dose as per table below. At third review agrees to reduce temazepam
Follow-up agreed at a suitable time by phone between jobs e.g. between 2-3pm weekdays
Prescription changed to acute issue rather than on repeat

Key concepts in this case

Shared approach to reducing benzodiazepines, engaging with people and their willingness to reduce. After initial diazepam dose reduction went well, individual was content to attempt reduction of temazepam therapy
Rationalisation of preparations for dry eyes

Click on the table image to view a PDF version of the full 7 steps table for depression with anxiety case study.