Diagnosis of mixed personality disorder
18. Mr A states he was misdiagnosed with a mixed personality disorder in February 2019 when he in-fact had bipolar.
19. The Trust says in its response letter dated 14 July 2022, that a second opinion was also offered in November 2020 which supported the initial diagnosis of mixed personality disorder and so it believed it to be a correct diagnosis.
20. We considered with our adviser whether, based on the available medical records and Mr A’s symptoms, if an accurate diagnosis of mixed personality disorder was made.
21. Mr A was reviewed by Doctor A in the outpatient clinic on 20 February 2019 and then again on 12 April 2019. The first mention of a possible diagnosis of mixed personality disorder (referred to as mixed personality traits throughout Mr A’s medical records) was following the appointment of 12 April 2019. The advice provided to us suggests there is no justification within Mr A’s medical notes as to why Doctor A felt Mr A had or may have mixed personality disorder.
22. Doctor A also carried out subsequent outpatient reviews of Mr A on 9 May, 14 June and 1 August 2019, where a mixed personality disorder diagnosis is included within his mental health records. Within the outpatient clinic review letters, there is no explanation as to why mixed personality disorder remains a valid and relevant diagnosis. The only reference to mixed personality traits in any of the three outpatient clinic review letters is in the diagnosis section of each letter.
23. We also considered whether the Trust were correct to confirm the diagnosis of mixed personality disorder in the following appointments and when Mr A went for an appointment with the second opinion psychiatrist in November 2020.
24. Mr A queried his mental health diagnosis when he was reviewed by Doctor A on 20 February 2020, as he did not feel he had emotionally unstable personality disorder and instead felt he had bipolar. Doctor A suggested Mr A may have mixed personality disorder as there were elements of many different personality traits in Mr A’s presentation. The outpatient notes state Mr A has mixed personality disorder, with elements of narcissistic personality disorder and that he was unlikely to have bipolar. However, within the medical records, Doctor A does not mention any clinical features in Mr A’s presentation that would indicate or suggest he had any narcissistic personality traits or that a diagnosis of narcissistic personality disorder is valid.
25. In a further appointment on 20 June 2020, when reviewed in the outpatient clinic by Doctor W, Doctor W mentions about “people with a suspected BPAD” (bipolar) but then states in the diagnosis section of the letter that Mr A has “mixed personality traits”. We can appreciate why this appears contradictory and may be confusing.
26. Mr A then attended an appointment with Doctor O, (the consultant psychiatrist) for a second opinion on 10 November 2020. The consultant psychiatrist felt Mr A presented with ‘very dichotomous (black and white) thinking’ and had ‘very rigid views which he finds very difficult to have challenged.’ The consultant psychiatrist went on to state they felt Mr A did have a diagnosis of mixed personality disorder stating, ‘he has many features suggestive of that’.
27. The advice provided to us explained, in order for the consultant psychiatrist to state Mr A had a diagnosis of mixed personality disorder, they should have explicitly stated which specific traits of personality disorders in the ICD-10 Mr A was presenting. However, this has not been done.
28. Throughout Mr A’s medical records from 2019, we can see no information from any mental health care professional that would justify why a diagnosis of mixed personality disorder is relevant and applicable to Mr A, based on his history and clinical presentation.
29. The International Classification of Mental and Behavioural Disorders (ICD-10) (The ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines (who.int)) states the following in relation to a specific diagnosis of “Mixed personality disorder”, coded as ICD-10 F61.0:
“Features of several of the disorders in F60.- are present, but not to the extent that the criteria for any of the specified personality disorders in that category are met.”
30. In order for the Trust to state Mr A had a diagnosis of mixed personality disorder, we would expect it to explicitly state which specific traits of which specific personality disorders in the ICD-10 are present in Mr A’s presentation.
31. Based on Mr A’s medical records along with the advice provided to us, it is our finding that the Trusts diagnosis of mixed personality disorder is not fully justified. Throughout each of the outpatient clinic appointments with Doctor A and Doctor W, and following the second opinion consultant psychiatrist, it has not been explained why a diagnosis of mixed personality disorder is valid and applicable to Mr A.
Lack of psychological care and care co-ordinator
32. Mr A complains he was not provided with psychological help for anxiety and other mental health issues including not being given a care co-ordinator for over a year.
33. We considered with our adviser what guidelines are in place regarding a patient being appointed a care co-ordinator. The National Institute for Health and Care Excellence (NICE) has produced guidelines entitled “Coexisting severe mental illness and substance misuse: community health and social care services” (NG58), published on 30th of November 2016 (Overview | Coexisting severe mental illness and substance misuse: community health and social care services | Guidance | NICE). These guidelines would be appropriate to consult when considering the issue of whether Mr A was appropriate for allocation of a care coordinator, given he had a severe and enduring mental illness (i.e., suspected bipolar affective disorder) and that he had a history of alcohol and illicit substance use issues.
34. Within these guidelines, is states that, on acceptance of the individual with coexisting severe mental illness and substance misuse, one should “Provide a Care Co-ordinator working in mental health services in the community to: act as a contact for the person, identify and contact their family or carers and to help develop a care plan with the person and coordinate it.”
35. The relevant medical records show following a referral from Manchester mental health services, Mr A was allocated a care co-ordinator on 28 January 2019. He then continued to have a care co-ordinator involved in his community psychiatric care throughout 2019, 2020 and 2021. A decision was then made for a care co-ordinator to no longer be involved in Mr A’s care following his outpatient clinic appointment on 27 July 2021. The rationale for this decision being made and who made this decision is not clear within the available records.
36. The Trust’s response dated 14 July 2022 states it is ‘sorry you were told your care would automatically be transferred to another CPN/MHP when Ms E (previous care coordinator) left and this has not been actioned’.
37. This suggests Mr A’s care co-ordinator may have left the organisation, however, a new care co-ordinator had not been allocated. The Trust response advises ‘it would be routine practice to review a service user’s care at intervals and before such a transfer takes place.’ It also suggests Mr A was provided with support from the Neighbourhood Mental Health Team (NMHT) and the Reablement Service. The Trust also apologise for misinforming Mr A his care would automatically be transferred to another care coordinator.
38. It is our view that the Trust has not provided a clear reason to explain why Mr A was no longer given a care-co-ordinator. We have also found this was communicated poorly with Mr A.
Impact
39. Mr A states due to not receiving the correct diagnosis and subsequent treatment, he was unable to work due to being too unwell and only began working part time again prior to bringing his complaint to PHSO. He explains this led to a loss of earnings and time, meaning he required financial support from his family and continued to live at home as he was unable to afford to move out. This made him feel as though he was a burden on his family.
40. The diagnosis of mixed personality disorder that Mr A was given had a negative impact on how he viewed himself, affected his mental health and also led to him having suicidal thoughts. He felt there was no point in him seeking relationships and friendships because of how other people may view him despite this being something that he was keen to do.
41. Mr A explains the events complained about have led to him no longer trusting anyone within the NHS due to the negligent care he has received. This means it is now difficult for him to access NHS services.
Medication
42. Mr A also states he received the incorrect medication due to him being diagnosed with mixed personality disorder, rather than bipolar. This led to a deterioration in his mental health and prevented him from getting better. He says it led to an alteration in his mood and led to him having suicidal feelings and feelings of paranoia. We considered with our adviser whether Mr A being given a potentially inaccurate diagnosis, would have meant he was then prescribed the incorrect medication.
43. Upon review of the relevant medical records we can see at the time of his outpatient review with Doctor A on 12 April 2019, Mr A was prescribed three medications for his mental health. These were:
• Quetiapine 150 mg at night, with the dose increased to 300 mg at night and switched from the immediate release form to the prolonged release form (Quetiapine XL) following Dr Naveed’s review of Mr A
• Depakote 500 mg in the morning, 750 mg at night, with the dose increased to 750 mg in the morning, 1000 mg at night following Dr Naveed’s review of Mr A
• Zopiclone 7.5 mg at night
44. According to NICE guidance, British National Formulary the immediate release form of Quetiapine is used for:
• treatment of schizophrenia • treatment of mania in bipolar disorder • treatment of depression in bipolar disorder • prevention of mania and depression in bipolar disorder.
45. The same guidance also states the prolonged release form of Quetiapine is used for:
• treatment of schizophrenia • treatment of mania in bipolar disorder • treatment of depression in bipolar disorder • prevention of mania and depression in bipolar disorder • adjunctive treatment of major depression.
46. We are aware Mr A disagrees with the diagnosis of mixed personality disorder and as explained above, have concerns that the Trust’s reasoning for this diagnosis has not been fully explained. However, based on the above evidence, our decision is that the use of Quetiapine as a pharmacological treatment for Mr A was not incorrect and would still be suitable treatment had he been diagnosed with bipolar.
47. The advice provided to us explained the Quetiapine would have both provided mood stabilisation and prophylaxis (preventive treatment) against depressive and manic or hypomanic (abnormal, elevated extreme changes in mood or energy level) and also effectively treated any depressive and/or hypomanic episodes that Mr A experienced or may have experienced whilst under the Trust’s care.
48. NICE guidance, British National Formulary also states Depakote is a mood stabilising medication. It is licensed to prevent mania and depression in bipolar and to treat mania. It is therefore our decision that should Mr A’s diagnosis have been given a diagnosis of bipolar, the use of Depakote as a pharmacological treatment was not incorrect and would be clinically indicated and justified. The Depakote would have provided preventive treatment against depressive and manic or hypomanic episodes and would also have effectively treated any manic episodes that Mr A may have experienced.
49. We have found the Trust did not provide adequate explanation and reasoning as to why it believed Mr A’s diagnosis to be mixed personality disorder. This means the diagnosis could have been potentially incorrect. However, regardless of the diagnosis, the prescription of Quetiapine and Depakote as a pharmacological treatment would have been correct and clinically justified to treat bipolar. This means should Mr A have been diagnosed with bipolar, it is possible the above medication would still have been prescribed.
50. As per the above, Mr A was also prescribed with Zopiclone which is a hypnotic medication licensed for short term use (i.e. daily use for up to four weeks, to be taken at bedtime) to treat insomnia. The medical records show this was prescribed as a regular nighttime prescription on a long-term basis and longer than the recommended maximum duration of four weeks.
51. NICE guidance, Managing Insomnia states ‘do not prescribe long-term hypnotic treatment.’ We have therefore found, any use of Zopiclone on a daily basis for longer than four weeks would have been clinically inappropriate and not in keeping with good clinical practice and appropriate and safe prescribing practice.
52. Following a review by Doctor A on 14 June 2019, it was recommended that Mr A switched from Quetiapine to Aripiprazole. According to the British National Formulary, this is licensed for use in:
• schizophrenia • treatment and recurrence prevention of mania • rapid control of agitation and disturbed behaviour in schizophrenia and mania
53. The advice provided to us explained the Aripiprazole would have treated any manic episodes that Mr A experienced or may have experienced whilst under the care of the Trust and prevented recurrence of any other manic episodes. Our decision is that the prescription of this was clinically indicated and justifiable.
54. Mr A was then reviewed on an outpatient basis by Doctor A on 1 August 2019, when he was prescribed Melatonin MR (modified release) 4mg at night, in place of his previous Zopiclone 7.5mg at night.
55. The Nice guidance, British National Formulary states the modified release form of Melatonin is licensed for use in the treatment of insomnia for adults aged 55 years and over, with a recommendation initial duration of three weeks and it being given if there is a response to treatment for a further 10 weeks only. Given that Mr A was under the age of 55 at the time he was prescribed Melatonin, it was being used for him as an off-licence (used outside the terms of the licence) basis.
56. Nice guidance, Managing Insomnia, states ‘pharmacological therapy should be avoided in the long-term management of insomnia.’ Mr A’s prescribed dose of Melatonin MR went up to 6mg at night, which is above the 2mg at night recommended in the British National Formulary.
57. The medical records show Mr A was prescribed Melatonin on an off-licence basis and was also prescribed a higher than recommended dosage of Melatonin MR. There is, however, no documentation within the medical records to show Doctor A informed Mr A, consulted with him regarding this or received consent from him to make this decision. It is our decision that this is a failing on the Trust’s behalf.
58. Mr A was reviewed on an outpatient basis by Dr W on 12 May 2020 and he was prescribed Amisulpride 400mg twice daily. Mr A informed Dr W he was currently only taking 100mg at nighttime. According to British National Formulary, Amisulpride is used in the treatment of acute psychotic episode in schizophrenia and schizophrenia with predominantly negative symptoms.
59. The advice provided to us explained that should Mr A’s correct psychiatric diagnosis have been felt to be bipolar, then the use of Amisulpride as a pharmacological treatment would not have been clinically indicated or justified. NICE guidance, bipolar disorder: assessment and management does not mention the use of Amisulpride in the treatment of any aspect of bipolar. The Maudsley Prescribing Guidelines in Psychiatry also state there is little data supporting the use of Amisulpride in the treatment for bipolar. We have found the prescription of Amisulpride would not have been appropriate should Mr A’s diagnosis have been bipolar.
60. An outpatient review by Dr W was carried out on 23 June 2020 and Mr A was commenced on 150mg Trazodone. This is an anti-depressant medication licensed for use in depressive illness and anxiety. The advice provided to us confirmed even if Mr A’s diagnosis would have been bipolar, this prescription would have been clinically justified as it could feasibly be used in the treatment of a depressive relapse of bipolar particularly if sleep disturbance as a major presenting problem, as in Mr A’s case.
61. In conclusion, with regards to Mr A’s complaint that due to receiving an incorrect diagnosis, he was then prescribed the incorrect medication, our decision is that he was inappropriately prescribed two medications for his mental health. These were Amisulpride and Melatonin MR.
62. We have found the Amisulpride was inappropriately prescribed for Mr A because it is not clinically indicated and not licenced for use in any aspect of the pharmacological management of bipolar as determined by NICE guidance. Mr A was, however, prescribed 200mg at night and the maximum recommended dose according to British National Formulary is 1,200mg daily. The advice provided to us explained that Mr A taking 200mg of Amisulpride would not have caused significant alteration or disturbance in his mood nor would it have caused any emergent paranoia or suicidal feelings. None of mood disturbance, paranoia and suicidal feelings are reported as being known side effects in the British National formulary.
63. Our view is that Melatonin MR was inappropriately prescribed for Mr A in that it was being used on an off-licence basis and at a dose (6mg at night) which is above the recommended dose (2mg) for short term treatment. The British National Formulary lists ‘mood altered’ as an ‘uncommon’ side effect and so our finding is that the inappropriate use of Melatonin MR may have caused mood alteration in Mr A.
64. The British National Formulary does not list paranoia or suicidal feelings as a side effect of Melatonin MR and so although we have found this was prescribed inappropriately, we cannot say this will have led to the development of paranoia or suicidal feelings in Mr A.
Care co-ordinator
65. Upon review of Mr A’s medical records, on 20 February 2019 during his outpatient review, Dr A recommended that the team chase the psychology assessments Mr A had completed whilst he was under the care of the local community mental health services. This was done whilst Mr A lived in Manchester. Dr A said these previously completed assessments should be used to guide a referral to the local psychology service.
66. The review letter from the outpatient appointment on 29 March 2019 with Dr A states they would discuss the possibility of referring Mr A for psychological therapy, possibly cognitive behavioural therapy with his care co-ordinator. At the next review with Dr A, the review letter states they needed to ‘chase psychology referral’ indicating that Mr A had not started any psychological therapy with the community team at this point.
67. On 14 June 2019, Mr A informed Dr A he was unhappy that he had been placed on a waiting list to commence psychological therapy. Review letters from outpatient appointments on 1 August and 14 November 2019, suggest Mr A remained on the waiting list. On 20 February 2020, the medical notes suggest Mr A had commenced psychological therapy but that the psychologist delivering this had resigned, so he was waiting to be assigned a new one.
68. NHS Service Standards, states that all NHS Talking Therapy services should be providing timely access to treatment and says:
• 75% of patients should have a first appointment within six weeks of referral • 95% of patients should have a first appointment within 18 weeks of referral
69. A review of Mr A’s medical records suggest he had to wait just under three months for a psychology assessment, from the point of referral, and that he had to wait just under one year before commencing psychological therapy.
70. We have found the Trust did provide Mr A with an initial appointment in line with the above guidance, however, following the psychology assessment, he did have to wait an exhaustive period of time before he actually began psychological therapy.
71. The advice provided to us explained it is possible that the delay in Mr A being able to commence psychological therapy may have had a negative impact on his mental health. However, there are lots of other factors that would also need to be considered that could also have negatively impacted his mental health during the time he was waiting for psychological therapy. These could be things like underlying physical health issues, ongoing sleep disturbance or significant life events.
72. It is therefore our decision that whilst this may have been a possibility and we appreciate the distressing impacts Mr A has described this had on him, it cannot be said for certain that the delay in Mr A being able to commence psychological therapy definitely had a negative impact on Mr A’s health.
73. As above, the relevant medical records show Mr A had a care co-ordinator throughout 2019, 2020 and 2021. Within this time period, Mr A did have several care co-ordinators for differing reasons. The medical records from Mr A’s outpatient review on 5 April 2022 shows there was no care co-ordinator in place at this time and that there had not been since the beginning of 2022.
74. Within the medical records and throughout the complaint response letters from the Trust, we cannot see that any reason has been given or explained to advise why Mr A no longer had access to a care co-ordinator. We have found this should have been done and the communication with Mr A could have been better. This would likely have led to increased stress for him. We can also appreciate that as Mr A described, this contributed to him developing a lack of trust both in the Trust itself and in wider healthcare services.
75. Based on the advice we have received and the available medical records, we have found that whilst it is possible there was or may have been deterioration in Mr A’s mental health in the period, he was not allocated a care co-ordinator by the Trust, we are unable to make this conclusion with any degree of certainty or conviction.
Summary
76. In summary, whilst we cannot say for certain the incorrect diagnosis of mixed personality disorder was made, the Trust did not provide adequate explanation or reasoning as to why it believed this to be the diagnosis which does raise concerns of the validity of the diagnosis.
77. Despite this, as per the above, the majority of medication Mr A was prescribed would have been clinically correct and justified even if a diagnosis of bipolar was made. This is with the exception of Amisulpride and Melatonin MR.
78. As stated above, we have found that although Melatonin MR was prescribed inappropriately, we are unable to say there was a direct link between Mr A taking this and his increased paranoia and suicidal feelings. Melatonin MR does, however, have mood alterations listed as an ‘uncommon’ side effect based on The British National Formulary. Our decision is that based on this, it is possible the inappropriate use of Melatonin MR may have caused mood alteration in Mr A.
79. We have found Amisulpride was also inappropriately prescribed by the Trust. As above, due to the small dosage (200mg), this would not have had significant alteration or disturbance in Mr A’s mood, nor would it have caused any emergent paranoia or suicidal feelings. None of mood disturbance, paranoia and suicidal feelings are reported as being known side effects in the British National formulary. Our decision therefore is that we are not able to link the prescription of Amisulpride with Mr A’s change in mood, paranoia, or suicidal feelings.
80. With regards to having an allocated care co-ordinator, our finding is that we cannot say for certain that the absence of a care co-ordinator during the early stages of 2022 will have had a direct impact on the deterioration of Mr A’s mental health. Our view is that this could have been documented (within the medical records and complaint responses) and communicated better with Mr A, to prevent a decline in the level of trust and faith he had in the service.