Prescribing in mental health

Anxiety and depression

Anxiety and depression are primarily managed with the use of selective serotonin reuptake inhibitors (SSRIs) such as sertraline and citalopram. The risk-benefit ratio of SSRIs has been shown to be favourable in comparison with other forms of medication (NICE, 2015). The tetracyclic mirtazapine is often used, especially where mild sedation is deemed to be of value. It is also thought to be of potential benefit as an adjutant to SSRIs when treating post-traumatic stress disorder (PTSD) (Schneier et al, 2015). Mirtazapine is not typically used as a first-line treatment, although this is an option. In general, SSRIs are used first-line with progression to mirtazapine, either as monotherapy or as an adjutant. When considering the use of an adjutant drug, it is important to consider the increased risk of serotonin syndrome associated with the use of multiple medications.

Tricyclics such as dosulepin are no longer recommended due to the high risk of fatal toxicity in overdose (NICE, 2015). However, there are a number of other options available, either under the guidance of the specialist psychiatry team or to be instigated in secondary care and continued in primary care once safely tolerated. These include serotonin and noradrenaline reuptake inhibitors such as duloxetine and venlafaxine or serotonin uptake inhibitors such as trazodone. Rarely, medication such as melatonin receptor agonists or monoamine oxidase inhibitors can be used. If it has not been possible to manage a patient's symptoms with the pharmacological options available to primary care, a referral or advice and guidance request to the local psychiatric team will likely be of benefit.

Beyond pharmacology

Prescribing for mental health is dependent on much more than pharmacology—building a rapport with the patient and giving them the knowledge and tools to understand and support their mental health are pivotal. Structured history-taking and examination underpin much of paramedic practice. Prescribing is no different, perhaps especially so when prescribing for mental health patients. Tate (2005) advocated the questioning, recognition and consideration of the patient's belief systems to improve patient satisfaction and concordance with management plans. Tate recommends using the ‘ICE’ model to identify the patient's ideas, concerns, and expectations. Allowing the patient to discuss their thoughts has been associated with improved initiation and concordance with medication (Anderson et al, 2015).

Prescribing antidepressants

For patients to make an informed decision, they need to understand their condition and the potential role of medication. Research suggests that patients are often innately opposed to taking antidepressants, however accept the prescription as they are not made aware of other treatment options. This may have a negative impact on adherence, resulting in unnecessary delays to finding an effective treatment (Gibson et al, 2014). To improve concordance, it is important to have an open, frank discussion about the potential benefits and downsides of medication, as well as other, non-pharmacological measures that may be of benefit.

Antidepressant therapy should be started at the lowest dose with no dose increase for 3–4 weeks as a minimum, and continued for a further 6 months after symptoms have resolved (NICE, 2009).

Forms of depression

Some forms of depression, such as seasonal affective disorder or post-natal depression, are predictable, either due to following a set pattern or having followed on from specific events. Reactive depression is, perhaps, the most common of these, in part due to it being an over-arching term which incorporates elements of grief and trauma.

In cases of reactive depression, it may not be appropriate to prescribe antidepressant therapy as antidepressants typically take 6 weeks to build to full effect and are commenced at the lowest dose. The reason for this delayed effect—like much of the pharmacodynamics of antidepressants—is not fully understood (Harmer et al, 2017). However, it is essential to consider whether the underlying causes of reactive depression are likely to resolve over that period, rendering the medication unnecessary. If insomnia is a significant symptom, it may be appropriate to prescribe a short course of sedating medication, alongside or following advice on sleep hygiene (NICE, 2020). However, it is important to consider the legislation relating to paramedic prescribing of controlled drugs.

Pregnancy-related depression, whether antenatal or postnatal, and treating depression in women who may become pregnant while on treatment, comes with its own challenges. Some antidepressant therapies are believed to be safe to continue during pregnancy; however, the risk-benefit ratio must be considered. Teratogenic harm from antidepressants tends to occur in the very early stages of pregnancy; as such, it is likely that women already on medication will not be aware they are pregnant until the period of greatest potential harm has passed. However, if a woman is actively trying to become pregnant, it is important to discuss risks of antidepressant therapy, though maternal stress is believed to pose greater risk to the foetus than antidepressants (Burt, 2018).

Addiction concerns

Many patients have a priori concerns relating to the addiction potential of antidepressant medication. However, with modern medications, these concerns are unfounded. In a report for the Medicines and Healthcare products Regulatory Agency (MHRA), Weller et al (2005: 145) clarify that, despite some misleading use of terminology, ‘none of these reports describes features of dependence other than withdrawal’.

However, while withdrawal—sometimes called discontinuation syndrome—is not the same as addiction, it is important that patients are made aware of the process of titrating down medication prior to stopping. Kendrick (2020) suggests a number of methods to facilitate the gradual reduction of pharmacotherapies with a view to improved cessation. These include ensuring adequate non-pharmacological support is in place and the use of tapering strips to reduce the dose gradually over weeks or months.

The REDUCE Programme (Kendrick et al, 2018) is an ongoing, multi-stream study analysing the use of online services to provide 24-hour support to patients reducing their antidepressant dosing. The full findings will not be reported until 2024; however, the early literature review supports the need for adequate psychological and emotional support while patients titrate down their medication, including ensuring continuity of carer.

Emotional concerns

Patients may be concerned that their emotions will be dulled by medication—a problem associated with the older forms of antidepressant medication such as Valium (diazepam) and Prozac (fluoxetine). This is a less frequent concern with SSRIs; however, it has still been found to occur, though the epidemiology data are unclear (Sansone and Sansone, 2010).

It is important to reassure patients that, in the majority of cases, there is no problem with medication-induced apathy; however, it does remain a risk and this should not be kept from the patient. The aetiology is also unclear. One theory is that this emotional blunting is linked to the impact of SSRIs on the body's ability to produce dopamine (Barnhart et al, 2004), while others suggest that SSRIs cause a dysfunction within the frontal lobe of the brain (Wongpakaran et al, 2007). Reassuringly however, SSRI-induced apathy has been shown to resolve swiftly with dose reduction or cessation.

Other side effects

Other common side effects during the initiation phase of antidepressant use include abdominal and digestive discomfort, headaches, and mood fluctuations; these typically settle within 10–14 days, however may persist in some cases. When the short-term nature of these side effects has not been adequately explained, patient concordance is often negatively impacted (Warden et al, 2010; Sansone and Sansone, 2012).

Knowing how—and when—not to prescribe

One of the fundamental skills of prescribing is to know when, and how, not to prescribe. Pharmacotherapies are an important, but not essential, element of managing anxiety and depression. As previously mentioned, some presentations of anxiety and depression are less likely to benefit from antidepressant therapies.

The NICE (2009) guidance stresses the importance of non-pharmacological means of addressing the symptoms of anxiety and depression; talking therapies such as cognitive behavioural therapy (CBT) are one of many possible approaches. An unpublished 2019 literature review identified a number of alternative methods including mindfulness, exercise, music therapy, journaling, and eco-therapy. This study guided the development of an evidence-based patient information leaflet (Appendix 1) currently being used to guide consultations and provide both reassurance and education to the patient. Many areas of the country have referral pathways in place for social prescribers; this service enables users to identify areas of interest such as hobbies and signposts to local groups and organisations that may be of interest. It is important to be aware of the services, both NHS-led and voluntary, that are available in the local area.

When discussing antidepressant use and the concomitant use of non-pharmacological measures, a useful analogy is that of being at the bottom of a hole. For some, it is possible to adopt positive coping strategies and lifestyle changes which fill the hole in, while others require medication to lift them out of the hole so they have the strength and emotional resilience required to make those changes and adopt those strategies. However, if medication is used to lift the patient out of the hole, it remains necessary for the individual to make those changes; failing to do so is likely to result in the patient finding themselves back in the hole.

One area that many find challenging—yet is of fundamental importance—is asking about suicidal ideation. It is essential that this question is asked in such a way that there can be no ambiguity and no sense that the patient's suicidal thoughts are being, in any way, undermined or belittled. Asking ‘Have you thought about doing anything stupid?’ merely serves to reinforce for the patient the feeling that they are stupid, weak or useless to feel the way they do. It may feel blunt, harsh, or even rude, but it is important to ask ‘Have you had any suicidal thoughts?’ and give the patient the time and space necessary to answer.

Suicidal ideation is not, in and of itself, a reason to withhold medication; however, it does add a further layer of complexity to the prescribing process. Risk factors such as age, gender and access to means should be balanced against protective factors such as children, a supportive partner, or a strong social network. Whilst SSRIs such as sertraline are deemed less dangerous in overdose (Lau and Horowitz, 1996), care should still be taken to minimise these patients' access to large quantities of medication. This may also require a review of their repeat prescriptions to consider reducing the quantity issued each time. A 2-month prescription, 56 tablets, may be appropriate for stable patients who are tolerating a medication, whereas a patient deemed to be at higher risk of overdose may benefit from 7 or 14 day prescriptions.

Suicidal ideation should not be the sole reason for choosing not to prescribe. If the patient is thought to be at an increased risk and is unable to tolerate medications such as sertraline, it may be necessary to speak to a GP or psychiatric team for guidance, unless the patient requires Crisis team input—in which case, this takes priority.

Conclusion

The suggestions made in this article, and those in the many other reports, guidelines, and reviews written over the years, are nothing more than that—suggestions. As David Karp explains, ‘…efforts to document absolute, invariable truths about any human experience are doomed to failure’ (2017: 13). In medicine, perhaps especially in mental health consultations, this is complicated further by the tantalising possibility of an easier alternative: medication. As Franz Kafka stated, ‘To write prescriptions is easy, but to come to an understanding with people is hard’ (1919: 30).

In the current period of continually changing working practices as a result of the COVID-19 pandemic, it is essential that the procedures and practices that are put in place allow for continuity of carer. It is also imperative that the clinician develops their interpersonal skills to allow them to build a rapport with the patient, broadens their understanding of consultation models so they may adjust their approach for each patient, and—perhaps most importantly—develops the essential listening skills to enable them to ascertain the patient's ideas, concerns and expectations to guide a mutually-agreeable management plan.

Key Points

CPD Reflection Questions