The Pharmaceutical Journal
Vol 273 No 7323 p657
30 October 2004

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United Kingdom Psychiatric Pharmacy Group

Patient safety in mental health care

Patient safety in mental health was the subject of the keynote address by David Cousins. Professor Cousins, head of safe medication practice at the National Patient Safety Agency described how the NPSA and mental health pharmacists could work together to improve the safety surrounding medicines management in mental health. Lessons learnt from safety critical industries elsewhere clearly indicate that underlying systems are often the root cause of problems in this area. He said the National Reporting and Learning System will be launched in 2005 as a reporting system for medication errors as well as near misses across primary and secondary care in England and Wales. Mental health pharmacists working closely as integral members of the multidisciplinary team, as well as with patients and carers, are well placed to prevent untoward events occurring, to promote the safe use of medicines and to ensure that risk reduction systems are in place.

Bipolar disorder

In a session devoted to bipolar disorder, Stephen Bazire, chief pharmacist, Norfolk and Waveney Mental Health Partnership NHS Trust spoke about the importance of an early and accurate diagnosis. He suggested prevalence rates for this potentially life long, disabling disorder may underestimate the true situation. Bipolar disorder is thought to be significantly under-diagnosed and is associated with considerable co-morbidity, as well as substance misuse and a high suicide rate.

Tony Hale, professor of psychiatry, University of Kent, went on to describe the latest treatments for bipolar disorder. He told the conference that between 1993 and 2000 nine new mood stabilisers had been approved by the US Food and Drug Administration. There were good data for seven of these for the treatment of bipolar disorder, however, with the exception of oxcarbazine, they were generally ineffective in mania. Some efficacy had been demonstrated for bipolar depression and associated co-morbidities. Lamotrigine, in particular, is effective as a prophylaxis against bipolar depression and although not licensed for this indication in the UK it is licensed and extensively used elsewhere in Europe. He concluded by reviewing atypical antipsychotic as treatments for bipolar mania. Olanzapine, quetiapine and risperidone are all licensed for this indication and the evidence to date suggests that the prescription of a mood stabiliser as monotherapy is inferior to the combined use of an atypical antipsychotic with a mood stabiliser.

Patients’ and carers’ viewpoints were then presented by Vicky Lawson, self-training training manager of the Manic Depression Fellowship. She talked about the work of the MDF and how people affected by the disorder can be assisted to manage their mood swings. She also presented some results of the “Our points of view survey”, a joint venture between the MDF, Rethink and Mind. General concerns focused around lack of choice, side effects and attitudes of professionals, including pharmacists, to service users and poor follow-up. Pharmacists have an important role to play here in addressing some of these issues which clearly cause patients and their carers considerable distress.

The final presentation in this session was from Peter Kinderman, reader in clinical psychology, University of Liverpool. He addressed the psychological treatment of bipolar disorder and talked about holistic and integrative care. We need to know how medicines impact on the psychological processes involved in the disorder. He spoke in some detail about cognitive behavioural therapy and relapse prevention. Sufferers are often able to recognise prodromal signs of both depressive and manic relapse. They should then be encouraged to seek help. He concluded that psychological therapies are effective and must be made available, together with medication to those suffering from this distressing but manageable condition.

Treating children and adolescents

An overview of mental health services for children and adolescents was provided by Helen Holmes, consultant child psychiatrist, Cardiff. She described the multidisciplinary nature of such services but added that service provision remains patchy despite the Health Advisory Service review document which introduced the concept of four tiers. The Audit Commission report in 1999 first recognised the importance of the correct diagnosis and treatment of mental disorders in young people who may previously have been described as suffering from “growing pains” and left to the parents to manage. Extra resources have since been made available to help authorities and trusts to tackle this agenda, and improve the lives of the many children and young people who are among some of the most disadvantaged in our society. More recently the Children’s National Service Framework has, as standard 9, the mental health and psychological well-being of children and young people. It also endorses and encourages multi-disciplinary working.

Gordan Bates, from Birmingham, gave an overview of attention deficit hyperactivity disorder and its treatment, including the use of Ritalin as well as the newer agent atomoxetine. He gave practical advice about the management and treatment of this condition. Examples include the need to add immediate release Ritalin to the modified release formulation in the afternoon to facilitate homework sessions, the value of the modified release formulation in reducing the stigma attached, in some schools, to having to go to the school nurse for a dose of the medicine, and the use of high doses when lower dose fail.

Following the recurrent theme of looking at psychological as well as pharmacological interventions, Steve Killick, a chartered clinical psychologist, said that cognitive behavioural therapy (CBT) is increasingly used with children, young people and their parents and families. Treatments have been developed for a whole range of disorders in this group, including anxiety, depression, eating disorders, anger management and behaviour change. CBT is essentially a mix of behavioural theory, cognitive science and humanistic therapy with the aim of producing a collaborative, problem solving and psycho-educational approach. Perhaps as much as 20 per cent of young people experience mental health problems. There has been a 70 per cent increase in depression and anxiety in young people aged 15 since 1986: 50,000 children and young people in the UK were on antidepressants in 2003. Following the recent Medicines and Healthcare products Regulatory Agency warnings about the use of antidepressants in children and adolescents, CBT for this population should be more available, he said.

Legal issues surrounding the use of medicines in young people were mentioned by Tony Nunn, clinical director of pharmacy, Royal Liverpool Children’s NHS Trust, who commented upon the lack of licensed indications and the regulatory status of the selective serotonin reuptake inhibitors. Further legal issues around informed consent and confidentiality were mentioned by Don Batton, a consultant child psychiatrist from Swindon. He emphasised the fact that children need to be given information in an understandable form and that their ability to understand will change with time as they are constantly developing. He confirmed that parents are usually the best judges of what is in a child’s best interest and reminded the audience that refusal is complex and not absolute and that treatment should only be enforced if absolutely necessary.