Return to PJ Online Home Page
The Pharmaceutical Journal Vol 265 No 7125 p830-831
December 02, 2000 Forum

United Kingdom Psychiatric Pharmacy Group

Current issues in mental health

Katie Sims

Current issues in mental health and the problems of co-morbidity were two themes discussed at the 25th Annual (7th International) Psychiatric Pharmacy Conference, which took place in Berkshire from October 6 to 8. Katie Sims reports

The existence of co-morbid conditions presents challenges to psychiatrists and pharmacists alike, complicating diagnosis and treatment, and often contributing to poor outcomes.
Pharmacists can play a key role in assessing factors altering treatment response, and predicting the complex interactions between medications and co-morbid conditions. One particularly relevant example is the co-morbidity of physical and psychiatric illnesses in elderly patients.

Adverse drug effects

Medication often adversely affected an elderly person's mental and physical state, Dr MAVIS EVANS (consultant old-age psychiatrist, Wirral and West Cheshire community trust) told the conference.
Discussing physical and mental co-morbidity in elderly patients, Dr Evans described how commonly prescribed medicines such as beta-blockers and digoxin, had well-known depressor effects. Corticosteroids, often used in "pulsed "regimens for rheumatoid arthritis, could produce mood alterations and paranoia. The sedating effects of medicines such as analgesics and antihistamines simply added to the problems of patients with dementia, causing confusion and paranoia. Consideration should also be given to medicines, such as cimetidine, now available over the counter that could cause CNS side effects.
Psychotropic medicines, particularly older agents such as the phenothiazines and tricyclics, had well known deleterious effects on the physical health of the elderly. Falls could result from their hypotensive effects, and from dystonic or other extra-pyramidal side effects. Anticholinergic effects could produce acute confusional states, as well as dry mouth, blurred vision and urinary retention.

 Mavis Evans
Mavis Evans: fewer problems with atypical antipsychotics

Mental health problems were often missed in the elderly, who were particularly conscious of the stigma attached to mental illness. Problems were frequently somatised into physical symptoms, which might seem more acceptable to discuss, although this process could be totally subconscious. As many as one in three elderly patients in acute hospitals might have depression, which could remain undiagnosed or not followed up.
An eight- to 12-week trial of an antipsychotic was needed to treat psychotic illness in a physically ill elderly patient. Response to treatment was delayed, and there might be a temptation to increase the dose or change the drug too soon. In addition, side effects were more common, occured at lower doses, and might be the result of drug-drug interactions. In Lewy-Body dementia, use of "old "antipsychotics was associated with increased morbidity and mortality. Problems were much less frequent with the newer, atypical antipsychotics.

Co-prescribing of atypical and typical antipsychotics

Ms SHAMEEM MIR (senior clinical pharmacist, South London and Maudsley NHS trust) presented the results of an investigation into the co-prescribing of antipsychotics. Ms Mir's original award-winning nationwide survey of over 1,100 patients last year had described how only 30 per cent of patients were prescribed an atypical antipsychotic as sole antipsychotic therapy. This year's study had investigated the reasons for co-prescribing atypical and typical antipsychotics.
Atypical antipsychotics were known to cause less extra-pyramidal side effects, less hyperprolactinaemia and less secondary negative symptoms, as well as a probable reduction in tardive dyskinesia, compared with typical antipsychotics. All these benefits would be negated if a typical antipsychotic was co-prescribed with an atypical one. Although a few small studies supported the augmentation of clozapine with agents such as sulpiride after a partial response to clozapine, the vast majority of evidence for atypical antipsychotics was for their use as a single antipsychotic.
A total of 38 patients who were eligible for inclusion in the study had been prescribed an atypical with a typical antipsychotic for over six weeks. In half the patients, an atypical had been added to a typical antipsychotic, often a depot injection, while in the remainder the typical had been added to the atypical antipsychotic. In 37 per cent of the patients' anticholinergic medication was also being taken, a figure similar to earlier findings. Studying the use of anticholinergic drugs was useful as a surrogate marker for treatment-emergent extra-pyramidal side effects.

 Shameem Mir
Shameem Mir: benefits of atypicals negated by co-prescribing

The main reason for the co-prescribing had been an attempt to treat residual psychotic symptoms (23 cases). Other documented reasons had included clozapine augmentation, adverse effects and non-compliance. In a third of cases, no outcome had been documented. Improvements recorded in the medical notes for nearly half the patients had included improvements in sleep and anxiety, as well as observations such as "more settled "and "satisfactory mental state”. However, when considering psychotic symptoms, only six patients had improved — a striking finding. Furthermore, no formal rating scales had been used to assess psychotic symptoms before or after the additional antipsychotic.
Ms Mir concluded that the co-prescription of atypical and typical antipsychotics was not evidence-based, worsened adverse effect burden, and rarely resulted in clear clinical benefit.
Mrs Christine Glover (President, Royal Pharmaceutical Society), chairing the session, remarked on the lack of information on co-prescribing of antipsychotics in the British National Formulary, and wondered whether a statement, such as the conclusion above should appear in future editions.

Health authority funding for acetylcholinesterase inhibitors

Ms SHUBRA MACE (senior clinical pharmacist, South London and Maudsley NHS trust) reminded participants of the effectiveness of acetylcholinesterase inhibiting drugs for Alzheimer's disease. The number needed to treat (NNT) value for these drugs [the number of study participants required to produce the drug's effect in one person] had been shown to be five or seven, according to recent studies. This compared well with the NNTs for antipsychotics and antidepressants (five and three, respectively). Ms Mace had conducted a postal survey of 135 prescribing advisers in health authorities and boards in England, Scotland and Wales. Surveys had been anonymous and confidential, consisting of a simple questionnaire. A total of 70 per cent of prescribing advisers had responded.
Acetylcholinesterase inhibitors were used in 84 per cent of health authorities, but specific funding for these drugs was only available in 48 per cent. In the remainder, the cost burden was shared by primary care groups and trust budgets.
Where funding was provided, in 71 per cent, prescribing was restricted to secondary care. Other conditions imposed by health authorities for funded use of these agents had included consultant-only prescribing (56 per cent), use under an agreed protocol (60 per cent), and use only for a restricted number of patients (11 per cent).

 Shubra Mace
Shubra Mace: prescribing of acetylcholinesterase inhibitors restricted

No reason had been given by the health authorities for not providing funding for these drugs in 44 per cent of replies. The reason in 30 per cent had been that these drugs were not considered to be cost-effective. Guidelines from the National Institute for Clinical Excellence (NICE) were being awaited by 14 per cent, while in 24 per cent the drugs were undergoing local clinical trials.
Ms Mace concluded that the new Alzheimer's disease drugs were widely used, but less widely funded by health authorities. Where funding was provided, a variety of conditions were imposed upon their use.
NICE guidelines on the use of acetylcholinesterase inhibitors were due in the near future.

Medication education

Medication education programmes should be a standard component of every mental health service, Ms HELEN TENNANT (pharmacy services manager, Norfolk Mental Health Care NHS trust) told the conference. Ms Tennant received the Bayer Old-Age Psychiatry Award for her study into the effectiveness of drug attitude changing techniques in elderly psychiatric patients.
It was well established that improving compliance with appropriate medicines reduced the risk of relapse. According to the "health belief model”, to comply with treatment, a patient had to accept the health issue to be of sufficient priority, accept themselves as being vulnerable to illness, accept that the illness needed treating, be convinced of the effectiveness of treatment, and consider the risk to benefit ratio to be acceptable.
The pharmacy at Norfolk Mental Health Care NHS trust already operated a ward-based medication education programme, in line with that philosophy. This programme involved six pharmacist-led sessions outlining how drugs worked, their positive and negative effects, issues of addiction, tolerance and withdrawal, relapse prevention and theories behind the illness itself. A discharge package included individualised information leaflets, information for carers and general practitioners, as well as access to a telephone helpline and website. Leaflets had been shown to have no effect on adherence, with or without counselling, whereas counselling significantly improved compliance (Peveler et al, British Medical Journal 1999;313:612). The education programme had been adapted for the old-age services, providing a weekly pharmacist-led course which was offered on old-age day hospitals. The four sessions had included general medication knowledge assessment and introduction, acute and chronic illnesses and medication, positive and negative effects of drugs and drug groups, and the action of drugs, including issues of addiction, tolerance and withdrawal.

 Helen Tennant
Helen Tennant: education by pharmacists can improve outcome

Any patient on long-term psychotropic medication had been included in the study. Four similar day hospitals had been used (two active, two control). The active group had taken part in the four weekly education sessions, with the controls attending four discussion groups instead. Assessment had been by means of the Drug Attitude Inventory scale (DAI-30), a scale validated for patients with schizophrenia taking antipsychotics. Patients had been assessed two weeks pre-course, immediately pre-course, immediately post-course and four weeks post-course.
Preliminary data indicated a detectable effect on attitude, which should result in improved compliance. Patients were in a better position to make informed and rational decisions in conjunction with professionals about their drug therapy. Limitations of the study had included the lack of patients (only six in the control group, with a target of 30) and the lack of confidence limits as yet.
Ms Tennant concluded that planned, structured and routine education of users about medication was vitally important to ensure optimum long-term outcomes. Pharmacists were the professionals best placed to provide this.
Patients' requirements for information about their treatments and compliance with therapy were key points (standards three and five) in the national service framework for mental health, published recently.