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People who experience mental illness and/or addiction have higher rates of physical illness and die up to 25 years earlier than the general population. There are a number of factors that account for this disparity, including socio-economic status, side-effects of psychotropic medication and greater exposure to risk factors such as smoking. Health care delivery can also be a contributing factor, for example, through fragmentation of care across different providers, lack of clarity with regard to who is responsible for the monitoring and ongoing management of the physical health of people with mental illness and/or addiction, and stigma and discrimination. (Te Pou o Te Whakaaro Nui, 2014)
Provision of holistic care is an important focus for me as Mental Health Commissioner. General Practitioners (GPs) play an important role in ensuring that both the physical and mental health needs of people who experience mental illness and/or addiction are assessed and responded to. By providing seamless, non-judgmental care for the whole person, health providers can positively influence outcomes for this population group.
HDC recently released a report finding a general practitioner (GP) and a medical practice in breach of the Code of Health and Disability Services Consumers' Rights (the Code) for the services provided to a man with longstanding psychiatric issues and a number of physical co-morbidities (including diabetes, obesity, obstructive sleep apnoea, fatty liver and previous pulmonary embolus) (15HDC00196, 23 June 2016).
When the man became a patient of the GP he was on a drug regimen that included high doses of diazepam, paroxetine, lithium and codeine. This drug regimen had been established by psychiatrists in both New Zealand and overseas. Over a period of six years, the man was prescribed lithium without regular reviews of his serum lithium levels. The man's blood tests began to indicate deterioration in his renal function, and the man reported a hand tremor, a common side effect of lithium toxicity. On two occasions the man was reviewed by specialists, a consultant psychiatrist and an endocrinologist, who both recommended changes to this medication regime, but these changes were not implemented in a timely manner.
While HDC acknowledged the man's conditions and management were complex and a mitigating factor when considering those failures, he remained critical of the care provider. HDC found that the GP failed to assess the man's serum lithium levels adequately, did not document any consideration that the man might be suffering side effects from lithium toxicity, took no action to assess whether the lithium might be causing the man's tremor, and failed to ensure that specialist ordered changes to the man's medication regimen were made in a timely manner.
HDC also found that the GP's medical practice failed to have systems in place to facilitate co-operation between providers to ensure that quality and continuity of services were provided to the man. In relation to the failures by the medical practice HDC's expert clinical advisor stated "[the man] saw multiple providers and had multiple prescribers and I feel this situation may have contributed to some of the suboptimal aspects of his management … While staffing at [the medical centre] may have made such continuity of care difficult, this situation necessitated effective communication between providers and robust processes particularly around review and actioning of reports and results, and repeat prescribing, and I feel there were significant deficiencies in these areas."
HDC recommended that the GP provide a written apology to the man and undertake training on the prescribing of psychotropic medication. It was recommended that the Medical Council of New Zealand consider whether a review of the GP's competence was warranted.
With regard to the GP's medical practice, HDC recommended it put in place and finalise a repeat prescribing policy that includes information on patient review timeframes; and a policy for the robust filing of reviews and reports, including specialist advice, received by the practice requiring action. These recommendations have been met by both the GP and the practice.
Many people with coexisting mental health and/or addiction and physical health needs present with complex conditions that can be challenging to manage (1). This case is a reminder of the care and responsibility of practitioners to be familiar with the side effects of psychotropic medication when prescribing and to assess the patient's condition adequately, including to review new information about a patient's condition and health for repeat prescriptions. For medical practices, it demonstrates the need to consider service linkages and strategies and policies to mitigate structural separation between mental and physical health care to ensure care for the whole person.
(1) Footnote: The need for GPs to adequately consider the physical health of people with mental health or addiction issues was also identified by HDC in 13HDC00048 and 10HDC00610.