Norfolk lithium database
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Transcript of Norfolk lithium database
Norfolk lithium database
Stephen BazireChief Pharmacist
Norfolk and Waveney Mental Health NHS Foundation Trust
Hon Prof, School of Pharmacy, UEA
Famous people thought to have had bipolar disorder
Adam Ant (musician) Frank Bruno (sportsman) Lord Byron (writer) Winston Churchill
(politician) Kurt Cobain (musician) Ray Davies (musician) Charles Dickens (writer) Ernest Hemingway (writer)
Linda Hamilton (actor,
Terminator) John Keats (writer) Otto Klemperer (musician) Paul Merton (comedian)
Spike Milligan (writer and comedian)
Marilyn Monroe (actress) Florence Nightingale (nurse) Edgar Allan Poe (writer) Axl Rose (musician) Robert Schumann (musician) Tony Slattery (comedian and
actor) Robert Louis Stevenson
(writer) Mark Twain (writer) Vincent van Gogh (artist) Tennessee Williams (writer) Virginia Woolf (writer)
Prof. Kay Redfield Jamison
“Lithium moderates the illness but therapy teaches you how to live with it”
Prof. Kay Jamison 1995
Bipolar spectrum
Bipolar I (classical manic-depression) Mania and severe depression or mania alone Mean age of onset 21, peak 15 - 19 years 0.8% US adults
Bipolar II depression with at least one hypomanic episode 0.5% US adults, slight gender difference (F > M) May be genetically distinct from Bipolar I
Bipolar III (Pseudounipolar Bipolar Disorder) Recurrent depression and mixed states antidepressants may induce hypomanic switching
and/or mixed states
Bipolar disorder is multidimensional
Sub-syndromal mania (hypomania)
Mania
Depression
Mania
Subsyndromaldepression
Remission
Acute and maintenance drug therapy
Licensed and widely used as mood stabilisers:
Lithium Carbamazepine (non-response
to lithium) Olanzapine (manic episode)
Licensed for mania/hypomania and relapse prevention
Valproate semisodium Antipsychotics Quetiapine Olanzapine Risperidone
Acute and adjunctive treatments:
Antipsychotics Benzodiazepines Antidepressants
Unlicensed/being investigated:
Lamotrigine (bipolar depression) Gabapentin Topiramate Other atypicals including
risperidone and clozapine Calcium-channel blockers Cannabis
Lithium - the gold standard
Cade JFJ, Lithium salts in the treatment of psychotic excitement Med J Aust 1949;36:349-52
Effective in mania Reduces number of relapse Reduces severity of relapses Reduces mortality Reduces suicide Reduces incidence of Alzheimer’s Disease Putative therapeutic plasma range
Plasma levels
Prophylactic therapy plasma levels 0.4-0.8mmol/L
Analysis of RCTs by NICE revealed that: 0.6-1.0mmol/L had lowest relapses 0.4-0.6mmol/L higher level of relapse Generally higher levels needed in acute
mania
POMH-UK audit showed monitoring was poor across the UK
The risks of not monitoring
102 litigation claims involving lithium prescribing and monitoring 53 due to inadequate monitoring 13 deaths (suicides excluded) 7 cases of renal failure 6 cases of neurological sequelae
(MDU November 2003)
Norfolk lithium database project
Norfolk-PCG/NMHC Clinical Liaison group 2000
Prescribing sub-group Lithium prescribing and monitoring:
Initial prescribing and monitoring responsibilities
Variations in therapeutic plasma levels quoted between N&N and JPH
Inconsistent approach to continuing monitoring Issuing guidelines doesn’t work
Eagles et al, Acta Psychiatr Scand 2000, 101, 349-53
Lithium monitoring- Norfolk and not very good
Lithium guidelines existed but not widely followed
Survey showed poor monitoring against Royal College of Psychiatrists guidelines (except Coast)
Surgeries showed huge variation Norfolk & Norwich Pathology lab one-year survey
32% of patients had only had one level less that 30% of patients had adequate monitoring
Shared care responsibility not recognised Plasma levels quoted
JPH 0.4-0.8mmol/L, N&N 0-1.0mmol/L
If you want a job done properly, do it yourself…
Norfolk-wide lithium database was set-up to: Maintain register of all people taking
lithium in Norfolk Send blood test reminders to all patients
every 3 months Send up to three reminders
third alerting the GP directly Ensure adequate information, education
& access to specialist advice Be integral with a full shared-care
agreement
Shared care agreement showing secondary and primary care responsibilities
It is the GP’s responsibility to act should a plasma level by out of range after stabilisation
Standard process of Norfolk lithium database
11 wkly recall letter & blood form
Test?
Yes
2nd reminder & blood form
No
No
GP ALERT& Recall 3
Test?
Yes
Letters sent out each week
Registration Welcome and
consent 7 4-week consent 2 12-week consent 1 26-week 0
* average 2002-2010
Blood reminder letters
13-week 87 17-week 17 GP alert 5
Outcomes(Lithium database started in 2002)
Tests per year
1999 2003 2004 2009
n= 1457 1283 1249 1288
3+ 46% 79% 77% 81%
2 22% 13%* 16%*
1 32% 8%* 7%*
0 ?? 0.5%
* Includes new starters and discontinuers
Structure
Based in Pharmacy at Hellesdon hospital Run by 0.8wte Band 5 plus cover
Covers Trust catchment area Norfolk and NE Suffolk
Programme is at the limits of capacity
NPSA Alert December 2009
1. Monitoring according to NICE Guidelines
2. Reliable systems for test results between labs and prescribers
3. Initiation with appropriate verbal and written information
4. Blood tests monitored regularly, no repeats without safety assured
5. Systems to detect interactions
To be implemented by December 2010
Could Norfolk system be extended?
Currently no Current database uses Access, no
further capacity Could be considered with web-
based system if rewritten
Post-PHEN/Waltham Abbey meetings update (1.7.10)
NWMHFT has allocated funds to commission P1 (software company in Norwich, maintains current database) to formulate proposals and options:
Draft Specification and vision Options include:
1. Database programme written that PCTs/Trusts could purchase and run themselves
2. NWMHFT runs national data collection from Path Labs, local PCTs/Trusts access that and send own reminders out
3. NWMHFT runs everything, with contact person locally Due to report back to PHEN (Eastern Region Chief
Pharmacists/Prescribing Advisors Network) on 20.7.10
Some issues being considered
Confidentially Continuity Would PCTs or mental health Trusts run this? Would still need a contact person locally (at least initially)
to roll-out implementation Accessing and updating changes in GPs That for each PCT/Trust, there will be patients getting
blood tests done at Path labs in different PCTs Makes tracking all patients difficult e.g. some patients from the edges of Norfolk get bloods done
in Ipswich and Bury St Edmonds Would make a national/regional data source more efficient
Stephen Bazire 1.7.10