PSYCHIATRY OVERVIEWPharmacy 421

October 24, 2002

Albert Chaiet B.Sc.Phm., M.Sc.Phm., M.B.A.

Beth Sproule B.Sc.Phm., Pharm.D

Wende Wood B.A., B.S.P.

Beliefs about Mental IllnessWhat do YOU think?????

The Myths of Mental Illness(source: Canadian Mental Health Association)

People with mental illness are violent and dangerous

People with mental illness are poor and/or less intelligent

Mental illness is caused by a personal weaknessMental illness is a single, rare disorder

The Myths of Mental Illness

More likely to be victims of violence Can affect anyone regardless of intelligence,

social class, incomeNot a character flaw-an illness-cannot just snap

out of itA broad classification for many disorders

What is Mental Illness?

• Mental illnesses are characterized by alterations in thinking, mood or behaviour (or some combination thereof) associated with significant distress and impaired functioning.

• The symptoms of mental illness vary from mild to severe, depending on the type of mental illness, the individual, the family and the socio-economic environment

Mental Illnesses in Canada-An Overview

Mental illnesses indirectly affect all Canadians through illness in a family member, friend or colleague

20% of Canadians will personally experience a mental illness during their lifetime

Mental illnesses affect people of all ages, educational and income levels and cultures

The onset of most mental illnesses occurs during adolescence and young adulthood

Overview continued

A complex interplay of genetic, biological, personality and environmental factors causes mental illnesses

Mental illnesses can be treated effectivelyMental illnesses are costly to the individual, the

family, the health care system and the communityThe economic cost of mental illnesses in Canada

> $7.3 billion (1993)

Overview continued

86% of hospitalizations for mental illness in Canada are in general hospitals

3.8% of all admissions in general hospitals were due to anxiety disorders, bipolar disorders, schizophrenia, major depression, personality disorders, eating disorders and suicidal behaviour

The stigma attached to mental illnesses presents a serious barrier not only to diagnosis and treatment but also to acceptance in the community

What is Mental Illness?

• Physical symptoms and illnesses• Concurrent disorders• Broad categories: Mood disorders Schizophrenia Anxiety disorders Personality disorders Substance abuse

What is Mental Illness?

Special issues:

SuicideSpecial populations:

ChildrenElderlyDevelopmental delay (dual diagnosis)

Mental Illness-Prevalence

• 20% of Canadians will personally experience a mental illness during a one year period

• 3% will experience profound suffering and persistent disablement

Mental Illness-Prevalence

• Mental Illness One-Year Prevalence

Mood DisordersMajor (unipolar) depression 4.1 to 4.6 %Bipolar disorder 0.2 to 0.6 %Dysthymia 0.8 to 3.1 %

Schizophrenia 0.30%Anxiety disorders 12.2%

Mental Illness-Prevalence Personality disorders 6.0 to 9.0 % (U.S.) Eating disorders

– Anorexia 0.7 % women0.2 % men

– Bulimia 1 .5 % women0.5 % men

Deaths from suicide 2 % of all deaths24% of all deaths (15-24)16% of all deaths (24-45)

• Addictions• alcohol• 1 in 10 report problems• >6,500 alcohol-related deaths (1995)• >80,000 hospitalized for alcohol-related problems

Mental Illness-Prevalence

Addictionsalcohol

– 1 in 10 report problems– >6,500 alcohol-related deaths (1995)– >80,000 hospitalized for alcohol-related problems

Smoking 1 in 6 deaths (34,700) related to smoking

Impact of Mental Illness

• 58.8% admissions women

• 50% admissions in age 25-44

• 25% admissions in age 45-64

• High rate in 15 –24 age group

Impact of Mental Illness

• Onset of most mental illness during adolescence and young adulthood:

Educational achievementCareer opportunitiesPersonal relationships

Impact of Mental Illness

• Suicide

• Family impact

• Economic impact-enormous $7.33 billion

Stigma and Discrimination

• Superstition, fear, old stereotypes etc

• Force people to remain quiet about their mental illness, often causing them to delay seeking treatment,avoid following through with recommendations, avoid sharing concerns with family, friends, colleagues.

Legal Framework

• Legal framework for the care, treatment and hospitalization of those suffering from mental illness and those incapable of making their own life decisions

• These laws are meant to balance the right to autonomy and self-determination with the right to care, protection and treatment as well as the safety of the community

Mental Health Act

• Psychiatric facilities

• Admitting

• Retention

• Access to records

• Financial incapacity

• Rights of patients to information

• Community treatment orders

Health Care Consent Act

• Informed consent prior to treatment or admission

• Emergency situations

• Capacity to provide consent

• Substitute decision-makers (SDM)

• Options re:improper SDM decisions

Substitute Decisions Act

• Powers of attorney, guardianships

• Continuing powers of attorney for property or personal care

• Courts

• Rules

DSM-IV-TR

• Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision

• American Psychiatric Association 2000

• Classification system for clinical, educational and research purposes

• Categorical and subjective

• Diagnostic criteria, course specifiers

Multiaxial System

• Axis 1 Clinical Disorders

• Axis 2 Personality Disorders/Mental Retardation

• Axis 3 General Medical Conditions

• Axis 4 Psychosocial and Environmental Problems

• Axis 5 Global Assessment of Functioning

DSM-IV Major Depressive EpisodeCore Criteria

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).

Major Depressive EpisodeFull Symptom Criteria

5 symptoms for 2 weeksfrom previous functioning:

• depressed mood• loss of interest/pleasure appetite sleep• psychomotor agitation• fatigue

must include 1 of these

• worthlessness concentration• thoughts of death

and represent a change

Major Depressive EpisodeAdditional Criteria

• Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

• Symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

• Symptoms are not better accounted for by Bereavement

Major Depressive EpisodeSpecifiers

• Mild, moderate, severe

• With psychotic features

• With catatonic features

• With melancholic features

• With atypical features

• With postpartum onset

Major Depressive Disorder

• One or more major depressive episodes

• Never had a manic episode

• Course Specifiers:– With inter-episode recovery– With seasonal pattern

DSM-IV CLASSIFICATION

Anxiety Disorders

Psychotic DisordersMood Disorders

Sleep Disorders

Substance Use Disorders

Eating DisordersCognitive Disorders

Childhood Disorders

• Major Depressive Disorder

• Dysthymic Disorder

• Bipolar I Disorder

• Bipolar II Disorder

• Cyclothymic Disorder

Mood Disorders

• Panic Disorder

• Specific Phobia

• Social Phobia

• Obsessive-Compulsive Disorder

• Posttraumatic Stress Disorder

• Generalized Anxiety Disorder

Anxiety Disorders

• Schizophrenia

• Schizoaffective Disorder

Psychotic Disorders

• Primary Insomnia

• Primary Hypersomnia

• Narcolepsy

Sleep Disorders

• Dementia– Alzheimer’s– Vascular Dementia

• Amnestic Disorders

• Delirium

Cognitive Disorders

• Anorexia Nervosa

• Bulimia Nervosa

Eating Disorders

• Substance Dependence

• Substance Abuse

• Substance Induced Disorders– Intoxication– Withdrawal

Substance Use Disorders

• Learning Disorders

• Developmental Disorders– Autistic Disorder

• Attention-Deficit Hyperactivity Disorder

• Conduct Disorder

Childhood Disorders

THERAPEUTIC CLASSIFICATION

Mood Disorders

Anxiety Disorders

AntipsychoticsAntipsychoticsPsychotic Disorders

Sleep Disorders

AntidepressantsAntidepressants

Mood StabilizersMood Stabilizers

Sedative-Hypnotics

TCAs• amitriptyline (e.g., Elavil)• nortriptyline (e.g., Aventyl)• imipramine (e.g., Tofranil)• desipramine (e.g.,

Norpramin)• clomipramine (e.g.,

Anafranil)

MAOIs• tranylcypromine (e.g.,

Parnate)• phenelzine (e.g., Nardil)• moclobemide (e.g., Manerix)

SSRIs• fluoxetine (e.g., Prozac)• paroxetine (e.g., Paxil)• sertraline (e.g., Zoloft)• fluvoxamine (e.g., Luvox)• citalopram (e.g., Celexa)

Others• nefazodone (e.g., Serzone)• venlafaxine (e.g., Effexor)• bupropion (e.g., Wellbutrin ) trazodone (e.g., Desyrel) mirtazapine (e.g., Remeron )

Antidepressants

Mood Stabilizers

• lithium (e.g., Carbolith)

• valproic acid (e.g., Epival)

• carbamazepine (e.g., Tegretol)

Sedative-HypnoticsBarbiturates-          secobarbital (e.g., Seconal)Benzodiazepines diazepam (e.g., Valium)-          lorazepam (e.g., Ativan)-          clonazepam (e.g., Rivotril)-          alprazolam (e.g., Xanax)-          temazepam (e.g., Restoril) Non-Benzodiazepine Hypnotics zaleplon (Starnoc ) Buspirone (e.g., Buspar )

AntipsychoticsTypicals

haloperidol (e.g., Haldol)– chlorpromazine (e.g., Largactil)– perphenazine (e.g., Trilafon)– thioridazine (e.g., Mellaril)– pimozide (e.g., Orap)– fluphenazine (e.g., Moditen)

Atypicals– clozapine (e.g., Clozaril)– risperidone (e.g., Risperdal)– olanzapine (e.g., Zyprexa)– quetiapine (e.g., Seroquel)

THERAPEUTIC CLASSIFICATIONMood Disorders

Anxiety Disorders

AntipsychoticsAntipsychotics

Psychotic Disorders

Sleep Disorders

AntidepressantsAntidepressants

Mood StabilizersMood Stabilizers

Sedative-Hypnotics

Eating Disorders

Substance Use Disorders

Etiology of Mental Health Disorders

• ????

• Biological Environmental

• Neurotransmitter theories (NE, DA, 5HT)

• Neuroendocrine theories

• Membrane and cation theories

• Second messenger theories

Concurrent Disorders

• Substance use disorders and other mental health disorders

• Very high comorbidity• Pharmacological Challenges:

– Diagnosis (drug-induced?, self-treatment?)– Drug interactions– Compliance– Abuse of therapeutic agents

Guidelines

• Canadian Network for Mood and Anxiety Treatments (CANMAT)

– www.canmat.org

– Depression

• Ontario Program for Optimal Therapeutics – www.opot.org/guidelines

– Anxiety

POTENTIAL AREAS FOR PHARMACIST CONTRIBUTION

(Royal Pharmaceutical Society of Great Britain Mental Health Task Force Report September 2000)

Prevention Recognition of undiagnosed illness Responsibilities during active treatment Support to patients, families and

caregivers

PREVENTION Raise awareness and help minimize stigma -

posters, community lectures Promote healthy lifestyles- health promotion

leaflets Liaise with other members of community

mental health team and caregivers to improve quality of pharmaceutical care for service users includes care planning for patient and professional

development for team members

PREVENTION

Ensuring the work environment and the workload placed on pharmacists and their staff is not detrimental to their own mental health!!

RECOGNITION OF UNDIAGNOSED ILLNESS

Respond to symptoms potentially caused by undiagnosed mental illness (which may or may not have presented initially as other health problems)

Identify mental health problems which may be caused by side effects of medications

Then Refer patients as appropriate

Screening Questions For Use In Primary Care Setting

(U.S. Preventive Services Task Force 2002)

US task force looked at literature and concluded that asking two simple questions about mood and anhedonia may be as effective as using longer instruments (Hamilton depression scale, etc)

Intended for GP’s, but can absolutely be applicable to community pharmacists - frequent patient contact, can observe changes over time, patients sometimes disclose more than they would to MD

Screening Questions For Use In Primary Care Setting

(U.S. Preventive Services Task Force 2002)

“Over the past 2 weeks, have you felt: – Down, depressed, or hopeless?”– Little interest or pleasure in doing

things?”

If patient answers yes to either of these questions, refer them for further assessment

DURING ACTIVE TREATMENT Support patients and caregivers in maintaining

adherence to treatment Identify adverse reactions and drug interactions

and give advice on management Monitor treatment and outcomes Provide drug information Promote safe, effective & appropriate drug

treatment Liaise with others for continuity of care Recognize signs of relapse and refer

SOME OF THE REASONS FOR NON-COMPLIANCE

Feel that the medications don’t work When they feel better, they don’t ‘need’ the

medications anymore Overly complex regimens Fear of drug dependence Symptoms are enjoyable Fear of recovery Lack of family support Lack of alliance with psychiatrist & other health care

professionals

COMPLIANCE ISSUES

Be patient; recognize that non-compliance and relapse are often the rule, not the exception

Remember that most other patients (patients on antihypertensives, antibiotics) also have high levels of non-compliance

Offer dosettes or blister packs If med is given in divided doses, ask why Investigate excessive polypharmacy

PHARMACEUTICAL CARE Developing rapport/ therapeutic alliance is ESSENTIAL Patient focus – negotiation; patient goals rather than

paternalistic approach Monitor for drug related problems

Encourage patients to check OTC purchases, herbals, etc. with you (or other team member)

Encourage lowest effective dose, especially with maintenance treatment (this is by far the toughest “battle” to fight!!)

PC is continuous - not over when one DRP solved

PARADIGM SHIFT

Our goal used to be to reduce psychiatric symptoms and manage DRP’s such as EPS

Now the goal is much more ambitious – functional recovery

BUT Medical DRP’s such as weight gain,

glucose intolerance, cardiac effects are now in the forefront

CO-MORBIDITY

Psychiatric patients have higher than average risk of medical co-morbidity and/or substance abuse co-morbidity

Medical and substance abuse co-morbidity predictor of more adverse mental health outcome

LABELS AND TERMINOLOGY

Follow patient’s lead Newly diagnosed may uncomfortable with terms,

however some patients actually prefer labels as it ‘explains’ their symptoms

Don’t assume diagnosis – Many psychotropics used for multiple psychiatric or non-

psychiatric indications, both approved and unapproved DSM-IV-TR vs. Symptoms

– Many symptoms cross more than one diagnosis– Meds treat symptoms, not the disorder per se

LABELS AND TERMINOLOGY

Attempts to de-stigmatize:– Neuroleptic is outdated term– Anti-psychotic is correct term– Atypical is also probably outdated

•Doesn’t really describe drug class, and some patients worry that they are “different” or “atypical”

•Preferred term may be “second generation”?

LABELS AND TERMINOLOGY

– Disorders vs. Disease vs. Illness– Some patients still prefer “manic

depression” to “bipolar” as they feel it describes the illness better

– A person is not “a schizophrenic”; they are someone who has “schizophrenia”, or “schizoprenic symptoms”

– Just what exactly IS “normal”?

PROVIDE DRUG INFORMATION Role and benefits of drug therapy Potential and actual side effects Supporting patients by providing

information and advice to those wishing to reduce their doses, or to come off medication completely Full disclosure of risk of withdrawal effects

and chance of relapse Encourage further dialogue with team

PATIENT COUNSELLING TIPS Ask: what did your doctor tell you about the

medication? May give insight into diagnosis/symptoms being

treated, & level of knowledge about meds Don’t assume a long-term patient knows all

about their medication Always tell patient when med should start to

work – they often don’t realize how long it takes for onset of effect

Start with most common, transient side effects and how to manage

PATIENT COUNSELLING TIPS Mention what signs to watch for more serious

reactions, and put in perspective (seriousness of illness, incidence of rxn)

Reinforce need to take regularly, and inform of possible discontinuation symptoms

Start dialogue about chronic nature of illness and need for long term pharmacotherapy, even when symptoms improve

Explain difference between “addiction” and long-term maintenance therapy

WRITTEN PATIENT INFO

Patients with psychiatric illness have as much right to this as patients with medical illness; won’t necessarily ‘overreact’

Informed consent issues May or may not have literacy issues Very important to discuss WHY they are

taking this medication - written info usually doesn’t include unapproved indications, and may use terminology they are unfamiliar with, so go over it with them, don’t just staple to the bag!

MISSED DOSES Very important to mention discontinuation

syndrome with antidepressants, as this can happen with even one missed dose

Most psychotropics can be given once daily, so try to simplify regimen and avoid missed doses

If more than 2 doses missed, may not be able to restart at original dose (example: clozapine)

POLYPHARMACY

Increases risk of non-compliance, drug interactions, side effects

Is often the rule rather than exception in psychiatry

Almost all combos not “evidence based”; clinical trials often of limited usefulness due to heterogenicity of patients, unlimited number of combos

POLYPHARMACY

Some combinations are more rational than others - based on complementary mechanisms SSRI + bupropion

Other combinations are usually irrational and likely indefensible 1st generation antipsychotic + 2nd generation

antipsychotic 3 mood stabilizers + antipsychotic + antidepressant

POLYPHARMACY Even if a combination seems irrational, there

may be a semi-reasonable explanation (not ideal, but okay)– Patient on lower dose 1st generation antipsychotic

depot to cover symptoms if they miss doses of 2nd generation oral antipsychotic

– Approach MD in non-confrontational way; “I’ve not seen this particular combination before, and I was interested/curious/ wanted to double-check it with you”

– Leave note on file to avoid multiple phone calls

A FINAL THOUGHT/ RANT ON POLYPHARMACY

Often a patient was in the middle of being switched from one med to another, and they ‘stabilized’ midpoint so the meds were kept that way

Is ‘stable’ the best we can offer our patients?? Who benefits - us or them?

Maybe VERY SLOWLY decrease dose of one med, monitor closely and hopefully eventually discontinue

CONTINUITY OF CARE Confirm medication regimen when patient is

discharged or changes pharmacies Try to help ensure continuity and consistency

of supply of medications, and explain any changes Ask patient first about dose change before calling

MD Explain change in brand/generic - some patients

can be very upset by minor changes in colour or markings

RECOGNIZING SIGNS OF RELAPSE

Relapse doesn’t usually happen suddenly - watch for early warning signs

Some signs of relapse are more “obvious” and consistent - “decompensation”

Other signs vary from individual, so get to know your patients! And help them to know themselves and recognize their own early signs so they can ask feel comfortable expressing concerns to team members

SUICIDE

Some studies have found some psychiatric meds can reduce suicide risk when they are used properly Non-compliance, sub-therapeutic dose,

relapse, poor monitoring are risk factors Risk higher just after hospital discharge

and/or starting new med Difficult to detect signs of self-harm

SUICIDE Respect confidentiality, BUT when concern is

great enough, contact caregiver, MD or team member

Encourage patients and families not to hoard discontinued meds; return to pharmacy for disposal

Those thought to be at risk should receive smaller quantities of medications

If you have a patient who does suicide, get counselling for yourself

KEY ROLES FOR COMMUNITY PHARMACISTS

Educate patients and psychiatrists about medical aspects of care

Check for drug interactions from different prescribers

Smoking cessation support Increase awareness/sensitivity about

concurrent substance use/abuse

PROVIDING SUPPORT

Provide information about local, provincial & other services, such as self help groups, telephone helplines, etc

Educate caregivers about medications, side effects, drug interactions; make them active participants in monitoring for DRP’s

Encourage caregivers to take time to care for themselves

KEYS TO CARING FOR PSYCHIATRIC PATIENTS

Treat them with empathy and patience Treat them like a person, not a diagnosis Respect patient confidentiality BUT Report drastic changes in behavior to patient

care team/family Recognize that lack of insight is part of the

illness and relapse is common Adapt for differences in comprehension,

cognitive function, literacy, etc.

KEYS TO CARING FOR PSYCHIATRIC PATIENTS

DON’T say “I know how you feel” – you probably don’t; try saying “I can see how that would be frustrating”

DON’T condescend or talk down to them DON’T be frightened or uncomfortable DON’T confront their delusions if possible DON’T tolerate abusive behavior; set

limits as you would for other customers

KEYS TO CARING FOR PSYCHIATRIC PATIENTS

If the dose or combo of meds is unusual, check with patient or caregiver first, to see if this is what they have been taking and if they know why

If you need to call the doctor, don’t hide behind the counter and call - let the patient know what you are doing and why in order to avoid paranoia; emphasizes your role as team member/ advocate for patient

Which Warning Label Do You Use? Why?

WHAT YOU CAN DO Keep up to date with CE Join CPNP or other listserve Know when to ask for consultation or referral Addiction clinical consultation service at

CAMH: 1-888-720-ACCS Keep up with media reports to anticipate

worries/questions Learn from your patients! Honesty and humor!!!