The 1st European Psychopharmacy Congress

Lundbeck International Psychiatric Institute
Skodsborg, Copenhagen, Denmark
12th-14th November 1998

Delegates:

Guy Biermez, Willy De Boever, Gert Laekeman, Fernand Mathot, Jeannine Peters, Johan Reyntens, Cécile Van den Eynde (Belgium),
Leis Andersen, Karen Højfeldt, Lene Jensen, Anne Marie Schmidt (Denmark)
Marie-Lise Biscay, Jacqueline Surugue, Dr Charles Gury, Claudine Fabre (France)
Gina Wildeshaus (Germany)
Tara Glynn (Republic of Ireland)
Carla Breuer, Walter Broekema, Walter Hermens, Gerard Hugenholtz, Harrie Martens, Bernard Schueler (Netherlands)
Elisabeth Eide, Ingeborg Hartz (Norway)
Vicenta Casany (Spain)
Stephen Bazire, Valerie Dixon, Morag Martin, Nurjehan Moledina and Chris Sutton (UK)

The group has met twice before (Brussels and Lille).

Thursday 12.11.98

The first EPP General assembly discussed the future of European Psychopharmacy co-operation and development:

Opening session

Introduction:

Joan Jørgensen (LIPI) welcomed delegates to the Lundbeck International Psychiatric Institution. She explained that the Institute was set up in 1997 as a serious commitment by Lundbeck to helping improve the quality of treatment for patients suffering from illnesses of the CNS. Lundbeck had founded the Lundbeck International Neuroscience Foundation with the mission "To provide an international interactive setting where consensus can be achieved in order to improve the diagnosis, treatment and compliance in disease areas such as schizophrenia, depression, Parkinsonism and dementia." The Institute is a legally and administratively independent organisation, partly funded by Lundbeck and partly elsewhere, and supported by WHO, WPA and AEP. It organises workshops, symposia and educational programmes designed to be useful to participants, and can then to help train others. The Faculty has around 100 internally respected psychiatrists who help develop the Institute. Seventeen one-week evidence-based courses have been run in 1998, and 20 are planned for 1999, mostly on schizophrenia and with some on affective disorders. These residential seminars take place at the Skodsborg Kurcentre and Villa Rex, in Skodsborg, about 10 miles north of Copenhagen in Denmark.

First session:
"The present and future of psychiatric pharmacy in Europe"

Delegates were welcomed by EPP President Johan Reyntens (Belgium), who formally thanked the Lundbeck Foundation for their international support of the event.

Chairman for the first session Stephen Bazire (England), welcomed delegates and reminded them that the term pharmacy means different things to different people and that we should bear this in mind with the presentations. No one is saying the models presented are the only or the best way to fulfil our role, but the presentations are to help us gain ideas from, and support, each other.

Delegates from each country then detailed recent changes in psychiatric Pharmacy in their country, based on the perceived strengths and weaknesses of each country, as outlined on the EPP website (www.ukppg.co.uk/epp.html). There was a familiar theme throughout the contributions of reduced mental health bed numbers, dilution or dispersion of specialised pharmacists and pharmacists often restricted by the demands of the core service distribution function but wanting to develop a more clinical role. In some countries e.g. Belgium, it is about to become law that patient information or education is compulsory. Many of these changes could be seen as threats, but also opportunities.

Stephen Bazire then outlined some of the methods by which inter-professional communication had been developed in his hospital. Pharmacy in the UK is often seen by other professionals as being a "closed shop" i.e. pharmacists know lots but don’t pass it on. Education of patients and staff about drugs and drug therapy is, he thought, a good idea, since there are not enough pharmacists to help everyone and so we have to work through others. Pharmacy staff in Norwich had produced a 110 page book "Your Medicines - Any Questions?", run a telephone helpline, run a web site, provide "Bespoke" leaflets on discharge, run group medication education programmes on acute wards, supported by a "MedEd" book, have a Pharmacy Discharge Letter, information sheets for GPs, lithium and MAOI cards etc. He noted that all these took time to set up, but not much time to keep running in some cases. They helped reinforce and maintain profile of pharmacy as the drug experts and the source of info and education (Drugs ‘r’ us!), and recommended others to consider adopting some of these to help establish their credibility. There was perhaps a "Critical mass" for staffing, below which you didn’t have enough time to prove what you could do. There is a need to get above this and prove our worth and such activities helped do this. In discussion, Chris Sutton (UK) mentioned the open and mutually co-operative relationship between Hospital and Industry in the UK, which can be used to good effect. Stephen agreed, as several of the items mentioned above had been supported by Industry, which had helped their development. The relationship between Industry and Hospitals in the UK was fairly "transparent" and open, which helped.

Walter Broekema, Netherlands
"Future for psychiatric pharmacy."

Walter outlined some of the things that Pharmacy needs in the future e.g.

Other issues that faced us include:

Walter (the walker) proposed that automatic dispensing may be a way to improve future pharmacy functioning eg Baxter ATC-212 and others. The reasons for this included:

The main disadvantages were that they only took tablets and capsules not in foil packs and no syrups but after nine years experience concluded that such machines were very "psychiatry friendly". Other robotics systems, many based on motor industry technology, are available, but at massive costs, and using a lot of packaging,

Jacqueline Surugue and Marie-Lise Biscay
"Pharnaceutical services in french psychiatric hospital. Actual situation and perspectives: results and inquiry."

Jacqueline and Marie-Lise reported on the 1998 enquiry into psychiatric hospitals in France. The main findings were that 51,000 beds in 95 hospitals were surveyed. 62 answered (64%), covering 26K beds and 8700 day places (thus quite representative selection). Of these:

Of these:

Of the 95 pharmacists, 75% are hospital practitioners

Workload:

Since August 1991 it has been compulsory for pharmacists to analyse prescriptions - 77% now do this
Average of 3-4 clinical trials per year per pharmacy, although 4 hospitals took up to 40% of total.
71% use autoclaves and 20% still use paraldehyde
Average 3.3 computers per hospital

The main desires of pharmacists were:

Friday 13.11.98

Quality Assurance.
Chairman Bernard Schueler, Netherlands

Elisabeth Eide, Bergen, Norway
Survey of the use of hypnotics in the elderly in Hordaland, Norway.

There had been much media attention about hypnotic use in the elderly in Norway. A survey was thus carried out, covering 2282 patients in total. Some findings were:

The survey illustrated good co-operation between doctors and the pharmaceutical advisory service in Norway.

In the validation phase, 53 replies were received from the follow-up questionnaire, covering 1460 patients. Some results were:

Conclusion:

The study was a good basis for further work, which is now being carried out.

The audience was most impressed with the work and results.

Harry J. Martens (Netherlands)
"Quality assurance in hospital pharmacy"

In the next session, Harrie Martens discussed Quality Assurance in hospital pharmacy in the Netherlands. Quality is extent to which the product or service will satisfy the customer. There is now a 5 year quality programme 1997-2002 (Q system) in Hospital pharmacy in the Netherlands. An impressive range of standards, guidelines, internal and external audits, Certification, GMP, Q handbook etc. were detailed and future goals (e.g. facilitation of the implementation of Q system, self-evaluation tests etc.) were mentioned.

Jeannine Peters and Cécile Van den Eynde (Belgium) discussed quality assurance of dispensing systems in Belgium.

Dr Claudine Fabre (Chief Pharmacist, Toulouse) then discussed quality Assurance in French hospitals. There was a need for an individual approach in the pharmaceutical service of the psychiatric hospital of Toulouse. The regional group of 47 hospital pharmacists have written a quality manual covering management, preparation, dispensing, sterilisation etc. 600 hours work was involved, and the quality manual was published in September 1998, applicable to other or even all hospitals.

Discussion:

As a result of Elisabeth’s study, there was discussion of an attempt to repeat this across Europe. The discussion covered:

Psychiatry of old age:

All beds within a defined area would be surveyed, probably one weekday in April 1999. The protocol will be organised by the Belgium team, data possibly analysed in Copenhagen University. Each country needs a co-ordinator, and local data put on to an Excel template (to be supplied).

Afternoon session: Clinical trials
Chair Jacqueline Surugue

Dr. Charles Gury
"Clinical trials organisation in France: an example of involvement of the French Pharmacists"

Charles (doubly qualified as Doctor and Pharmacist) works at the main (only) psychiatric hospital in Paris. He outlined clinical trials in France, the obligations facing the promoter, the investigator e.g. informed consent (including special protected patients), and in people where informed consent is not possible. He mentioned the advantages of pharmacists as key players in clinical trials e.g. at the crossroads of information about drug use.

He detailed a recent study on the doses and conversion factors relevant where patients switch from Clopixol acetate (Acuphase) to the decanoate (Clopixol) when used for acute exacerbation of psychosis. The results of the study are expected soon. A second study was investigating the use of midodrine (an alpha-blocker) for the treatment of psychotropic-induced orthostatic hypotension.

Charles, doubly qualified as a doctor and pharmacist, emphasised the importance of such studies as pharmacists had thought of the idea, initiated the research, joined together the investigators, drafted the protocols, collected the data, assumed responsibility for organisation and negotiated with management.

Willy de Boever, Belgium.
"SSRI versus tricyclic antidepressants: a Belgian survey"

Willy discussed that some pharmacists in Belgium wanted to do studies into antidepressants. There were lots of trials in progress, with SSRI use rising. Epidemiological studies and prescription surveys are not common in Belgium and so a naturalistic study was started. The study team asked the questions:

  1. Do both drug groups (SSRI/TCA) have similar efficacy?
  2. Do they have similar effectiveness?

During the 17-month study duration, 368 depressed patients were screened, 68 included and 40 have completed so far. They were assessed for safety and side effects, rating scales, economic assessment, health outcome, and one year follow-up, including drugs, doses and duration. Pharmacists, nurses and Doctors took part in assessments.

Results are being produced but many problems were outlined, a list delegates found honest and useful:

Outcome was that there is much good data collected, but there are problems retrieving it. There is a need for pharmacists to be better aware of these potential pitfalls before embarking on trials. However, it helped establish and develop clinical pharmacy in some Belgium hospitals.

Nurjehan Moledina (Sutton, England)
"Extra-pyramidal side effects with SSRIs"

Nurjehan presented the data obtained during her MSc, concerning extra-pyramidal side effects from SSRIs. She noted that there had been a large number of anecdotal reports of EPSEs with SSRIs, including akathisia, which may complicate the diagnosis and management of depression. The cause is not well known, but may be from hyperstimulation of some serotonin receptor sub-types, or perhaps a complex cascade from serotonergic inhibition of dopamine function (which disinhibits acetylcholine, in turn enhancing GABA, and then disregulating motor muscle control). Her retrospective epidemiological study looked at the incidence of EPSEs with SSRIs and tricyclics, using a postal questionnaire of out-patients prescribed tricyclics and SSRIs.

Results:

Saturday 14th November

Free Communications.
Chairman Johan Reyntens (Belgium)

Fernand Mathot, Belgium
"Long QT syndrome and psychotropic drugs"

A prolonged QT syndrome can provoke cardiac arrhythmia and Torsade de Pointe and is associated with sudden death. It can occur naturally (long QT syndrome) or with some drugs. The QTc interval is important but there is quite a range of lengths in normal life. Potassium channel-blockers affect QT interval, but a genetic basis also postulated, and drugs may unmask this genetic disposition. Many drugs cause QT prolongation e.g. Class 1a and 3 arrhythmics, calcium-channel blockers, neuroleptics, antidepressants, antihistamines, antimicrobials, antimalarials, cisapride, macrolides etc and others (e.g. chloral etc).

Fernand outlined the CHP survey of 500 in-patients in 1997. A "normal" QTc was fixed at 420msec.

Fernand called for more research e.g. defining the problem better. Patients at risk probably have pre-existing QT prolongation, uncorrected bradycardia, hypokalaemia, hypomagnesaemia and genetic abnormalities in drug metabolism. He called for more research into at risk patients and monitoring of these.

Valerie Dixon (Norwich, England)
"Developing the role of the Pharmacy technician in UK"

Valerie outlined the new models of care in the UK, with more clinical activities and pharmacists as regular members of multidisciplinary team. She also mentioned that there were no pharmacists qualifying in the UK in 2000, leading to a projected shortage of pharmacists. Thus, there was a need to make the best use of staff, particularly pharmacists. In most organisations, there are three levels of staff i.e. the professionally qualified (e.g. pharmacists), the operationally qualified (e.g. technicians) and the unqualified (e.g. assistants), and pharmacy is no exception. She then outlined how UK technicians were trained and how they have begun to assume traditional pharmacist roles.

UK Technician training – "BTEC" one day a week day release for 2 years. An alternative is the NVQ course, which is all locally managed study, and an alternative to BTEC with internal education and an external assessor. Some ATOs (unqualified pharmacy assistants) were now training as NVQs, with some learning to dispense.

Valerie outlined the current status of "tech-check" (technicians checking items dispensed by technicians). Suitably qualified technicians now make the final check of dispensed items in some hospitals. Pharmacists make the clinical check at beginning of the process, then technicians do the rest. This makes best use of pharmacist time, and uses the technicians technical skills. There is now a two-part national accredited scheme for "tech-check" in use in South Thames Region:

Part one:

Part two;

A number of other roles were outlined:

Future plans might include some ward rounds, a clinical role e.g. doing drug histories.

Valerie finished by stating that she was not saying this was the only way to go, but hoped that her talk might provide some options and points for discussion.

Dr. Gert Laekeman, VZA Belgium
"Evaluation of continuing education programme in clinical psychopharmacology"

Gert mentioned that the course is for hospital pharmacists in psychiatric hospitals in Belgium, and the aim is to educate, stimulate and certificate, as well as improve teamwork ability, improve confidence, and enhance participate in clinical trials.

His first hospital contact was in 1995, when the first session ran on depression. Then October 1995, a 3 year course was commenced. The structure was:

44 pharmacists started the course and 39 carried on to the bitter end. All participated in projects and the mean result from tests was 81% (range 67-93%).

On enquiry:

Conclusions:

The strengths of the course were the positive course interaction, strong involvement of lecturers through interactive sessions, quality of course, receipt of certificate, facilitation of international contacts by stimulating interest. The weaknesses included the feedback on the evaluation exercises (mainly time constraints) and now implementation of the certificate at a national level. It was considered a major success and will continue, with the continued support from Johan Reyntens (driver), Willy de Boever (clinical trials feeder), Marc de Vos, Marc van den Berghe (chose lecturers) and Michel Dierick (lecturer). Validation of the course is being carried out and can be taken on. Jacqueline Surugue and Stephen Bazire congratulated the Belgians on the course, the organisation and their enthusiasm.

Vicenta Casany (Alicante, Spain)

Vicenta outlined a study of 3 hospitals in Spain:

There are significant differences between HP and SR in the actual antipsychotics prescribed but not in the doses used. There were no differences in hospitalised adults with mental retardation.

Differences in prescribing appeared to depend on the "cultural care" e.g. staff sensitivity and tolerance, organisation, ideology and expectations) i.e. there were more prescriptions for antipsychotics where patients are in wards, and less where patients are rehabilitated.

The findings were:

She mentioned other findings, but I didn’t write them down well enough to repeat them here.

Morag Martin (Glasgow, Scotland)
"The Glasgow experience of community care."

Morag would have presented data on Glasgow, but we ran out of time, so she passed around a handout outlining Glasgow’s approach to the provision of community based mental health services and the pharmaceutical input. There are currently 19 community-based mental health teams, funded by "Bridging Resources". There are distinct under and over-65 teams. The resource Centre Pharmacist attends allocation and review meetings, provides medication histories, identifies and liases on supply, and regularly reviews medication. Also provided is drug information, information services to service users, budgetary reports and has an education and training role. Lithium and clozapine clinics are being developed. Other projects include a needs assessment scheme, drug utilisation evaluations of antipsychotics, shared care projects and patients own medication projects. In summary, there are well established community teams in Glasgow, but patchy input from pharmacists. This input is essential and valued but insufficient to meet the demands. There was a need for a structured service in Glasgow, perhaps with locality-based psychiatric pharmacists.

Plenary session:

In the final session, the following was discussed:

Stephen Bazire - 19.11.98
Probably mostly inaccurate notes made at the time. Appologies for any errors or omissions. please let me know of any mistakes etc and I will correct them.