Chapter 34: Psychopharmacology for mental health nurses

Case Study: Community psychiatric nurse

Bill is a community psychiatric nurse (CPN) who has a large caseload of people diagnosed with serious mental health problems. Within the best of his capabilities Bill attempts to work psychosocially and include interested family members in the care of service users with their agreement. Bill has a few people on his caseload who are fairly cooperative with the care team’s ideas for care and treatment, but who dislike or even outright reject their diagnosis. Typically, this is a diagnosis of schizophrenia. In these circumstances Bill takes a pragmatic approach, valuing engagement and therapeutic alliance above insisting that people accept a diagnostic category. In these circumstances, Bill tempts to work in a co-productive way, focusing upon agreed problems and needs rather than a psychiatric view of symptoms.

As long as people are keeping well and agree to take medication, this approach does not cause problems for other members of the care team. Indeed, many of the team are committed to a continuum model of mental distress. In circumstances were patients also reject the idea of medication, or wish to reduce dosage or cease taking a prescription all together, then there is the potential for more disagreement amongst the team. Presently, one of Bill’s patients, Anne, has begun to attend a local hearing voices group and wants to reduce her prescribed antipsychotic medication with a plan to come off it all together. Anne is confident that friends she has in the HV group have successfully come off their medication in the past, and they are willing to help and support her to do the same. She has discussed this decision with her family and they are broadly supportive, but also anxious about what lies ahead.

Questions

  • How should Bill work with Anne from this point in time?
  • What sort of discussions should take place with other members of the care team? And what should happen if there is disagreement amongst the care team?
  • What resources might Bill support Anne to access so that her choices are fully informed and she may be optimally supported to action her decisions?
  • If the care team are willing to support a decision to cease medication, how should this proceed to ensure safety and what contingency plans should be put in place?

› Possible answer

Bill’s commitment to co-produced care and a person-centred approach can carry on, including respecting Anne’s wishes as she clearly has the capacity to make such a decision for herself and appears to have a decent support network including the hearing voices group. Working psychosocially, Bill would be advised to meet with Anne and her family to talk through plans and help to ease family anxieties. In this regard, the concerned family members can also be involved as supporters of Anne’s goals and critical friends in helping her see if things are going off the rails, for instance keeping an eye out for signs of worsening mental health, perhaps as a rebound effect of stopping the medication or dose reduction.

Ideally, all of the care team, especially the psychiatrist will be on board with helping Anne. They will probably recommend a period of incremental dose reduction with monitoring of impact, usually being prepared to reintroduce dosages if mental health deteriorates rapidly. At such a juncture it is important not to confuse withdrawal effects with actual relapse. Anne, Bill and the team can access advice and resources from initiatives such as Icarus or UK-based teams who exist to help people make transitions off psychotropic medication. Plans can then be put in place that also include how best to respond if Anne becomes unwell in the course of transitioning off drugs.

The team may not be willing to support Anne in her decision, because of concerns over her best interests as they see them. This might involve Bill and others in more challenging dialogue within the team: regarding the value of person-centredness, balancing risks of relapse with benefits of being drug free, and more general points about positive risk taking. Bill may also wish to suggest that Anne seeks the support of an independent advocate.