Critical Reflection
Goodwills
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10 PRESCRIBING IN MENTAL HEALTH PRACTICE – THE
BALANCING ACT BEN GREEN
Learning outcomes:
By the end of this chapter you should be able to:
• Discuss the potential impact of psychiatric pharmacology on the physical health of individuals with mental health problems
• Consider the potential impact of medical prescribing on the mental health of such individuals
• Reflect on the role of the mental health practitioner in medication management
INTRODUCTION
Psychiatric prescribing undoubtedly has a major role in the treatment of mental health conditions, alleviating symptoms, assisting recovery and enabling people with such conditions to gain the stability they need for rehabilitation and psycho- therapy. Nevertheless, such prescribing benefits can also incur a cost in terms of adverse effects, from drowsiness to coronary heart disease. This chapter addresses the effects on physical health caused by the prescription of psychiatric drugs and, conversely, mental health problems associated with medical prescribing. Some of the
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main physical problems associated with psychiatric prescribing will also be consid- ered, including side-effects, drug safety and drug–drug interactions. The chapter finally discusses the means by which psychiatric prescribing can best be monitored and managed more safely.
Epidemiological studies repeatedly show that most people with mental health problems are not diagnosed and are not treated (by counselling, psychotherapies or prescribed drugs). Even so, the scale of prescribing of psychiatric drugs is huge and increasing, with primary care physicians calling on their use in about 50% of the cases of mental health problems they identify (Linden et al. 1999).
Some countries have tried to address this by using psychological therapies as first-line options for anxiety and depression and yet the trend for prescribing persists. Outside any discussion of the relative therapeutic values of the various treatment options, it is prudent to note that roughly 10% of all health service expenditure, in the UK, is on medicines and the cost of prescribing rose more than tenfold between 1980 and 2007 (Office of Health Economics 2009). The huge scope of psychiatric prescribing is worth considering for various reasons, but key to this chapter is the fact that there are many physical implications of these medicines and with their increased use such implications are becoming more prevalent.
PSYCHIATRIC PRESCRIBING FOR INDIVIDUALS WITH MENTAL HEALTH PROBLEMS
THE DRUGS DO WORK! Before embarking on what will be a dauntingly long list of the negative aspects of psychiatric prescribing, it is worth considering briefly whether the positive aspects outweigh the negative. In short, do the benefits outweigh the risks? On balance, I believe the benefits far outweigh the risks, but there will be counter-arguments, sometimes forceful and well-reasoned. Other counter-arguments are sometimes philosophical or perhaps overly optimistic regarding the severe and pervasive nature of mental illness.
One way to consider the impact of the twentieth-century advances in psychiatric pharmacology is to reflect on the consequences of severe mental illness (SMI) prior to the introduction of first-generation antipsychotic medication in the 1950s. During this time the long-term nature of SMI, together with the relatively low frequency of spontaneous recovery, led to a progressive accumulation of patients in asylums. In 1870 there were 27,109 psychiatric beds in England and Wales. In 1910 there were 97,580 (Gregory 2004). At the start of the National Health Service (NHS) in 1948 over half of all NHS beds were psychiatric beds (Figure 10.1). However, something happened to reverse this expansion. The bed numbers peaked at 148,100 in 1954 (Gregory 2004). Thereafter there was a rapid and persistent decline in bed numbers so that in 2007 (when the UK population was 60,943,912), there were only 20,000
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THE PHYSICAL CARE OF PEOPLE WITH MENTAL HEALTH PROBLEMS142
or so psychiatric beds. This is a similar number to the late 1800s when the popula- tion was about 17 million or a third of that in 2007 (Green 2009).
The fall in psychiatric bed occupancy starting in the 1950s pre-dates any political move towards community care and is based upon the efficacy of a new class of drugs (the dopamine blockers), antipsychotics such as chlorpromazine (first synthe- sised in 1950 and first used in psychiatry in 1952) and others such as haloperidol (1958) and levomepromazine (1959) (Green 2004).
It was the success of these drugs which enabled patients to be discharged from the psychiatric hospitals back into the community. Sometimes the effects were remark- ably quick. Hospital records from this time include case histories where patients admitted for decades were able to be discharged after weeks on the new drugs.
The argument can thus be made for the dramatic efficacy of psychiatric medication in the treatment of mental illness. For the first time in millennia, humankind has had the means to treat mental illness and alleviate suffering, preventing the need for the incarceration of the majority of mentally ill people. Without the use of such drugs we arguably might require an asylum-building programme of unthinkable proportions.
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Figure 10.1 Public psychiatric bed numbers in England and Wales 1850–2007 (peak in 1954) (Green 2009)
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Having made the public health case for psychiatric medication, we must now turn to the individual’s experiences of such drugs, which are not always completely positive. It can be argued that some adverse physical effects are infinitely preferable to decades of in-patient care for schizophrenia, or years of severe depression, but to inform such an argument we must first increase our awareness of the extent of the physical effects of some medications.
WHAT IS THE COST TO PHYSICAL HEALTH? All medicines are associated with side-effects or adverse effects. These are difficult to classify. Some of the effects are predictable, based upon the drug’s known phar- macology, and others are somewhat unpredictable or idiosyncratic. Those working in mental health care should consider the relative advantages of medication as well as the prevalence and severity of any negative side-effects. Unfortunately, psychiatric medication exposes individuals with a mental health problem to a wide a range of serious physical health conditions, such as diabetes (see Chapter 3) and cardiovas- cular problems (see Chapter 4), while also causing physical adverse effects which can impact on the individual’s daily functioning. A drug like chlorpromazine, for instance, is thought to derive its main antipsychotic effects from blocking dopamine receptors in the brain (D2 receptors), but it also affects other receptors, such as his- tamine. Its effects on histamine receptors cause the drowsiness associated with the drug. In one way the sedation is an unwanted or adverse effect. In another sense, for overactive and disturbed patients with insomnia this side-effect becomes a desired effect. We can also predict its Parkinsonian-like side-effects (tremor and muscle rigidity) from its effects on cholinergic receptors, and its tendency to cause postural hypotension on its effects on adrenergic receptors. Its more unpredictable or idiosyncratic effects are less easy to predict from pharmacology and are derived from experience with the drug over many years – such as the photosensitive skin suffered by people who take chlorpromazine (and a consequent need for topical sun-blocking agents).
One of the key problems faced by individuals with mental health problems when taking medicines is that their complaints about them are often attributed to their underlying illness. No one can know every side-effect of a drug and even the litera- ture does not always record them all. This can lead to problems when the health pro- fessional discounts the individual’s experience. I shudder with embarrassment and hesitate to disclose that as a student I found it difficult to credit a young woman’s account of lactation on an antipsychotic and a male patient’s complaint that on an antipsychotic he was ‘firing blanks’ when he masturbated. A little more experience talking to clients and reading about psychopharmacology taught me the error of my ways! New drugs are also sometimes marketed without all the side-effects being known. Again, listening to the client is key. Shortly after paroxetine was marketed in the 1990s I noted that it was a very good antidepressant and very good at allay- ing anxiety, but I also had clients telling me, after some time on the drug, that they felt very tearful if they failed to take the medication for a few days. Some described
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THE PHYSICAL CARE OF PEOPLE WITH MENTAL HEALTH PROBLEMS144
towering rages; others described ‘electric zap sensations’ or ‘a series of images over- lapping when I turn my head’. You can see how easy it might be to assume these were symptoms of illness. The pharmaceutical company was not much help in iden- tifying these experiences. It was only when dozens of clients described these symp- toms and doctors started talking together about them that the unusual descriptions gathered value as descriptions of withdrawal effects.
THE PHYSICAL IMPACT OF PSYCHIATRIC MEDICATION
The relationship between physical and mental health is complex and psychiatric medication has been implicated as a causative factor in a wide range of adverse physical effects and conditions.
WEIGHT GAIN While effective against psychosis, many of our current antipsychotic drugs promote weight gain, and in such clients there appears to be a higher incidence of weight-related disorders such as diabetes and coronary heart disease. In particular, second-generation antipsychotic medication, once enthusiastically endorsed by pharmaceutical companies and agencies such as the National Institute for Health and Clinical Excellence (NICE), have now been found to promote weight gain, especially clozapine and olanzapine (Tschoner et al. 2009). For example, the body mass increase with these can be a significant (25% +) long-term increase. Over 10 weeks’ treatment with clozapine, Allison et al. (2009) found that the average service user put on 4.45 kg; with olan- zapine this was 4.15kg; and with risperidone it was 2.15 kg.
Weight gain is not confined to antipsychotics. Many antidepressants, if used long term, also stimulate weight gain and this too is associated with the development of metabolic syndrome (Andersohn et al. 2009). Implicated antidepressants include amitriptyline, paroxetine and mirtazapine.
Apart from the physical risks associated with these complications, patients do not like an altered appearance, as can be seen in Hamer and Haddad’s (2007) study where 73% of patients reported concern about weight gain. This was particularly prevalent in women and a consequent effect on compliance was noted.
In view of these problems, guidelines now state the need for prescribers to con- sider physical health factors such as diabetes, or family history of diabetes, and conduct relevant tests before embarking on antipsychotic therapy. A cautionary note should be sounded about the use of antipsychotic drugs outside their intended field. Sometimes, because of the side-effect of sedation, antipsychotics can be used as sleeping tablets or as anxiolytics. This kind of use can be legitimate, but it is also off licence – that is, neither the pharmaceutical company nor the state regulatory bodies would readily sanction the use of the drug for off licence uses. This leaves the
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client in a position of being able, in the event of an adverse reaction, to recover dam- ages from the prescriber only, rather than from the usually wealthier pharmaceuti- cal company. For instance, a prescriber could find themselves sued for prescribing olanzapine to a client with anxiety disorder who later developed diabetes, especially without ensuring the client had been through the necessary screening for diabetes risks beforehand.
There are many ways of minimising weight gain and some of the key consider- ations are outlined below:
• Consider antipsychotics that are least associated with weight gain, particularly in clients with a family history of cardiac problems and/or diabetes
• Recent research has noted the possibility of using metformin in treating olanzapine- induced weight gain (Praharaj 2011), although switching antipsychotics would seem more practical than exposing a client to two drugs where a single alternative might do
• Dietary education/modification, for example healthy eating programmes • Exercise programmes, coaching and training, such as referral on prescription schemes • Weight monitoring programmes, examples of which can be found in Chapter 11
METABOLIC SYNDROME AND DIABETES The link between a metabolic syndrome of obesity and insulin resistance and schizo- phreniform illness has been appreciated for some time. In 1897 Henry Maudsley (of the Maudsley Hospital, London) noted ‘diabetes is a disease which often shows itself in families where insanity prevails’ (Green 2009). This basic link between schizophre- nia and a metabolic syndrome is explored in Chapter 3 but its relevance to this particular chapter is in the fact that antipsychotic drugs often increase weight, as outlined above, which consequently increases not only the risk of metabolic syn- drome and diabetes but also that of cardiovascular diseases (Allison et al. 2009).
CARDIOVASCULAR DISEASES For individuals with mental health problems the risk of developing cardiovascular disease is two to three times greater than that of the general population, depending on where in the world the person lives (Hennekens et al. 2005; Filik et al. 2006). Part of the reason for this increased risk is again the increase in weight as a result of some of the medications, but it is also wider than this. Chapter 4 investigates cardiovascular disease in more detail but it is worth considering here the risk of postural hypotension, which can be a side-effect of some antidepressants and anti- psychotics. It is related to alpha-1 blockade, which is produced by drugs like chlor- promazine, amitriptyline, venlafaxine and others.
Postural hypotension (or orthostatic hypotension) involves a drop of 10–20 mmHg in systolic blood pressure on changing of posture from sitting to standing, which may lead to dizziness, fainting sensations and falls (and thus to hip fractures in the elderly).
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The management of postural hypotension includes monitoring the service user’s blood pressure on a regular basis. Being alert to complaints of dizziness is also important, as is acting on these by checking blood pressure both while the client is sitting and standing.
If postural hypotension is present, consider using an alternative drug – especially in older patients who might fall. Until the old drug is replaced, give a full explana- tion about the risks of sudden movements to both the client and their family/carers, and advise them about standing up gradually, and avoiding triggers such as high temperature environments, heavy meals and prolonged periods of standing still.
Also worthy of discussion is adult sudden death syndrome, which some clients may be exposed to due to the impact of psychiatric medication on the cardiovascular system. This is linked with drugs that can delay the repolarisation of heart muscle – measured on ECG by a QTc prolongation beyond 420 ms. This is seen in all antipsychotics, although Glassman and Bigger (2001) report that with first-generation antipsychot- ics the risk of sudden death syndrome is almost three times greater, although this is still very rare. Various risk factors are associated with sudden death syndrome and antipsychotics, including organic psychiatric disorder, hypertension, high body mass index, smoking and history of a myocardial infarction. Particularly risky antipsychotics for prolonging QTc on ECG are thioridazine and haloperidol. Various medical drugs are also associated with sudden death syndrome, including amiodarone (ironically this is an anti-arrhythmic).
An effective means of managing the risk of adult sudden death syndrome is tack- ling associated risks such as hypertension, weight reduction and smoking cessation in combination with informed prescribing. As a guideline, prescribers are advised to use low-risk drugs at the lowest effective dose. Monitoring baseline and regular ECGs looking for QTc prolongation will also facilitate early detection and treatment. Before moving on, take this opportunity to consider Action Learning Point 10.1.
Action Learning Point 10.1
• Discuss with your team how they routinely monitor ECG changes in clients on antipsychotics.
CANCER There is a small body of literature which considers the possibility of a carcinogenic risk associated with psychiatric medication. In the USA, the Food and Drug Administration (FDA) requires extensive animal testing to determine the carcino- genic potential of drugs. For instance, drug information in the USA refers to the potential of, say, a very high dose of risperidone to induce pituitary adenomas in mice. The relevance to humans is not clearly established. Such tumours are thought to be related to prolonged dopamine D2 antagonism and hyperprolactinaemia.
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PRESCRIBING IN MENTAL HEALTH PRACTICE – THE BALANCING ACT 147
Hyperprolactinaemia occurs in about 40% of women on antipsychotics (excluding clozapine) (Bushe et al. 2008). It is probable that this area of research will grow in future years.
There is concern that some antipsychotic drugs can interfere with chemotherapy regimes. For instance, chemotherapy can affect the bone marrow and so can clo- zapine. Opinion is somewhat divided on whether clozapine therapy should be sus- pended during chemotherapy, but the limited evidence suggests continuation is not problematic (Goulet and Grignon 2008). Research is ongoing, however. See Chapter 6 for further information relating to the management of cancer.
SEXUAL SIDE-EFFECTS Chapter 8 explores the sexual health of individuals with mental health problems. Here consideration will be given specifically to the effects of medication on sexual functioning.
Sexual side-effects (SSEs) of medication affect a person’s quality of life and lead to poor compliance. Sexual side-effects may be experienced by about 43% of cli- ents on antipsychotics (Wallace 2001). SSEs with antipsychotics can include loss of libido due to hyperprolactinaemia, erectile failures (e.g. 40% of men had difficulty in achieving and maintaining erection with chlorpromazine) and ejaculatory fail- ures (e.g. total inhibition of ejaculation or even retrograde ejaculation) and priapism (painful prolonged erection of the penis or clitoris).
Selective serotonin reuptake inhibitors (SSRI) antidepressants can delay ejacula- tion in males so fluoxetine is sometimes used for treating premature ejaculation. The side-effect of delayed ejaculation/climax in males can be unpleasant for some couples and welcomed by others. The antidepressant clomipramine has been linked to complete anorgasmia. Clients frequently discontinue medication as a result of SSEs, which highlights the need for mental health practitioners to incorporate sexual health into their assessment and care. Unfortunately the research evidence indicates that professionals generally fail to even ask about SSEs. Most psychiatrists (77%) surveyed in a recent study, for instance, only explored the topic of SSEs when they were cued by clients (Singh et al. 2010). Sexual function can, of course, be compro- mised by psychiatric illness itself and by physical illness.
BLOOD DYSCRASIA Blood dyscrasia is an abnormality of the blood and generally implies some disorder in the production of blood cell components, for instance insufficient erythrocytes (anaemia) or insufficient platelets (thrombocytopenia).
Clozapine, used in treatment resistant schizophrenia, can affect bone marrow function leading to reduced white cell production or even agranulocytosis (a more profound reduction of white cells which can become permanent). At the start of clozapine therapy, blood counts should therefore be monitored weekly.
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Other drugs, like carbamazepine, chlorpromazine and zuclopenthixol, can also impair white cell production and mental health practitioners should be alert for the signs of infection in any client prescribed these drugs. They should also ensure that a white cell blood count is carried out in the event that they do develop an infection.
HYPERPROLACTINAEMIA Prolactin is a hormone secreted by the pituitary gland. Various drugs, including antipsychotics, can trigger higher blood prolactin levels. Dopamine blockade by some antipsychotics leads to more prolactin. High levels of prolactin can cause infertility in women, through disturbance of, or absence of, the normal menstrual cycle. Hyperprolactinaemia can lead to lactation, amenorrhoea, gynaecomastia, vaginal dryness and hirsutism. Hyperprolactinaemia also occurs in men taking anti- spychotics and may lead to loss of libido or erectile dysfunction. Of all the antipsy- chotics, quetiapine is probably least likely to cause this side-effect.
A recent study found hyperprolactinaemia in a third of patients on antipsychotics, mainly in females (47.3% and 17.6% in males) and was associated with all antip- sychotics except clozapine (Bushe et al. 2008). The highest prevalence rates were found with amisulpride and risperidone. Long-term hyperprolactinaemia has been linked to osteoporosis, bone fractures, pituitary tumours and breast cancer (Bushe et al. 2008). An awareness of these side-effects should enable those engaged in the care of individuals with a mental illness to seek early treatment for their clients. In addition, consideration should be given to reducing the dose of the medication and also to switching it to a prolactin sparing antipsychotic. Now take a look at Action Learning Point 10.2.
Action Learning Point 10.2 • Discuss with your team what efforts they make to routinely detect hyperprolactinaemia. • What measures do they take to tackle the long-term consequences of hyper-
prolactinaemia?
MOVEMENT DISORDERS Among the most common side-effects of psychiatric medication is a change to the client’s gait, posture and movement. These are frequently distressing to clients, are stigmatising and target them for unwanted attention by others. Extrapyramidal symptoms (EPSES) are motor side-effects usually caused by antipsychotics acting on the dopamine system. They include drug-induced Parkinsonism, a dopamine-blockade- related side-effect which can include limb and hand tremor, abnormal gait, ‘cog- wheel’ or ratchet-like muscle tone, and mask-like faces – relieved by oral procyclidine
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or an equivalent. In addition, an unpleasant inner restlessness called akathisa can be observed by the client’s abnormal walking or pacing about or fidgeting when seated. This inner agitation is so upsetting it can lead to thoughts of suicide or violence.
Dystonia can present as a sudden (acute dystonia) or late (tardive dystonia) per- sistent muscle contraction or spasm. The dystonia is often seen with first-generation antipsychotics like haloperidol (dystonia is also seen with the anti-emetic drug metoclopramide – Maxolon). Such dystonias are usually seen in the neck (30%), tongue (17%), jaw (15%), or as an oculogyric crisis (in which the eyes roll back, and neck arches) 6%, and as opisthotonus (body arching) in 3.5% (Swett 1975). Acute dystonia is involuntary and very frightening for the client. The management is by administration of procyclidine, which may need to be repeated. The drug that precipitated the dystonia should be avoided thereafter.
Finally, tardive dyskinesia occurs in 5–30% of patients treated with long-term first-generation antipsychotics (Kane et al. 1988) and involves repetitive, involun- tary movements without purpose. These may consist of any of the following: move- ment of the lips and tongue, such as grimacing, lip smacking, lip pursing, sticking out of the tongue; rapid blinking; ‘fluttering’ of the fingers; rapid movements of the arms; truncal movements – twisting of the trunk of the body; toe tapping; and mov- ing the leg up and down. Some historical descriptions of these kinds of movements in clients with schizophrenia pre-date the development of antipsychotics, so there is debate as to whether they are side-effects of medication or something to do with the central nervous system disease that is schizophrenia. Also tardive dyskinesia has been found in up to 14% of first-degree relatives of people with schizophrenia – that is to say, tardive dyskinesia is found in relatives who have never had antipsychotics (McCreadie et al. 2003).
Agencies like NICE initially recommended switching patients to new antipsychot- ics to avoid tardive dyskinesia. However, subsequent experience with the drugs has shown that second-generation antipsychotics are also associated with tardive dys- kinesia. The clinical antipsychotic trials of intervention effectiveness (CATIE trial), for instance, found that 4.5% of patients on quetiapine and 2.2% of patients on risperidone developed tardive dyskinesia (Miller et al. 2008).
Abnormal movements can be measured and monitored using instruments like the Abnormal Involuntary Movement Scale (AIMS) (Munetz and Benjamin 1988) and Extrapyramidal Symptom Rating Scale (ESRS) (Simpson and Angus 1970).
Catatonia is a profound generalised condition where patients may hold rigid poses for hours and will seemingly be oblivious to any external stimuli. It has been described since the 1870s and although it may be classified as a reaction to medi- cation by some, it is still of uncertain aetiology. It can be treated with hydration, benzodiazepines and electroconvulsive therapy (ECT).
Neuroleptic malignant syndrome (NMS) is an idiosyncratic reaction to a variety of medications, including antipsychotics, antidepressants and lithium. It occurs in about 0.5% of those taking antipsychotics (Adnet et al. 2000). Its aetiology is somewhat uncertain and may be a variant of a condition described many years ago called lethal catatonia. NMS is traditionally held to be a reaction to medica- tion. It is associated with raised temperature, increased muscle tone, delirium and
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autonomic instability. It is associated with raised creatine phosphokinase blood levels. It has a mortality of about 10–15% and is a medical emergency (Adnet et al. 2000). In the event of NMS, medical help should be sought immediately. Medication should be stopped and on later re-introduction the client must be monitored very closely.
SEDATION Psychiatric drugs which affect histaminergic neuroreceptors, like tricyclic anti- depressants and some antipsychotics, can be sedating. This is useful in control- ling behavioural disturbance and also in tackling insomnia. Sedation is also seen to a lesser or greater extent with many other psychiatric drugs, including the newer antidepressant and antipsychotics. Such sedation affects vigilance and the ability to respond quickly and appropriately when using machinery or driving and so clients need warning about this problem. Reassurance should, however, be given that sedation is often at its worst in the first couple of weeks and that after this point many people will develop a tolerance and the sedative effects will become less. Where sedation persists, the possibility of reducing the dose should be considered along with the potential for splitting the dose between morning and evening. Thought should also be given to the need for the sedative effect as switching to a less sedative drug may be an option. Please refer to Action Learn- ing Point 10.4
Action Learning Point 10.4 • Look up the side-effects of the psychiatric medication for one of your clients.
What physical health conditions are they at potential risk of and how is this being managed?
THE ROLE OF THE MENTAL HEALTH PRACTITIONER
MINIMISING THE COST THROUGH EFFECTIVE MEDICATION MANAGEMENT Despite the potential controversy surrounding psychiatric medication, it is still widely regarded as one of the major therapeutic tools available to mental health professionals. Unfortunately, the lack of service users’ adherence to medication is a long-standing and global concern (World Health Organization 2003), and how best to encourage engagement in such an approach has therefore drawn wide interest. Two of the main influences on non-adherence are proposed to be adverse side-effects
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and a lack of collaborative care, which has led to the suggestion that any attempts to enhance adherence should include strategies aimed at minimising adverse effects and maximising service user involvement (World Health Organization 2003).
Concordance is the term used to describe these combined aims, and is an approach that recognises the adverse effects of medication – regarding non-adherence as a legitimate and understandable response from the service user. The MHP’s role in such circumstances is to discuss the reasons for non-adherence with the service user and in doing so take the opportunity to assess for the presence of adverse effects.
Medication assessments can be undertaken at many points throughout the care process but it is useful at the initial assessment to take some historical information about previous experiences of medication in order to identify any potential physical effects. Asking directly about the physical health of the individual’s family could also identify a predisposition to some of the physical conditions associated with psychi- atric medication. This can then be factored into any treatment decisions made. The use of standardised and validated assessment tools is also advocated as an additional tool for assessment, with the intention of reducing the MHPs reliance on the service users’ self-report and introducing a more objective measure (Jones and Jones 2005). There are many available but a commonly adopted tool is the Liverpool University Neuroleptic Rating Scale (LUNSERS) (Day et al. 1995) and the recommendation is to continue to use these tools to monitor changes throughout treatment. If you are working in a rehabilitation service or depot service, then you can use one of these with service users every 3–6 months to monitor for the presence of the adverse effects outlined. This would be a prompt to monitor ECG changes, the development of abnormal involuntary movements (AIMs), and so on. For suggestions on what to include if devising a tool for your own service, see Box 10.1.
Box 10.1 Suggestions for Devising an Assessment Tool Suggested headings would be:
Weight, BMI, waist circumference, blood pressure, heart rate and rhythm, temperature, anticholinergic side-effects, EPSEs, AIMs, excess sedation, prolactin levels, creatine kinase levels, sexual function, diabetes symptoms, glucose levels, HBA1 levels, liver function tests, lipid levels, ECG, full blood count.
There are general best practice principles to follow when it comes to medication man- agement, many of which have already been adopted in the previous discussions on minimising adverse effects. However, the following guidance focuses particularly on the collaborative nature of the process and starts with an open, honest discussion about the medication that has been prescribed, including both the beneficial effects and the potential negatives associated with that particular medication. It is the latter that MHPs tend to shy away from, which is understandable given that this information may prevent an individual
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from taking a potentially very beneficial medication. However, it is actually the lack of preparation for these negative effects that is of most concern to service users, thus ensur- ing that it is paramount to give sufficient information (Gray et al. 2005).
Asking service users what knowledge they already have of the medication can be a good opening to the discussion and can also be a good way of identifying any miscon- ceptions or lack of understanding. These can then be used as the basis for introducing education around the signs and symptoms of the potential adverse effects, and it is worth considering providing the information in written form so that it can be taken away and referred back to at a later date. Both service users and their family and carers should be involved in these discussions, and all involved in the care should be encouraged to take a proactive approach in the monitoring and reporting of any such symptoms. Monitoring is also a key role for the MHP, who should be aware of the medication regimes of indi- vidual service users in order to check for any signs and symptoms of adverse effects.
Should any adverse effects become apparent, the care of the individual should be reviewed. It is recommended that thought be given to the medication and whether any changes to this would be beneficial and possible (as outlined under the different adverse effects) and also that lifestyle changes are considered. The provision of health promotion advice in relation to lifestyle choices and changes is a developing role for MHPs and more guidance on this can be found in Chapter 11. However, it is worth reinforcing at this point that the provision of such advice can be empowering for service users as it allows them to collaborate fully in their care and affords them the opportunity to take some control over their own health and wellbeing. Take a look at the case study of Sinita below for an example of medication management in practice.
Sinita Sinita, aged 45, has a history of recurrent depression and was admitted to hospital in a very agitated state. While there it was decided that her antidepressant would be changed to amitriptyline, as all previous antidepressants had failed to provide lasting improvement. Sinita, however, was reluctant to comply and it was only when asked about this that the MHP was able to identify that Sinita thought that the medication would make her ‘like a zombie’. It seems that others on the ward had told her that the heavy sedative effects would render her unable to do or feel anything and this had understandably made her hesitant. The MHP took the opportunity to inform Sinita about the potential side-effects of the medication, honestly acknowledging the sedative effect but pointing out that this would assist with her feelings of agitation. The other potential side-effects were then discussed (principally weight gain and metabolic syndrome) and Sinita was informed that there were ways in which these could be managed. The benefits of the medication were finally reinforced before a summary of the information was written down and given to Sinita.
The following day the MHP met with Sinita and her family to further discuss the medication and an agreement was made that she would take this if she and her family could be involved in the monitoring and management of the adverse effects. Further meetings were therefore arranged to facilitate more education around the signs and symptoms of potential effects and to discuss potential lifestyle changes.
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AWARENESS OF INTERACTIONS WITH OTHER DRUGS The greater the number of medications a client is taking the higher is the risk of a serious drug interaction and MHPs are advised to have an awareness of the potential for this. Many individuals with mental health problems will be pre- scribed psychiatric medication which may increase their risk of physical health problems, leading to further prescribed medications. Should these medications cause side-effects, yet more medication may be used in an attempt to address them and the outcome may well be polypharmacy and a significantly increased risk of drug interactions.
Interactions can arise where there is competition for the bodily systems that elimi- nate drugs from the body. For instance, most drugs are metabolised by the liver. Therefore clients taking multiple medications may be putting their liver under con- siderable strain. Furthermore, some drugs, such as carbamazepine, may increase the rate at which the liver metabolises other medications. This has the potential to lower the serum levels of these other drugs and lead to breakthrough symptoms such as psychosis or depression. Service users prescribed medicines that can affect liver func- tion should be monitored for changes in their Liver Function Tests (LFTs).
A section at the back of the British National Formulary (BNF) (2010: Appendix 1) details the most important known interactions between various drugs. The section in the September 2010 BNF is closely printed and nearly 90 pages long, indicating the complexity and number of potential interactions. It is therefore impossible to summa- rise them all and each service user has to be thought about individually in terms of their age, sex, weight, physical state of health and other medications. Table 10.1 lists some examples of interactions. Before moving on, think about Action Learning Point 10.5.
Action Learning Point 10.5
• Audit the number of prescribed drugs that each of the clients in your care is on. What is the mean number of medications? Could this be safely reduced? If so how?
• What would be the potential risks and benefits of reducing the number of medica- tions for each client?
Physical health medication Mental health medication Effects of interaction
Ibuprofen, aspirin and other non-steroidal anti-inflammatory drugs
Lithium
SSRI antidepressants and venlafaxine
Lithium toxicity
Increased risk of bleeding
Table 10.1 Common drug–drug interactions
(Continued)
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AWARENESS OF THE PSYCHOLOGICAL EFFECTS OF PHYSICAL HEALTH MEDICATION Given the propensity for physical illness in individuals with mental health prob- lems, a further area of consideration for MHPs is the psychological effects of physical health medication. Several of these medications can cause symptoms of depression, anxiety and even psychosis and in such instances it is not uncommon for individuals to acquire new diagnoses or extra treatments they do not need. It is therefore important that MHPs are alert to the possibility that new psychological
Physical health medication Mental health medication Effects of interaction
ACE inhibitors (used in hypertension)
Antipsychotics, beta- blockers and MAOIs
Hypotension
Amiodarone (anti-arrhythmic) Lithium, amisulpride and other antipsychotics
Arrhythmias
Anticonvulsants SSRIs, tricyclics, carbamazepine, haloperidol, olanzapine, quetiapine, risperidone, Fluoxetine, mirtazapine, paroxetine
Lower fit threshold Impact on the concentration of psychiatric and/or anticonvulsant medication
Anaesthetics Tricyclic antidepressants Arrythmia and hypotension
Diuretics (used to treat heart failure, liver cirrhosis, hypertension and certain kidney diseases)
Tricyclics Hypotension
Lithium Increased risk of lithium toxicity
Oestrogens (in oral contraceptives and HRT)
Tricyclics Impair antidepressant effect
Lamotrigine Reduce serum levels of lamotrigine
Thyroid hormones Antidepressants Enhanced effect
Antifungals Aripiprazole, quetiapine alprazolam and midazolam
Increases concentration of psychiatric medication
Pimozide Arrthymias
Histamine antagonists (used for oesophageal reflux)
Citalopram, mirtazapine, imipramine, chlorpromazine and benzodiazepines
Increases concentration of psychiatric medication
Methyldopa (antihypertensive) MAOIs, anxiolytics and hypnotics.
Hypotension
Metoclopramide (anti-emetic) Antipsychotics Increased risk of Extrapyramidal Side Effects
Table 10.1 (Continued)
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symptoms, or a worsening of existing symptoms, may be a result of medication that has been prescribed for the service user’s physical health and that they liaise with the care team if they suspect that medical prescribing is having a psychological effect. Table 10.2 identifies a range of physical health medication and the potential psychological side-effects and Harry’s case illustrates how such effects may present in practice.
Harry
Harry, a 72 year-old man, was under the care of the mental health team for long- standing moderate anxiety. Over the past two months it had been noted that his anxiety had become significantly worse and that he had also been demonstrating signs of profound low mood and agitation. After discussion at a case review, the suggestion was made that Harry start cognitive behavioral therapy (CBT) and perhaps a course of antidepressants, but after discussion with Harry about his current medication it was revealed that he had been started on amiodarone, for an irregular heartbeat, 10 weeks before. Knowing that amiodarone is associated with depression, agitation and anxiety, the MHP referred Harry to the psychiatrist for a medication review and, rather than embark upon CBT or an antidepressant, the amiodarone was stopped and an alternative substituted. The depression and agitation resolved within a week or so and his anxiety returned to a moderate level without any further treatment being required.
Medication Prescribed for Psychological effects
Propranolol Hypertension Depression, bad dreams
Simvastatin Hypercholesterolaemia Depression, tiredness
Amiodarone Rhythm disturbances Depression, psychosis
Aminophyline Chronic Obstructive Pulmonary Disease
Anxiety, panic
Salbutamol Asthma Anxiety, panic
Corticosteroids Asthma, rheumatoid arthritis Depression, psychosis, delirium, mania
Methotrexate Chemotherapy, psoriasis, rheumatoid arthritis
Depression
Omeprazole Acid reflux Depression
Isotretinoin Acne Depression, suicidal ideation
Penicillins Antibiotics Depression, agitation
Oral contraceptives Contraception Depression
Table 10.2 Psychological effects of some medicines prescribed for physical health
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SAFETY IN PREGNANCY A final consideration is the potential adverse effects of prescribed medication on an unborn child, which is an area that tends to cause some anxiety for all involved in the care team. As with the sections above, the intention here is to assist in increasing the MHP’s knowledge and awareness.
Seven per cent of mothers in their childbearing years suffer mental illness (NICE 2007). This, combined with the fact that 50–60% of pregnancies are generally ‘unplanned’ (NICE 2007), means that for many weeks the expectant mother may be potentially unaware of her pregnancy and consequently be unwittingly exposing her unborn child to psychotropic drugs.
The first step in facing this problem is an awareness of the risk. First trimester exposure is associated with abnormal organ formation and third trimester expo- sure is linked to withdrawal effects in the neonate – for example, the withdrawal seen with some antidepressants and antipsychotics. It should also be borne in mind that following birth babies may encounter any drugs that are secreted in breast milk.
Unfortunately, no drug can be deemed wholly safe. This means that a policy of avoiding drugs during pregnancy (especially in the first trimester) is the wisest course unless the risks posed to the mother by any relapse are severe and probable.
The following points are worth considering in planning an approach for women with mental health problems in their childbearing years. No guarantees about safety are available and there is a relative lack of research and certainty in this area.
When considering antidepressants, tricyclics are relatively safe in terms of any risk of malformations, but if used in the third trimester can lead to withdrawal symptoms in the neonate. There is less certainty about SSRIs and malformations. In relation to antipsychotics, phenothiazines are associated with a small risk of malformations, while haloperidol and olanzapine are considered safer. The mood stabiliser lithium is definitely associated with foetal cardiac abnormalities such as Fallot’s Tetralogy, while valproate and carbamazepine are associated with neural tube defects. Finally, phenytoin is associated with facial cleft defects. To avoid problems with psychiatric drugs in pregnancy the following suggestions are made:
• In women of childbearing years prescribe drugs which are safer – just in case these patients become pregnant.
• Advise potentially fertile women with long-term mental health problems of the risks of medication and pregnancy and encourage planned pregnancies following discussion with the care team.
• Weigh up risks of using no medication during pregnancy or switching drugs to ones less associated with risk.
• Use scanning or other imaging for embryos exposed to potentially damaging drugs – this might lead to consideration of prenatal surgery for vascular abnormalities, neural tube defects or, sadly, termination in some cases.
• Folic acid supplements (used for neural tube defect prophylaxis).
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CONCLUSION
After the daunting array of adverse effects and problems associated with the medica- tion listed above the reader would be forgiven for wondering about the wisdom of prescribing any medication for mental health problems. There is without doubt a cost to the physical health of individuals who are prescribed these medications, but there is also a clear advantage – improved mental health. Despite the recent growth of psychotherapies, medication remains a major therapeutic tool, so it seems that MHPs are faced with a dilemma: whether to prioritise mental over physical health.
Perhaps the answer is to balance both, treating the psychological aspects while managing the physical. There are many ways that MHPs can minimise the adverse physical effects of psychotropic medication, but one of particular relevance to this topic is medication concordance. By taking a collaborative approach to minimis- ing the potentially harmful effects of mental health prescribing, the service user is afforded the opportunity to take some control over their own health and wellbeing, which will not only enhance the chances of adherence for mental health treatment, but also that which is physical.
USEFUL RESOURCES
At the time of writing in the UK we recommend the following resources:
National Prescription Centre – www.npc.co.uk British National Formulary – http://bnf.org/bnf/index.htm Royal Pharmaceutical Society for Great Britain – www.rpharms.com/home/home.asp Association of British Pharmaceutical Industries – www.abpi.org.uk/Pages/default.aspx Association for Nurse Prescribing – http://anp.org.uk/ Drug Tariff Online – www.drugtariff.com/ Electronic Medicines Compendium – www.medicines.org.uk/emc/ Medicines and Healthcare Products Regulatory Agency – www.mhra.gov.uk/index.htm www.nelm.nhs.uk/en/ - National Electronic Library for Medicines
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