The Pharmaceutical Journal
Vol 279 No 7475 p474,479
27 October 2007

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United Kingdom Psychiatric Pharmacy Group

Raise profile of mental health pharmacy

The involvement of mental health pharmacy services can lead to significant improvements in medicines management, but they are in short supply. Tackling the shortfall was one of the key messages from this year’s conference for pharmacy staff working in mental health.

“New ways of working” have focused attention on mental health pharmacy, said David Branford, chief pharmacist, Derby Mental Health Services NHS Trust. The five-year programme with the National Institute for Mental Health in England had come to an end with four main components:

• the spread programme

• a workforce survey

• a service user and carer’s medicines leaflet

• a “new ways of working” document, which details how mental health pharmacy can develop and sustain a capable and flexible workforce.

Various aspirational visions were described for all levels of staff. Chief pharmacists were urged to take charge of medicines management in their trusts and become members of the senior management team.

Taking this responsibility, leading medicines governance and controlling the entire way in which medicines are selected, procured, delivered, prescribed, administered and reviewed was a huge undertaking for one individual, he said.

Split roles were suggested, where one pharmacist took on the business role while another had a lead clinical role. For specialist mental health pharmacists, mechanisms were needed to attract and train them. Exposure of undergraduates, preregistration trainees and rotational pharmacists to mental health was seen as a key part of this.

Development of consultant pharmacist posts was also vital. Technician roles would develop as they became members of the ward or community team with responsibility for ordering, supply and information. Roles in audit, finance and training would also materialise.

The small number of technicians in mental health was acknowledged as a barrier to service development. It was recognised that some trusts were more advanced than others in these proposed practices.

While the “new ways of working” programme has ended for other professions, for pharmacy it carries on with development of a self-assessment toolkit and learning sets designed to develop leadership for medicines management.

Such sets will bring together chief pharmacists, chief nurses and chief medical officers, said Mr Branford.

Healthcare Commission endorses pharmacy involvement

Julia Sonander, from the Healthcare Commission, commented on many aspects of medicines management in mental health trusts. She was impressed at how many mental health trusts had taken part in the medicines management review, even though they knew results would not be applicable in the same way as in acute hospitals.

The Healthcare Commission has since recognised that mental health is different. Inpatient stay is longer and many services are provided in the community.

Pharmacy involvement in mental health units has been shown to improve medicines management and the number of interventions per patient is similar to acute medical wards. However, many units are under-resourced and have less clinical pharmacy time than medical hospitals.

In crisis teams, where medicines responsibility was deemed to be the same as for inpatients, input was even less, she said. Many community units had no clinical pharmacy services at all.

Some agreement has been reached as to what clinical pharmacy activities are appropriate for mental health. Examples include undertaking fuller medication reviews, ensuring monitoring for physical health, talking to patients and carers about medication and advocating on their behalf.

More work needs to be done to develop performance measures, but some had been agreed. Measurement of clinical pharmacy time, self-medication schemes and shared-care agreements were all suggested.

In conclusion, mental health trusts need to invest in clinical pharmacy time and pharmacy needs to be promoted so that people understand it. Ms Sonander concluded by assuring the audience that medicines were on the agenda of the Healthcare Commission and would remain there.

Developments in mental health pharmacy practice

Delegates heard from peers about exciting work carried out by pharmacists in mental health. John Donoghue, school of pharmacy and chemistry at Liverpool John Moores University, spoke of research on hypnotic use and antidepressant prescribing.

Ten years of data from 750,000 patients suggested that a diagnosis of depression or prescribing of an antidepressant increased the length of hypnotic treatment in primary care. This suggested that disturbed sleep was an intractable feature of depression and antidepressants may not be effective for this part of the illness.

Sarah Harris, of Birch Hill Hospital, Rochdale, Pennine Care NHS Trust, described how a bid for money to improve community pharmacy services in Scotland for drug abusers was secured.

Community pharmacy had initially been overlooked when addiction services were considered. However funds were secured and used to increase the number of supervised methadone places. Strategies ranging from improved consultation areas, CCTV cameras and bigger CD cabinets were funded.

Pat Morgan, from Nevill Hall Hospital, Abergavenny, suggested that her audit of olanzapine levels showed a wide variation for a given dose. Some people seemed to be poor metabolisers, resulting in high olanzapine levels and increased side effects.

Despite the costs, she believes there is a need to check in some cases whether non-response is due to non-compliance.

Ray Lyon, chief pharmacist, Sussex Partnership NHS Trust, described the challenges of training junior doctors across a large geographical area on medicines management. Preventing recurring errors on drug charts and getting across clinical information were seen as key issues.

Using an IT company, an e-learning package has been produced that covers all aspects of the drug chart. Junior doctor starting at the trust will be expected to complete the online training.

Naaz Coker, chairman of St George’s Healthcare NHS Trust, remarked that pharmacists should be presenting their work at board level to promote medicines management because it is critical for patient safety.

A structured approach brings benefits for patients

What do STAR*d, STEP, and CUTLASS mean? They are all trials, not sponsored by pharmaceutical companies, that aim to look at medication in real-life settings. These trials were used by leaders in their fields to illustrate treatment in key areas of psychiatry, namely depression, schizophrenia and bipolar disorder.

Ian Anderson, senior lecturer in psychiatry at the University of Manchester, described medication used in treatment-resistant depression.

Despite being a pioneer for evidence-based guidelines, he advised that his lecture would “stop here” if he were to concentrated on robust evidence alone, because it was scanty at best.

This was despite the fact that 10 per cent of patients with depression end up with a chronic refractory illness unresponsive to treatment.

Many trials are small with differing methodologies. He described the STAR*d trial — a large US naturalistic study of sequential treatments in depression. Patients were first given citalopram. If this was ineffective they could choose between switching or augmenting therapy.

As the study progressed diminishing returns were seen with each treatment strategy. The paucity of evidence for such strategies as increasing dose, switching treatments and augmenting therapy was discussed. However, adopting a structured approach to treatments did seem to be beneficial.

With so many questions left unanswered the only real option left seemed to be to practise in advance of the evidence.

John Geddes, professor of epidemiological psychiatry, University of Oxford, described how the use of antidepressants for bipolar depression may fade with time. Drugs such as lamotrigine and quetiapine may supersede them, a shift already occurring in the US, he said.

The National Institute for Health and Clinical Excellence guidance for bipolar disorder also hinted at this, suggesting that selective serotonin reuptake inhibitors or quetiapine be used for moderate to severe depression.

SSRIs were to be avoided in rapid cycling or recent mania. Where SSRIs were to be used, early discontinuation was encouraged. More needs to be done to research the best way to use these and other adjunctive therapies, he suggested.

He added that combination therapies, eg, lamotrigine and quetiapine, might prove useful to overcome shortcomings of each one but such combinations were untested.

Finally, Peter Jones, from the department of psychiatry, University of Cambridge, questioned whether second-generation antipsychotics were any better than first-generation ones despite early optimism, and asked whether their increased cost was justified. He cited the CUTLASS study which compared the effects of both on quality of life at one year.

The findings tended to favour first generation over second generation, a finding not expected by researchers. He suggested a way forward might be more thoughtful prescribing of first-generation antipsychotics to ensure all the tools in the box were used to benefit patients.

A former patient’s view of depression

With a mixture of poetry, song and eloquent speech, Bill Davidson described his experience of depression, the health service and pharmacists. He described the descent into darkness as akin to “a cloud, the one unseen at first that spreads silent and omnipotent” and he told of the humiliation associated with being made to go through the ritual of lining up at the drugs trolley to receive doses.

He had thought that pharmacists were people in the back at the chemist shop, but as a result of his involvement in the new ways of working group, he had learnt that pharmacists have much more to offer.

Mr Davidson urged pharmacists to “think like a customer” and put themselves in the patients’ shoes. The long journey of recovery requires a monumental effort by patients, but it also needs enablers.

He firmly believes that pharmacists have a clear role as enablers but are not currently used to their maximum potential.

Conference marketplace allows shared experiences

A new idea — the marketplace — was trialled at the conference. The idea is sharing good practice. “Stall holders” set out their wares, each offering advice on a different topic.

Delegates could choose from medicines management, alternatives to service level agreements, pharmacist prescribing, automated dispensing, physical health skills, substance misuse and carer education. At the blow of a whistle, delegates went to the table that most interested them and heard a 15-minute snapshot of skills or advice. This was repeated four times throughout the day, enabling a wealth of experience to be carried away by all.