Over the years the ‘depot clinic’ has become little more than a conveyor belt for patients to receive depot medication from nursing staff within a hospital setting. Indeed, the concept of the depot clinic has not significantly changed since the introduction of neuroleptic medication in the 1950s. A lack of review of the service has resulted in suboptimal treatment, unchecked side-effects and a lack of monitoring of physical health. We describe the redesign of a depot service within an inner city community service, with emphasis on evidence-based practice, regular, patient-centred reviews, support, health promotion and education.
Need for review and development
In 2002, as part of the ongoing development of services, we undertook a re-evaluation of medication services at our team base in South East Lambeth. Our aim was to provide a ‘one-stop shop’ for patients, thus minimising the need to attend the local psychiatric hospital. Rather than simply dispense medication, it was envisaged that the service would also provide advice on health and lifestyle issues. The review was informed by developments in other services (Reference Ohlsen, Pilowsky and SmithOhlsen et al, 2002) and recently published guidelines on evidence-based practice and physical health monitoring, with particular emphasis on diabetes and hypertension, in the management of schizophrenia (National Institute for Clinical Excellence, 2003). Psychiatric patients are vulnerable to physical health problems, which can often be complex to monitor and, if not assessed systematically, can lead to long-term complications and non-adherence to medication.
Medication review service
The medication review service operates full-time and is nurse led, employing two part-time staff. Although it is part of the case management team, patients attending the clinic are on the standard care programme approach register; clinic nurses fulfil care coordinating roles. This allows for continuity of care and ensures that patients who fail to attend for medication are followed up assertively, including by home visits. Such a model encourages the development of strong therapeutic links.
Attendees include patients with ongoing and severe mental health problems who are on long-term psychotropic medication which, for a variety of clinical reasons, is not prescribed by their general practitioners. Referrals primarily come from the case management team or out-patient clinics, and include those patients who no longer need intensive support because of ongoing stability. The clinic also provides a dispensing service for patients who are otherwise fully supported by a care coordinator within the case management or assessment and treatment teams. The system therefore permits the movement of patients from other components of the community mental health team, taking pressure off teams and maximising the appropriate use of resources.
Services focus on the ordering, dispensing and monitoring of medication, including depot preparations, in accordance with Royal College of Nursing guidelines (Royal College of Nursing, 1996). Medicines are supplied by a central pharmacy at the Maudsley Hospital and delivered once every 2 weeks. The frequency of attendance by patients depends on need, and ranges from weekly to monthly.
Patients are regularly weighed and vital signs monitored. Nursing staff are trained to take blood samples for measurement of drugs or for other assays. Electrocardiography (ECG) is carried out by nursing staff as indicated, either before or during treatment. Nurses meet with carers as part of ongoing support. Referrals are made to outside agencies, such as the dietician, welfare advisor or physiotherapist, for advice or treatment. The medication clinic provides a useful focus where up-to-date information can be disseminated. A small library and resource information pack is available to all staff, containing relevant updates, guidelines and drug information sheets.
All patients are reviewed on a regular basis by medical staff. The community senior house officer dedicates one session per week to the service and is supervised by a consultant psychiatrist. Doctors who continue to have direct clinical contact with patients, usually through their out-patient clinics, also undertake medical reviews. Most patients are seen every 6 or 12 months, but some are seen more frequently if they are undergoing a change in medication or showing signs of relapse. Medical assessment includes review of mental state, efficacy of psychotropic medication and side-effects. Switching to atypical neuroleptics, including clozapine, is encouraged. Physical examination includes ECG (at least annually) and measurement of body mass index (Reference Ohlsen, Pilowsky and SmithOhlsen et al, 2002). Cardiovascular risk factors are assessed and routine enquiry and advice given on smoking cessation, alcohol consumption, diet and exercise. Monitoring of metabolic measures, such as glucose and prolactin, is carried out in accordance with American Diabetes Association guidelines (American Diabetes Association et al, 2004) and local protocols provided by the South London and Maudsley NHS Trust (available on request). Information is passed on to general practitioners, with a request for further input if necessary. Close liaison with primary care ensures that both teams are aware of all medications being prescribed, thus minimising the risk of serious interactions or adverse effects.
Role of the pharmacist
A trust pharmacist attends the clinic on a monthly basis. This allows medical and nursing staff to discuss pharmacological issues, including potential problems or drug interactions. Patients have the opportunity to meet the pharmacist individually, and discussions are relayed to clinical staff.
Groups meet on a fortnightly basis, but are not restricted to clients of the medication service. The focus is primarily on healthy living and general health issues. Two facilitators lead the groups: a clinic nurse and another member of the community mental health team. Advice is given on diet, alcohol consumption, weight management, smoking cessation and exercise. Adherence therapy is available, but most patients are actively involved with treatment and adherence is generally good.
Clinical profile of the patients
Currently, the medication service caters for around 110 patients (54% men and 46% women), but has the capacity to manage 150 patients. Annual figures suggest a mean of 114 clinic visits per month, 15 of which include taking blood, 5 medical reviews (not including those carried out by other medical personnel) and 8 home visits. Non-attendance rates of 3% per month compare favourably with other parts of the service (Reference McIvor, Ek and CarsonMcIvor et al, 2004) and reflect the relative stability of this population.
In relation to diagnosis, 67% of patients have a diagnosis of schizophrenia, 14% bipolar affective disorder, 2% schizoaffective disorder and 17% other diagnoses (including major depressive disorder, anxiety disorder and personality disorder). Reflecting the evidence-based development of the service, the most commonly prescribed medication is atypical antipsychotics, followed by typical antipsychotics (the majority being depot medications), mood stabilisers, antidepressants, anxiolytics/sedatives, anti-muscarinics and ‘ other’ drugs respectively (mainly medical preparations such as antihypertensives). Drug combinations are common, with 41% of patients prescribed more than one psychotropic medication.
In this age of evidence-based practice, it is essential that depot clinics are updated. The medication review service has allowed us to optimise the psychiatric and physical care of patients, a model which could be of relevance to mental health services in general. Turning the depot clinic into a medication review service has reduced the clinical case-load of mental health workers within other teams, thereby giving them the opportunity to engage new clients. The service reinforces community-centred care and obviates the need for the patient to attend the local hospital, hopefully encouraging engagement. It is envisaged that many of the patients will be discharged to primary care over time.
Initial financial investment in equipment (an ECG machine, weighing scales, fridge, phlebotomy equipment and assorted furniture) is required. In addition, although not resulting in increased staffing levels, nursing job plans may require review, with some additional training being necessary. Consideration needs to be given to logistical issues such as the storage and transport of blood samples or the interpretation of ECG results.
Informal feedback indicates that patients appreciate the service, with its emphasis on support, health promotion and education. Future development will include formally assessing patient satisfaction, reviewing cost-effectiveness, increasing patient numbers and expanding available services.
Declaration of interest