Patients with enduring mental health needs living in the community but in contact with the mental health services do not always have direct access to a psychiatric pharmacy specialist. Below are described two projects for this population of patients which involve medication and professional input from a pharmacist working in psychiatry.
The programme is designed to provide an additional service for the long-term mentally ill patients by reviewing their medication in a systematic way. Patients who may benefit are referred to the programme by the Consultant Psychiatrist. The referrals are mostly out-patients though a few are resident in the rehabilitation unit. The majority are on either oral or depot antipsychotics. One afternoon each week is devoted to the programme with patients given appointments to return at four to six monthly intervals.
Accredited rating scales (BPRS, AIMS or LUNSERS), are used to assess effectiveness of medication and side effects of medication. There is also plenty of opportunity to discuss medication and listen to the patients views. The interview is reported in the patient's notes and a letter written to the GP with a copy to the Consultant. I allow one hour per person for the interview but the time needed varies from person to person.
The patients are still seen regularly by their co-ordinators and by the Consultant at varied intervals according to stability. For these patients, the interest in their welfare by another professional is appreciated, as is the opportunity to discuss their medication freely. The rating scales are easy to use once you get used to them and become confident in taking the patients through the tests. I did have some training in their use before starting the programme.
MIDAS (Medication Information, Discussion, Advice and Support) is a medicine education group loosely based on the Norwich initiative in this field. It is facilitated by myself and a staff nurse and devoted to learning, mostly by discussion. Unlike first-time acute patients, those with enduring mental health needs know a great deal about their medication by experience and by exchange of information with others at the Day Hospital. Our purpose is to guide the discussion and dispel misinformation. Patients learn a great deal from each other about medication and about their illnesses and are able to advise each other in a way that would not be accepted if it came from a pharmacist! The most popular sessions are those devoted to side effects and how the drugs work. We run MIDAS as a closed group for one hour a week for six weeks.
When we first started the group, the sessions were more formally educational. After we had attended an RSA groupwork skills course (one day a fortnight for seven months with a three day residential course, run by the Trust although local Colleges of Education also run them), we began to run the group in a very different way. We had increased confidence to let the patients take the discussion where they wanted to go knowing we could return to the point whenever we chose. The group is continually evolving due to incorporation of suggestions made on the feedback questionnaires distributed in session six.
Diana Jones, Senior Clinical Pharmacist, Avalon Somerset NHS Trust, Priory House, Glastonbury Road, Wells, Somerset. (October 1997)
Classic neuroleptic drugs can give rise to a broad spectrum of problems that are so widely recognised as to require little formal specification; they adversely effect numerous aspects of patient well-being, from several neurological (extra-pyramidal) side effects through to non-motor physiological disturbances, in the face of what can be limited antipsychotic efficacy. It is, therefore, encouraging that we are entering a period over which an increasing number of new "atypical" antipsychotics are becoming available; but how is their place in therapy to be conceptualised? The prototypical antipsychotic agent clozapine is to date unique in showing efficacy superior to that of classical neuroleptics. This includes a somewhat greater amelioration of negative symptoms and, in particular, efficacy in a proportion of patients who fail to respond the older drugs. It therefore seems a perverse trick of nature that these important advantages, together with clozapine's very low liability to induce extrapyramidal side effects, should be offset by multiple adverse effects, most seriously agranulocytosis and the resultant requirement for mandatory blood-count monitoring.
Given the liabilities of clozapine, the modest impact of sulpiride and the demise of remoxipride, risperidone represents the first of the new "atypicals" to lay claim to a major role in antipsychotic therapy; but what does "atypical" actually mean?
Though lacking a clear theoretical basis, the prevailing definition of "atypical" focuses on a reduced propensity to induce extrapyramidal side effects. Evidence indicates that risperidone has such a reduced propensity, though only over a limited dose range beyond which a more classic neuroleptic profile is apparent. In addition, there is an enduring debate as to the consistency and meaningfulness of any superiority it may show against negative symptoms. There is as yet no systematic body of evidence for clozapine-like efficacy in otherwise non-responsive patients, and it is not free of a number of the non-motoric adverse effects which characterise classical neuroleptics.
The range of 'atypical' antipsychotics has been joined recently by sertindole and olanzapine. These agents each exert significant efficacy against both positive and negative symptoms and appear to have a very low liability to induce extrapyramidal side effects. However, sertindole causes nasal congestion, decreased ejaculatory volume and prolongs electrocardiographic QTc interval, while olanzapine causes some sedation, weight gain and anticholinergic side effects. Although there are as yet no systematic data to indicate for either agent any clozapine-like efficacy in otherwise non-responsive patients, controlled clinical trials do suggest the efficacy of olanzapine against negative symptoms to be greater than that of haloperidol. A tranche of additional agents are at varying stages of clinical development.
Given the number of new and emergent agents, all showing clinical efficacy and few extrapyramidal side effects, the designation atypical, as currently applied, is likely soon to encompass an unexpectedly large number of drugs that may be far from identical. In this situation it would seem appropriate to re-evaluate 'atypicality' and consider a more conservative definition that focuses on additional characteristics likely to be of broader benefit to patients beyond a reduced level of extrapyramidal reactions. These might include issues of greater efficacy and reductions in dysphoria, sedation, autonomic/cardiac effects, prolactin elevation, sexual dysfunction and weight gain. Certainly, over the next decade classical neuroleptics are likely to face a considerable challenge in clinical terms, though their superficial cost advantage will endure. In this regard it is of importance to evaluate the overall profiles of these new agents, as greater efficacy and improved patient acceptability would reduce hospitalisation, improve compliance and lower relapse rates. This could shift materially the cost-benefit analysis in relation to 'typical' versus 'atypical' antipsychotics and the extent of the cost-benefit shift may differ between the new agents. Any such consideration of the holistic effects of medication, to include quality-of-life domains, will engender vigorous debate in terms of health economics.
It should be emphasised that the designation 'atypical' is usually based on phase III trials of generally limited duration; these cannot answer questions such as outcome in the long-term, liability for tardive dyskinesia, association with unexpected sudden death and likelihood of very rare idiosyncratic reactions. However, given their apparent advantages, these issues should not deter from seeking to define the optimal role of the new 'atypicals' in contemporary therapy.
John Waddington is Professor of Neuroscience at the Department of Clinical Pharmacology of the Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin, Ireland (January 1997)
References and further reading;-
For many patients with schizophrenia, negative symptoms are the most enduring and disabling element of their illness. Flattening or blunting of affect and poverty of speech are the core symptoms, and are rated on all of the commonly-used rating scales for the negative syndrome. Other negative features include lack of volition and drive, loss of feeling, social withdrawal, and decreased spontaneous movement. Carpenter (1996) suggests that 30-50% of people with chronic schizophrenia show deficit features of this kind. There is, however, still only limited understanding of the prognostic significance of negative symptoms, the extent to which they account for behaviour and level of social functioning, and their psychological impact.
Negative symptoms represent deficiencies in the normal repertoire of human behaviour and function, such as emotional responsiveness, spontaneous speech and volition. Thus, by their nature, negative symptoms are hard to define operationally. Research work in this area also suffers from some uncertainty regarding the validity of current measures of negative symptoms (Barnes 1994). Nevertheless, recent work confirms the negative syndrome in schizophrenia as a distinct dimension of psychopathology on both empirical and theoretical grounds. Factor analytic studies in schizophrenia consistently generate a discrete negative syndrome in schizophrenia (sometimes referred to as the psychomotor poverty syndrome) (Liddle 1987, Lenzenweger and Dworkin 1996), and its relationship with other symptom dimensions and other clinical variables has been explored both cross-sectionally and over time (Van der Does et al 1993, Fenton and McGlashan 1994, Fennig et al 1995). These studies suggest that negative symptoms that persist over time may be more reliable predictors of functioning than those elicited at a single, cross-sectional assessment, particularly during an acute episode. Further, negative symptoms are consistently associated with impaired cognitive and intellectual functioning. Recent studies have shown correlations between particular negative symptoms and impaired performance on distinct neuropsychological tests, suggesting a different pathophysiological basis for individual negative symptoms (Hammer et al 1995, Joyce et al 1996).
There is tentative evidence from both first-episode and long-term follow-up studies of schizophrenia that a delay in initiating treatment with antipsychotic medication may lead to a worse prognosis in terms of negative symptoms or an increased susceptibility to relapse (Crow et al 1986, Waddington et al 1995, 1996). Thus, it is hypothesised that the longer a patient's psychotic illness proceeds untreated, the poorer the response will be when antipsychotic medication is eventually administered, and the poorer the long-term outcome in terms of negative symptoms. The simplest explanation for such an association is that illness with an inherently poor prognosis only comes to the attention of psychiatric services at a later stage, perhaps because it has a more gradual onset. Alternatively, the social and psychological disruption over a prolonged period of unchecked psychosis might be associated with a poor prognosis. It has also been proposed that persistent, untreated psychosis may be biologically toxic, causing long-term morbidity (Wyatt 1991). Whether or not early intervention with antipsychotic medication can reduce the subsequent vulnerability to relapse or the development of negative symptoms is a question that can only be answered by careful, prospective investigation.
The current view is that negative symptoms show a poor response to conventional antipsychotics. Although acute studies with such drugs have tended to show improvement in both positive and negative symptoms, the apparent response of negative symptoms may be at least partly a consequence of the successful treatment of positive symptoms and relief of associated depressive features. However, during an acute psychotic episode it is difficult to differentiate clinically between primary, enduring negative symptoms and social and emotional withdrawal secondary to positive psychotic symptoms, or related to depressive features or drug-effects such as sedation and the bradykinesia component of parkinsonism (Barnes and McPhillips 1996).
The newer, atypical, drugs, such as clozapine, risperidone, sertindole and olanzapine, also treat both positive and negative symptoms in acute schizophrenia, and have a lower liability for extrapyramidal symptoms (parkinsonism, akathisia and dystonia). The proposed mechanisms underlying the therapeutic action on negative symptoms with the newer drugs include 5-HT2 antagonism and relative activity at alpha2 adrenoceptors (Duinkerke et al 1993, Litman et al 1993). The claim is that these new drugs are superior to conventional antipsychotics for the treatment of negative symptoms, but the studies of acute schizophrenia on which this is based have methodological limitations. For example, for investigators planning to compare a new antipsychotic with a conventional drug in a fixed-dose study, it is not possible to calculate precise dose equivalents for the two drugs. A further problem is that the lower occurrence of side-effects, particularly parkinsonism, with the newer drugs may partly confound the clinical assessment of negative symptoms. Thus, while clinical improvement in negative symptoms is reported in these acute, short-term studies, the extent to which this represents a response of secondary rather than primary negative symptoms remains uncertain. However, the critical issue is whether the benefit seen in acute studies can be extrapolated to the treatment of deficit symptoms in patients during a more stable phase of illness, that is, whether the new antipsychotics exert a direct, beneficial effect on persistent negative symptoms. Recent studies, particularly those which have selected samples of patients with stable, chronic illness characterised by predominant negative symptoms, have tended to support the possibility of a modest but direct effect of newer antipsychotics on primary negative symptoms (Carman et al 1995, Moller 1995, Boyer et al 1995, Bustillo et al 1996). Further work is required to establish the nature and extent of any such benefit.
Thomas R.E. Barnes, Professor of Clinical Psychiatry at the Department of Psychiatry, Charing Cross and Westminster Medical School, London W6 8RP, UK. (January 1997)
References and further reading:
Two minutes after the start of the Chairman's Address at the end of the 1997 UKPPG Conference dinner I knew why a number of people had been treating me with undue respect! To say I am delighted to be the Group's first Honorary Life Member is understating it; I am overwhelmed!
It struck me, however, that the majority of those at the dinner could well wonder why I should be chosen for this honour, so I hope you will not mind me quoting part of the introduction I wrote to the proceedings of the first Seminar for Pharmacists in psychiatric Hospitals in 1976.
"Psychiatric hospitals have often been termed the Cinderella's of the Health service. Isolated, huge, understaffed, the patients shunned by the public at large, the specialities of little interest to many health service professionals, treatments until recently palliative and restrictive - small wonder that those who worked in them were often regarded by colleagues in other fields as inadequate and ineffectual.
It is important to remember that originally most psychiatric hospitals were in Hospital Management Groups of their own. Even though there have been a number of incorporation's into general groups over the last twenty years, the amalgamations rarely bought the psychiatric hospital" [which usually only had one pharmacist, who therefore had little or no regular contact with other pharmacists] "into much closer contact with other hospitals in the group. Yet, at the NHS reorganisation in 1974, 17% of the 500 hospital groups were still for psychiatric treatment only, and of the 800 hospitals which had a pharmacy, 20% were in psychiatric hospitals. Probably few administrators, to say nothing of suppliers and educators, realised that one fifth of all hospital pharmacy departments were in this field"
There were virtually no psychiatric hospitals in London, these hospitals having been built in Victorian times in two country areas, near Epsom in the south and round St. Albans in the north. I was appointed Group Pharmacist at Leavesden Hospital in 1970. Soon realising how isolated we were, but how close we were to three other psychiatric departments, I arranged (and I can't now remember which pharmaceutical company supported us!) for a Saturday study meeting. From that we went on to hold UK-wide occasional meetings in one or other of the large psychiatric hospitals in places like Birmingham, Ilkley and Edinburgh. As the first proceedings pointed out, "it was obvious how little study had been done in the field of psychiatric pharmacy, and how essential it was for these pharmacists to meet and work together from time to time."
Janssen Pharmaceuticals were the first company to meet the challenge we undoubtedly presented and, although it was not long before other companies began to take part, it is Janssen we must thank for the first four or five conferences. You will be pleased to know that Dave Branford was a speaker at the first (one of two talks on "Drug Administration", the other being by a Senior Nursing Officer), though Celia Feetam did not appear until 1981, as leader of a workshop (although few other conferences at that time did, we included them from the beginning), taking part with Christine Clark on "Clinical Pharmacy in the Eighties".
One of the things I am most pleased about is the development of so many things which in my day (I retired nine year ago) we were thinking should be looked at and worked on. yes, I suppose I did start the ball rolling, but very many have kept it rolling ever since. "Inadequate" or "ineffectual" are certainly not the adjectives I would - or could - choose if I was writing about the pharmacists in the psychiatric service of today.
Margaret Benfield, Hemel Hempstead Former Group Pharmacist, Leavesden Hospital and first Chairperson of the PPG. (January 1998)
The increase in numbers of substance misusers and media awareness of the problems of drug misuse have created a massive demand for treatment. The available treatment options for opiate addiction are not cheap and don't necessarily result in abstinence from illicit drug use. This has resulted in an increased involvement of pharmacists in planning services and dispensing for drug misusers.
Leeds Community & Mental Health Trust (LCMH) have responded to the problems by creating a pharmacist and a pharmacy technician post with the aim of improving the quality and cost effectiveness of the service. They will work together with current staff at the Leeds Addiction Unit (LAU), including doctors, nurses and addiction therapists. In addition, the pharmacist will work together with the clinical pharmacy team of LCMH, including the audit pharmacist, to provide budgetary support and appropriate advice on prescription cost to the LAU management.
I have taken on the role of Unit Pharmacist for the Leeds Addiction Unit, currently for a period of one year. This most interesting and demanding role is still developing. The major function of the pharmacist is to run the de-toxification from opiates and alcohol/methadone stabilisation clinic, together with the nursing staff. Dispensing is carried out for substance misusers to specific guidelines developed in conjunction with Yorkshire Addictions Research Training and Information Consortium (YARTIC) (1).
Opiate detoxification is carried out for outpatients using either lofexidine or dihydrocodeine with concurrent symptomatic relief. Although there are more reasons for choosing inpatient rather than outpatient detoxification from opiates (2), the current demand on inpatient beds makes it necessary to restrict in-patient treatment to high risk patients with other medical complications, or with previous failures to detoxification. As well as dispensing the medication, it is important for the pharmacist to provide both verbal and written information to assist compliance with the treatment regimen.
Alcohol detoxification is available on an out-patient basis, using chlordiazepoxide starting with doses of up to 100mg per day, for those patients not at high risk, particularly of seizures. Standard charts to rate the severity of withdrawal are used for both alcohol and opiate withdrawal.
It is important to understand that in all cases the treatment goal may not be abstinence from all drugs but may well be harm reduction. In these circumstances methadone has proved a useful tool (3). Planned treatment with methadone is shown to be effective in reducing illicit opioid use, reducing criminal activity, reducing drug related mortality, reducing injecting and sharing behaviour and reducing rates of HIV infection (1).
The prescribing of methadone is rapidly increasing. It is used for stabilisation of substance misusers, in reducing programmes and as maintenance treatment. Although used for the treatment of opiate addiction it is in itself addictive. The increase in prescribing has resulted in the allegation that legally prescribed methadone has become available on the streets. This has resulted in patients having to take their methadone under the observation of a pharmacist. The rising numbers of methadone prescriptions and the lack of resources have led to an increase in prescribing and issue directly from the LAU. The pharmacy technician is employed partly to dispense the methadone under the supervision of a pharmacist in the hospital pharmacy department and partly to issue the dispensed medication to patients collecting from the unit. This will help reduce the number of methadone prescriptions issued into the community. If deemed necessary individual patients are observed taking their medication. Regular urine analysis is carried out to ensure compliance with treatment and abstinence from other drugs of abuse.
As this is a new venture I would welcome letters from other pharmacists with an interest in addictions, maybe with the aim of setting up a specialist interest group linked to the UKPPG.
A study day is being arranged to be held in Leeds on June 3rd 1997, with the aim of getting together pharmacists working in, or interested in, treatment of substance abuse. The programme will include both in and outpatient treatment regimens for substance misuse, case studies in addictions and look at the psychopharmacology of compulsive drug use. See details under "What's On" on the last page.
References
Lynn Haygarth is Unit Pharmacist, Leeds Addiction Unit, Leeds. (April 1997)
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