Antidepressants: experiences with the community mental health team (CMHT)

The GP is usually the first point of contact for people seeking help with depression and other mental health problems and will normally provide ongoing support. However, where problems are more complicated the GP may refer people to a community mental health team (CMHT) for more specialist help. Some specialist teams accept referrals directly from families, social workers or voluntary groups.

The CMHT includes a number of workers with specialist knowledge and skills such as a mental health worker, psychiatrist, community psychiatric nurse (CPN), social worker, occupational therapist, clinical psychologist and outreach worker. There are different types of mental health teams that operate in out-patient clinics, hospitals, day centres, and team members may also visit people at home. There are separate teams who work with children and adolescents, and the elderly.

When someone is referred, they will be assessed and the team will decide who will work with each individual. People are usually allocated a ‘key worker’ who coordinates their treatment.

‘Home Treatment’ or ‘Crisis Resolution’ are teams that are available 24 hours a day for help in an emergency. They aim to treat people in the least restricted way and as close to home as possible.

CMHTs should work closely with the GP as both are involved in prescribing medicines. If a psychiatrist recommends or starts a prescription the GP must be informed so that he or she can issue prescriptions in the usual way and be aware of all the medicines a person is taking, to keep the medical records up to date. Usually any changes or alterations to the medicines will be decided by the psychiatrist but the GP still issues the prescription. Some CPNs are able to prescribe certain medicines. (See The psychiatrist and Treatment in hospital).

It was clear from our interviews that there were variations in the way care was organised by CMHT’ in different health trusts. People told us they had seen CMHTs for treatment in hospital, at out-patients clinics, or in their own homes. Usually they had been referred because of severe or recurrent problems and the GP felt they needed specialist help. Rachel felt that being looked after ‘in the community’ was preferable to being admitted to hospital. Collette found it helpful to speak to different health professionals who had experience with mental health issues, and knew about the different medicines and their effects.

Collette said the CPN knows more about mental health…

Age at interview 28

Gender Female

Age at diagnosis 19

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Yes I said to him look this isn’t making any difference really I’m still feeling really low and I’m still having very bad thoughts, you know, and I’ve been on this for the best part of a year now, so why don’t we try something else. So he came up with a couple of suggestions and we actually worked through the pros and cons of each drug that he came up with.

And the pros and cons meaning what?

The side effects of the drug over the benefits of the drug because we obviously we’d looked at sertraline but we also looked at using in conjunction with the duloxetine quetiapine and he explained the drug and the side effects, well potential side effects and we decided in the end that Sertraline was a better option.

Is it quite helpful then to have another person that you can go to for support or advice rather than always just having the one person with their own take on things?

Yes different viewpoints give you a much wider, I don’t know experience, what might affect me might not affect you and to get different people’s experiences of it gives you a broader vision and you get to see more of how is this happening but this person coped this way and this person coped this way well maybe I can try a bit of both.

And I suppose of course a CPN has quite a wide experience of people who are experiencing mental health problems whereas GP’s aren’t quite so specialised necessarily are they?

No well that’s part of the problem the GP and I have had with the medication because she doesn’t have the experience of the mental health drugs whereas the CPN since, particularly since doing his nurse prescribers course does have the experience of the drugs and, you know, he sees the patients and he sees what side effects they have.

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Sharon’s CPN helped to integrate other therapies into her care as well as antidepressants

Age at interview 37

Gender Female

Age at diagnosis 22

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Doctors are very good but they’re a jack of all trades whereas the mental health nurse specialises in mental health and I think it’s very easy for the doctors to just, “Oh well well try you on another one,” and not to look at what effect it is having, what emotional effects it’s having or not dealing with and trying to interlock it with other therapies, that’s certainly what the mental health nurse did was put it alongside psychotherapy and the mindfulness and bring them all together and use them altogether and I think that’s been the key to not just have therapy or just have anti-depressants but to use it all because I think for me definitely you need the anti-depressants to get you up to a level that you can engage and make use of the tools that they can you provide you.

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Sometimes people are referred to the CMHT because the GP has concerns about their safety, or contact can be started in a crisis or an emergency such as an overdose, or being ‘sectioned’ under the Mental Health Act. (See Treatment in hospital).

Rachel has a long history of depressive episodes and has taken antidepressants at different times in her life. There have been several occasions when her care has been transferred to CMHT. “I thought I was going to kill myself, so I had emergency care and I was with the crisis team.” Hannah was referred to the crisis team on several occasions because she had taken an overdose. She was admitted to hospital, and when she returned home they visited her.

Rachel has been referred to the community mental health team several times…

Age at interview 51

Gender Female

Age at diagnosis 11

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When an episode has, when an episode has started the familiar, the sort of routine seems to be that I take heed or not very much of the fact that I think I’m slipping in that way, I have tried to intervene sometimes and gone to the GP sooner. I’ve then had a referral to the, I mean initially I must have just been referred but now, I mean they tend to think I think oh it’s Rachel – we’ll put her back in touch with the mental health team and part of that is because they have a whole team approach so you see the CPN of the psychiatrist and I asked for the psychologist because I’d been sort of looking into it and reading stuff and it apparently it’s slowly getting accepted that medication isn’t the be all and end all that people can be greatly helped with psychological therapies. And so I basically asked for it and kept on, kept on saying to anybody who’d listen, you know, to the CPN I was put with and the psychiatrist and stuff like that. I was saying I feel that seeing a psychologist would be really good because, because I’d rather have strategies to cope than, than medication and no strategies.

So what’s the difference then would you say between going to see a psychiatrist and seeing a psychologist?

Psychiatrists are very clinical and their answer is virtually always medication.

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When Hannah was feeling suicidal a member of the crisis…

Age at interview 28

Gender Female

Age at diagnosis 23

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I was continuing taking that but then I think they, like things were really bad at this stage and I think the Crisis Team were worried that that I was at risk of taking my life and, because they did talk to me about going into hospital as an inpatient but didn’t really say anything more about that.

But then I think so towards the end of the week there were a few times when they’d called to try and get in touch with me and I didn’t want to see them so they were concerned then. And they came, one of the staff from the Crisis Team came round and organised an urgent appointment for me to see the psychiatrist that morning and told me I had to go with him, he wanted me to go with him to see him. so then I saw the psychiatrist and he like had asked, how things were and he did ask about my medication and I think for some reason he was quite surprised that my GP hadn’t upped the dose of venlafaxine but I’m not sure if they’d instructed my GP to do that or not, I just remember that was when he asked me what I was on and I said I was on 75, I think he was surprised by that. Or yes I think like he was expecting me to be on 150 I think and yes so at the end of that meeting he had to go and speak to his consultant about what would be the best thing to do next and, so I had to wait in the waiting room for a while and then he came back and said they wanted me to come into hospital which came as a real shock to me because even though they’d mentioned it previously they’d only really mentioned it and they hadn’t, specifically said they wanted me to go in…and I was really worried about going in and what that would involve and he told, because the Crisis member of staff was still with me at that time and he told the Crisis member, team member of staff to try and find a bed for me and it just, it all seemed to be happening so quickly.

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Hannah felt unsupported when she was first diagnosed…

Age at interview 28

Gender Female

Age at diagnosis 23

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I’d gone from having not much help at all because I’d had to wait for all the time to see someone up to that point, from after being in hospital, I had the Crisis Team ringing me up all the time and you know, having to see . appointments to see the psychiatrist which in one way, you know, it was really helpful that I had that support but at the same time I found it very I felt a bit harassed almost like it was quite hard to deal with because suddenly it all happened at once and also I think I was kind of, I just wanted to go back to work and for things to be the way they were before and I didn’t, suddenly I felt like I didn’t want all of this which was, it was .

You felt it was being imposed on you?

Yes and I felt a bit like the, because I knew as well that I was in quite a vulnerable place I felt that I would come to rely on that support and one of the things I really value is, is you know being independent and I think that ties in a lot with my self-esteem when I just, so I actually pushed a lot of people away like the Crisis Team I didn’t want to see anymore.

And who, who from the Crisis Team did you see, what types of, was it CPN or?

No I’d see, well they wanted me to see a CPN, who I met with once but and he tried to arrange an appointment for me to see him but I didn’t want to see him. So he informed the consultant but.

Why, what was the reason just because of that whole that you didn’t want so many people involved?

Yes and it was just someone else new and it was, and it was almost ironic in that when I really needed the support which was when I was in hospital staring at those four walls and they weren’t coming to see me and, you know, that was when I really needed it.

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People who were felt to be at risk of harming themselves were sometimes visited at home by their key worker, in some instances daily, to give them their medicines. If the team were concerned that the person might take an overdose this was safer than allowing them a supply of their own at home.

Dina did not want to continue with the medicines she had been prescribed and felt she was being coerced by the CMHT: “They said I had to take it physically in front of them because, I mean, I didn’t want to take my medication basically – the only thing that they were doing were to bring the drugs and insist that I take the drugs.”

Although often people knew why they were being closely monitored, it could feel quite imposing. Others found that home visits gave them opportunities to talk to someone about how they were feeling or about the treatment, and get expert advice. Rachel found it difficult to leave the house, so home visits were helpful.

Sonia said her mental health team had “an open door policy” which meant that she could return to see them when she felt she needed to, without having to get a new referral from her GP.

Rachel was worried that she might not be able to access the CMHT once she had been discharged and that she would have to go through the referral process again if she needed further help.

lora thought mental health teams should work more preventatively, rather than waiting for a crisis. Several people were aware of a lack of continuity and “joined-up thinking” between the members of the mental health teams, the GP, and other therapists or counsellors they were seeing. Thomas felt frustrated that his GP, psychiatrist and psychologist seemed to have conflicting agendas: My psychologist… never focused on medication… He would see it as the psychiatrist’s job or the GP’s job. The GP and psychiatrist would see medicine as their job but not the talking therapies. So it was a complete non-communication between the people that I was seeing.”

Janet felt let down when she was transferred to the elderly care team: “It’s just hopeless, you never see the same person.”

Sonia sees a private therapist and found it was difficult being under the care of different health professionals. “They (CMHT) don’t like the fact that they have no awareness of what he’s [therapist] doing with me, equally he feels very frustrated because he feels that they’re stopping him from doing the work that he wants to do… He doesn’t agree with the medication I’m on, they want me to have therapy with them rather than him.” But Sonia preferred to see the private therapist because she had built a relationship with the person, and it was easier to fit appointments around her job.

Flora reflected that by the time she was seen by the…

Age at interview 43

Gender Female

Age at diagnosis 21

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In terms of psychiatrists and medical profession they’ve all been wonderfully kind, supportive, helpful I really, you know, can’t thank them enough because they have, they’ve been very good. The things that I feel that, where there have been shortfalls is that I feel that GP’s I don’t think know enough about how to support someone with mental health even those with the best of their intentions and so I think that appropriate referrals maybe in the past for me were not made quickly enough and in terms of medication again I think, I don’t know what the answers are for this but the GP’s just get their generic training on what they’re told the latest things are. But I actually feel that the best support that I’ve had and I’ve got has been when I have been referred to a psychiatrist and that’s when we can have in-depth conversations, that’s when I really can find out more about things because GP’s are very, you know, GP’s could never have put me on MAOI because they’re told that they can’t, it has to be only a psychiatrist.

And in terms of accessing a community mental health unit support either to get a CPN visiting you and to get psychiatric help I just feel it’s not as easy and as fast as it should be and I think it’s just that they’re very overwhelmed. And that people in my situation who generally are managing in life, have a few blips but are mostly in employment where there’s a history known the GP will try and support and suggest the counselling and the rest of it but I think that the specialists are fire fighting a lot of the time. but what happens is, certainly I found in my situation is that a lot of the time when things got extremely bad and extremely serious a lot of resources and costs had gone in to me which maybe could have been avoided, if I’d had access to their services earlier it costs a lot of money to be in there, you know, three months that are in a patient unit or, you know, to have regular CPN support and lots of meetings and lots of different health professionals, it’s very, very costly and I think the money isn’t there for the real preventative work to kind of avoid people like myself actually.

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