Out of my comfort zone (Rachel Hall)

As an independent prescriber, the need to offer holistic care to my patients sometimes takes me outside my comfort zone.

One such case was with a 47-year-old man with type 2 diabetes and asthma, who was also morbidly obese and desperately needed to lose weight to control his diabetes. However, he was clearly depressed and admitted to “comfort” eating to try and make himself feel better.

His other depressive symptoms included low mood, poor sleep, lack of motivation, anhedonia, agoraphobia, feelings of worthlessness and panic attacks. Although he had a history of alcohol and drug misuse, this was not currently a problem and he denied any thoughts of self harm or suicide.

He lived alone after a divorce from his wife a few years earlier and had been stopped from seeing his children — he had also suffered an episode of depression at this time. I suggested he might benefit from some counselling, but he believed this would not help him. I offered him an appointment with one of my GP colleagues but he was adamant he did not want to see anyone other than me.

I understood this: it had certainly taken me a while to gain his trust for him to start opening up to me. I received his permission to seek advice from one of the GPs since I did not feel confident making a decision about his care in isolation.

I had previously undertaken more in-depth training in the area of mental health to enhance my role — given that 50% of patients with chronic diseases are known to suffer with some form of depression. With this training in mind and after a long discussion with a GP colleague, I felt the risks of me not trying to treat his depression, especially as we got closer to Christmas, were too great. So I prescribed him citalopram 10mg, with an aim of titrating the dose to 20mg at a follow-up consultation two weeks later.

I had chosen a selective serotonin reuptake inhibitor in line with national guidance as a first-line treatment, taking into account interactions with his other medicines. Furthermore, I surmised that, with his body mass index of 42, the appetite-suppressing properties of citalopram might indeed be beneficial for him (and treating his depression was likely to be the first step towards him adopting a healthier lifestyle).

Over the next few months he did lose weight — his BMI reduced to 38 — and his HbA_1c level reduced from 8.6% to 5.7%.

This was certainly a challenging case in terms of my development as a prescriber. Nonetheless, I was satisfied with the outcome and felt that I had certainly made the right decision by treating his depression.

 

Rachel Hall is clinical pharmacist at The Old School Surgery, Bristol