Psychiatric Pharmacy Conference 1997

Friday 3rd to Sunday 5th October Latimer House

Friday 3rd October:

Pre-symposium session for pharmacists new to psychiatry (with further sessions throughout the conference)

Chairman Dr. Sheila Adam, Head of Mental Health Division, NHS Executive, London


Dr. Harry McConnell

Saturday 4th October

Chairman Prof. Robert Kerwin, Institute of Psychiatry, London


Rob Kerwin centre stage.


Ron Diamond holding forth.

Workshops;-

AGM

Conference reception, dinner and disco.

Sunday 5th October

Chairman Peter Curphey, President, RPSGB

Should we use drugs to treat...

Conference report from the UKPPG Bulletin

The 1997 conference again sold out, with delegates welcomed from Belgium, Netherlands, France, America, New Zealand, Australia and Ireland as well as the United Kingdom.

During the conference dinner Terry Scoles, Commercial Manager of Zeneca , presented the first UKPPG/Zeneca Travel Award. It was won by Brett Hill from Cardiff for his work on 'Optimising Antidepressant Compliance in Primary Care.' Unfortunately Brett was too ill to attend and so the award was accepted on his behalf by John Donoghue. Mr Sccoles also announced the UKPPG/Zeneca National Psychiatric Medication Helpline, which is to be funded by Zeneca for at least the next two years.

After the first committee election vote in many years, Chairman John Donoghue announced that David Branford, David Taylor and himself had been re-elected to the committe, and that Lynn Haygarth would join the committee again after a two-year break. Margaret Benfield was awarded the first ever Life Membership of the UKPPG, in recognition of her work in the early days of the speciality.

In his speech Mr. Donoghue thanked the pharmaceutical industry for their coninued support of the UKPPG. He noted that short-term outcomes in psychiatry were now good, but that long-term outcomes in mental health were generally poor. He therefore challenged pharmacists to have an influence on long-term care and support of patients, and help blur the distinction between primary and secondary care.

Dr Hiram Wilgust (Lilly Psychiatry) presented the poster and oral presentation prizes in his usual inimitable style. He praised the 14 posters and noted that CINP was in in Glasgow in 1998, urging pharmacists who had presented at this meeting to present there as well. Jean Stubbs (Northampton) was awarded first prize for her oral presentation, with Christine Hastie (Caterham) receiving second prize. Helen Shaw (Woodville Hospital) received the first prize for posters, with Stephen Bazire (Norwich) second. Two special poster prizes were presented, to Catherine Fewster (Scotland) and Carol Paton (Bexley).

Major presentations

Schizophrenia, antipsychotics and pharmacoeconomics
Ms Linda M Davies, York University

The treatment and care of people with schizophrenia is resource intensive and costly. It involves a range of health and social welfare services, as well as informal care. The extent of service use will depend upon the severity and duration of disease and the availability of formal and informal services. In 1992, annual expenditure of health and social care for people with schizophrenia was approximately £1 billion, or 10% of total service spending. The majority of expenditure is for people with resistant schizophrenia or who respond poorly to or cannot tolerate conventional antipsychotic medication.

Several new atypical antipsychotics are, or soon will be, available. They may benefit patients in terms of symptom control, social functioning and quality of life. They may also reduce the use of scarce health and social care resources such as hospital inpatient stay. However, they are perceived to be expensive, when compared to conventional antipsychotics such as haloperidol. Economic evaluation of clozapine for example, has indicated that the drug may lead to fewer relapses requiring hospitalisation and lower lengths of stay per hospitalisation. This means that the drug may be saving cost overall. There have been no direct economic comparisons of the newer antipsychotic drugs.

Should we use drugs to treat sleep problems in the elderly?
Dr David Bramble

The prevalence rates of reported sleep-related problems increase steadily with age. Nearly 50% of elderly people report sleep problems which significantly affect their quality of life. The bulk of these problems comprise the various forms of 'insomnia' which result from either the normal changes of sleep with age, long-standing poor sleep habits, the effects of either physical or psychiatric illnesses or any combination of these factors. The over-use and abuse of both prescribed and OTC sedative hypnotics is still prevalent despite evidence that such agents have only limited utility in the treatment of chronic insomnia and many older-type drugs are associated with accidents and other sequelae of daytime psychomotor impairment. This state of affairs is, at least in part, directly attributable to the poor training of doctors in sleep disorder medicine currently in the U.K. This suggests the need for a rational approach to the assessment and treatment of the various common sleep disorders of old age with a strong emphasis on non-pharmacological management strategies. Dr. Bramble argued that pharmacists and pharmacologists are now in a strong position to influence positively practice in this area of clinical activity. He also discussed the pharmacological management of the sleep problems associated with specific medical disorders which are most prevalent in older people (obstructive sleep apnoea, dementia, restless legs, periodic limb movements etc.).

Should we use drugs to treat behavioural problems in the elderly?
Dr Robert Baldwin

In medical practice diagnosis should always precede treatment. So the short answer is no; the use of psychotropic drugs to treat behavioural problems in the absence of a proper medical assessment cannot be condoned. An eclectic approach to aetiology involves understanding psychological and social factors as not only biological ('medical') ones. For example, many instances of so-called aggression in confused people can be managed by the use of appropriate psychosocial skills and imaginative manipulation of the environment.

For many psychiatric disorders there are fairly specific indications for psychotropic drugs - antidepressants for depression, neuroleptics for schizophrenia and mania, anxiolytics for morbid anxiety and mood stabilisers for relapsing affective disorder. In most instances drug treatment will ameliorate behavioural problems which arise directly from the primary illness - insomnia in depression; aggression in schizophrenia and restlessness in mania, for example.

All this is non-controversial. It is the use of tranquillisers and other drugs in dementia which is contentious. Studies indicate that a majority of residents of nursing homes have cognitive impairment and upwards of three-quarters will have received neuroleptic agents, half of whom experience adverse effects. Recent evidence suggests that injudicious use of neuroleptics actually hastens cognitive decline in dementia and patients with Lewy body dementia are extremely sensitive to side effects, sometimes with life-threatening consequences.

Approaches to dementia include subdividing symptoms and complaints into cognitive (amnesia, dysphasia, visuospatial dysfunction, acalculia, etc.) and non-cognitive (mood disturbance, disorders of thought and behavioural disturbance). Non-cognitive problems such as depression and psychosis are responsive to conventional treatment. Behavioural problems can be subdivided into challenging behaviours (aggression, wandering, unco-operativeness, disturbance of sleep cycle) and deficit behaviours (apathy, lack of self care). The latter are amenable to environmental and social factors. Challenging behaviours are commonly treated with tranquillisers. Aggregated data indicate about a 10% overall improvement in disruptive, challenging behaviours in drug treated patients. It is difficult to predict which patients may respond.

A rational approach to the management of behavioural problems in dementia includes: 1) an accurate assessment, including environmental triggers and exacerbators; 2) targeting specific behaviours, which should be measured in some way, for drug treatment; 3) balancing the effects of treatment against the likely side effects; 4) assessing outcome and discontinuing in the event of nil improvement. Often the choice of drug will be made more on the basis of predicting side effects than because of differential drug efficacy, although there may be a place for novel approaches (for example SSRIs, lithium and anticonvulsants) and the newer antipsychotics. On the whole though, the evidence base is thin.

Pharmacist oral presentations;-

Relationship of akathisia to aberrant behaviours.
Jean Stubbs, Pharmacy Department, St Andrew's Hospital, Northampton

Akathisia is a common and distressing side effect associated with antipsychotic drug administration (Lancet, 1986). The condition may contribute to aggressive behaviour or impulsive suicidal attempts (Keckich, 1978; Drake and Ehrlich, 1985; Schulte, 1985; Azhar and Varma, 1992). The aim of this study was to investigate the relationship between akathisia and aberrant behaviours.

The prevalence of drug-induced akathisia was assessed for a group of 64 mentally disordered patients subject to a behavioural programme as a part of their treatment. The aberrant behaviours studied were five types of aggressive behaviour:- verbal abuse/aggression, threatening behaviour/violence, physical aggression, destruction of property and deliberate self harm. Assessment was carried out using the rating scale for drug-induced akathisia introduced by Barnes (Barnes, 1989). Fourteen subjects (21.9%) were rated as having akathisia. The prevalence of pseudoakathisia was 6.3% (n=4).

Akathisia was more likely to occur in women than in men (P<0.05). The patients with akathisia demonstrated significantly more incidents of threatening behaviour and physical aggression than the patients without akathisia. The association with other behaviours did not reach statistical significance.

The data provide evidence for a relationship between the experience of akathisia and the incidence of two forms of aberrant behaviour.

References:
Azhar MZ, Varma SL (1992). Akathisia-induced suicidal behaviour. European Psychiatry, 7, 239-241.
Barnes TRE (1989). A rating scale for drug-induced akathisia. British Journal of Psychiatry, 154, 672-676.
Drake RE, Ehrlich J (1985). Suicide attempts associated with akathisia. American Journal of Psychiatry, 142, 499-501.
Keckich WA (1978). Violence as a manifestation of akathisia. Journal of the American Medical Association, 240, 2185.
Lancet (1986) Akathisia and antipsychotic drugs (editorial). Lancet, ii, 1131-1132.
Schulte JL (1985). Homicide and suicide associated with akathisia and haloperidol. American Journal of Forensic Psychiatry, 6, 3-7.

An antipsychotic drug audit in people with a learning disability living in the community.
Hastie C, Sales I, Stanley R, Lifecare NHS Trust, Coulsdon Road, Caterham, Surrey.

Lifecare NHS Trust is a first wave trust and was committed to moving its Learning Disability clients into the community. This was accomplished over 3 to 4 years and the hospital closed in October 1995. Acute care of the clients was then contracted to local GPs with the Trust's doctors and consultants retaining the responsibility for psychiatry and epilepsy. The Trust has now taken the step of registering its homes. As the clients are discharged, they have become full NHS patients. The audit was to examine a) why the client was receiving antipsychotic medication and how often it was reviewed, b) the side effects as perceived by people involved in the client's care and c) what, if any, changes had resulted from the move in to the community.

Sample - Six homes were chosen with comparable number of clients receiving antipsychotic medication and this provided a total of fifty-nine clients, of which thirty-seven were male and twenty-two were female. The average age was 48 years and all clients had been receiving antipsychotic medication for many years.

Data Collection - Two data collection instruments were devised, the first being a questionnaire including details of the drug(s), the date of review and change of dose, the reason for the prescription and the perceived side effects. This was carried out by means of a structured interview with the home manager and access to medical notes. The second was a compatible self-reporting questionnaire for doctors, key workers and therapists, resulting in sets of data for each client. The audit was completed between October, 1996 and May, 1997.

Of the 59 clients sampled, nine different antipsychotics were identified with more than 50% of clients receiving thioridazine. Fifty-four clients were receiving only one antipsychotic with the other five receiving two. Nine clients were concurrently receiving antidepressant drugs.

Duration: It was discovered that some clients had been continuously prescribed that particular antipsychotic as far back as 1967. The average duration on that antipsychotic was 7.57 years.

Review: The last review date ranged from September 1993 to January 1997, while the last change of dose ranged from September 1988 to December 1996. Reviewing had declined in recent years.

Reason: There was a specific diagnosis for fifteen of the clients, with forty receiving antipsychotic medication for behaviour. There appeared to be no reason for the prescription of four clients. There was no acknowledgement of antipsychotics being used for tranquillisation (Wressell et al, 1990).

Side effects: The most commonly noted side effects were those related to the antimuscarinic side effects (23 clients) with 19 clients exhibiting extrapyramidal effects and 18 sedative effects. 16 clients had no known side effects according to the home manager (although one was receiving an antimuscarinic drug). In answering the questionnaires, there was a lack of agreement on perceived side effects and this was also true as regards the reason for the use of the antipsychotic.

The audit indicates a need for:-

References:
Aman MG, (1984). Drugs and learning in mentally retarded persons. Advances in Human Psychopharmacology, Vol 3 (eds GD Burrows & JS Werry) pp121-63 JAI press, Greenwich CT.
Clarke DJ, Kelley S, Thinn, Corbett JA (1990). Psychotropic drugs and mental retardation: disabilities and the prescription of drugs for behaviour and for epilepsy in three residential settings. Journal of Mental Deficiency Research, 34, 385-95.
Wressell SE, Tyrer SP, Berney TP, (1990). Reduction in antipsychotic drug dosage in mentally handicapped patients: a hospital study. British Journal of Psychiatry, 157, 101-6.

Workshops:

Adverse drug reactions workshop - challenges for pharmacists
Pat Murray, Chief Pharmacist, Edinburgh Healthcare NHS Trust

The aim of this well-received workshop was to review the role of the pharmacist in prevention, detection and reporting of adverse events. This included defining such events, describing the methods used to identify events, the pharmacists role and how to apply the theory. Two statements were used to challenge pharmacists - "It is claimed that the psychiatric patient brings a greater challenge to the healthcare professional in controlling or minimising the risk of an adverse drug event" and "describe the factors involved in optimisation of drug therapy".

Participants were reminded of the other causes of ADRs;-

A reading list was suggested, not just for clinical information, but to help focus the minds of pharmacists hoping to take a significant role;-
"From compliance to concordance. Achieving Shared goals in medicine taking" - RPSGB 1995.
Clinical Pharmacy in the Hospital Pharmaceutical Service: A framework for practice. CRAG. Scottish Office, 1996.
Reporting Adverse Drug Reactions. A BMA Policy Document. ISBN 07279 10981, 1996.

EFFECTING CHANGE AT THE INTERFACE
Helen Shaw, Woodilee Hospital, Lenzie, Glasgow G66 3UG

This workshop aimed to increase awareness of the problems experienced in achieving continuation of pharmaceutical care across the primary/secondary care interface and identify ways of improving this care. Participants discussed the effect of the implementation of the NHS and Community Care act on the way psychiatric patients were treated. Groups identified poor discharge planning and communication of treatment plans plus insufficient information about medicines and side-effects as major problems leading to non-compliance in many cases. A brainstorming session highlighted the differences in the way pharmaceutical care was provided in the different environments. Ready access to notes and personnel together with presence at multidisciplinary team meetings were advantages in influencing treatment for hospital pharmacists. Community pharmacists were seen to be in an ideal position to know patients and monitor the effects of medication over a period of time as well as having medication records on PMR in many cases. Community pharmacists discussed projects in East London involving specialisation in mental health, setting up databases for patients and improved communication with secondary care personnel. In conclusion a greater understanding of factors affecting patient care in the community/hospital was needed and pharmacists had to adapt their provision of care to this.

The Development and Applications of the Health of the Nation Outcome Scales (HoNOS)
Roy Curtis MA, Dip Psych, C Psychol, MBA, ABPsS, MHSM, Honorary Research Fellow Royal College of Psychiatrists Research Unit and member of the HoNOS Development team (1993 - 1997)

The development of HoNOS was commissioned by the Department of Health, the primary purpose being to provide a means of setting and monitoring the Health of the Nation target: to improve significantly the health and social functioning of mentally ill people. In order to achieve this, some means of measuring the severity of problems and change over time (i.e. outcomes) is required. Information will have to be collected from all secondary mental health services and accordingly some basic criteria have to be met. Such an instrument should be

The workshop consisted of a description of the development phases of HoNOS, and an examination of the 12 scales that comprise HoNOS. There was an opportunity for workshop participants to practise using some of the scales in order to illustrate some of the key principles underlying the use of HoNOS in routine clinical practice.

Finally, there was an opportunity to discuss some of the intended and potential applications of HoNOS including areas of relevance to psychiatric pharmacy.

Issues that arose in the discussion included:-

Reducing doses of antipsychotic drugs
Dr. David Branford, Leicester

The workshop firstly addressed the questions of why reduce the doses of antipsychotic drugs and what are the criteria for dose reduction. The agreed criteria were

In the second part of the workshop these criteria were applied to two case examples. In the final part of the workshop the problems associated with reducing the doses of antipsychotics were identified. These included:

The posters

A survey of pharmacists' knowledge of antidepressant discontinuation symptoms.
John Donoghue, Wirral Hospital (NHS) Trust, Bebington and Dr. Peter Haddad, Prestwich Hospital, Manchester

Discontinuation symptoms can occur on stopping all types of antidepressants, though different antidepressants differ markedly in their propensity to cause these symptoms. Symptoms may occur at any time that antidepressants are stopped, including doses missed inadvertently or as a result of intermittent compliance, but are less likely to occur when antidepressants are tapered down at the end of treatment. Discontinuation symptoms may have serious clinical consequences resulting in serious morbidity or misdiagnosis leading to inappropriate response. The latter is particularly true when health professionals are unaware that such symptoms may occur.

To assess pharmacists' knowledge of discontinuation symptoms, we mailed questionnaires to all members of the UK Psychiatric Pharmacy Group, and to all community pharmacies in Liverpool.

Specialist psychiatric pharmacists are the most knowledgeable group about discontinuation symptoms, and community pharmacists the least knowledgeable. This is as expected, as most of the literature on discontinuation symptoms is confined to case reports. However, it may be that pharmacists overrate their knowledge in this area, as 13% of pharmacists who claimed to be "confidently aware" were not aware of at least one class of antidepressant known to cause discontinuation symptoms. Only 23% of pharmacists reported counselling patients about discontinuation, and 38% of pharmacists reported that doses of paroxetine were not usually tapered before stopping. This is surprising as the data sheet for paroxetine clearly advises tapering before stoppage. Among community pharmacists only 11% counselled patients about stopping treatment, which is disappointing because the majority of depression is treated in primary care.

Young (1) showed the psychiatrists were more knowledgeable about this area than GPs. Similarly, specialist psychiatric pharmacists and hospital pharmacists are more aware than community pharmacists. If correctly identified and managed appropriately, these symptoms will be mild and short lived. If misdiagnosed, they may result in spurious clinical investigations, inappropriate treatment and preventable morbidity for the patient. This study identifies that there is considerable scope for community pharmacists in particular to improve their knowledge of discontinuation effects to better support patients, carers, and GP colleagues.

Reference
Young AH, Currie A. (1997). Physicians' knowledge of antidepressant withdrawal effects: a survey. Journal of Clinical Psychiatry, 58 (Suppl 7), S28-S30.

Prescribing patterns of selective serotonin reuptake inhibitors in primary care in the United Kingdom.
John Donoghue, Clatterbridge Hospital, Bebington, Liverpool

The aim of this study was to investigate the prescribing of selective serotonin reuptake inhibitors (SSRIs) for the treatment of depression during the Defeat Depression Campaign. Cross sectional data for prescriptions for SSRIs for patients with a diagnosis of depression were obtained from a large primary care computerised database (750,000 patients) for four consecutive twelve month periods ending June 1993, 1994, 1995 and 1996.

Analysis of the prescribing patterns of SSRIs shows that their prescribing patterns are consistent over time. 100% of prescriptions for SSRIs are in effective doses. Dosing patterns suggesting titration to higher doses are evident during the study period, showing the least dose titration with fluoxetine and the greatest with sertraline. This pattern of prescribing may have both clinical and economic implications. Naturalistic studies reveal differences between drugs which may not be apparent in clinical trials. In particular, an effective dose may be achieved earlier in treatment with fluoxetine, and the incidence of side effects may be less. These are significant advantages which may simplify treatment and result in improved outcomes. Sertraline is prescribed in higher doses, and because of this may increase the cost of treatment significantly.

Pharmacist produced medication histories. Carol Paton, Oxleas NHS Trust, Bexley, Kent

The pharmacists in Oxleas NHS Trust have, for some years, provided a detailed 'medication history' service on request. These histories map the patient's admissions to hospital, mental state, life events and medication received since their illness began. The findings are presented at the patient's next multi-disciplinary review, along with recommendations for future management. A sample of ten consecutive medication histories with treatment recommendations were followed up to determine whether the advice given by the pharmacist had been followed and, if so, what the outcome was for the patient. Outcomes in this sample, as judged by the acceptance and implementation of recommendations, and the positive effect that these had on patients' mental states were good. The service was considered by referrers to offer good value for money.

Pharmacist medication counselling: a randomised controlled trial in schizophrenia.
Madden FM, Donoghue JM, Wirral Hospital (NHS) Trust, Clatterbridge, Bebington, Wirral.

Antipsychotic medication is the mainstay treatment for patients with schizophrenia. Poor compliance with treatment is a major reason for relapse and is often accompanied by acute exacerbation of symptoms, Corrigan et al (1990). Where clinical pharmacists have been involved in the education of patients with schizophrenia they have improved compliance and knowledge of treatment, Dorevitch et al (1993); Greco (1994).

To test the hypothesis:
A pharmacist counselling patients with schizophrenia about medication will:
1. Improve understanding of treatment
2. Improve compliance with treatment
3. Reduce distress caused by the side effects
4. And these outcomes will be sustained for at least three months.

The study was conducted as a blinded, placebo controlled evaluation of a pharmacist's input into the pharmaceutical care of patients with schizophrenia. Patients were recruited from the inpatient cohort and from community depot clinics. Participants were randomly allocated to either the active group or the placebo control group. Participants in the active group were given standardised counselling and a United Kingdom Psychiatric Pharmacy Group antipsychotic leaflet. Participants in the control group were given standardised counselling and an information leaflet on the benefits of exercise. Outcomes were measured using three instruments: Medication Quiz, Drug Attitude Inventory Hogan (1983) and LUNSERS, Day et al (1995), applied prior to the intervention, one week after and then at three months.

Knowledge: an improvement, particularly in specific areas.
Compliance: an improvement, which was significant at three months (p=0.007).
Side effects: a significant reduction in distress from side effects post intervention (p=0.035).

It can be concluded that there is a positive trend in the improvement of patients' knowledge and compliance, also a reduction in distress from side effects of the medication. These findings illustrate that pharmacists have a significant contribution to make to the continuing care of patients with schizophrenia.

References:
Corrigan PW et al (1990). Hospital and Community Psychiatry, 41, 1203-11.
Day JC, et al (1995). British Journal of Psychiatry, 166, 650-53.
Dorevitch A, et al (1994). Consultant Pharmacist, 9, 864-71.
Hogan TP, et al (1983). Psychological Medicine, 13, 177-83.

The use of olanzapine in non-complying or treatment resistant clozapine patient populations in a psychiatric hospital.
Jean Stubbs, MRPharmS, Alexander Baldacchino, MRCPsych, MPhil, David Nevison-Andrews, MRCPsych, St Andrew's Hospital, Northampton

Olanzapine is an atypical antipsychotic drug for people with schizophrenia. The aim of this study was to record any evidence of a treatment effect with olanzapine in patients that had been withdrawn from clozapine for a variety of reasons (Category A) or were resistant to conventional antipsychotics and were clozapine naïve (Category B).

We reviewed the use of olanzapine at St Andrew's Hospital, Northampton. In this retrospective study 23 of the 37 patients prescribed olanzapine, between October 1996 and June 1997 fitted the inclusion criteria. The sample comprised 16 Category A and 7 Category B patients. Incidence of side effects, reasons for discontinuation, and treatment response with olanzapine (based on responsible consultant psychiatrists' subjective impression of improvement in mental state) were recorded.

Olanzapine demonstrated an acceptable degree of overall tolerability. Only one patient was discontinued from the drug due to the experience of side effects (skin rash). The most common reason for withdrawal of treatment was patient refusal (4 patients). The same 4 patients had similarly refused clozapine. Six (38%) of the patients in Category A and five (71%) of patients in Category B were judged to have demonstrated moderate to marked improvement in their mental state.

Olanzapine appears to offer a promising new option for treating resistant schizophrenia. This is a result of specific pharmacological properties but is also due to the drug's acceptable degree of tolerability. A depot preparation of an atypical antipsychotic medication seems the next logical step.

Using a computer model to assess clozapine as a cost-effective treatment for schizophrenia in East Sussex Health Authority.
Kate Peperell, ABACUS International, Bicester, Oxfordshire and Dr Jennifer Bennett, East Sussex Health Authority, Lewes, Sussex.

Based on an original model developed by Matheson et al, an interactive computer model was developed to investigate, at a local level, the impact of the introduction of clozapine on the total costs of providing schizophrenic care. This computer model has been used in East Sussex Health Authority to investigate local needs and the economic impact of increasing the number of patients treated with clozapine.

In East Sussex (population 730,864), the model predicted the number of schizophrenic patients to be 2,377, of which 231 would be treatment-resistant. A total of 60 (26%) patients were currently receiving clozapine. Using the computer model, the impact on costs of current clozapine prescribing and the potential costs if all treatment-resistant patients receive clozapine were calculated.

Table 1: The effect of clozapine on 5 year costs (60% efficacy assumed)
No clozapine usage Current clozapine usage (26% patients) Total clozapine usage (100% patients)
Drug costs £5,644,334 £6,221,140 (+10%) £7,862,819 (+39%)
Community care costs £13,567,326 £13,565,256 (0%) £13,559,365 (0%)
Hospital care costs £45,125,688 £44,138,345 (-2%) £41,328,214 (-8%)
Total £64,337,348 £63,924,741 (-1%) £62,750,399 (-2%)

The introduction of clozapine causes an increase in drug expenditure, however due the decrease in in-patient stay and associated costs, total healthcare expenditure is reduced. This analysis has encouraged East Sussex Health Authority to allocate extra funds, so that an additional 30 patients can receive clozapine, in the coming year.

Reference:
Matheson L A et al (1994). British Journal of Medical Economics, 7: 25-34.

Evaluation of the effect of continuing pharmaceutical care on medication problems experienced by discharged acute-admission psychiatric patients.
Shaw H, Mackie C+., Martin M*., Sharkie I*. (* Glasgow Community & Mental Health NHS Trust. + University of Strathclyde)

With the closure of psychiatric hospitals it is essential that adequate provision for care of patients in the community be made. Very often seamless transfer of care from hospital to the community relies on effective discharge communication between hospital doctors and GPs (1). However it has been indicated that hospital pharmacists should establish links between community pharmacists and clients with identified needs, to ensure that these needs can be readily met in the community (2).

Discharged acute-admission psychiatric patients were randomly allocated to control or intervention groups over a 6-month period. A specially designed pharmacy discharge plan was completed and sent to the community pharmacy of choice for intervention-group patients. All patients were followed up by domiciliary visits at 1,4, and 12 weeks post-discharge. Medication problems were noted using a continuing-care questionnaire. After each visit the patient's community pharmacist was contacted and information collected about the dispensed medicines and use of the discharge-plan, where applicable.

Ninety-seven patients were recruited during the study period - intervention group (n=51) and control group (n=46). Discharge Plans contained an average of 6.4 (1.3) information issues. Overall a total of 344 medication problems were identified from domiciliary visits. Over the 6 month period 63% of patients regularly attended the same pharmacy. Pharmacists in receipt of a discharge plan identified 81% more problems than those who did not. An average of 1.5 (2) information issues was used by community pharmacists one week post-discharge.

This study has demonstrated the benefits of continuing pharmaceutical care post-discharge.

References:
1. Beecham L (1991). Prescribing responsibility. British Medical Journal, 303:1289
2. Policy statement: pharmaceutical aspects of community care. Pharmaceutical Journal, 1992;248: 541-544.

SDZ ENA-713 (ExelonTM) in dementia: review of clinical development.
Vincent SA, Novartis Pharmaceuticals UK Ltd.

Treatment objectives in dementia are directed towards cognition and daily functioning. Any treatment needs to be safe and well tolerated, and should reverse or slow progression of the disease symptomatology. SDZ ENA-713 is a 'pseudo-irreversible' inhibitor of acetylcholinesterase (AChE) of the carbamate type. It is not metabolised by the liver, has a plasma half-life of approximately two hours, and a single dose inhibits AChE highly selectively in the brain for 10 hours.

In 516 patients with mild to moderate Alzheimer's disease (AD), and dementia of Alzheimer's type, studied for 26 weeks, significantly more patients were improved on SDZ ENA-713 3mg bid than on placebo (p<0.05), assessed by clinical global impression of change (CGIC). Psychometric test also showed significant improvements in all scores for SDZ ENA-713 3mg bid (p<0.05).

The Adena programme ('Alzheimer's Disease treatment with ENA-713').

3,300 patients in 120 centres in 10 countries, were treated with SDZ ENA-713 or placebo for 6 months, with open-label follow-up, and were assessed using tests of cognitive function, quality of life, clinical impression (including caregiver input), mental state, and staging of the disease. Patient recruitment was completed early and exceeded target. Results so far show highly significant improvement for SDZ ENA-713 v placebo in cognitive function after 26 weeks of treatment (p<0.001, n=581).

The same outcome measures were used in all 4 studies in the ADENA programme. Multinational investigator training sessions ensured consistency of clinical assessment, and the protocol included "real life" patients with varying concomitant diseases and medication. Results so far reported indicate that SDZ ENA-713 substantially slows the progression of Alzheimer's disease.

Eradicating the need to administer medicines in day centres for people with learning disabilities.
Branford D, Knifton C, Jackson S, Glenfrith Division of Fosse Health Trust, Groby Road, Leicester.

A previous study had identified the problems associated with the need to administer medicines at day centres for people with learning disabilities. Prescribers and carers were informed of the findings of that study and provided with recommendations for the reorientation of the prescription for their patients. For those patients receiving continued supervision from specialists in learning disabilities the dose regimen was altered in 50% of cases. For those supervised by GP's a change occurred in 30% of cases. There were only 2 reports of adverse events following the change, both of a minor nature.

Drug administration in day centres for people with learning disabilities.
Branford D, Knifton C, Jackson S, Glenfrith Division of Fosse Health Trust, Groby Road, Leicester.

A study was made of the problems associated with the need to administer medicines at day centres for people with learning disabilities. In Leicestershire 167 (13%) of the 1317 people with LAD who attended day centres required the administration of medicines. The percentage of attendees requiring drug administration varied from day centre to day centre (min 4%, max 23%). Antiepileptic drugs were the most commonly administered drugs, followed by antipsychotic drugs. The administration of medicines took a significant amount of time for senior members of the day centre staff and had a great potential for errors. In only 32 cases was it deemed essential that the drug administration occurred at the day centre.

Epilepsy in adults with learning disabilities 1 - a description of seizures.
Branford D, Duncan F, Glenfrith Division of Fosse Health Trust, Groby Road, Leicester.

Epilepsy is a common problem of people with learning disabilities (LD). The aim of the study was to provide an overview of the nature of the epilepsy suffered by adults with LD. Six previous surveys of the population of adults with LD who live in Leicestershire had identified 796 as possibly suffering both LD and epilepsy. A postal questionnaire enquiring about many aspects of the epilepsy was devised and distributed. 689 questionnaires were completed (86%) and epilepsy was confirmed in 532 cases.

The key findings were:
1. Approximately half suffered more than one seizure type.
2. Tonic-clonic seizures were the most common (59%) followed by absence (40%) and myoclonic jerks (21%).
3. The seizures often occurred in clusters (48%).
4. The faking of seizures was rarely reported (less than 5%).
5. Seizures are commonly precipitated by physical illness, excitement, constipation and menstruation.

These findings have implications for the management of epilepsy in people with learning disabilities.

Epilepsy in adults with learning disabilities 2 - The refractory nature of seizures.
Branford D, Duncan F, Glenfrith Division of Fosse Health Trust, Groby Road, Leicester.

Epilepsy is a common problem of people with learning disabilities (LD). The aim of the study was to provide an overview of the performance in the treatment of the epilepsy suffered by adults with LD. Six previous surveys of the population of adults with LD who live in Leicestershire had identified 796 as possibly suffering both LD and epilepsy. A postal questionnaire enquiring about many aspects of the epilepsy was devised and distributed. 689 questionnaires were completed (86%) and epilepsy was confirmed in 532 cases.

The key findings were:
1. In 75% of cases the person continued to suffer seizures despite treatment with antiepileptic drugs (active epilepsy). For 7% the epilepsy was in remission (no seizures for 3-5 years) and for the remainder the epilepsy was inactive (no seizures for 5 years). Those suffering from partial seizures, absences and myoclonic jerks proved the most refractory to treatment.
2. 17% were reported to have suffered at least one status epilepticus during 1996 with 5% reporting it to have occurred on more than 10 occasions. These findings have implications for the management of epilepsy in people with learning disabilities.

www.nmhc.co.uk - a 24 hour a day mental health drug information resource for service users and carers
Stephen Bazire, Pharmacy Services Director, Norfolk Mental Health Care NHS Trust, Hellesdon Hospital, Norwich NR6 5BE

An Internet website was set up in 1997, specifically to provide detailed information and education about psychotropic drugs for people with mental health needs, their carers and their relatives.

The scheme was undertaken to address the following problems:

The resource is:

The website contains readily accessible independent information and education of a high quality. It provides people with both what they want and need. It is based on the information needs of patients e.g. the risks of taking drugs (e.g. side effects) and risks of NOT taking drugs (e.g. relapse). The common fear of patients that full and balanced information is not available is thus allayed. The site now has an average of over 300 visitors per month. Questions have been left by visitors from all over the world, as well as from the local area. A register of responses is maintained, and suggestions for improvements are being acted upon. Norwich and Norfolk Service User group involvement is growing.