Introduction to Pharmaceutical Care in Mental Health

Update 2011

Introduction to Pharmaceutical Care in Mental HealthUpdate 2011

This insert provides new evidence and legislation that has been published since this pack was produced in 2007.

Key changes to the original document are highlighted page by page. It is recommended that you work with the insert and the original pack side by side to ensure that you do not miss any key points.

Patients with mental illness are vulnerable and require long term medication to maintain their mental health. Many patients on simple drug regimens or on long term treatment require monitoring e.g. weight gain in patient on antipsychotics (pharmacy intervention possible) or plasma level monitoring in lithium patients, and of greatest importance compliance / concordance. Reduction in compliance is often the first sign of a decline in mental state. Community pharmacies are ideally placed to spot the early signs of relapse and communicate with the patient’s mental health team. The local mental health team, especially the local mental health specialist pharmacists may be contacted to offer support.

Chapter 1 – Introduction to mental health and mental illness

Page 14 1.2 History of mental healthcare 3rd paragraph

Link changed to: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/

PublicationsStatistics/DH_076516

Compare with the latest report published in 2010 see: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_114795 there has been some significant improvement of attitude over the last few years and the numerous Government initiatives are aimed to maintain and improve public attitudes.

For 2006 report use: www.scotland.gov.uk/Resource/Doc/197512/0052833.pdf

See also: www.wellscotland.info/guidance//tamfs/impproving/index.aspx

Page 16 2nd paragraph

Link changed to: http://www.vhscotland.org.uk/library/misc/Hear_Me_report_june_07.pdf

3rd paragraph

Link changed to: http://pb.rcpsych.org/cgi/reprint/24/8/315-b.pdf

Page 16 1.3 Development of mental health law and social care 2nd paragraph

Link changed to: http://www.studymore.org.uk/4_13_ta.htm

Page 18 7th paragraph

Link changed to: www.audit-scotland.gov.uk/docs/health/1999/nr_9910_adult_mental_health.pdf

Page 20 2nd paragraph

Link changed to: www.sehd.scot.nhs.uk/onh/onh-00.htm

Page 21 1st paragraph

Link changed to: http://www.breathingspacescotland.co.uk/bspace/CCC_FirstPage.jsp

4th paragraph

www.headsupscotland.co.uk no longer supported.

6th paragraph

National Resource Centre for Ethnic Minority Health This organisation is no longer active, the final report can be found at: www.healthscotland.com/documents/3844.aspx

Add: Towards a mentally flourishing Scotland http://www.handsonscotland.co.uk/publications/towards_a_mentally_flourishing_scotland_policy_and_action_plan.pdf

Aims of this policy: Our mental health is important to all of us as it affects every aspect of our lives. There is no health without mental health. The Scottish Government is committed to working to improve the mental health of Scotland’s people through ensuring that appropriate services are in place, but also by working through social policy and health improvement activity to reduce the burden of mental health problems and mental illness and to promote good mental wellbeing.

Page 23 Compulsory Treatment Order (CTO) Last paragraph

Links changed to: www.legislation.gov.uk/asp/2003/13/contents www.mwcscot.org.uk/mwc_home/home.asp

1.5 Classification systems for mental and behavioural disorders Page 28 Table 1

Note - DSM-V is still being developed and expected 2011/2012

1.6 Mental health rating scales Page 30 Table 3 The most commonly used rating scales

Add GASS (Glasgow Antipsychotic Side Effect Scale) becoming increasing popular for side effects of atypical antipsychotics.

Page 31 Add GASS (Glasgow Antipsychotic Side Effect Scale) as reference 16:www.icptoolkit.org/docs/NeedsAssessmentandOutcomeMeasures/GASS.doc

Page 31 3rd last paragraph

Link changed to: http://www.cnsforum.com/clinicalresources/ratingscales/ratingpsychiatry/

2nd last paragraph

Add in Tidal Model: http://www.tidal-model.com

Page 32 1st paragraph

Link changed to: http://www.healthscotland.com/documents/2349.aspx

1.7 Guidance on care in Mental Health Page 32 Delivering for Mental Health Last paragraph

Link changed to: http://www.scotland.gov.uk/Publications/2006/11/30164829/0

Page 33 Integrated Care Pathways: Assessment of Quality of Care and Treatment – NHS QIS

Delete NHS QIS link as no longer exists

Page 35 Amendments to Table 4 NICE and SIGN guidance in psychiatry

Title, Published technology appraisals (TA) Completed Review

Alzhemier’s Disease – Donepezil, galantamine, rivastigmine (review) (TA111) Set 2007 Ongoing

Bipolar disorder – new drugs (TA66) (replaced by Clinical Guideline 38) Sept 2003 TBC

Depression and anxiety – computerised cognitive behaviour therapy (CCBT) (TA97) Feb 2006 Ongoing

Electroconvulsive therapy (ECT) (TA59) Apr 2003 TBC

Insomnia – newer hypnotic drugs (TA77) Apr 2004 TBC

Schizophrenia – atypical antipsychotics (TA43). Replaced by (CG82) June 2002 May 2005

Published NICE clinical guidelines Completed Review

Anxiety (CG22) Dec 2004 TBC

Depression in Adults (CG90) Oct 2009 Oct 2012

Eating disorders (CG9) Jan 2004 TBC

Schizophrenia (CG82) Mar 2009 Mar 2012

Self harm (CG16) Jul 2004 TBC

Violence (CG25) Feb 2005 Feb 2012

Depression in children and young adults (CG28) Sep 2005 Feb 2011

Bipolar disorder (CG38) Jul 2006 Jul 2011

Obsessive compulsive disorder (OCD) and body dysmorphic disorder (BDD) (CG31) Nov 2005 March 2011

Antenatal and postnatal mental health (CG45) Feb 2007 Feb 2012

Dementia (CG42) Nov 2006 Nov 2011

Published SIGN guidelines Completed

Management of patients with dementia Feb 2006

Bipolar affective disorder May 2005 (updated July 2005)

The management of harmful drinking and alcohol dependence in Primary Care

Sept 2003 (updated Dec 2004)

Postnatal depression and puerperal psychosis June 2002

Management of attention deficit and hyperkinetic disorders Oct 2009

Psychosocial interventions in the management of schizophrenia

Oct 1998 (updated Aug 2005)

Interventions in the management of behavioural and psychological aspects of dementia

Feb 1998(reviewed 2005)

Chapter 3 – Schizophrenia

3.7 Treatment of schizophrenia Page 57 Delete link for `The Clinical Standards for Schizophrenia` as these are no longer active.

Exercise 3

Replace NICE link with: http://guidance.nice.org.uk/CG82

Page 58 4th paragraph

Olanzapine and paliperidone are now available in depot formulation, though their place in therapy has yet to be established.

2nd bullet point

`Caution in patients who choose to stop or start smoking during treatment with clozapine and olanzapine as smoking significantly increases the metabolism of these drugs`.

3.8 Side effects of antipyschotics Page 60 Hormonal side-effects 2nd paragraph

There has been recent studies suggesting a link between hyperprolactinaemia and breast cancer though the true clinical risk has yet to be established.

Page 61 Cardiovascular side-effects 3rd paragraph from bottom

Last sentence should read `Prolonged QT interval has also been liked to specific antipsychotics and was the basis for withdrawal of droperidol, thioridazine and sertindole`.

Page 63 Hyperlipidaemia, diabetes and weight gain 3rd paragraph

Sibutramine now discontinued.

Page 66 Further reading Remove 2, 3 and 4 and website links.

Change NICE website link to: http://guidance.nice.org.uk/CG82

Chapter 4 Depression

4.5 Treatment of depressionPage 78 The NICE guideline 23 has been partially updated.

NICE guidance – Clinical Guideline 90 Depression: the treatment and management of depression in adults was published in October 2009

http://guidance.nice.org.uk/CG90

The recommendations are largely unchanged and the full partially updated guideline can be downloaded at:

www.nice.org.uk/nicemedia/live/12329/45888/45888.pdf

Page 79 Non-pharmacological treatment of depression www.csi.scot.nhs.uk, this link is no longer available. The national evaluation of the

‘Doing Well by People with Depression’ project can be found at: www.scotland.gov.uk/Resource/Doc/135895/0033676.pdf.

Page 80 Computerised Cognitive Behavioural Therapy (CCBT) NICE technology appraisal 97 – the recommendations in this technology appraisal have

been replaced by recommendations in the depression clinical guideline 90. http://guidance.nice.org.uk/CG90

Electroconvulsive Therapy NICE technology appraisal 59 – the recommendations in this technology have been

replaced by recommendations in the depression clinical guideline 90.

http://guidance.nice.org.uk/CG90

In summary, the guidance recommends that ECT should be considered for acute treatment of severe depression that is life-threatening and when a rapid response is required, or when other treatments have failed. The decision to use ECT should be made jointly with the person with depression as far as possible, and valid informed consent should be obtained if the person has the capacity to grant or refuse consent. Consent should be obtained without pressure or coercion, and the person should be reminded of their right to withdraw consent at any time.

Page 80 Pharmacological treatments for depression Typo – duroxetine should read duloxetine.

Page 84 Choosing an antidepressant Moderate or severe depression 3rd paragraph

Pregnancy and lactation issues - Additional reference

NICE clinical guideline 45 - Antenatal and postnatal mental health: clinical management and service guidance was issued in February 2007 and makes recommendations for the prediction, detection and treatment of mental disorders in women during pregnancy and the postnatal period (up to 1 year after delivery).

http://guidance.nice.org.uk/CG45

Page 87 Further reading Update the NICE reference to the most up to date guideline.

National Institute for Clinical Excellence. NICE Clinical Guideline 90. Depression: the treatment and management of depression in adults. October 2009. London: National Institute for Clinical Excellence.

http://guidance.nice.org.uk/CG90

Add the additional reference in pregnancy and lactation issues.

National Institute for Clinical Excellence. NICE Clinical Guideline 45. Antenatal and postnatal mental health: clinical management and service guidance. February 2007. London: National Institute for Clinical Excellence.

http://guidance.nice.org.uk/CG45

Page 88 References Update the NICE reference to the most up to date guideline.

3 National Institute for Clinical Excellence. NICE Clinical Guideline 90. Depression: the treatment and management of depression in adults. October 2009. London: National Institute for Clinical Excellence.

http://guidance.nice.org.uk/CG90

Remove reference 4 as it has been replaced by NICE clinical guideline 90.

Chapter 5 Bipolar affective disorder

5.6 Treatment of bipolar affective disorderPage 99 Antipsychotics However atypical antipsychotics are not currently licensed for the treatment of bipolar

depression – remove this statement and replace with Quetiapine is the only atypical antipsychotic currently licensed for the treatment of major depressive episodes in bipolar disorder.

Prevention of recurrence Lamotrigine is not licensed in the UK for this indication – remove this statement and

replace with `Lamotrigine is now licensed for the prevention of depressive episodes in patients with bipolar I disorder who experience predominantly depressive episodes`.

Page 100 Antipsychotics Olanzapine, quetiapine and aripiprazole are now licensed for long-term treatment, for

patients who responded well in a manic episode. There is also evidence to support the use of risperidone and a license is expected soon.

Lamotrigine Lamotrigine is now licensed for the prevention of depressive episodes in patients with

bipolar I disorder who experience predominantly depressive episodes.

Psychotherapy

Last paragraph There is a typo in the link, should be http://www.nelm.nhs.uk/

Page 106 Further reading There is a new edition of the Psychotropic Drug Directory.

Bazire S. Psychotropic drug directory. HealthComm UK Ltd, 2010.

BAP bipolar guidance - update 2009 Evidence-based guidelines for treating bipolar disorder: revised second edition—

recommendations from the British Association for Psychopharmacology 2009, 23(5): 574-591

http://www.bap.org.uk/pdfs/Bipolar_guidelines.pdf

Page 107 Further reading There is a new edition of the Maudsley Prescribing Guidelines.

Taylor D, Paton C, Kapur S. The Maudsley Prescribing Guidelines. 10th Edition, Informa Healthcare, 2009

Page 107 References 6. BAP bipolar guidance - update 2009

Evidence-based guidelines for treating bipolar disorder: revised second edition - recommendations from the British Association for Psychopharmacology 2009, 23(5): 574-591

http://www.bap.org.uk/pdfs/Bipolar_guidelines.pdf

7. There is a new edition of the Psychotropic Drug Directory.

Bazire S. Psychotropic drug directory. HealthComm UK Ltd, 2010.

8. There is a new edition of the Maudsley Prescribing Guidelines.

Taylor D, Paton C, Kapur S. The Maudsley Prescribing Guidelines. 10th Edition, Informa Healthcare, 2009

Remove reference 9 as now out of date.

Chapter 6 Anxiety disorders

6.6 Management of anxietyPage 120 2nd paragraph

The link to the NICE guideline is no longer available, replace with: http://guidance.nice.org.uk/CG22

Page 124 Amendments to Table 7 Additional licensed indications for the treatment of anxiety disorders with the newer antidepressants.

Antidepressant GAD Panic Disorder OCD Social

Phobia PTSD

Paroxetine Yes Yes Yes Yes Yes

Fluoxetine No No Yes No No

Sertraline No Yes Yes Yes Yes

Citalopram No Yes No No No

Fluvoxamine No No Yes No No

Escitalopram Yes Yes Yes Yes No

Venlafaxine Yes Yes No Yes No

Page 125 Combined pharmacological treatments The link to the BAP guideline is no longer available, replace with: http://www.bap.org.uk/pdfs/Anxiety_Disorder_Guidelines.pdf

Chapter 7 Sleep disorders

7.2 InsomniaPage 141 Insomnia in elderly people 2nd paragraph

There is now a melatonin formulation licensed on the UK market, Circadin (Lundbeck Limited). See the Summary of Product Characteristics (SPC) for dose and indications.

7.3 Management of insomnia 1st paragraph

Pharmacy staff should be aware of the risk that patients may self medicate with alcohol which may lead to dependence and significant harm. Brief interventions and patient education can be beneficial.

Page 143 Pharmacological treatment of insomnia 4th paragraph

Pharmacy staff should review any repeat prescriptions for hypnotics, all are licensed only for short courses. Prolonged courses of treatment should be investigated and alternatives suggested.

Page 146 Withdrawal of hypnotics 3rd paragraph

Pharmacies that dispense for nursing homes etc should review any prescriptions for hypnotics especially for patients who have been taking them long term and question the use of the medications. Alternatives should be suggested and advice given on reducing and stopping the hypnotics.

Page 148 Replace NICE link with http://guidance.nice.org.uk/TA77

7.4 The presentation and management of other sleep disorders Page 150 Sleep apnoea syndrome Obesity is a significant risk factor for sleep apnoea and pharmacies are able to offer

advice on weight loss.

Page 152 Further Reading Add following references

GPs’ attitudes to benzodiazepine and ‘Z-drug’ prescribing: a barrier to implementation of evidence and guidance on hypnotics. Br J Gen Pract. 2006; 56(533): 964–967.

Magic bullets for insomnia? Patients’ use and experiences of newer (Z drugs) versus older (benzodiazepine) hypnotics for sleep problems in primary care. Br J Gen Pract. 2008;58(551):417-22.

Chapter 8 Dementias

8.5 Classification of the dementiasPage 162 Alzheimer’s disease (AD) 1st paragraph

Link changed to: www.nia.nih.gov/Alzheimers/Publications/Unraveling/

8.6 Assessment tools in dementiaPage 164 1st paragraph

Link changed to: www.fpnotebook.com/Neuro/Cognitive/Index.htm

8.7 Management of cognitive features of dementiaPage 166 Cholinesterase Inhibitors (ChEIs) and Alzheimer’s Disease 2nd paragraph

http://guidance.nice.org.uk/TA111

Change text to `The NICE guidance on the use of donepezil, rivastigmine, galantamine and memantine have been challenged by drug manufacturers and advocacy groups. Despite this recent review in 2009 the recommendations remain similar to those released in 2006`.

NOTE: This technology appraisal was first issued in November 2006. It was amended in September 2007. This second amendment is effective from August 2009

This guidance applies to donepezil, galantamine, rivastigmine and memantine within the marketing authorisations held for each drug at the time of this appraisal; that is:

• donepezil,galantamine,rivastigmineformildtomoderatelysevereAlzheimer’sdisease

• memantineformoderatelyseveretosevereAlzheimer’sdisease.

The benefits of these drugs for patients with other forms of dementia (for example, vascular dementia or dementia with Lewy bodies) have not been assessed in this guidance.

The three acetylcholinesterase inhibitors donepezil, galantamine and rivastigmine are recommended as options in the management of patients with Alzheimer’s disease of moderate severity only, those with a Mini Mental State Examination [MMSE] score of between 10 and 20 points, and under the following conditions:

• onlyspecialistsinthecareofpatientswithdementia(thatis,psychiatristsincluding those specialising in learning disability, neurologists, and physicians specialising in the care of the elderly) should initiate treatment. Carers’ views on the patient’s condition at baseline should be sought.

• patientswhocontinueonthedrugshouldbereviewedevery6monthsbyMMSE score and global, functional and behavioural assessment. Carers’ views on the patient’s condition at follow-up should be sought. The drug should only be continued while the patient’s MMSE score remains at or above 10 points and their global, functional and behavioural condition remains at a level where the drug is considered to be having a worthwhile effect. Any review involving MMSE assessment should be undertaken by an appropriate specialist team, unless there are locally agreed protocols for shared care.

When using the MMSE to diagnose moderate Alzheimer’s disease, clinicians should be mindful of the need to secure equality of access to treatment for patients from different ethnic groups (in particular those from different cultural backgrounds) and patients with disabilities.

In determining whether a patient has Alzheimer’s disease of moderate severity, healthcare professionals should not rely, or rely solely, upon the patient’s MMSE score in circumstances where it would be inappropriate to do so. These are:

• wheretheMMSEisnot,orisnotbyitself,aclinicallyappropriatetoolforassessing the severity of that patient’s dementia because of the patient’s learning or other disabilities (for example, sensory impairments) or linguistic or other communication difficulties or

• whereitisnotpossibletoapplytheMMSEinalanguageinwhichthepatientis sufficiently fluent for it to be an appropriate tool for assessing the severity of dementia, or there are similarly exceptional reasons why use of the MMSE, or use of the MMSE by itself, would be an inappropriate tool for assessing the severity of dementia in that individual patient’s case.

In such cases healthcare professionals should determine whether the patient has Alzheimer’s disease of moderate severity by making use of another appropriate method of assessment. For the avoidance of any doubt, the acetylcholinesterase inhibitors are recommended as options in the management of people assessed on this basis as having Alzheimer’s disease of moderate severity.

The same approach should apply in determining and in the context of a decision whether to continue the use of the drug, whether the severity of the patient’s dementia has increased to a level which in the general population of Alzheimer’s disease patients would be marked by an MMSE score below 10 points.

See also http://guidance.nice.org.uk/CG42 Dementia 2006 and http://www.sign.ac.uk/pdf/sign86.pdf 2006 Management of patients with Dementia.

Page 167 Amendment to Table 15 Differences in ChEIs

AChEI Donepezil Rivastigmine Galantamine

Dosing 5 - 10mg daily 1.5 - 6mg twice daily

Also available as patches:4.6mg over 24 hours and 9.5mg over 24 hours

8-12mg twice daily,once daily with M/R formulation

Time to serum max 3 - 5 hours 0.5 - 2 hours 0.5 – 1 hour

Effect of food on absorption

No Yes Yes

Serum t½ 70 - 80 hours 2 hours(8 hours activity)

5 – 7 hours

Protein binding 96% 40% 10 -20%

Metabolism and excretion

Liver CYP450 (3A4 and 2D60, Renal excretion

No liver metabolism,Renal excretion

CI in severe hepatic and renal impairment

Interactions Inhibitors of CYP 3A4 and 2D6

Nil significant

Inhibitors of CYP450 3A4 and 2D6

Page 168 The controversy of treatment with ChIEs 3rd paragraph

Add text `Due to the controversies over the NICE guidance many areas have developed local guidelines on the use of these medications. Check with local area drug and therapeutics committee for advice`.

Page 169 NMDA receptor antagonists 3rd paragraph

Links changed to: http://guidance.nice.org.uk/TA111 NICE guideline and http://guidance.nice.org.uk/CG42 Dementia 2006 as well ashttp://www.sign.ac.uk/pdf/sign86.pdf 2006 Management of patients with Dementia

Chapter 9 Multiple pathology, multiple problems

Page 185 3rd paragraph

There is updated information regarding Scottish drug using prevalence and trends, see Drugs Misuse in Scotland: Findings From the 2006 Scottish Crime and Victimisation Survey. http://www.scotland.gov.uk/Publications/2007/09/26163243/3

9.4 Polypharmacy NICE guidance on atypical antipsychotics – updated and replaced by new schizophrenia

guideline.

Core interventions in the treatment and management of schizophrenia in primary and secondary care (update) March 2009, clinical guideline 82

http://guidance.nice.org.uk/CG82

Page 196 Further reading There is a new edition of the Psychotropic Drug Directory.

Bazire S. Psychotropic drug directory. HealthComm UK Ltd, 2010.

Reference The link to the BAP guideline is no longer available, replace with:

http://www.bap.org.uk/pdfs/Anxiety_Disorder_Guidelines.pdf

Reference The BAP guideline for bipolar disorder has been updated

Evidence-based guidelines for treating bipolar disorder: revised second edition—recommendations from the British Association for Psychopharmacology 2009, 23(5): 574-591

http://www.bap.org.uk/pdfs/Bipolar_guidelines.pdf

Chapter 10 The role of the pharmacist in managing mental health

10.2 Setting the scenePage 205 2nd paragraph

The new link to the Our National Health document is: http://www.scotland.gov.uk/Publications/2000/12/7770/File-1

Page 206 2nd paragraph

The new link to NHS QIS is: http://www.nhshealthquality.org/nhsqis/2315.html

4th paragraph

The new link to the 10 essentials shared capabilities is: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4087169

Page 211 Well informed leaflets The link to these leaflets is no longer available.

The UKPPG patient advice leaflets available on a CD ROM have been replaced by the choice and medication website. The site is commercially available on subscription to NHS trusts, specialist interest pharmacy groups, community pharmacies, independent healthcare providers and charitable mental health organisations. http://choiceandmedication.org.uk/cms/

Page 212 1st bullet point

The link to the Norfolk and Waveney Mental Health Partnership NHS Trust pharmacy department website no longer exists. It has been replaced by the choice and medication website, to which they subscribe.

5th bullet point

The NELM link has been updated to: http://www.library.nhs.uk/mentalhealth/

1st paragraph

Link to NES resources has been updated to: http://www.nes.scot.nhs.uk/disciplines/pharmacy/general-resources,virtual-room,webcasts

Page 215 Case study 9 - NICE guideline 23 has been partially updated.

NICE guidance 90 Depression: the treatment and management of depression in adults was published in October 2009 http://guidance.nice.org.uk/CG90

10.8 An advocacy role for pharmacistsPage 217 2nd paragraph

The UK Psychiatric Pharmacy Group telephone helpline based at the Maudsley Hospital closed in May 2007.

10.9 The specialist mental health pharmacistPage 218 3rd paragraph

The United Kingdom Psychiatric Pharmacy Group (UKPPG) and the College of Mental Health Pharmacists have now merged to form the College of Mental Health Pharmacy. The website is currently being updated.

4th paragraph

The United Kingdom Mental Health Pharmacy Technician Network (UKMHPTN) aimed to provide support and education to all pharmacy technicians who specialise or have an interest in mental health. However, joining the College of Mental Health Pharmacy is now the preferred option.

NHS Education for Scotland (Pharmacy)3rd floor, 2 Central Quay89 Hydepark StreetGlasgow G3 8BW

Telephone 0141 223 1600Fax 0141 223 1651

Email pharmacy@nes.scot.nhs.uk

www.nes.scot.nhs.uk/pharmacyApril 2011