Raising the profile of mental health

Speakers at the College of Pharmacy Practice college day in Dunchurch, Warwickshire, on May 4 discussed treatment of psychiatric disorders and the implications for the profession of the recently published national service framework on mental health

Acute concerns about psychiatric care

Mental health was a major priority for the Government, which was deluging health care professionals with papers on the subject and yet, to most pharmacists, mental health had an extremely low profile, said Dr DAVID BRANFORD (director of pharmacy, Southern Derbyshire mental health NHS trust).
Among other things, the Mental Health Act was being reviewed and a new national service framework that dealt with mental health had been published. New medicines were becoming available for treating depression, schizophrenia, Alzheimer's disease and mania. All of these were expensive and were causing a big problem with funding. Patients had major concerns about their medicines and, with the difficulty of recruiting doctors, including consultant psychiatrists, expertise in the treatment of psychiatric illness was desperately needed. Most consultants dealt with their community caseload with no access to drug information. In most hospitals, pharmacy was either detached from the service or entirely absent, with supply made by other hospitals as pharmacies were closed down.
In general, pharmacists were poorly trained to cope with the demands of acute psychiatric wards and most posts were filled by insufficiently experienced pharmacists. Yet, up to 45 per cent of admissions could be avoided if adequate arrangements were made in the community. In some ways, this figure was no surprise, as patients and carers were rarely provided with any information about the nature of their illness or treatment. There was little liaison between hospital and community pharmacists and yet, out of all of the health care team, the community pharmacist had the most regular contact with these patients. This was a link that had to be exploited, Dr Branford concluded.

David Branford: psychiatry currently a low priority for pharmacists

The national service framework for mental health

Pharmacists and pharmacy were hardly mentioned in the national service framework (NSF) for mental health but this did not mean that there were no opportunities for the profession to be involved, said Mr PETER PRATT (chief pharmacist, Community Health Sheffield). The document had been developed as part of the government's vision for modernising the NHS. The NSF aimed to improve the overall quality of health care and the service to patients requiring mental health services, Mr Pratt said.
A literal interpretation of the NSF would suggest that pharmacists had little part to play in the care of mental health patients. However, it was his belief that pharmacy had a central role in getting drug treatment right. Pharmacists could be involved in developing drug protocols, helping to manage drug treatment of patients who had complex drug regimes and those whose needs fell outside standard treatment guidelines. Pharmacists specialising in mental health could educate and train other members of the health care team, be a source of drug information for patients and carers and be involved in audit. Lastly, pharmacists who wished to undertake research should use the NSF as a guide to suitable topics.
If pharmacists regarded the NSF as an opportunity and actively looked for ways in which they could contribute, they would be seen as one of the main drivers for its implementation. If they could not do this and simply sat back feeling left out, they would have no role in a modern mental health service, he warned.

The case for atypical antipsychotics

It could be knowingly causing harm to continue to use typical antipsychotics in patients with schizophrenia, as atypical antipsychotics are better tolerated and are as effective as typical antipsychotics, said Mr DAVID TAYLOR (chief pharmacist, Maudsley hospital).
The main side effects of typical antipsychotics, such as thioridazine and haloperidol, included extrapyramidal symptoms, tardive dyskinesia, akathesia and increased prolactin production.
Clinical trials had shown that atypical antipsychotics, such as olanzapine and risperidone, were as effective as older drugs at treating positive symptoms of schizophrenia and were at least as effective for negative and cognitive symptoms. Atypical anti-psychotics had fewer side effects, yet even leading psychiatric hospitals only used them in 35 per cent of their patients, he said.
Many health authorities were not funding atypical antipsychotic drugs currently and were waiting for forthcoming guidance from the National Institute for Clinical Excellence, he continued. Mr Taylor said that recent recommendations that low doses of typical antipsychotic be used as a way to reduce side effects were unhelpful both because the drugs did not work and still caused problems at low doses. It was for these reasons that nobody currently prescribed typical antipsychotics in this way.
He suggested that the recommendation to use low doses had been made because the alternative was to use expensive atypical drugs. Mr Taylor speculated that if the atypical drugs had been cheaper, they would have been recommended instead.
If patients suffering from their first attack of schizophrenia were exposed to drugs that caused severe side effects, this could affect their attitude to drug treatment for the rest of their life, he concluded.

David Taylor: use atypical antipsychotics

Anxiety - when does it become a disorder?

Anxiety was a normal response to stressors but it became pathological when no stressor could be identified, when the anxiety was disproportionate to the degree of stress and when it stopped the sufferer from leading a normal life. So said Mrs CELIA FEETAM (clinical psychiatric pharmacist, Priory Hospitals), who gave participants at the college day an overview of the treatment of anxiety.
Many patients did not seek treatment and received little help when they did. Of those who sought treatment, only 33 per cent were correctly diagnosed, of whom 60 per cent received treatment, and of whom fewer than 10 per cent received adequate treatment, Mrs Feetam stated.
Anxiety could be either primary or secondary, she explained. Primary anxiety manifested itself as panic disorder, as phobia and as generalised anxiety disorder (GAD) - a chronic, unremitting feeling of anxiety. These disorders had similar symptoms but different triggers and time scales. Secondary anxiety arose as a result of another illness, such as depression, thyrotoxicosis or phaeochromocytoma. In addition, some patients suffered from a combination of primary and secondary anxiety.
Pathological anxiety affected 15 per cent of the UK population and the incidence of suicide among sufferers was high. Symptoms included motor tension (eg, muscle rigidity), autonomic hyperactivity (eg, sweating, dry mouth) and hyperarousal. However, patients might present complaining of heart, gut or respiratory problems rather than anxiety, she warned.
GAD affected between 2 and 5 per cent of the UK population. Diagnosis could only be confirmed if the patient had had persistent, excessive anxiety, together with symptoms of apprehension and worry, for six consecutive months. Onset was generally in early childhood and females were more likely to suffer than males. The cause was not known but might be a biological abnormality or be caused by an indirect genetic link. About 30 to 90 per cent of sufferers had another major psychiatric disorder, which was frequently either depression or a personality disorder.
GAD was hard to treat, Mrs Feetam said. It could be managed pharmacologically, non-pharmacologically (eg, with counselling), by a mixture of these treatments or surgically. Drugs used included benzodiazepines, antidepressants, buspirone, beta-blockers, antipsychotics or antihistamines. Antihistamines were largely used for their sedative effect, she commented.
Future drug treatments might include inositol, cholecystokinin antagonists, GABA analogues and drugs that acted as both 5HT1A partial agonists and 5HT2 antagonists.

Dealing with treatment of depression

Pharmacists must become more involved in ensuring that patients with depression receive appropriate treatment, said Mr STEPHEN BAZIRE (pharmacy services director, Norfolk mental health care NHS trust). The NSF for mental health had highlighted that treatment of depression often had a poor outcome, antidepressant drugs were used at ineffective doses, there was a need for protocols for the use of drugs to treat depression and patients were given inadequate information abut their drugs.
Appropriate medication and improved concordance reduced the risk of relapse. Pharmacists could provide information and education about drugs to both patients and carers, as this improved the attitude and compliance of patients to their drugs. In addition, pharmacists should encourage the use of appropriate doses and durations of treatment with antidepressants and recognise and minimise discontinuation effects. The profession was ideally placed to be involved in the development of primary and secondary care protocols. In particular, by emphasising the correct use of antidepressants, providing advice on switching drugs and discontinuing treatment and on the place of newer drugs in therapy. Pharmacists were also in a position to determine whether depression might be drug-induced.
Tricyclic antidepressants were used at subtherapeutic doses. In the UK, 88 per cent of prescriptions were for subtherapeutic doses, while in Italy and Denmark, the figures were 80 per cent and 75 per cent, respectively. Tricyclic antidepressants had been shown to be about 70 per cent effective at preventing relapse at full doses but this figure decreased to about 25 per cent at half doses. When tricyclics were compared with selective serotonin reuptake inhibitors (SSRIs), it had been found that patients were seven times more likely to complete a course of adequate dose and duration (more than 120 days) of SSRIs than tricyclics.
Mr Bazire said that patients who did not respond even minimally during the first four weeks of a therapeutic dose of an antidepressant should be switched to a different drug. Those who improved minimally before, but not after, five weeks of treatment should also be switched. However, those who improved minimally in week five should continue for another week. When switching a patient from one antidepressant to another, the factors that had to be considered were the speed at which the switch was needed, the current dose of the first drug, the type of drugs being used and the susceptibility of individuals to side-effects. The problems that might be encountered when switching from one drug to another included discontinuation symptoms, interactions and discontinuation effects of the first drug being mistaken for side-effects of the second. A number of recommendations had been made regarding the continuation of antidepressant treatment after resolution of symptoms. These ranged from 16 to 20 months to six months or more after recovery.
Turning to discontinuation phenomena, Mr Bazire said that these usually began to be noticed one to three days after the antidepressant had been withdrawn and had even been noted when patients missed doses. They were short-lived, only lasting one or two weeks and could be suppressed rapidly by reintroducing the drug. Discontinuation phenomena were distinct from relapses or recurrence, which tended to occur more than two weeks after stopping drug treatment. It was controversial as to whether antidepressants were addictive as no craving for the drug was felt by the patient.
The symptoms of withdrawal of tricyclic antidepressants included cholinergic rebound (headache, restlessness, diarrhoea, nausea), 'flu-like symptoms, lethargy, sleep disturbances and movement disorders. Those encountered with SSRIs included dizziness and light-headedness, sleep disturbances, agitation and volatility, a sensation of a sudden "electric shock" to the head, 'flu-like symptoms, headache and fatigue. These symptoms could cause morbidity. For example, ataxia might be a problem for working patients and dizziness might lead to unnecessary investigations being made. There was a potential for misdiagnosis, as discontinuation symptoms might be mistaken for a relapse of depression or a physical disorder. In addition, they could have a negative effect on compliance.
To overcome these problems, patients should be warned what to expect. They should be told that antidepressants were effective and that they began to work after two to four weeks. The importance of taking their medicine every day and not stopping taking them suddenly should be emphasised. It was important that patients remembered to take their antidepressant with them when they went on holiday. Pharmacists could provide patients with this support, he said.

The Pharmaceutical Journal Vol 264 No 7096 p734-735
May 13, 2000 Forum

College of Pharmacy Practice