Discharge letter
16. Miss W complains that consultant psychiatrist 1 did not warn against prescribing her antidepressants in their discharge letter dated 15 March 2017. She thinks the antidepressants caused her psychotic episode in January 2014. She emphasises that between 2014 and 2016 consultant psychiatrist 1, and another psychiatrist at the Trust, had recommended she avoid antidepressants because of their belief antidepressants could trigger a psychotic episode. They wrote this in her clinical records.
17. The Trust says it would only have been necessary to be cautious with antidepressants, without mood stabilisers being prescribed at the same time, if Miss W had bipolar disorder, but on 15 March 2017 her diagnosis was unspecified non-organic psychosis, not bipolar disorder. The Trust also highlighted that consultant psychiatrist 1’s discharge letter does not suggest prescribing Miss W antidepressants.
18. The GMC’s guidance on prescribing says doctors must make sure they safely transfer patients between health providers. This includes making sure they share all relevant information about a patient’s current and recent medicines, any adverse reactions to medicines, any medicines which they have stopped or changed and the reasons why.
19. We have reviewed the discharge letter and agree it does not suggest prescribing Miss W antidepressants. But it also does not clarify if the earlier advice to avoid antidepressants was still valid considering the Trust’s new diagnosis of non-organic unspecified psychosis rather than bipolar disorder. Our psychiatrist adviser told us this was important as up until this point the Trust had repeatedly warned Miss W and the Practice against using antidepressants.
20. Miss W had a history of seeking medical support for her mental health. If she needed support in the future, it was foreseeable that the Practice may consider prescribing her antidepressants. When discharging her back to the care of her GP, to ensure a safe transfer as per the GMC guidance, consultant psychiatrist 1 should have provided all the most current and relevant information about her mental health care. To do this the psychiatrist should have made an explicit reference to whether she should be prescribed antidepressants in the future.
21. Our view is there was a failing in the Trust not clarifying in the March discharge letter whether it was appropriate to prescribe Miss W antidepressants in the future. This information was relevant to Miss W’s ongoing care and therefore to a safe transfer of her care. We discuss our view on the impact of this in the section below called ‘impact’.
Medication
22. In an appointment with GP 1 in July 2017, Miss W discussed how she had begun to experience a low mood, tearfulness, and tendency to worry. Miss W complains that the Practice did not follow the medication recommendations in consultant psychiatrist 1’s discharge letter which said if she began to experience ‘a resurgence of psychopathology, such as mood dysregulation […] it would be useful to first think about’ prescribing a short-term sleeping tablet such as zopiclone or a long-acting sedative such as diazepam.
23. GP 1 says they did not prescribe Miss W medication on 27 July 2017 because Miss W preferred to try a mindfulness approach, so they did not think prescribing medication was in Miss W’s best interests at the time. Miss W told us she did not prefer a mindfulness approach, as GP 1 says. She says GP 1 did not offer or discuss medication with her, so she was not given a choice of approaches to have a preference.
24. We have reviewed Miss W’s clinical records. On 27 July 2017 GP 1 noted Miss W had no suicidal ideation or evidence of psychosis. GP 1 noted they discussed options for Miss W to manage her low mood, such as mindfulness, exercising and socialising. They agreed she would be referred to psychological therapies and GP 1 encouraged her to return to the Practice for a review if she needed it.
25. We cannot see Miss W made any further contact with GP 1 until two months later, in September 2017.
26. The Mental Health Foundation says if you speak to your GP about your mental health, they can ask you about how you feel, recommend lifestyle changes that can improve your mental health, offer you medication if it is appropriate and/or talking therapy and invite you back for another appointment in a few weeks’ time to check up on you.
27. The National Institute for Health and Care Excellence guidelines on depression do not initially encourage using medication. They first encourage doctors to offer the least intrusive help which includes ‘assessment, support, psychoeducation, active monitoring and referral for further assessment and interventions.’ It is only the next level of help which includes considering medication. The NICE guidelines say you should only be offered help in the next level once the first level of help has been unsuccessful, or the person has declined it.
28. Trying to address this in the least intrusive manner is considered a way which may help someone manage their mental health and allow them to begin to feel better and only if this does not work would other more intrusive options be considered. We appreciate Miss W’s discharge letter said it would be useful to first think about medication such as zopiclone or diazepam. But as Miss W had initially presented with a low mood rather than any psychopathology, and considering the NICE guidelines, our view is there was not a failing in GP 1 not prescribing zopiclone or diazepam on 27 July 2017. We are not persuaded there was a failing in the approach GP 1 took so we do not uphold this part of the complaint.
Antidepressants
29. Miss W complains that GP 1 should not have prescribed her antidepressants on 26 September 2017. She said her mother had warned them not to and it was contrary to the warning in her clinical records.
30. The Practice says the Trust had previously warned Miss W to be cautious with antidepressants because of her earlier diagnosis of bipolar disorder. It said this had changed in March 2017 to non-organic unspecified psychosis. GP 1 says Miss W’s symptoms on 26 September 2017 were more consistent with anxiety and depression rather than psychosis.
31. We have reviewed Miss W’s clinical records and we can see Miss W continued to experience low mood and anxiety. She returned to the Practice on 26 September 2017, and her records say she did not feel the same as when she had a psychotic episode in 2014. Her records say she was ‘tearful’ and ‘worrying’ with ‘no psychotic symptoms’. While waiting for an appointment with the Primary Care Mental Health Service, GP 1 prescribed her the antidepressant sertraline with a follow up GP appointment in two weeks.
32. NICE guidelines on depression say antidepressants can be considered when less intrusive interventions have not worked, and the person has a previous history of moderate or severe depression.
33. Our GP adviser told us it was appropriate for GP 1 to offer Miss W the antidepressant, sertraline, in combination with the planned talking therapies. The most recent information from her psychiatrist said her diagnosis had changed from 2014 to 2017 and her presentation was anxiety and depression rather than psychosis/bipolar disorder. While the GP was aware that Miss W did not want to take fluoxetine it was appropriate to prescribe sertraline which is a different antidepressant.
34. The Trust thought Miss W’s previous adverse experience with antidepressants was linked to aggravating her bipolar disorder, specifically the possibility that antidepressants could cause rapid cycling between depressive and manic or psychotic episodes.
35. The option of prescribing Miss W the medication suggested in consultant psychiatrist 1’s discharge letter was open to GP 1 at this point. However, as the Trust had decided Miss W no longer had bipolar disorder, we are not persuaded we can say the GP prescribing her antidepressants, with the plan to monitor its effect on her, was wrong when she was presenting with low mood and without any psychotic symptoms. Therefore, we do not uphold this part of the complaint. For completeness, we note Miss W did not take the sertraline GP 1 prescribed her.
Psychiatrist’s advice
36. Miss W complains that on 14 November 2017 the consultant psychiatrist 2, recommended GP 2, prescribe Miss W antidepressants. She says this was contrary to the risk of antidepressants noted in her clinical records and contrary to the medication recommendations in the March discharge letter.
37. The Trust says it was appropriate for consultant psychiatrist 2 to advise GP 2 to prescribe Miss W antidepressants as her diagnosis had changed from bipolar disorder to unspecified non-organic psychosis.
38. Miss W continued to experience low mood and anxiety and returned to the Practice in November 2017. GP 2 sought advice from consultant psychiatrist 2, who was aware of Miss W’s earlier experience with antidepressants when giving the advice. Consultant psychiatrist 2 advised that GP 2 could prescribe Miss W antidepressants and if she was concerned then the Practice should monitor her mood closely. On consultant psychiatrist 2’s advice, GP 2 prescribed Miss W the antidepressant venlafaxine.
39. The GMC’s guidance on prescribing says that doctors should prescribe medicines only if they have enough information about the patient’s health and are satisfied the medicine will help the patient and they should be able to give their reasons for prescribing a new medication. The guidance is clear that ‘prescribing’ can also be used to describe doing things related to prescribing such as giving advice on prescriptions.
40. The British Association of Psychopharmacology’s guidelines on the treatment of anxiety disorders recommends doctors should consider other medication if someone is intolerant to antidepressants. In Miss W’s case she had previously developed manic and psychotic symptoms after taking antidepressants.
41. While consultant psychiatrist 2 considered Miss W’s presentation at the time to be more in line with anxiety and low mood rather than bipolar disorder, Miss W still had an earlier diagnosis of bipolar disorder. NICE’s guidelines on bipolar disorder advise against people with bipolar disorder taking antidepressants, or advise taking an antipsychotic at the same time as the antidepressant if the patient has developed mania or hypomania. Miss W had a previous history of manic/psychotic behaviour following antidepressants and a new diagnosis of non-organic unspecified psychosis, which is not completely dissimilar to bipolar disorder.
42. While our view is there was not failings in GP 2’s actions, unlike a GP, a psychiatrist is a specialist in mental health, so we hold them to a different standard to a GP. Considering the British Association of Psychopharmacology’s guidelines, we would expect a more robust documented justification for prescribing antidepressants. Especially when this was contrary to the advice Miss W had previously received, and considering Miss W’s reluctance to take antidepressants. Therefore, our view is there is a failing in consultant psychiatrist 2 recommending GP 2 prescribe Miss W antidepressants. We discuss the impact of this below.
Impact
43. Our view is there were failings in the Trust not clarifying in the March discharge letter whether it was appropriate to prescribe Miss W antidepressants in the future and in consultant psychiatrist 2, recommending GP 2 prescribe Miss W antidepressants on 14 November 2017.
44. Miss W says as a result this led to her mental health deteriorating, her having a psychotic episode in 2017, and being admitted to hospital in January 2018. Miss W also says it caused her and her family a lot of stress and distress and to lose confidence in the NHS.
45. We fully appreciate that the Trust not referring to antidepressants in her discharge letter, and the Practice prescribing her antidepressants which she had been previously told to avoid, may have led her to lose confidence in the NHS and caused distress for her and her family. Mrs W has described how this experience has affected her sleep, work, and her general health, and led her to seek counselling. We have no reason to doubt this.
46. Given Miss W’s medical history, our psychiatrist adviser told us the antidepressants are likely to have played an important role in Miss W’s decline in mental health and her hospital admission in January 2018. It could be argued that this could have happened anyway as Miss W was already struggling with her mental health at the time, but the evidence we have seen suggests a direct link between the two events.
47. The British Association of Psychopharmacology’s guidelines on treating bipolar disorder explain that people with bipolar disorder who use antidepressants, such as venlafaxine, without any medication specifically for mania are at increased risk of experiencing mania or mood instability. NICE’s guidelines on bipolar disorder echo this and recommend if someone experiencing mania or hypomania is taking antidepressants, they should stop taking antidepressants or at least begin taking an antipsychotic.
48. While we appreciate the Trust has stressed that Miss W’s diagnosis was no longer bipolar disorder, she still had a history of symptoms which were previously thought to be bipolar disorder and at the time she had a diagnosis of unspecified non-organic psychosis. We note that before she started taking the antidepressants the Trust advised in November 2017 Miss W’s mental health had been stable for a long time, to the point where she had been discharged from the community mental health team back to the Practice in March 2017.
49. Miss W did not have any psychotic symptoms until after she started taking the antidepressants and then she experienced a quick deterioration in her mental health. Therefore our view , on balance, is the antidepressants significantly contributed to Miss W experiencing a psychotic episode and later being admitted to hospital.
50. Mrs W described in more detail the impact this had on Miss W. She told us Miss W was unable to complete the final year of her studies but still has to repay her student loans for this course. She explained she provided Miss W with a lot of financial support because she was previously unable to keep a full-time job. Mrs W says her daughter has lost out on years of earning a salary.
51. We are unable to link Miss W leaving her course, being unable to hold down a job or losing out on years of earning a salary to the failings we have identified. This is because Miss W’s GP records indicate she was already struggling with college in September 2017 due to her low mood, which was before she was prescribed the antidepressants in November 2017. Furthermore, we do not know how effective a different approach to her mental health would have been and we have no way of confirming she would have secured a job any earlier, nor what her salary would have been.
52. Mrs W told us a relative paid for private counselling for Miss W. However, we are not persuaded we can link this to the failings we have found. While we appreciate Miss W may have wanted this as soon as possible, counselling is available on the NHS.
53. Mrs W shared with us that Miss W has experienced withdrawal symptoms from her antipsychotic medication. While we appreciate how concerning this must be, we are not persuaded that we can link Miss W’s withdrawal symptoms to the failings we have found because most medication has side effects. If Miss W had taken alternative medication, she may have also had side effects and they may have been the same or worse, but we have no way of saying.