Psychiatric Bulletin (2007) 31: 19-21. doi: 10.1192/pb.31.1.19
© 2007 The Royal College of Psychiatrists
Psychiatric Bulletin (2007) 31: 19-21
© 2007 The Royal College of Psychiatrists
Service innovations: from depot clinic to medication review service – developing an evidence-based service within a community mental health team
Amlan Basu, Senior House Officer in Psychiatry
South London and Maudsley NHS Trust, Denmark Hill, London
Ronan J. McIvor, Consultant Psychiatrist and Honorary Lecturer
Maudsley Hospital and Institute of Psychiatry, 103 Denmark Hill, London
SE5 8AZ, email:
r.mcivor{at}iop.kcl.ac.uk
Declaration of interest
None.
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Introduction
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Over the years the ‘depot clinic’ has become little more than a
conveyor belt for patients to receive depot medication from nursing staff
within a hospital setting. Indeed, the concept of the depot clinic has not
significantly changed since the introduction of neuroleptic medication in the
1950s. A lack of review of the service has resulted in suboptimal treatment,
unchecked side-effects and a lack of monitoring of physical health. We
describe the redesign of a depot service within an inner city community
service, with emphasis on evidence-based practice, regular, patient-centred
reviews, support, health promotion and education.
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Need for review and development
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In 2002, as part of the ongoing development of services, we undertook a
re-evaluation of medication services at our team base in South East Lambeth.
Our aim was to provide a ‘one-stop shop’ for patients, thus
minimising the need to attend the local psychiatric hospital. Rather than
simply dispense medication, it was envisaged that the service would also
provide advice on health and lifestyle issues. The review was informed by
developments in other services (Ohlsen
et al, 2002) and recently published guidelines on
evidence-based practice and physical health monitoring, with particular
emphasis on diabetes and hypertension, in the management of schizophrenia
(National Institute for Clinical
Excellence, 2003). Psychiatric patients are vulnerable to physical
health problems, which can often be complex to monitor and, if not assessed
systematically, can lead to long-term complications and non-adherence to
medication.
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Medication review service
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The medication review service operates full-time and is nurse led,
employing two part-time staff. Although it is part of the case management
team, patients attending the clinic are on the standard care programme
approach register; clinic nurses fulfil care coordinating roles. This allows
for continuity of care and ensures that patients who fail to attend for
medication are followed up assertively, including by home visits. Such a model
encourages the development of strong therapeutic links.
Attendees include patients with ongoing and severe mental health problems
who are on long-term psychotropic medication which, for a variety of clinical
reasons, is not prescribed by their general practitioners. Referrals primarily
come from the case management team or out-patient clinics, and include those
patients who no longer need intensive support because of ongoing stability.
The clinic also provides a dispensing service for patients who are otherwise
fully supported by a care coordinator within the case management or assessment
and treatment teams. The system therefore permits the movement of patients
from other components of the community mental health team, taking pressure off
teams and maximising the appropriate use of resources.
Nursing review
Services focus on the ordering, dispensing and monitoring of medication,
including depot preparations, in accordance with Royal College of Nursing
guidelines (Royal College of Nursing,
1996). Medicines are supplied by a central pharmacy at the
Maudsley Hospital and delivered once every 2 weeks. The frequency of
attendance by patients depends on need, and ranges from weekly to monthly.
Patients are regularly weighed and vital signs monitored. Nursing staff are
trained to take blood samples for measurement of drugs or for other assays.
Electrocardiography (ECG) is carried out by nursing staff as indicated, either
before or during treatment. Nurses meet with carers as part of ongoing
support. Referrals are made to outside agencies, such as the dietician,
welfare advisor or physiotherapist, for advice or treatment. The medication
clinic provides a useful focus where up-to-date information can be
disseminated. A small library and resource information pack is available to
all staff, containing relevant updates, guidelines and drug information
sheets.
Medical review
All patients are reviewed on a regular basis by medical staff. The
community senior house officer dedicates one session per week to the service
and is supervised by a consultant psychiatrist. Doctors who continue to have
direct clinical contact with patients, usually through their out-patient
clinics, also undertake medical reviews. Most patients are seen every 6 or 12
months, but some are seen more frequently if they are undergoing a change in
medication or showing signs of relapse. Medical assessment includes review of
mental state, efficacy of psychotropic medication and side-effects. Switching
to atypical neuroleptics, including clozapine, is encouraged. Physical
examination includes ECG (at least annually) and measurement of body mass
index (Ohlsen et al,
2002). Cardiovascular risk factors are assessed and routine
enquiry and advice given on smoking cessation, alcohol consumption, diet and
exercise. Monitoring of metabolic measures, such as glucose and prolactin, is
carried out in accordance with American Diabetes Association guidelines
(American Diabetes Association et
al, 2004) and local protocols provided by the South London
and Maudsley NHS Trust (available on request). Information is passed on to
general practitioners, with a request for further input if necessary. Close
liaison with primary care ensures that both teams are aware of all medications
being prescribed, thus minimising the risk of serious interactions or adverse
effects.
Role of the pharmacist
A trust pharmacist attends the clinic on a monthly basis. This allows
medical and nursing staff to discuss pharmacological issues, including
potential problems or drug interactions. Patients have the opportunity to meet
the pharmacist individually, and discussions are relayed to clinical
staff.
Therapeutic groups
Groups meet on a fortnightly basis, but are not restricted to clients of
the medication service. The focus is primarily on healthy living and general
health issues. Two facilitators lead the groups: a clinic nurse and another
member of the community mental health team. Advice is given on diet, alcohol
consumption, weight management, smoking cessation and exercise. Adherence
therapy is available, but most patients are actively involved with treatment
and adherence is generally good.
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Clinical profile of the patients
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Currently, the medication service caters for around 110 patients (54% men
and 46% women), but has the capacity to manage 150 patients. Annual figures
suggest a mean of 114 clinic visits per month, 15 of which include taking
blood, 5 medical reviews (not including those carried out by other medical
personnel) and 8 home visits. Non-attendance rates of 3% per month compare
favourably with other parts of the service
(McIvor et al, 2004)
and reflect the relative stability of this population.
In relation to diagnosis, 67% of patients have a diagnosis of
schizophrenia, 14% bipolar affective disorder, 2% schizoaffective disorder and
17% other diagnoses (including major depressive disorder, anxiety disorder and
personality disorder). Reflecting the evidence-based development of the
service, the most commonly prescribed medication is atypical antipsychotics,
followed by typical antipsychotics (the majority being depot medications),
mood stabilisers, antidepressants, anxiolytics/sedatives, anti-muscarinics and
‘other’ drugs respectively (mainly medical preparations such as
antihypertensives). Drug combinations are common, with 41% of patients
prescribed more than one psychotropic medication.
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Discussion
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In this age of evidence-based practice, it is essential that depot clinics
are updated. The medication review service has allowed us to optimise the
psychiatric and physical care of patients, a model which could be of relevance
to mental health services in general. Turning the depot clinic into a
medication review service has reduced the clinical case-load of mental health
workers within other teams, thereby giving them the opportunity to engage new
clients. The service reinforces community-centred care and obviates the need
for the patient to attend the local hospital, hopefully encouraging
engagement. It is envisaged that many of the patients will be discharged to
primary care over time.
Initial financial investment in equipment (an ECG machine, weighing scales,
fridge, phlebotomy equipment and assorted furniture) is required. In addition,
although not resulting in increased staffing levels, nursing job plans may
require review, with some additional training being necessary. Consideration
needs to be given to logistical issues such as the storage and transport of
blood samples or the interpretation of ECG results.
Informal feedback indicates that patients appreciate the service, with its
emphasis on support, health promotion and education. Future development will
include formally assessing patient satisfaction, reviewing cost-effectiveness,
increasing patient numbers and expanding available services.
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References
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AMERICAN DIABETES ASSOCIATION, AMERICAN PSYCHIATRIC ASSOCIATON,
AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS, et al
(2004) Consensus Development Conference on Antipsychotic Drugs
and Obesity and Diabetes. Diabetes Care,
27, 596
–601.[Free Full Text]McIVOR, R., EK, E. & CARSON, J. (2004)
Non-attendance rates among patients attending different grades of psychiatrist
and a clinical psychologist within a community mental health clinic.
Psychiatric Bulletin,
28, 5
–7.[Abstract/Free Full Text]
NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (2003)
Schizophrenia. Full National Clinical Guideline on Core
Interventions in Primary and Secondary Care. Royal College of
Psychiatrists & British Psychological Society.
OHLSEN, R., PILOWSKY, L., SMITH, S., et al
(2002) The Maudsley Antipsychotic Medication Review
Service Guidelines. Taylor & Francis.
ROYAL COLLEGE OF NURSING (1996)
Nurses’ Involvement in the Use of Neuroleptic
Drugs. RCN.
eLetters:
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Introduction
Need for review and...