Independent Prescribing

Introduction

This portfolio has been compiled in order to complete the non-medical prescribing qualification through the University of Central Lancashire. Throughout the portfolio, the author has analysed situations encountered whilst working along a designated medical practitioner (DMP). The author is a mental health nurse and is employed in a community mental health team, offering support to individuals who suffer with severe and enduring mental health problems. In the practice area, new ways of working (Department of Health (DH), 2007) is beginning to take effect which has enabled expansion of current roles, including non medical prescribing. The portfolio is organised into sections, with an index page for navigation. Two consultations are presented; the first involving an individual with a neurotic illness, where independent prescribing was deemed appropriate in the absence of co-morbid illness or significant risk. The second consultation pertains to an individual with severe and enduring mental health problems who has suffered adverse reactions to medication previously and for whom supplementary prescribing appeared to be the safest prescribing option. The consultations are followed by an evidence section and appendices. Completion of the portfolio has facilitated extensive development of knowledge in terms of pharmacology, including physiological variance (evidence 15). Knowledge of psychotropic medicines has also greatly improved and the importance of physical health monitoring for service users has since become a priority. The author believes that becoming a non-medical prescriber will provide an ideal opportunity to have a direct effect on public health targets such as reducing avoidable death from suicide and offering quicker, more appropriate treatment options to people with mental illness. The author also feels confident that non-medical prescribing in mental health will lead to increased concordance and better service user satisfaction. The required practice hours of the course have been achieved (evidence 1) through working with members of the prescribing team (evidence 2a, 2b, 2c, 2d, 2e). Throughout the portfolio, the author has ensured protection of confidential information, as directed by the Nursing and Midwifery Council (NMC) (2008) by referring to the service users by pseudonyms i.e. Alexander and by anonymising information related to the Trust for which the author works. Furthermore, consent forms have been obtained for named professionals and user perspectives

Independent Prescribing

Independent prescribing is defined as "prescribing by a practitioner (e.g. doctor, dentist, nurse, pharmacist) responsible and accountable for the assessment of patients with undiagnosed and diagnosed conditions and for decisions about the clinical management required, including prescribing" (DH, 2006 p2). The author will critically analyse an independent prescribing situation, addressing learning outcomes 1,2,3,4 and 5 in doing so. Reference to the stages of the prescribing pyramid will be made as this is a useful model to ensure appropriate prescribing (National Prescribing Centre (NPC), 1999). The patient will be referred to as Anne Knowles. Anne was a 28-year-old woman with a history of depression, referred by her General Practitioner who suspected a relapse. In order to confirm this, a full assessment was undertaken. Fortunately in mental health, adequate time is allocated for practitioners to gather information. Prescribers are encouraged to approach consultations in a structured way (NPC, 2003) therefore the Calgary-Cambridge model (Silverman, Kurtz and Draper 1998) was used alongside a structured tool in support of this approach. Health authorities have formulated unique Care Programme Approach (CPA) assessment tools based on the original guidance in Caring for People (DH, 1990) to accomplish a holistic assessment and this is what is advocated by the NPC (1999), as the first element of good prescribing practice. The author used the tool designed by the local health authority in the assessment of Anne (evidence 3). While the CPA assessment is comprehensive, the author elected to enhance it with additional tools to better inform prescribing practice. Incorporating Morton's (1992) symptom analysis tool a thorough assessment of Anne's presenting symptom was facilitated. Furthermore, an individualised report obtained using a solution-focused approach (de Shazer, 1988), gave the author an appreciation of what was currently happening and how improvement would be detected (evidence 3, page 13). The author also utilised Becks Depression Inventory-II (BDI-II) (Beck, Steer and Brown, 1996) (evidence 4). Although routinely used in the practice environment due to its ease and speed of completion, it has been criticised due to the gender and cultural bias (female, Caucasian), which it represents (Hagen, 2007). This is something with which the author would agree and plans to use the Montgomery-Asberg Depression rating scale (Montgomery and Asperg, 1979) in the future as this has a broader reflection than the BDI-II. The remainder of the assessment, including a full medical, social and medication history, allergy status and exploration of Anne's beliefs about her illness and future treatment were also included in the assessment. It is commonplace in clinical practice for staff to present assessments to the medical team where discussion of differential diagnosis occurs. Such discussion facilitates accurate diagnosis and debate of treatment options; however it is reliant on a precise initial assessment and effective presentation of the case. Following this a diagnosis of moderate depression was agreed under section F32.1 of the International Classification of Disease (World Health Organization (WHO), 1992). Considering the prescribing pyramid, the second step requires deliberation of the appropriate strategy to use. As the diagnosis of moderate depression was established, the author knew that a prescription was needed. Guidance from the National Institute of Clinical Excellence (NICE) (2004) suggests that individuals diagnosed with moderate to severe depression should routinely be offered a pharmacological intervention before psychological interventions. When considering choice of products, the third step of the prescribing pyramid, prescribers have available various antidepressants from diverse groups, namely Monoamine-oxidase Inhibitors (MAOIs), Tricyclic Antidepressants (TCAs), and Selective Serotonin Reuptake Inhibitors (SSRIs). There are also listings in the British National Formulary (Royal Pharmaceutical Society (RPS) & British Medical Association (BMA), 2007) for other antidepressant drugs that cannot be classified into specific groups due to their unique pharmacology i.e. Mirtazapine and Reboxetine. In choosing between the agents, the author consulted national guidelines (NICE, 2004) which examine the effectiveness, appropriateness, safety and cost-effectiveness of drugs. NICE (2004) favours use of SSRIs to other antidepressant groups. This is because they are as effective as TCAs but concordance is higher because of the better side effect profile (NICE, 2004). Barbui and Hotopf (2001) reported that Amitriptyline, a TCA was more effective than SSRIs however conceded that use of SSRIs was higher because of their enhanced tolerability. SSRIs are less likely to cause sedation and cause much fewer anti-muscarinic effects than TCAs (RPS & BMA, 2007). The other major distinction is that should they be used in overdose, SSRIs are considered less toxic than TCAs. Use of an MAOI was not considered as first-line treatment for Anne. Although once viewed as less effective than other antidepressants, when used in adequate doses, MAOIs are as efficacious (Riederer, Lachenmayer and Laux, 2004). However MAOIs are generally better in treating atypical depression (Riederer et al, 2004) and are associated with dangerous dietary and drug interactions (Nash and Nutt, 2007). SSRIs are the agents of choice in the practice area (evidence 5), in line with national guidelines. The common pharmacology of SSRIs is the prevention of reuptake of the neurotransmitter serotonin into the pre-synaptic cell, leaving increased amounts of serotonin available to bind to post-synaptic receptors (Carrasco and Sandner, 2005). Although the central nervous system is the desired site of action, SSRIs also exert their effect throughout the body, which explains their side effects. Aside from the primary pharmacology of the SSRIs, each has diverse properties, knowledge of which assists prescribers to choose the most appropriate agent. NICE (2004) directs prescribers to opt for Fluoxetine or Citalopram due to their ease of discontinuation as with other SSRIs, users have reported distressing discontinuation symptoms. A review by Haddad (2001) found as many as fifty different discontinuation symptoms, ranging in severity from mild to severely disabling. These included dizziness, nausea, lethargy, headache, electric shock like sensations, insomnia and nightmares. An understanding of the physiological mechanisms underlying the syndrome has yet to be realised. Theorists such as Tamam and Ozpoyraz (2003) and Blier and Tremblay (2006) speculate that the readaptation of the neurotransmitter systems, which rapidly increase reuptake of serotonin and subsequently decrease the amount of serotonin able to bind to post-synaptic receptors, are the likely triggers. Drugs with shorter half lives i.e. Paroxetine are the most problematic and those with longer half-lives and active metabolites i.e. Citalopram and Fluoxetine appear to fair better (Taylor, Paton and Kerwin, 2007). In terms of appropriateness, all SSRIs share identical cautions and contraindications and research has shown that Citalopram is just as effective as Fluoxetine in treating depressive symptoms (Patris, Bouchard, Bougerol, Charbonnier, Chevalier, Clerc, Cyran, Van Amerongen, Lemming and Hopfner Petersen, 1996). Consideration of patient-specific factors during the history taking identified that Anne found previous success with Citalopram. The medical history had not highlighted any conditions where cautions apply such as epilepsy, cardiac disease, diabetes mellitus, allergies etc and the author was aware that use of all antidepressants was contra-indicated in mania (RPS & BMA, 2007). The choice of product was made in discussion with Anne. She had a preference for Citalopram and after reviewing the available evidence, the author concurred with this choice and prescribed Citalopram (evidence 6). See evidence 7 for a profile of Citalopram. Next, it was necessary to negotiate a contract with Anne, stage four of the prescribing pyramid. Anne understood Citalopram from previous use, however education regarding what the prescription was for and how long it would take to work (evidence 7) was given. Anne did not have a preference in terms of formulation and therefore tablets were prescribed, as this was the cheapest option. The side effects and red flag concerns of the medication were then identified to Anne (evidence 1, section 6). All antidepressants have been linked with a possible increased risk of suicidality. Research into SSRIs and suicidality demonstrates conflicting findings in that Healey (2003) found increased risk in early treatment and Isacsson, Holmgren and Ahlner (2005) reported a reduction. The Medicines and Healthcare products Regulatory Agency maintain that prescribers of SSRIs should monitor and assess for this regularly. Due to the possibility of suicidality occurring as a red flag, a prescription for treatment to last seven days was given and the rationale explained to Anne and her partner. In the practice area, service users are given information from the United Kingdom Psychiatric Pharmacy Group (UKPPG), available via the Trust intranet; the data regarding Citalopram was given to Anne (Appendix 1). Furthermore, Anne was encouraged to refer to the patient information leaflet, dispensed with the product from the chemist. Anne's partner expressed concerns about media reports questioning the efficacy of antidepressant medication; this was addressed by giving him a copy of the Trusts response to the information (Appendix 2). This information was successful in reassuring him (evidence 8), along with the arrangements for reviewing Anne on a regular basis. In terms of reviewing Anne, stage five of the prescribing pyramid, a further appointment was made for seven days, in line with NICE (2004) guidance due to her higher background risk of suicide as an individual under the age of thirty years. Based on the evidence that SSRIs can increase risk of suicide, planning to see any patient commenced on antidepressants within a week would better ensure safety and professional accountability, in addition to addressing the public health target to reducing suicide. Although increased energy and motivation is apparent a week into treatment, the antidepressant effect is not, therefore the individual may continue to experience depressive symptoms and have the impetus to act on suicidal thoughts (NICE, 2004). Frequent monitoring thereafter is recommended by NICE (2004) who suggest professionals look for signs of akathisia, suicidal ideas and increased anxiety and agitation, which can occur with all antidepressants, including Citalopram. The author elected to give Anne and her partner the contact details for the Crisis Team in the local area, should support be needed out of working hours, explaining that they could be contacted if her mental health further deteriorated or she began to suffer with suicidal thoughts. It was indicated to Anne that she would be unlikely to feel the full benefit from the treatment for approximately two weeks due to the pharmacology of the drug (evidence 7) and that once the depression had lifted; guidelines suggest treatment should continue for at least six months after this marker. Geddes, Carney, Davies, Furukawa, Kupfer, Frank and Goodwin (2003) found that treatment continued for this time frame reduces the risk of relapse. In terms of keeping records, stage six of the prescribing pyramid, Anne's progress was recorded using the electronic Care Programme Approach (eCPA) system. Use of eCPA in the practice area is a new development, intended to replace the paper-record system, allowing immediate access to relevant mental health staff. It is currently inaccessible to other health professionals; therefore duplication of work is necessary in order to ensure effective communication. Currently, professionals involved in the care of an individual seen by psychiatric services are identified as part of the initial assessment (evidence 1, section 19) and are advised of their treatment plan and progress via separate letters (Appendix 3). Working in this manner ensures safe, ethical practice by good communication with members of the multi-disciplinary team (NMC, 2008). In line with the NMC standards for recordkeeping (NMC, 2005) the author recorded and disseminated the information in a timely manner, using the same format as her DMP. In the future, the author plans to work with the non-medical prescribing lead to develop an appropriate format for her practice, which should enhance professional accountability. The seventh and final principle of the prescribing pyramid encourages reflection on prescribing practice. The author was confident that a prescription was necessary and therefore did not feel pressured by the patient to issue treatment against better judgement as can be the case (Britten, Ukoumunne and Boulton, 2002). Neither did the advertising activities of the relevant drug company influence the choice of product. Reliance on independent research was used to inform prescribing practice.

Supplementary Prescribing

Supplementary prescribing is described as "a voluntary partnership between an independent prescriber (a doctor or a dentist) and a supplementary prescriber to implement an agreed patient-specific Clinical Management Plan with the patient's agreement" (DH, 2005a paragraph 8). A critical analysis of a supplementary prescribing scenario will follow, addressing learning outcomes 1, 2, 3, 4 and 5. As in the IP scenario, reference will be made to the prescribing pyramid (NPC, 1999). The patient will be referred to as Alexander Stewart. Alexander's General Practitioner (GP) had been managing his care; however he had been referred to the service following discontinuation of antipsychotic medication Risperidone, due to sexual dysfunction. Alexander was under the care of a consultant psychiatrist who had diagnosed Schizophrenia of the paranoid type, under Section F20.0 of the International Classification of Disease 10 (WHO, 1992). At the time of meeting Alexander, early warning signs of relapse were evident in that he believed others were against him and were sending messages via media sources. Alexander had sufficient insight to be able to recognise that his mental health was declining and had attended the appointment in the hope that an alternative treatment could be prescribed. The independent prescriber (IP), Dr Gater, felt that Alexander was a suitable candidate for a supplementary prescribing arrangement as there were no issues of substance misuse, no co-morbid illnesses and he had a good history of engagement. It is recommended that these factors be considered before contemplating supplementary prescribing in mental health care (DH, 2005b). New Ways of Working in Mental Health (DH, 2005c) dictate that individuals with highly complex needs, including those with dual diagnosis, history of poor engagement, co-morbid physical illness and assessed high risk of harm to self or others are seen by more advanced, highly trained professionals such as consultants. Dr Gater discussed with Alexander the possibility of supplementary prescribing and he agreed to work in this way, with the author as the supplementary prescriber (SP), who also took on the role of care co-ordinator. The IP set the parameters of the Clinical Management Plan (CMP) and this was then drawn up and signed, (evidence 9) indicating agreement by the IP, SP and Alexander as is mandatory for supplementary prescribing situations (DH, 2005a). The IP and SP had shared access to the patient record. The CMP in this instance was broad and permitted prescription of antipsychotic medication from a wide choice of agents, however CMPs can be specific, for example, only allowing the SP to make dose or frequency of dose changes to an identified medicine (DH 2005b). In such cases, if a patient were to develop adverse side-effects from the medicine, a new CMP would have to be developed, leading to increased workload and time delays for treatment. In this instance, because of the knowledge and experience of the SP, the close working relationship of the IP and SP and the accessibility of comprehensive guidance regarding the management of Schizophrenia (NICE, 2002b) a broad CMP was considered appropriate. The author used the prescribing pyramid to aid practice (NPC, 1999) and adhering to the first principle, considered a holistic assessment. The IP had already taken a thorough history and made a diagnosis, however the history taking was repeated by the SP to ensure that Alexander's presentation had not changed. Difficulties can arise if this occurs (evidence 2d). A CPA assessment was carried out (evidence 10), supplemented by a symptom analysis tool, namely Morton (1992). The assessment confirmed the original diagnosis. The National Service Framework for Mental Health (DH 1999a) reported that individuals suffering with this illness are nine times more likely than the general population to commit suicide and that the risk of death from other violent incidents is over twice as high. Government policy since this time has aimed to ensure that people with mental health problems are better able to access services and appropriate treatments in a timely manner, to prevent the aforementioned likelihoods. The author was keen to uphold these principles and treat accordingly. Theorists such as Wyatt (1991) and McGlashan and Hoffman (2000) have speculated that prolonged non-treatment of Schizophrenia can result in brain-damaging neurotoxicity and synaptic plasticity, respectively; however there is limited research into these theories (McGlashan, 2006). Findings from 'duration of untreated psychosis studies' have lead to the recent development of Early Intervention Services which aim to ensure that people with mental illness receive timely treatment in order to prevent biological, psychological and social decline (Whitwell, 2001). Personal experience has further demonstrated that non-treatment of the illness results in further loss of insight, increased distortions of judgement and the possibility that the active phase will last indefinitely. This knowledge meant that the second principle of the prescribing pyramid was satisfied since the appropriate strategy was to issue a prescription. Alongside this, the author, working as care co-ordinator for Alexander highlighted interventions to address issues relevant to his quality of life and well-being including housing, finance and employment support etc as suggested by government policy (DH 1999a, DH 1999b). The third principle, consideration of product choice, was initially agreed via the CMP. This indicated use of antipsychotic medication; however the selection of agents was open for discussion between Alexander and myself. To aid the decision, referral was made to the NICE guidance for treatments in Schizophrenia (NICE 2002a). The guidance recommends use of atypical antipsychotics in the treatment of Schizophrenia. Evidence 12 explains typical versus atypical antipsychotics in further detail. Alexander previously had a good response to an atypical drug, namely Risperidone, however stopped it due to the adverse drug reaction (ADR) he suffered. Alexander developed retrograde ejaculation, a reasonably high reported adverse effect of this drug (Taylor et al, 2007). Alexander's G.P had been satisfied that the symptom was not caused by other conditions such as diabetes mellitus or multiple sclerosis; and as the symptom ceased following discontinuation of Risperidone, was satisfied that it was an ADR. Although evidence suggests that this effect is dose related (Raja 1999, Loh, Leckband, Meyer and Turner 2004), Alexander did not wish to recommence this treatment. In choosing the most appropriate treatment, the criteria was therefore further simplified to an atypical agent, where possible, with a low affinity for alpha1 adrenergic antagonism since this is thought to be the cause of retrograde ejaculation with Risperidone (Loh at al, 2004). From the atypical agents listed in the current British National Formulary (RPS & BMA, 2007), the two with the lowest affinity for alpha1 adrenergic antagonism are Aripiprazole and Quetiapine (Loh et al, 2004). Alexander was also presented with information comparing antipsychotics in terms of other commonly experienced side effects (Appendix 4) and then given the opportunity to ask questions. Finally, Alexander and I agreed on Aripiprazole and a prescription was issued (evidence 11). In addition to the importance of the positive side effect profile, Aripiprazole also rated as less expensive than comparable treatment with Quetiapine (Taylor et al, 2007) and this is a factor which prescribers are directed to pay attention to (NPC 1999, NICE 2002). In terms of preparations, Aripiprazole is manufactured in tablet form, orodispersible tablets and as an oral solution. As Alexander was happy to take tablets, this was the preparation prescribed. Aripiprazole is described as having a 'uniquely robust pharmacology' (Davies, Sheffler and Roth 2004), centred on it being a partial agonist at Dopamine D2 receptors. Evidence 12 provides a profile for Aripiprazole, which explains this in further detail. It is distinctive from the other atypical agents as it stabilises the spread of dopamine in two of the four major pathways (mesolimbic and mescortical) where the neurotransmitter Dopamine is found, as opposed to purely blocking dopamine receptors or working as an antagonist at D2 receptors. Despite this difference, a recent systematic review of Aripiprazole actually found that it did not have significant advantages over other atypical medicines, neither did it demonstrate increased efficacy over typical drugs (El-Sayeh and Morganti, 2004). Coupled with this, Aripiprazole was shown to instigate similar adverse effects as treatment with typical agents, with the exception of akathisia, which lead to improved compliance (El-Sayeh and Morganti, 2004). Aripiprazole has not been shown to cause elevation of prolactin levels, nor is it associated with the development of impaired glucose tolerance or weight gain, therefore in theory, monitoring of these factors is not required (Travis, Burns, Dursun, Fahy, Frangou, Gray, Haddad, Hunter, Taylor and Young, 2005). In fact, Travis et al (2005) purport that no specific monitoring is required outside of the basic screening advocated in NICE (2002b) i.e. monitoring for endocrine disorders and cardiovascular risk factors etc. Despite this, the NHS Trust for which the author works recommends extensive monitoring (Appendix 5). The author would therefore be compelled to work within the guidance of the employing authority. In negotiating a 'contract' (stage four), because Alexander and I shared the decision to try Aripiprazole, it was hoped that concordance would be achieved. Evidence 14 highlights the implications of excluding service users from the decision making process. Delivering the choice agenda in mental health is considered key to an effective prescribing value base for nurses (Jones and Jones, 2007), however it must be identified that issues of capacity for individuals with mental health problems can jeopardise this. For individuals lacking capacity during an acute Schizophrenic episode, guidance recommends the use of oral atypical medications, prescribed after consultation with the individual's carer or advocate (NICE, 2002a). Government policy has stated that service users should be encouraged to compile an Advanced Directive (AD) as part of their care plan, highlighting their treatment choices (NICE 2002b), although in practice, the author has limited experience of this happening (evidence 13) and does not feel it is something that the Trust encourages. Concerns have been expressed that service users might draw up unrealistic and illogical plans, refusing all forms of treatment, however a recent study found evidence to the contrary of this (Papageorgiou, Mohamed, King, Davidson and Dawson, 2004). It is the opinion of the author that where possible ADs should be formulated, allowing the patient to be autonomous, however the author also acknowledges that there may come a point where decision-making is replaced by that of the prescriber. At present ADs can be over-ridden if the patient is subject to compulsory treatment under the Mental Health Act (1983). In Alexander's case, an AD was offered but refused. Alexander was considered capable of providing informed consent and therefore, following the principles of good practice (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1996), the author communicated to Alexander, various details about the prescription. These included information on what the prescription was for, how long the drug would take to work, how long to take it for, what dose to take and the possible side effects. The UKPPG data regarding Aripiprazole was given to Alexander (Appendix 6). The fifth principle of the prescribing pyramid, review of the patient was dictated by the CMP. Weekly review was carried out in order to ensure that the treatment was effective, safe and acceptable. Had it not been, the broad CMP permitted use of alternative agents. The IP and SP reassessed Alexander as planned three months later. In this time however the IP and SP met frequently to discuss the progress of Alexander and record keeping was kept up-to-date using the eCPA system. At present, GP's are advised of supplementary prescribing arrangements and changes in these via Trust devised letters (see Appendices 7 and 8). In this instance the letters were compiled and sent within 24-48 hours in line with local policy. The author reflected on her prescribing decision as recommended by the final stage of the pyramid and is confident that neither patient pressure nor the action of pharmaceutical companies affected decision-making. In practice, the author has experience of nursing individuals on a range of antipsychotics and is aware that this may affect choice of drug in the future

Conclusion

The author has described and analysed an independent and supplementary prescribing experience and has attempted to meet the module learning outcomes in doing so. The author is confident that her rationale for prescribing decisions is based on sound comprehensive guidelines and practice experience. The author plans to base future decisions on the prescribing pyramid model, making a conscious effort to see outside of the prescriptive toolkit so as to remember the importance of other nursing interventions. It is the intention of the author to utilise the support and clinical supervision available in the practice area, including discussion about differential diagnosis and treatment options with the medical team following assessments. This will ensure safe practice, professional development and recognition of the contribution of non-medical prescribers within the team. Evidence 16 details the author's plans for continuing professional development in prescribing practice, both as an independent and a supplementary prescriber. These goals are important to ensure competency in prescribing practice is maintained. By ensuring that practice is updated, monitored and evaluated, service user experience is hopefully improved leading to increased concordance and better health outcomes

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