Mental Health Prescribing

NHS Somerset Formulary page for antidepressants

The SPS have published new guidance on managing antidepressants in February 2023 including:

The SPS guide to switching antidepressants, with links to:

Establishing whether a person needs to switch their antidepressant

Choosing an antidepressant to switch a person to

Planning and agreeing an antidepressant switching strategy

Monitoring a person during and after antidepressant switching

With more links to specific drug classes and drugs.

See below for antidepressant choices in pregnancy and lactation under the perinatal mental health section.

Formulary Chapter 4.11 Drugs for Dementia

The Deprescribing page has helpful resources and links to aid deprescribing, including STOPP START. This should be a planned and supervised process involving prescriber, patient and carer to ensure medicines that are no longer needed are stopped safely.

UKMi Q&A How to minimise the risks of medication errors with rivastigmine patches

Specialist Pharmacy Service: Summary of prescribing recommendations from NICE guidance – This guideline covers the diagnosis and management of Dementia.

See Somerset County Council and Somerset Survivors for more information.

Safe places for those experiencing domestic abuse

See Formulary Chapter 4 – Central Nervous System

Advice for prescribers- patient’s taking antidepressants with hyponatraemia

Hyponatraemia (usually in the elderly and possibly due to inappropriate secretion of antidiuretic hormone) has been associated with all types of antidepressants; however, it has been reported more frequently with SSRIs than with other antidepressants. Hyponatraemia should be considered in all patients who develop drowsiness, confusion, or convulsions while taking an antidepressant.

Hyponatraemia is associated with emergency admissions, especially in the frail elderly.

SFT have been receiving increasing numbers of referrals from primary care asking them to review patients who are taking antidepressants and have a finding of hyponatraemia.  SFT advise:

• In mild hyponatraemia (>125mml/L -133mmol/L) monitor sodium and symptoms in the first instance, rather than switching patients away from a medicine that is effective for them. Consider appropriateness of continuing the antidepressant and/ or other medications being taken which may increase the risk of hyponatraemia (e.g. diuretics, NSAIDs, antipsychotics, carbamazepine, cancer chemotherapy, calcium antagonists, ACE inhibitors and laxatives).

• If serum sodium <125mmol/L discontinue the antidepressant immediately and seek specialist medical care.

• Discuss the risks (of hyponatraemia if continuing the antidepressant vs risks of depression coming back if stopping the antidepressant) with patient and record the decision in the patient notes

• If antidepressant not effective, then stop the antidepressant. Royal College of Psychiatrists advice can be found here: Stopping antidepressants | Royal College of Psychiatrists (rcpsych.ac.uk)

• Please continue to ask for advice where patients have severe or worsening hyponatraemia or where symptoms of hyponatraemia persist, preferably by phone or email with your local mental health team rather than making a referral.

Mendip CMHT
Wells Tel:  01749 836600

Taunton & Minehead CMHT
Taunton Tel: 01823 368350
Minehead Tel: 01643 701701

Somerset Coast CMHT
Bridgwater Tel: 01278 720220

South Somerset CMHT
Yeovil Tel: 01935 428420

Sedgemoor:

Telephone: 0300 1245601 (option 1)

Email: OPMHSedgemoor@somersetft.nhs.uk

The Maudsley Prescribing Guidelines in Psychiatry 14th Edition. Accessible via NHS library knowledge hub.

For specific information and useful resources around prescribing of hypnotics and anxiolytics (including reducing and stopping) please see our hypnotics and anxiolytics webpage.

Formulary chapter 4.1 – Hypnotics and Anxiolytics

People with learning disabilities (LD) have poorer physical and mental health than other people and die younger. Many of these deaths are avoidable and not inevitable. Annual Health Checks can identify undetected health conditions early, ensure the appropriateness of ongoing treatments and establish trust and continuity care.

The Royal College of General Practitioners have published a toolkit which collects guidance and resources to help GPs, practice nurses and the primary administration team organise and perform quality Annual Health Checks on people with a learning disability.

Health checks for people with learning disabilities toolkit

Stopping over medication of people with a learning disability, autism or both (STOMP)

STOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines.  STOMP is about helping people to stay well and have a good quality of life.

NHS England – Stopping over medication of people with a learning disability, autism or both (STOMP)

Over-medication, and then lack of review, is a historic problem, but one that nobody knew the true scale of until recently. It is estimated that on an average day in England, between 30,000 and 35,000 people with a learning disability are being prescribed powerful drugs, with serious potential side effects, without clinical justification and for too long. This is often despite evidence-based alternative interventions being available.

This inequality in care is unacceptable, and it is incumbent on clinicians and every other professional involved in an individual’s care to ensure they are acting in their patient’s best interest at all times.

Royal College of General Practitioners

How healthcare providers can support STOMP

STOMP STAMP Day July 2021

See below a series of videos from the STOMP STAMP Day in July 2021 introduced by Carl Shaw & Dr Roger Banks

Somerset Health and Wellbeing list a number of mental health resources.

Mind in Somerset provide support and resources and also run a 24/7 emotional support helpline.

Every Mind Matters provides a wealth of information and resources around mental health including anxiety, low mood, stress, sleep, youth and also relating to coronavirus.

NHS recommended apps are are free to download and use. Some may have in-app purchases.

Consider HRT for low mood associated with menopause.

Consider CBT for low mood or anxiety associated with menopause.

There is no clear evidence for SSRIs or SNRIs.

See our menopause webpage for further information and resources around menopause and hormone replacement therapy.

The Somerset Emotional Wellbeing Podcast by NHS Somerset CCG’s Dr. Andrew Tresidder and Dr. Peter Bagshaw with special expert guests provides free mental and emotional wellbeing support.

The Somerset Emotional Wellbeing Staff Hub is a dedicated online resource for all health and care workers and volunteers in Somerset.

Please see our Medicines used in Pregnancy and Breastfeeding and Medicines pages for resources around prescribing in the perinatal period.

Depression / antidepressant use in pregnancy and lactation.

Please see the NHS Somerset information on prescribing SSRI’s and SNRIs in pregnancy and lactation January 2023.

The SPS have also recently published information on antidepressants used in lactation:

Using Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants during breastfeeding – SPS – Specialist Pharmacy Service – The first stop for professional medicines advice January 2023

Using tricyclic antidepressants during breastfeeding – SPS – Specialist Pharmacy Service – The first stop for professional medicines advice January 2023

Safety in Lactation: Antidepressants – SPS Information from the Specialist Pharmacy Service who host UK Drugs in Lactation Service.

Use of selective serotonin reuptake inhibitors in pregnancy- UKTIS The UK Teratology Information Service page on SSRIs.

Antidepressants and Breastfeeding – The Breastfeeding Network and Anxiety and Breastfeeding – The Breastfeeding Network The Breastfeeding Network provide evidence-based resources aimed at the public.

Anxiety

The SPS have published information on Using beta-blockers during breastfeeding

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Perinatal Mental Health Treatment provides free evidence-based resources for new parents and clinicians.

Bumps – best use of medicine in pregnancy  The Bumps website is the public facing site of UKTIS.

Improving physical healthcare for people living with severe mental illness (SMI) in primary care

The Lester Tool is recommended in the Somerset shared care guidance and nationally as a support for medication reviews in patients prescribed anti-psychotics. Although initially produced for SMI patients it should also be used as a resource for patients who also have a learning disability, autism or both and who are receiving anti-psychotic medication.

Shared Care Guidelines for ADHD, Agomelatine, Antipsychotics and Lithium can be found on our Shared Care Guidelines page.

Suicide Awareness Training ‘Suicide Lets Talk’ can be found on the Somerset Health and Wellbeing website.

Samaritans offer a free helpline 24 hours a day, 365 days a year.

Somerset Talking Therapies provide a range of options to support anyone 18 years and older who lives in the Somerset area or who is registered with a Somerset GP. Patients are able to self-refer to Talking Therapies.

• The Mental Capacity Act (2005) (MCA) and deprivation of liberty safeguards (DoLS) during the coronavirus (COVID-19) pandemic
• The Mental Capacity Act 2005: deprivation of liberty safeguards
• Deprivation of liberty safeguards: a practical guide – The Law Society have produced a practical guide for identifying a deprivation of liberty which can be found on their website
• Social Care Institute for Excellence (SCIE): Deprivation of Liberty Safeguards (DoLS) at a glance