The role of the emergency mental health practitioner involves the immediate management of those who present in mental health crisis. The service provides mental health review, risk assessment and short-term input before referral to secondary care for ongoing therapy. Independent nurse prescribing supports this service through timely access to pharmacological treatments to manage symptoms and ease the distress associated with a critical episode (Inman, 2017). For the nurse prescriber, autonomous decision-making and the ability to discuss all treatment options with service users can optimise adherence and concordance (Kelly, 2018).
This case study aims to review the pharmacological management of a patient with bipolar type II disorder who presented in a mental health crisis. Bipolar disorder is a chronic recurrent condition which is characterised by fluctuations in mood state. Bipolar type II is associated with less severe manic symptoms of hypomania combined with depressive episodes (Grande et al, 2016).
Case study
Jane, a 30-year-old female, had a long-standing history of low mood, anxiety, periods of poor sleep and one episode of hypomania. She had previously been prescribed several different selective serotonin reuptake inhibitors with various degrees of efficacy. Jane was noted to have poor engagement with services and non-adherence with treatment, which may have contributed to the limited efficacy of the anti-depressants but also crucially highlights the importance of establishing a therapeutic relationship to aid concordance (Rae, 2021).
Jane was diagnosed with bipolar type II disorder 3 years ago following the birth of her first child. She was prescribed her current medication, lamotrigine 200 mg, on diagnosis. Lamotrigine is an antiepileptic class drug used as monotherapy or adjunctive therapy for bipolar disorder. It is indicated to prevent seizures and treat mood by stabilising pre-synaptic neuronal membranes and inhibiting the release of excitatory neurotransmitters. Lamotrigine requires frequent drug plasma concentration monitoring before, during and after pregnancy due to fluctuating drug levels which can increase rapidly after birth (British National Formulary [BNF], 2022a). Jane gave birth to her second child 9 months ago and subsequently drug monitoring requirements have been reduced; however, this has led to less contact with healthcare professionals.
Consultation
Jane presented in a mental health crisis with features of low mood, insomnia and intrusive thoughts. She was struggling to care for herself and her children. Her intrusive thoughts included driving her car off the road, self-harm and suicide. She voiced suicidal ideation and had made plans to overdose on her prescribed medication.
The consultation process and mental health assessment took place during the height of the COVID-19 restrictions, which required practitioners to review their conventional practice and facilitate virtual consultations when possible. Within the emergency mental health service, this added additional complexity for already vulnerable individuals. Taylor et al (2018) reported that while experiencing a bipolar depression, 15% will commit suicide, therefore it was imperative to identify barriers which may impede Jane from accessing services. Foye et al (2021) also noted that for those who are not comfortable or competent in using remote media this can affect their engagement with services and compromise both ongoing treatment and monitoring of medicine efficacy. The pandemic and widespread lockdowns could also have played a role in the deterioration of Jane's mental health as low mood, stress, loneliness and boredom have been reported to be common symptoms precipitated by COVID-19 and its implications on daily life (Razai et al, 2020). Consultation settings had to be considered on an individual basis, with the clinical situation weighed against the risks of potential exposure and virus transmission (Churchouse et al, 2021). On discussion with Jane, she was unwilling to leave her home and felt uncomfortable participating in video calls. Given Jane's past treatment non-concordance, it was decided that a home visit with direct contact was the most appropriate consultation method (Murdie et al, 2021).
The principle of concordance advocates a holistic approach to shared decision making and the formation of a therapeutic relationship (Khokhar et al, 2015). This considers an individual's beliefs, concerns and expectations of the prescribing decision and facilitates adherence through mutual agreement and respect (Qureshi and Maxwell, 2014).
The acceptability of medications can be influenced by cultural or ethical beliefs and impact on treatment concordance, as ultimately individuals have bodily autonomy and control over whether they adhere to their medication regime (Dowell et al, 2018). However, a mental health consultation must assess whether the patient can make informed decisions on treatment adherence.
Jane engaged well with the consultation process including a physical and mental health examination and an assessment of capacity using principles of the Adults with Incapacity Act (Scot Gov, 2003). This legislation sets out provisions for protecting the welfare of adults with a mental health disorder who may be unable to make decisions for themselves. It guides practitioners to act for the benefit of the patient, providing the least restrictive treatment possible, taking into account the wishes of patients and their carers when making prescribing decisions. A risk assessment was carried out using Sainsbury's risk assessment tool (Morgan, 2000), which supports decision making through documentation of risk factors and making a management plan for these, as well as informing prescribing practice on the quantity of medication to be supplied based on the risk of overdose (Table 1).
Table 1. Sainsbury risk assessment tool (Morgan, 2000)
| Risk assessment | Risk indicators – suicide, neglect, aggression, any other factorsSituational context of risk factorsHistorical and/or current context of factorsSummary of ‘positive’ resources and potentialsSummary of ‘risk assessment’ |
| Risk management considerations | Opportunities for risk preventionShort term crisis management optionsLong term risk management optionsPositive risk options – and support needed |
| Responsibilities for actions | PersonnelTimescale and/or dates |
This tool indicated a medium risk due to mental state and decision making, and it was evident that a main debilitating factor in Jane's presentation was poor sleep. There is a well-documented relationship between sleep disorders and psychiatric disorders; considering the extent to which sleep deprivation impacted Jane's mental state guided the prescribing decision (Sedky et al, 2020). Short term crisis and long-term risk assessment both indicate medical, medication and psychosocial interventions as management options.
Medication management
In consultation with Jane and her husband, a medication treatment plan was made for short term crises relief and long-term management (Table 2). Immediate key treatment goals for Jane were rapid symptom relief to improve sleep and reduce anxiety and distress.
Table 2. Medication management
| Medication management | Pharmacology properties |
|---|---|
| DeprescribeLamotrigine reduced incrementally by 50 mg over 2 weeks. | Class: AntiepilepticsMonotherapy and adjunctive treatment of bipolar disorderPrevents seizures and treats mood by stabilising pre-synaptic neuronal membranes and inhibiting the release of excitatory neurotransmittersSide effects include skin reaction, such as a rash or hypersensitivity.Linked to blood disorders: signs may be anaemia, bruising or infection |
| Short term crises reliefLorazepam, 1 g – maximum 2 mg at night | Class: BenzodiazepamIndicated for insomnia associated with anxietyTarget area for effect is the GABA receptors, where it acts to increase frequency of chloride ion channel openingMay cause dependency and short-term use indicated. Paradoxical increase in hostility and aggression and adjustment of dose may attenuate impulses |
| Long term managementQuetiapine 50 mg/day 1 and increase incrementally by 100 mg per day to 300 mg/day 4 | Class: second-generation antipsychoticQuetiapine monotherapy indicated as first line treatment of depression in bipolar disorder. Response monitored and dose adjusted to maximum daily dose of 600 mgActs on Dopamine neurotransmitter receptors, adrenoceptor and histamine receptor antagonist to improve both depressive and manic symptoms of bipolar disorder |
Lorazepam 1 mg before sleep was the prescribed choice for short term crises relief, as this drug aids sleep and reduces distress. With a maximum dose of 4 mg indicated for insomnia and anxiety, this gave scope to increase as required (BNF, 2022b). Benzodiazepines act to provide rapid symptomatic relief and are used in periods of acute anxiety. It is recommended that they are prescribed at the lowest possible dose for the shortest possible length of time but no longer than 4 weeks. Use is only advised in severe and debilitating distress, because of the risk of physical dependence and withdrawal (Taylor et al, 2018). Due to suicidal ideation and present risk of overdose, as part of the risk assessment precautions, lorazepam was supplied in a small quantity, enough for 2 days. Jane's partner would manage this medication and keep it safely stored in a locked box, out of reach from Jane and the children (The National Institute of Health and Care Excellence [NICE], 2018).
Alternative drug choices considered for short term crises relief were zopiclone and diazepam. Zopiclone was excluded as it is indicated only for use in insomnia and would not relieve the major mood disruption or distress that required urgent management. Diazepam was excluded, although it is indicated for insomnia associated with anxiety, due to its longer onset of action and prolonged half-life (Taylor et al, 2018).
Lamotrigine has proven to be ineffective as prophylaxis for bipolar depression and therefore this was deprescribed by reducing incrementally by 50 mg over 2 weeks to reduce the risk of any side effects or withdrawal (Taylor et al, 2018).
Quetiapine was prescribed for long term management and treatment of Jane's depression in bipolar disorder. The recommend first-line treatment option for bipolar depression is quetiapine monotherapy or fluoxetine and olanzapine in combination (NICE, 2020). Quetiapine was selected as Jane had already tried fluoxetine and found it induced mania. The alternative drug choice considered was lurasidone, which is also a first-line option recommended by the British Association of Psychopharmacology guidelines (Goodwin et al, 2016). This was not selected as although lurasidone produces a positive effect, is less effective than quetiapine or olanzapine and its action is dose-related (Taylor et al, 2018).
Side effect profiles should be considered when selecting a medication, due to both unwanted and possibly desirable side effects. Quetiapine and lurasidone list sedation as a side effect, which could be considered beneficial for Jane to avoid the long-term use of lorazepam. Lurasidone has a smaller side effect profile of sedation and akathisia. Akathisia is defined as a psychomotor restlessness with an inability to remain still and is associated with antipsychotic medication. Lurasidone is required to be taken with a meal, and as Jane reported a lack of appetite, this may have a negative impact on adherence.
Non-pharmacological therapies
During the consultation, it is vital to give realistic expectations of what pharmacological interventions can achieve to support concordance. Jane and her partner had to understand that medication alone would not combat every symptom (Diez-Quevedo et al, 2021). Utilising non-pharmacological approaches and social prescribing can improve patient outcomes by providing holistic support to manage stressors that are not treatable through pharmacological approaches (Ninot, 2021). NICE (2020) recommend a combination of pharmacological and non-pharmacological approaches for managing bipolar disorder. Psychological interventions such as cognitive behavioural therapy, interpersonal therapy or behavioural couples therapy are potential strategies that could be employed in Jane's ongoing management.
Follow up
A verbal safety plan was agreed upon with Jane and her partner, who was considered a protective factor for reducing risk (McClatchy et al, 2019). The emergency mental health team liaised with the community practitioners to develop an intensive home treatment plan. Daily home visits were put in place to monitor mood, risk factors, response to medication and any side effects that may present. This would enable non-pharmacological input through a behavioural activation approach, which aimed to stimulate energy and confidence, improve motor activity and increase interest. Physical health can help to enhance well-being and reduce anxiety. Encouraging Jane to be physically active with a hobby she enjoys may facilitate improved mood and mental state in conjunction with the pharmacological and non-pharmacological approaches.
Conclusions
Independent prescribers with responsibility for bipolar disorders should familiarise themselves with the guidelines and range of pharmacological and non-pharmacological treatments available in order to know when and how to deploy them safely and effectively. The selection of medication should be based on mental health, physical and risk assessment of individual circumstances including assessment of capacity. Utilising a person-centred approach should aim to build a therapeutic relationship to minimise issues that may adversely impact concordance and adherence to treatment regimes. Prescribing enables the emergency mental health nurse to offer fully holistic and individualised management to ensure expedient access to treatment and optimise outcomes not only for the service user but the family as a whole.
Key Points
- Benefits of independent prescribing for the mental health nurse include the ability to discuss and instigate a range of management options for service users which can expedite treatment
- Immediate management of a patient in a mental health crisis involves risk assessment for patients, dependents and the public using validated assessment tools
- Awareness of concordance issues experienced by the service user and how to work in a person-centred, holistic manner is recommended to facilitate engagement and optimise treatment outcomes
- Management of mental health disorders should involve a combination of non-pharmacological interventions and pharmacological management.
CPD reflective questions
- How can you stay up to date with research into bipolar disorders and interventions to ensure you are following the latest evidence?
- What factors influence concordance and how can practitioners work with patients in a person-centred way to encourage concordance and promote engagement?
- Consider the importance of carers and families in the assessment process. How can this inform treatment and management plans?