Choice Case Studies Database

Patient A Presents to the GP 8 years ago with symptoms of depression and anxiety following birth of her first child

The patient has previous contact with CAMSH as a child (further details in relation to these psychology sessions as yet unknown but they stopped when the child went to high school)

The GP assesses and commences anti depressants (SSRI)

The patient continues to see the GP on and off for over 8 years during which time the antidepressant dose is gradually increased

Two years ago she discloses to her GP that her depression is worsening and the GP refers her to the primary care mental health service where she has an assessment

She attends the assessment appointment but does not take the counselling options offered to her and DNAs. She continues to access the GP who continues to offer monthly appointments and monthly antidepressant scripts

What no professionals are aware of is that over the past 7 years she has used Dihydrocodiene initially prescribed as pain relief and then when she sought higher amounts and the GP refused to offer prescribing this involved procuring medication from elsewhere.

Over the past 4 years the patient has been accessing 'over the counter' medication in the form of Nurofen Plus and Kapake - combination analgesics with codeine and paracetamol or anti inflammatory drugs. In addition she admits to abusing the antidepressant medication which she receives form her GP on a monthly basis.

She decides to refer herself to the community substance misuse team where she is comprehensively assessed including a risk assessment. She self reports taking upwards of 30 - 40 Kapake/nurofen plus daily - she is concerned for her health and well being.

A letter is sent to the GP to share information (with her consent and to ask the GP to facilitate some tests to check out liver and renal function) - these come back as normal

It is established that she has a long standing moderate opiate dependency more recently to OTC medications and issues in relation to the compliance with her antidepressant medication

There are no serious self harm issues but she continues to experience symptoms of low mood. She is a mother of one child and on incapacity benefit

A decision is taken to develop with the patient a care plan involving opiate substitute drugs to reduce the potential harm she is doing in taking large doses of potentially toxic simple analgesics and assist her to gradually wean herself off the opiate

She receives assistance from the specialist community drug team who liaise with the patient to involve the dual diagnosis specialists nurses from the local mental health trust to support her care around her depression and anxiety

A letter is sent to the GP offering to work with them to offer a safer prescribing plan to the patient around her antidepressants

She will receive care coordination through the substance misuse team who will work closely with the GP, The mental health team, the substance misuse GPwSI. It may be in the future possible to offer the patient access to computerised CBT at the substance misuse premesis to enrich the work being undertaken in relation to her addiction and if needed refer to adult psychological therapies or a structured day treatment programme to help with wider issues such as self esteem, skills and diversionary activities etc etc