Psychiatric Pharmacy Conference 2002

Kristof Seaton (left) is looking at Dave Branford (seen holding a battery-powered hamster in a ball) and Alan Pollard at the Conference dinner, after Steve and Andy had been selling Conference Speech Lottery tickets*.
What do you think was being said?
E-mail your entries to sbazire@ukppg.org.uk.

Everyone agreed with Richard Gere that spin the hamster was a lot more fun than spin the bottle. (Wildon@webtv.net)
and even though he was a test tube baby, Sigmond's followers were convinced they could find a way to blame it on his mother....... (Vanessa Brown, Yabbadaubado@cs.com)
Dave: "Oh, yes, stewed in ale with a handful of thyme and rosemary for five minutes and serve with mash and mushy peas, lovely"
Alan: "Cooking with alcohol, naughty!"
Kristof: "Uggh, beer, nice Chablis would be better"

(Juliet Shepherd)
Dave: "Good grief, that hamster has fastened Kristof's bottom waistcoat button!" (Paul Hardy)
(Alistair Edwards has e-mailed that "I seriously doubt if anyone (or any hamster) would succeed in fastening any of Kristof's waistcoat buttons")

*NB The lottery raised £144.71p for Norfolk Mental Health Alliance, for which they are very grateful. Thanks!

Conference and organising committee:

Conference report

Since the PJ doesn't like us using the report we write for them, we are indebted to Wendy Ackroyd and the Scottish Pharmacists for Mental Health for allowing us to reproduce the report wrote Wendy for their newsletter.

The UKPPG conference this year opened asking the question "Combination therapies - the more the merrier?".

Answering for the treatment of resistant depression was Prof. Phil Cowan (Dept Psychopharmacology, Oxford). Resistant depression is a term used loosely and in this case means a failure to respond to an adequate trial of two different antidepressant medications which would be about 15-20% of patients. Possible solutions to inadequate antidepressant response are to increase the dose, switch to another antidepressant or to add some augmentation agent. The evidence for the effectiveness of any of these strategies is scarce; however switching is probably the most common option employed. It has been hypothesised that if an antidepressant that has its effect via one monoamine system were ineffective using one that affects multiple monoamine systems would be more effective. Thus one would expect venlafaxine to be more effective than an SSRI and there is a little evidence to suggest this is true. Dose increases are less often employed although one study did show an increase in fluoxetine dose to be more effective than addition of lithium or tricyclic. Augmentation strategies are mainly anecdotal and those trials which do exists generally involve augmentation of tricyclics, so evidence for addition to such as a SSRIs is lacking. Use of lithium as augmentation has the most evidence for efficacy. Tri-iodothyronine is also often used, with less evidence to support it. Pindolol, use based on the theory that 5HT1a autoreceptor blockade enhances 5HT transmission when added to an SSRI, has so far been less effective, however the dose used is often far too low for any real degree of receptor occupancy.
A final option becoming more studied is the addition of an atypical antipsychotic to antidepressant treatment. Low dose olanzapine (2.5mg - 5mg) has been seen to give a more rapid response to fluoxetine, with weight gain being the main problem. Clozapine is also used off-label for treating resistant mood disorders.
Treatment of depression:

• 1 single antidepressant - trial 4 weeks then increase dose for another 4 weeks
• Switch to another antidepressant of a different class, trial as above
• Augmentation - lithium most successful, validated augmentation, atypical antipsychotic may be another option
• Combinations:
• SSRI + TCA : not shown to be very effective, drug
• interaction may be a problem.
• SSRI + trazodone: can get increased trazodone levels, fairly safe but serotonin syndrome reported, might help SSRI sleep disturbance.
• Mirtazapine + venlafaxine: "California rocket fuel" effective in small case series, serotonin syndrome reported
• Mianserin + SSRI: large study showed a lack of efficacy

Bipolar disorder is one area where more might just be merrier, according to Prof A. Young (Royal Victoria Hospital, Newcastle). He told the conference that although Lithium has been shown to be beneficial in all "manic" disorders, and in particular for the prevention of relapse and suicide in bipolar mood disorder, compliance with this medication is poor. Stopping lithium suddenly is a guarantee of relapse which then occurs more quickly than with no treatment at all. Problems with toxicity, side effects, monitoring and discontinuation problems make alternatives welcome. Divalproex is the most used antimanic in the US. Valproate has been shown to be as effective as lithium in the acute setting and although there is presently no evidence for prophylaxis, clinical use "suggests" it is effective. Carbamazepine is more useful in mixed affective states, bipolar 2, and where there are mood-incongruent features. It is marred by high rates of discontinuation and its P450 interactions. Gabapentin has been used but only really appear useful where there are anxiety symptoms. Lamotrigine has use in bipolar depression, but is not antimanic. Dose increases have to be very slow and cautious due to the risk of rash, which can be mild to Steven's Johnstone reaction. It is not as effective as lithium for preventing relapse to mania, but is more effective for preventing relapse into depression. Topiramate has been shown to be useful in open studies but this was not held up in RCTs. It might be useful for reversing antipsychotic induced weight gain. Antipsychotics are often used, and not solely for sedation - 58% of people with BAD will present with at least 1 psychotic symptom, which is not good prognostically. Typical agents cause EPS to which those with BAD are more sensitive and can induce or worsen depressive symptoms and cognitive impairment. Clozapine has been used in refractory bipolar disorder (200-350mg/day) off-label. Risperidone, quetiapine, olanzapine and ziprasodone have all been used in mania - for which olanzapine is now licensed. Prof. Young finished by saying that in BAD where there is little response to one medication, at an adequate dose, often a combination of medicines is more effective.

Dr Derek Brown, consultant in old age psychiatry at Stobhill Hospital, Glasgow discussed dementia and it's treatment, the NICE guidelines and the problems within them, including the use of the MMSE as a tool for the basis of prescribing the acetylcholinesterase inhibitors, or not. The MMSE is very dependent upon language and education and is only of great use in more severe disease. The possibility for polypharmacy in dementia is emerging with the recent launch of memantine, a non-selective NMDA receptor antagonist, for the treatment of moderately severe to severe Alzheimer's disease. However the combined use with an acetylcholinesterase inhibitor has not been investigated. The trials for this medication have not so far been very easy to interpret due to the mixture of Alzheimer's disease, vascular dementia and Parkinson's disease in the subjects included. Memantine is a chemical similar to amantadine so improvements in cognition may be awarded to improved control of parkinsonian symptoms in some people. The trials have not shown improvements in behavioural problems associated with Alzheimer's disease or caregiver burdens, so it's usefulness remains to be proven.

The final area for polypharmacy discussion was psychosis and schizophrenia, so Prof. Larry Ereshefsky from University of Texas, College of Pharmacy stepped forward for this. There are many problems with schizophrenia, he began; not least that a third of people with this diagnosis will not respond to usual treatment. Adherence is poor; many people relapse even when they do adhere to treatment and the picture is further complicated by comorbid drug use, multiple definitions, genetic differences, and people in different stages of illness who will respond differently to treatment. Polypharmacy in schizophrenia takes one of four forms: two medicines of the same class (for which there is little supporting evidence), two medicines from different classes, using one medicine to treat secondary symptoms or side effects and finally augmentation - using a lower dose of another medicine to "boost" the first. The problems with polypharmacy in schizophrenia include the increased incidence in side-effects or drug interactions, complicated regimens further reducing compliance, monitoring needs, cost, and often people say they feel better without the medications.

• Options used in schizophrenia have been:
  
• Monotherapy (work through all the medicines available)
• Adding divalproex
• Trying a typical if atypical only used, or vice versa
• Trying high dose - above the recommended doses
• Trying polypharmacy
• Typical and atypical combinations (recommended against in NICE/HTBS) may have some logic, in that
• residual positive symptoms with maximum dose atypicals might respond to a smaller dose of a dopamine blocker such as haloperidol.
• SSRIs have been used with depot typical antipsychotics to decrease negative symptoms - as an alternative to switching to an atypical.
• Lamotrigine, which stabilises glutamate, has been used with clozapine in some very ill people to good effect where carbamazepine has not shown to be useful. Glycine and D-cycloserine have been useful when added to some antipsychotics, but not clozapine.

Saturday of conference began with an opportunity to hear about the work that other pharmacists are doing around the UK. There were oral presentations about clozapine assays, care issues for older people with mental health problems in the community, a mental health pharmacy admission support service and a pharmacist-led benzodiazepine clinic. The presentations were excellent; it would be so good to be hearing form someone from Scotland there next year though. Lynn Haygarth, Principal pharmacist, Kirklees and Calderdale NHS Trust, was this years recipient of the AstraZeneca travel award for her work entitled "Finding the best way to improve pharmaceutical care with limited resources".

Prof. AC Moffat, Chief Scientist, RPSGB gave a very interesting lecture on the situation with cannabis, he talked about its history, legal position in various countries of the world, chemistry, pharmacology, the comparison of effect of extracts of the plant "v" pure individual cannabinoids and possible uses. Many uses of cannabis are connected to its muscle relaxant effects - asthma, menstrual cramps, muscle spasticity, pain, glaucoma etc. However, we are still a little way off from it appearing on our shelves.

Dave Branford gave a summary of the new Mental Health Bill (the English one) and it's likely pitfalls before Dr Peter Wilson, special advisor to the RPSGB, gave an account for the Society's new CPD process, to be mandatory in a couple of years time. Saturday afternoon was taken up with workshops. This year had a variety of subjects on offer from eating disorders, to weight gain with antipsychotics and TDM, audit, CMHP portfolio and pharmaceutical care planning.

A slightly later start on Sunday began with a discussion of the cognitive deficits seen in schizophrenia by Dawn Velligan, Associate professor at University of Texas Health Science Centre. Cognitive deficits may be present before the illness itself becomes evident and may be the most debilitating part of the illness in the long term. Problems may be present in attention, memory, information processing, and executive functions. This is why there is so much interest into whether the atypical antipsychotics may improve cognition in schizophrenia. EPSE and anticholinergic side effects all serve to lessen cognitive abilities. The atypicals have been shown to increase all areas of cognitive function, some more than others. Whether this is by a direct effect on cognition, a decrease in EPS, psychosis or anticholinergic effects is not entirely known, but is being investigated.

Mr Tim Newey gave a service user's perspective of the antipsychotics he had been treated with over the years. He described the atypicals as a "triumph" over the older style medication, that "allow a wonderful light through the darkness" of his illness. He also highlighted the importance of occupation and environment in his recovery and ability to remain well and how appropriate placement is possibly as important as the medication that gets him well. How feeling he had a part in the treatment decision has influenced his compliance with medication and other treatment and his determination to be well.

Dr Richard Gray Institute of psychiatry, London, continued to highlight the importance of treatment compliance, with his discussion of compliance therapy for people with schizophrenia. He highlighted that stopping taking medication is normal, people don't like taking medication generally. Compliance therapy is "a pragmatic intervention based on motivational interviewing and cognitive behavioural therapy to enhance treatment adherence". Dr Gray described a national process by which this training is being disseminated to nursing staff throughout the country. Something to look out for!

From a personal point of view the UKPPG is an incredibly useful experience. It's not just about the lectures and the things you learn from the speakers. It's about networking across the UK and even the world - it is international after all! It's about talking to your colleagues about the issues you deal with day to day, receiving support, stealing ideas, blowing off steam and realising there are people you can talk to even if you are isolated in your own practice. It's also about having a bit of fun, mixed with the serious stuff, dressing up and dancing, meeting socially, making friends. I recommend you try it sometime.

Wendy Ackroyd