CMHT Surely this isn't right?

[Bridget57]

My dh is under the care of the local community mental health team. Recently, following a meeting with his Psychiatrist at the CMHT offices with his key worker present, it was agreed that one of his meds would be gradually reduced then ceased altogether. This is due to him being on it for a few years and experiencing bad physical side effects. The Psychiatrist wrote to the GP and it was decided that dh would initially go onto half a dose of the drug for 2 weeks and then cease altogether. In the letter from the psychiatrist to the GP (of which I have a copy) it states that dh is expected so suffer increased anxiety during this withdrawal period but that he has been warned about this and wants to proceed but will have the continuing support of his keyworker at the CMHT. Dh is on the last day of his reduced dosage today and I received a phone call from his keyworker for the first time since this 14 day reduction period started. He asked how dh was and I explained he was very anxious but was on the last day of taking half a dose and that he wanted to proceed. He asked what I meant by "half a dose" and why was dh so anxious. I got the impression that he had no idea what I was talking about and I had to explain everything to him in great detail. He had been present during the meeting with the psychiatrist and I was shocked he did not seem to know what I meant. Am I expecting too much from the CMHT? We are constantly being told how lucky dh is to be with them as places are limited. Should I make something of this, contact his manager or someone, or should I just leave it? Its worrying that he hasn't checked up on dh until this late stage and I think he was only phoning to arrange a usual home visit. Dh has me to look after him but what if someone lived alone and was going through severe withdrawal symptoms and he'd forgotten to check up on them? I really don't know what to do.

I’m not surprised the key worker couldn’t recall the details of the review meeting, they’ve probably seen a hundred patients since then, but it is poor that the key worker had not updated themselves of the patient record and the plan before contacting you and DH - it does not come across as professional

I’m sorry your DH is struggling so much but, re the telephone call, that person may have been there whilst this was discussed in person with the psychiatrist but they will see dozens upon dozens of people each week and won’t necessarily be able to put a face (or previous conversation) to the name of the person they are calling. It is also a lot easier for the person they are speaking to to explain what is going on than to put you on hold and read pages of notes that were taken during the last meeting.
A key worker also isn’t medically qualified so it wouldn’t be right for them to assume they understand when you are talking about a half dose, or expect them to know that a side effect of reverse titration of a particular medication, is increased anxiety . I don’t think there is any need to contact their manager.

Sounds quite typical of a CMHT worker. They are so understaffed that things pass them by all the time.

That’s bullshit. Key worker should have an idea what is happening. To be honest they should have phoned your DH not you anyway - they are the service user.

Thanks for the replies. The reason they phoned me is that I'm also dh's carer and am authorised to speak for him on medical matters. He sits and listens in to the conversations but he likes me to speak on his behalf. I'm also his DWP Appointee so am allowed to speak on his behalf to PIP etc. The key worker is actually a qualified mental health social worker, so I'd assume he'd have some idea about the medication his service users are on and the possible side effects. I spoke to dh's support worker who visited earlier today and they also said that the CMHT keyworker probably hasn't been updated after the meeting with the psychiatrist and that the keyworker probably hasn't been shown a copy of the letter from the psychiatrist that was sent to the GP requesting them to reduce the dosage and how long for etc, although that's poor if they haven't copied the keyworker in, as it specifically says in the letter that dh will likely suffer increased anxiety during the withdrawal period but will be monitored by and receive support from his CMHT Keyworker. I suppose it's all as a result of mental health services being under such strain.

ah that makes more sense -
social workers are not trained in managing medications like mental health nurses are, so really not a good idea for psychiatrist to request the SW monitors the side effects !
often the social workers don’t have access to the medical record - in many areas social work and health are different patient records and cannot see each others .. not ideal.

All of this is unlikely in a CMHT. The mental
heslth social workers I have have an excellent knowledge of the MH medications and side effects. They are skilled practitioners who are used to this sort of work. I would also expect them to have shared EPR systems too because they are usually one team.

Clearly CMHT’s in differing trusts have differing set ups -

Different trusts have different set ups. Our mental health social care is not integrated and has a separate EPR.

Even where it is integrated the roles are still a bit different and even very experienced MH social workers and OTs do not have the same knowledge of medication as nurses and would not be expected to. If there is a medication issue the expectation would be that they report back to the psychiatrist who should deal with it.

Could you or DH not call in to the duty line and ask for a visit sooner if there was an issue with bad withdrawals? I think some responsibility for managing one’s own health is increasingly expected these days especially as the CMHT support will not be forever.

I don’t see that they have done anything terribly wrong. They have called to arrange a visit and see how he is and that is what is expected.

And he has a support worker as well. They would also be able to report back if he’s suffering badly with the withdrawal. It’s the psychiatrists job to make any adjustments to meds not anyone else’s. The rest of the team provide support to cope and feedback and they seem to be doing that.

Thanks again for the replies. Maybe I'm expecting too much from the CMHT. Dh was previously with the Psychosis team for 3 years and I think we must have been "spoiled" by them as they were a constant source of support and contact. Also, the local CMHT was previously under investigation as a service user was tragically found deceased at home after a family member reported concerns about them and what they had been saying, to the CMHT, yet, after trying to contact them twice and getting no response, their keyworker didn't do any further checks and didn't report back to their manager or the family member, that they'd been unsuccessful in contacting the service user. The family member, not hearing back from the CMHT, assumed (rightly or wrongly) that they'd been in touch with the person and that everything was OK. They made the shocking discovery themselves when calling at their home a while later. Maybe this has clouded my judgement of the local CMHT and how much support/contact they offer. I just wonder that if dh lived alone, would anyone from the CMHT have bothered checking up on him to see how he was coping with the withdrawal symptoms, especially after the Psychiatrist stated in his letter to the GP that dh would be closely monitored by his keyworker during this time. Again, maybe I am expecting too much from a mental health service that is under so much strain.

First episode psychosis services are much better resourced than a general CMHT. That is why they are time limited to 3 years. It’s a bit easier to provide an intensive service that I am sure is indeed much better if you are limited to one diagnosis and one 3 year period of input. The general CMHT have everyone with every diagnosis who can be re-referred at any time for their whole life. Resources are therefore spread much more thinly.

In our service having a key worker and a support worker would be considered a pretty high level of service that most people would not get. Weekly input from someone is the max. Most people would only have fortnightly or monthly care c/o input. Many people have outpatient clinic appointments only.

The focus is on time limited interventions to achieve a goal these days (eg a course of CBT, a number of rehab sessions with an OT, support work sessions to achieve a goal such as getting back to work or being able to travel independently) The ultimate goal is to teach people to cope with their illness themselves as services are not involved for life these days even with the most serious illness.

You do in fact know that they would check on him
because they literally just did. They called off their own bat to make an appt today didn’t they after 2 weeks which is a usual frequency of contact? I would expect the person to call in sooner if they were suffering and wanted extra support unless there was a good reason to think they are not capable of that. The fact he lives with someone is factored in to the plan so it’s pointless to wonder about what if he didn’t. They would likely act differently if he didn’t because having a support network is a protective factor.

The service received really doesn’t seem unreasonable to me although of course if resources were unlimited more could always be done. Perhaps you feel understandably anxious about relapse with this meds change and you worry that support will not be there if needed. If so talk to his care c/o about expectations and how to get help in a crisis etc.

Thank you for giving such a detailed reply, explaining the role of the CMHT. My dh has only ever had a phone call or visit about once every five weeks from the CMHT. We do not, and never have had, weekly or fortnightly contact or visits and nor would we expect to, unless he was going through a period of extreme crisis. They attend our home as dh uses a wheelchair and, logistically, it is easier for them to attend our home for a 20/30 minute visit than me having to arrange specialist transport etc for him to attend their offices and for that, we are very grateful. The Support Worker is provided by a local charity due to dh being ex-forces, he has no connection with the CMHT but is a retired mental health nurse who understands the mental health care system and I sometimes ask for his advice. The main thing I have learnt from this post is to drastically reduce my expectations of the CMHT. Thanks to all those who took the time to reply.

That's not even the correct way of tapering off drugs ffs! They really are useless, even on a good day but seriously?

Obviously there is an exception if you are having dangerous side effects or have to go onto another drug that is contraindicated, but usually you would reduce the dose, usually by a quarter if possible and hold at that dose until you are no longer getting any withdrawal symptoms, then drop some more and, again, hold until your brain adjusts.

Continue until completely off. The withdrawal with this method is minimal. Dropping while you're still having withdrawal symptoms from the last drop will be utterly miserable. Poor bastard.

Thank you so much for the reply (apologies as I can't tag people in since introduction of new mumsnet app). I, also, thought it was a very drastic way to reduce the drug. It's Mirtazapine and he's been on 30mg for years and the psychiatrist reduced it to 15mg for two weeks then none at all. It was the GP who said it's the Mirtazapine that's causing the physical side effects, he's been hospitalised on a number of occasions due to seizures, all of which I've reported to the psychiatrist and they've never mentioned a possible connection to the Mirtazapine. However, after the last incident the new GP we saw had researched the drugs dh takes and immediately said it was side effects of the Mirtazapine. A meeting was then held with the psychiatrist and the CMHT Keyworker and the withdrawal plan was arranged. He is on many other drugs for psychosis, GAD and severe depression as well as many meds for his physical health problems, so we didn't think it would make much difference to his mental health if he dropped the Mirtazapine, but the side effects of withdrawal have been awful. He's had many sessions of CBT via psychosis team and it was recommended that he have PTSD trauma therapy when he was transferred over to the CMHT in 2022 but we are still awaiting it. I had to give up my job to become his full time carer, which I don't resent but at times such as this, it can be extremely difficult. I phoned CMHT for help after the first week of withdrawal and it took another week for the keyworker to return my call (this might not be his fault as messages haven't been relayed to him in the past but I've also texted him, as he specifically requested me to do, and he rarely replies to or even acknowledges my texts) then when he didn't appear to know what I was talking about regarding the withdrawal plan, when he'd been sat in the actual meeting with us, it just made me lose all faith in these people. However, I can appreciate that they are very busy and see many other people, probably making it difficult to keep track of individual cases.

It might have been because of the seizures, if they needed to get him off it quickly.

15mg is the lowest dose so the only way to come off it any slower would be to get the very expensive liquid preparation or you could try to halve a 15mg tab to get 7.5mg but it’s not an ‘official’ dose. It would be very hard to go slower with mirtazapine as smaller increment tabs just don’t exist and it’s not one that’s notorious for withdrawals so most people would have the kind of withdrawal regime that he has been advised and be OK with it. If he isn’t then the choices are to wait it out or to go back to the previous dose and try to withdraw it more slowly by halving tabs or trying to to get liquid (not always available)

Thank you for the information about the Mirtazapine, that's really useful. He is struggling at the moment, he's just told me that he is feeling very low. He desperately wants to persevere with the withdrawal as, if the Mirtazapine really is causing the seizures, then he has to cut it out completely. He is also on quite high doses of Olanzapine and Venlafaxine, so I was hoping that these would be enough to help him cope with the anxiety and depression after he cuts out the Mirtazapine. I think we are both probably guilty of anticipating him suffering withdrawal symptoms after reading what the psychiatrist put in his letter about this being expected. I'll continue to monitor him myself and hopefully he'll start to feel better soon.