To illustrate this I will utilise the model of reflection adapted from (Boud, Keogh and Walker 1985) as to focus on influences on prescribing, psychology of prescribing working through the consultation, decision-making and therapy, and referral.
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Being present in the consultation as a non-medical prescriber challenged me to ask questions about my own practice and the consultant psychiatrist, focussing on how we arrived at our decisions and occasionally resulting in contrasting views.
According to (Butler et al 1998) many authorities advise that the prime skills associated with the prescribing process are:
Adequate exploration of the patient’s worries
Adequate provision of information to the patient regarding the natural processes of the disease being treated
The advisability of self-medication in trivial illness
The issue pertaining to poor communication has a negative impact with patient-practitioner relationship and was acknowledged in an informative paper by (Britten et al 2000). Ultimately, all of the failures of communication were linked with an absence of the patient’s involvement during the consultation process.
There is evidence that failure to actively engage in, or even consider, the patient’s perspective is a common failing amongst prescribers. (Britten et al 2000).
Very often there is a focus on the term compliance and it is only recently that nurses are focussing on the more apt term of concordance. The term compliance was viewed as being authority laden (Marinker 1997) where it was expected that patients complied implicitly and without question when a prescription was given. There was little acceptance that patients would actively participate in the decision making process that surrounded the generation of the prescription. (Cox et al. 2002)
Objective recognition of the patient’s perspectives, requirements and beliefs need to be acknowledged and then the recognition of any major differences between these and the prescriber’s needs could be perceived when providing nursing care.
It is not just the act of writing out the prescription that is important, but it is the understanding of the processes and dynamics of the interactions that are taking place between prescriber and patient that are the fundamental key to good prescribing practice (Kuhse et al 2001).
The consultation I chose to focus on was carried out by a consultant psychiatrist who for the purposes of this work shall be known as DR S, with myself as an observer of the consultation.
The patient to be seen was a 45 year old gentleman who will be known for the purposes of this work as Mr A, who had been referred by dermatology to the mental health out-patients clinic as a new patient.
Dermatology had referred this gentleman after a 12 month history of attending their department where Mr A had complained of persistent generalised skin irritation, and despite receiving treatment with them it appeared he may have an underlying mental health issue.
Dr S began the interview by thoroughly reading the referral from dermatology and establishing what had been the concern from their point of view.
The patient was then seen and before Dr S had chance to ask the patient anything Mr A expressed that he was confused as to why he had been referred to the mental health department, and not dermatology, which he perceived his medical complaint to be related to.
The British Medical Journal (2000) has recognised a common theme amongst studies of patients in that they have a tendency to prefer prescribers (doctors or nurses) who listen and provide time for the individual to express their concerns without feeling hurried
Dr S asked Mr A why he had been attending Dermatology to which Mr A detailed a 12 month history of describing an itchy scalp, generalised skin irritation and said no treatment had so far helped him. Mr A then went on to express that he felt all of these symptoms may be due to a parasite, or a bug which was doing something to him, and described a feeling of the bug weaving something on his face which enveloped his eyes. Other symptoms he described was that this bug or parasite was all the time making him feel thirsty and taking moisture from his body, and could somehow transpose itself to other people, including his own GP and friends describing like a magnetic type effect.
From this initial information it was evident that Mr A was suffering from a delusional disorder which was quite systemised and concrete and Mr A appeared not to display any other symptoms of mental health. A diagnosis of parasitosis delusional disorder was made.
It was clear Mr A needed treatment but the main factor to consider was that Mr A did not believe he any form of mental disorder and therefore there was a real issue surrounding concordance with proposed treatment.
Usually, it is difficult to obtain informed consent to treat patients with delusional parasitosis with antipsychotics. Therefore experienced clinicians tell their patients that the antipsychotics are effective `against the itch’ or the `problems with the pests’ in order not to have to lie. (Musalek, 1991; Driscoll et al, 1993; Winsten, 1997; Freudenmann, 2002).
This is due to the patients’ level of insight hindering their decision to accept treatment, because they hold a non-reality based idea that it is a somatic illness.
It is therefore found that the patient will normally have sought help from their G.P., dermatologists and will often be adverse to the idea of seeing a mental health professional
A full medical history was taken, looking at any familial medical problems, family composition and looking at the social aspects of MR A to include areas of employment, relationships, and any drug/alcohol usage.
There have been some criticisms of the education of nurse prescribing in relation to the communication skills of nurses, where it is felt that historically there has been too much of a focus on taking a history and coming to a diagnosis.
It was apparent to me that Dr S had to use his skill as an experienced mental health clinician to challenge Mr A’s concept of his illness not being related to a problem with his mental health
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Dr A approached the issue of explaining Mr A symptoms, not referring to mental health or delusions, but explaining Mr A’s perceived symptoms by informing him that although he believed that these experiences were real to MR A , that his brain was interpreting false signals resulting in these unusual thoughts. Dr A went on to use the analogy of an amputee who perceives that he can still feel is amputated leg, through false interpretations of the brain.
Drew et al. (2001). found that prescribers would emphasise the positive benefits of the medication far more frequently than they would discuss the risks and precautions, despite the fact that the patient’s perception was that such a discussion is seen as essential.
Therefore looking at this, this could lead to patient confusion, with patient anxieties, and a degree of ambivalence to medication being offered to them.
It is transparent that if there is a degree of empathic display between that of the patient and the prescriber, there is a greater chance of concordance.
This will hopefully lead to an increased level of compliance/concordance and patient satisfaction resulting in desired clinical results
Here we face the issue surrounding honesty, integrity, consent and acting in the best interest of the patients in focussing on treatment
The issue of treatment was then discussed by Dr A, who said to Mr S that he believed he could help him by prescribing some medication for him that would help relive the distressing symptoms he was experiencing.
Mr A initially expressed some confusion once more why he was not seeing dermatology as he perceived the problem needed treating by them
This indicates that Mr S was still not displaying any insight and the questions of concordance issues were reconsidered.
The National Institute for Clinical Excellence (NICE 2002) recommends that a risk assessment should be performed by the mental health clinician responsible for treatment and the multidisciplinary team regarding concordance with medication, and depot preparations should be prescribed when appropriate.
Mr A questioned the proposed medication and it was explained to him that he would be given a course of Neuroleptic medication of a new medication called Aripiprazole. Dr A said that although the medication leaflet would mention the medication was used for Schizophrenia, that Mr A should not be too worried about that as that was not the reason why he would be taking it. Dr A then went on to say that the leaflet would also explain possible side-effects and that although it listed quite a few they were quite rare.
The paper by (Cox et al.2000) found that it was common practice for prescribers to initiate the discussions about just what medication they were going to prescribe, rarely refer to the medicine by name and equally rarely refer to how a newly prescribed medication is perceived to differ in either action or purpose, to those previously prescribed. Patient understanding is rarely checked as it is usually assumed after the prescriber has given the prescription. Even when invited to do so, patients seldom take the opportunity to ask questions. (Cox et al 2000)
I felt it was the right thing to initiate pharmacological treatment, although on reading further research surrounding the best treatment for Parisitosis I would question the choice of medication Mr A was commenced on
However, after spending many clinical hours with this particular Consultant Psychiatrist, I am aware that he has high tendency of prescribing Aripiprazole for the majority of his clients.
On questioning Dr A about his decision for choice of medication, Dr A commented that it is the newest and most effective of the atypical medications with lesser incidence of side effect relative to other medications in its group. I had to question myself that there may be other factors influencing in the prescribing decision which were not based on any of the NICE guidance or that of the British Journal of Psychiatry. In fact, Dr A replied to me with medical jargon relating to molecular structures of both the brain and chemical make-up of Aripiprazole which was hard to follow due to its complexity.
I was conscious that as a consultant psychiatrist of many years experience, I was not sure of the honesty or consequences if I had challenged Dr A about his continued choice of Aripiprazole against other choices of medication any further.
After researching treatment for this disorder, I felt that the initiation of a typical antipsychotic should have seriously been considered due to its proven faster working efficacy. However, it is known that typical antipsychotics have an increased prevalence of side-effects. Therefore I had considered the preliminary use of typical antipsychotics to establish a degree of insight into the beneficence of taking medication, and if it was felt that further pharmacological treatment is required then switch to a typical antipsychotic as recommended by the NICE guidelines.
An article in the British Journal of Psychiatry (2007) highlighted that delusional parasitosis has shown significant treatment results with the use of typical antipsychotics. (Trabert’s 1995) found that the introduction of typical antipsychotics has substantially improved remission rates
(Frithz 1979) described another important treatment in delusional parasitosis is to consider typical anti-psychotic depot medication. This was suggested, as was earlier highlighted that one of the main stumbling blocks is a lack of insight that causes patients t be reluctant to accept oral medication.
However, the administration of medication in injection form might be viewed by the patient as the answer to their somatic perception of their illness. It would be hoped that the injection would lead to a degree of insight where the patient may be more open to accept regular medication
At the end of the consultation the patient Mr A agreed to take the medication as prescribed and was offered a further out-patients appointment in 2 weeks time.
Ultimately, I accept a clear indication for medication, and in conjunction with this at a later stage this could be combined with some cognitive behavioural therapy should symptoms persist.
Clinical Governance plays an important part in relation to prescribing., and in particular for non-medical prescribers role .(Bradley E and Nolan P 2005) state that training courses must remain up-to-date and flexible and must change in response to changes in government policy on non-medical prescribing, with nurse prescribing leads being involved in any discussion about course development.
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