Top ten advice and guidance requests in psychiatry

Consultant psychiatrist Dr Jennifer Mayes and GPSI in mental health Dr Emma Nash describe ten common advice and guidance requests in adult psychiatry and how to manage them

Note all ten requests featured in this article are hypothetical and developed for educational purposes

1. Stopping anti-psychotics

This 42-year-old woman with a history of severe depression was discharged from specialist care 3 years ago and has remained well since. She is on sertraline 200mg and aripiprazole 10mg. She would like to come off aripiprazole. Is it OK to stop it and if so how?

There’s no absolute rule on when a patient can or can’t stop a psychotropic medication that has got them well and kept them well for several years. This decision, while ultimately the patient’s choice, should be shared between doctor and patient and should take into account a number of factors:

• What are the patient’s concerns regarding aripiprazole? Do they have side effects? Are they concerned about the associated increased risk of cardiometabolic effects, such as weight gain or diabetes?
• What is the patient’s pattern of illness? A higher number of previous episodes, or more frequent relapses in the last few years, will increase their risk of relapse should they choose to stop their medication.
• Is the patient aware of their relapse indicators? If not, now would be a good time to speak to friends and family to see what they noticed first when they started to become unwell in the past. This may better prepare the patient to seek help early on in any future relapses
• What were the risks associated with previous episodes? If the patient has a risk of suicide attempts or severe self-neglect, this should be taken into account when making the decision whether or not to stop antipsychotic medication

There are also no absolute rules on how quickly to reduce antipsychotic medication. However, it should be noted that discontinuation symptoms are possible with antipsychotics, with higher doses and longer treatment periods increasing the risk of these. I would therefore suggest reducing the dose of this patients medication by 2.5-5mg every 2-4 weeks in the first instance, and reducing the frequency of later dose reductions should the patient start to experience discontinuation symptoms.

2. Partial SSRI response and sleep problems

This 34-year-old man has depression for which we have tried a few treatments. It has partially responded to escitalopram 15mg but he is struggling with sleep. He was unable to tolerate mirtazapine and we are unkeen to use Z drugs due to their addictive nature. Is there anything we can do to help his mood and sleep?

Before going any further, it’s worth enquiring about treatment concordance and any side effects that may be affecting this. Also check the patient is not taking escitalopram at night, as it best taken in the morning, particularly if sleep is an issue. If the medication is being taking as prescribed, there are several options to consider: The first is increasing the dose of escitalopram up to the BNF maximum of 20mg. I note the patient is only taking 15mg and it may be that they have experienced more side effects at a higher dose, without therapeutic benefit. If this is the case, another option would be to swap to an alternative single antidepressant, preferably either an SSRI or SNRI. However, it’s mentioned that several treatments have already been tried, and so this may not be the preferred option. Alternatively, a second antidepressant could be added. Since the patient has been unable to tolerate mirtazapine, adding in trazodone could help, as it also can have sedative effects, although not usually to the extent of mirtazapine. It also doesn’t bring the side effects of increased appetite. Combining two antidepressants increases the risk of serotonin syndrome, so it’s important that you advise the patient to look out for potential symptoms. Extra caution should be taken for patients on other serotinergic drugs such as tramadol or triptans. Psychological therapy, including adapted CBT for sleep problems, could also be considered instead of or as well as the above medication changes. NHS Talking Therapies offer CBT-I in many areas. Alternatively, apps are available which can support with CBT-I, such as Sleepful or Sleepio. CBT-I has the best evidence base for effective treatment of insomnia.

3. Stopping antidepressants

This 56-year-old woman has successfully been treated with venlafaxine for her anxiety and we have weaned her down to 37.5mg bd, however she is suffering prominent discontinuation symptoms below this. How should we manage this?

Discontinuation symptoms are particularly troublesome with medications that have a short half life, such as venlafaxine or paroxetine. There are a couple of options that the patient may find helpful. The first is to move from the tablet form of venlafaxine to a liquid form. This will allow you to lower the dose even more slowly, which we know is more likely to be necessary at the end of a downward titration, to prevent severe and disabling symptoms. Alternatively, you could try switching the patient from venlafaxine to fluoxetine, which has a much longer half-life. This will allow you to extend the time between doses much longer than for venlafaxine e.g. taking a tablet every other day or every three days, which should allow the patient to come off antidepressant medication more easily. Guidance on how to stop and swap antidepressants can be found in the Maudsley Guidelines and NICE guidelines for depression.

4. Pregnancy on SSRI

This 25-year-old woman is on citalopram 30mg for moderate anxiety and is planning a pregnancy. She is worried about stopping medication as she has previously relapsed off it. Is she OK to continue it?

In this case, careful thought should be given to the risks and benefits of each option, with an emphasis on shared decision making between doctor and patient. The first thing to consider is the potential benefits of continuing with citalopram during the pregnancy. Depression, especially severe depression, is associated with significant adverse outcomes in pregnancy and so, since our patient has previously relapsed off medication, continuing citalopram would reduce the risk of this occurring. In terms of risks associated with citalopram in pregnancy, it should be noted that SSRIs are commonly taken during pregnancy without any problems occurring. However, there are a few risks that patient and doctor need to be aware of. Some studies have linked SSRI use in pregnancy to pre-term labour and babies with a low birth weight. The patient needs to be aware that if she does take SSRIs during her pregnancy, a hospital delivery is likely to be recommended due to the potential for short-term withdrawal symptoms in the baby and the possibility of pulmonary hypertension of the newborn, although this is rare.

5. Raised prolactin in patient on medication for bipolar disorder

This 44-year-old man with bipolar affective disorder is on risperidone 6mg od, lamotrigine 200mg bd and sertraline 50mg od. His annual monitoring bloods have revealed a prolactin of 1800 mIU/L (normal range <325 mIU/L in males). Repeat sample confirmed the elevation. No other abnormalities were found and there are no abnormal clinical findings. We believe this is due to the risperidone. What should we do?

Risperidone is commonly associated with a raised prolactin, so in an otherwise healthy 44 year old man, the risperidone is the most likely culprit, in the absence of any other findings. With a persistently elevated prolactin at this level, it is likely that the patient will be symptomatic, although they may not disclose the symptoms spontaneously. It is important to ask about reduced libido, erectile dysfunction and gynaecomastia. Even if the patient is not symptomatic, a persistently raised prolactin will predispose them to infertility and reduced bone mineral density, so consideration should be given to measures that will reduce the prolactin level. One option would be to consider swapping to an antipsychotic that is less likely to cause an elevated prolactin, for example olanzapine or aripiprazole. If there is concern about the risk of swapping to an alternative antipsychotic, or the swap is unsuccessful, another option is to add a small dose of aripiprazole (either 2.5mg or 5mg) to the existing risperidone dose, as this can also reduce the prolactin level. It’s important to re-check the prolactin 2-3 months after the medication change. If the prolactin remains high, an alternative plan for managing the high prolactin and/or referral to endocrinology to rule out alternative causes should be considered.

6. Behavioural and psychological symptoms of dementia

This 88-year-old man lives in a care home and has advanced Alzheimer’s dementia. He is becoming increasingly unsettled at night, causing disruption to other residents, and at times can be physically aggressive to staff. This has been fairly gradual in onset and no reversible medical causes have been found. Staff have tried to implement behavioural measures but further guidance is needed on how we can manage him. We are aware that medication is best avoided in this situation if possible so are unsure on how to proceed.

Once reversible causes have been ruled out for behavioural and psychological symptoms of dementia (BPSD), the difficulty we have is with finding an appropriate evidence-based medication choice. Antidepressants and benzodiazepines are commonly prescribed, but with no evidence to support their use in BPSD. In the case of sedative medications, in particular benzodiazepines, there is however, plenty of evidence of their adverse effects, such as increased risks of falls and worsening of confusion. Antipsychotics are the only medication that has any evidence base for improving symptoms in BPSD. Unfortunately, the effects are described as ‘modest’ and, again, there is a long list of potential adverse effects. These include short-term side effects such as sedation and longer-term effects such as increased cardiovascular risk and overall increased risk of all-cause mortality. Understandably, this makes us all cautious of prescribing antipsychotics for patients with dementia and they should only be used in the most severe cases. When we do prescribe them, it is at the lowest dose possible and for the shortest possible time. I would usually start with a very small dose of risperidone (250 mcg bd, for example) and titrate slowly until the symptoms improve. If risperidone is not tolerated, it’s possible to use small doses of other second generation antipsychotics, e.g. olanzapine or aripiprazole. However, it should be noted that risperidone is the only antipsychotic with a specific license for treating non-cognitive symptoms of dementia. If there is no clear improvement after 2-4 weeks, the medication should be stopped immediately. If there is improvement, the dose should be reviewed again after 6-12 weeks and, if possible, it should be reduced and stopped.

7. Re-starting lithium

This 47-year-old woman with a history of severe depression and treatment-resistance has been well for several years. She has previously been on lithium, lamotrigine, sertraline and aripiprazole. She currently only takes sertraline 200mg and lamotrigine 100mg bd. Over recent months she has found her mood is sliding. She would like to go back on lithium. Is it reasonable to restart it, and if so how would you recommend we do this? She is not severely unwell and is low risk of harm to self or others.

While lithium is an older drug, it is a very effective mood stabiliser and some patients with treatment-resistant depression do need to take it long-term to maintain their mood. If the patient would like to go back on the lithium I think it is reasonable for you to restart it in primary care. The first challenge with lithium is to prescribe a dose that keeps the patients plasma concentration within the narrow therapeutic window of 0.4-0.6 mmol/L, for unipolar depression patients. They will need a blood test a week after each dose change until the plasma level is stable and within the therapeutic window. They will then need blood tests every three months for the first year and then every 6 months thereafter. Please note that patients over the age of 65, or who are at risk of impaired renal or thyroid function, will need plasma lithium levels every 3 months throughout treatment. The second issue is to ensure that the patients BMI, renal and thyroid functioning are monitored, as lithium can adverse effect these over time. The BNF states to check these at baseline and then every 6 months throughout treatment.

8. Co-morbidities and antidepressants

This 69-year-old man is taking venlafaxine MR 150mg for depression. He has recently been discharged from hospital following a STEMI with primary revascularisation. He is on appropriate secondary prevention medication and has recovered well. Is he OK to continue on venlafaxine (which is effective) or do we need to swap him to an alternative?

Again, there is not a straightforward answer to this. The BNF advises to use venlafaxine with caution in patients with heart disease. This is largely due to increased risk of hypertension associated with venlafaxine, although this is more commonly seen in patients taking doses above 150mg. There is also a small risk of arrythmia associated with venlafaxine. So, if the patient has tolerated venlafaxine for some time, without hypertension or arrythmia, and they are willing to undertake regular blood pressure monitoring, it may well be reasonable to continue prescribing it. After all, there is an increased risk of depression post-MI and so bringing the patient off his antidepressant too quickly may not be the best option either. Alternatively, you could consider cross-titrating the patient from venlafaxine to sertraline, as this is considered the safest antidepressant option post-MI. However, since many patients end up on venlafaxine after failed treatment response to SSRIs, it will be important to check what antidepressants the patient has tried previously, as well as their therapeutic effect and side effects, before making this choice. Whichever antidepressant you choose, please remember the increased bleeding risk associated with SSRIs and SNRIs, and consider adding a PPI if the patient is now also on aspirin and/or clopidogrel.

9. Therapy for emotionally unstable personality disorder (EUPD)

This 24-year-old woman has a diagnosis of EUPD and has bounced between services for some time. She is chronically suicidal but with no plans or intent and has been rejected by services as she is ‘sub threshold’. NHS Talking Therapies took her on for some group DBT but she did not find it helpful. She has a history of significant childhood trauma. She is happy to pay for private therapy and has asked me what type of therapy she should consider. What would you advise?

The first thing to say is that Dialectical Behavioural Therapy (DBT) remains a highly effective psychological therapy for emotionally unstable personality disorder, particularly when the patient is frequently self-harming or has recurrent thoughts of suicide. It sounds as though this patient has tried one element of DBT, i.e. the skills group. However, I do not think she should dismiss DBT as an option before trying a comprehensive DBT treatment programme, which would usually include a weekly skills group, along with a weekly 1:1 therapy session, as well as ad-hoc telephone support during the week, to help her know when to use specific skills.

If the patient still doesn’t think DBT is for her, there are a range of other options she may prefer, for example Cognitive Analytic Therapy (CAT), Interpersonal Therapy (IPT), trauma-focused Cognitive Behavioural Therapy (CBT). I note the patient’s history of childhood trauma and if her target symptoms also meet the threshold for a diagnosis of complex post-traumatic stress disorder, Eye Movement Desensitisation and Reprocessing (EMDR) may also be an option. Which is most suitable should be determined by the patient’s symptoms and goals for therapy. I would recommend a conversation with a psychologist trained in a number of these therapeutic approaches in the first instance, ideally through an MDT meeting with your CMHT or primary care mental health team. Alternatively, the British Psychological Society offers a useful list of such practitioners, who can help her decide which would be the best fit.

10. Exacerbation of anxiety

I have a 38-year-old woman with long-standing generalised anxiety who occasionally suffers exacerbations. She is maintained on sertraline and usually escalation of the dose for a period settles her down, but not on this occasion despite 200mg. Her anxiety is now incapacitating – what would be the best approach – change her to another treatment, use pregabalin (instead of or as well as the SSRI?) or a very short course of a benzodiazepine? She does not want a talking therapy at this point.

It is always worth double-checking the patient is taking the medication as prescribed, and enquiring about any side effects in the first instance. It is also important to check if the patient uses alcohol, caffeine or recreational drugs, which may be exacerbating or perpetuating their anxiety symptoms. Once this has been ruled out, the patient and doctor can choose from a few different options that may help: The first option would be to change the antidepressant to either an alternative SSRI or an SNRI. The patient should be warned that increased anxiety and suicidal ideation are possible during cross-titration and an appropriate crisis plan should be agreed. If the lady’s symptoms do not respond to this, then pregabalin can be added. Please note that while pregabalin is recommended by NICE for the treatment of GAD, it is a controlled substance and the patient should be made aware of this and the potential for addiction. With regards to benzodiazepines, NICE advises against their use in treating anxiety disorders in primary or secondary care, except their short-term use to support a patient in crisis. So a very short course of benzodiazepines may also be an option for this patient.

While the patient has said they do not want talking therapy at this time, they may also like to consider high-intensity psychological therapy in the future. They may be able to access this through your local NHS Talking Therapies service. If not, they may require referral to secondary care mental health services.

Dr Jennifer Mayes is a consultant psychiatrist in older person’s mental health and Hospital at Home, South East Hants clinical tutor and psychiatry tutor for University of Portsmouth, and Dr Emma Nash is a GPSI in mental health in Hampshire and clinical lead for mental health at Hampshire, Southampton and Isle of Wight ICB