Transcript PHARMACOLOGY OF DRUGS OF ABUSE

PSYCHIATRY OVERVIEW
Pharmacy 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 Illness
What 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 weakness
Mental 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, income
Not a character flaw-an illness-cannot just snap
out of it
A 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 effectively
Mental illnesses are costly to the individual, the
family, the health care system and the community
The 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:
 Suicide
Special populations:
 Children
 Elderly
 Developmental 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 Disorders
Major (unipolar) depression
Bipolar disorder
Dysthymia
Schizophrenia
Anxiety disorders
4.1 to 4.6 %
0.2 to 0.6 %
0.8 to 3.1 %
0.30%
12.2%
Mental Illness-Prevalence
 Personality disorders
6.0 to 9.0 % (U.S.)
Eating disorders
– Anorexia
0.7 % women
0.2 % men
– Bulimia
1 .5 % women
0.5 % men
Deaths from suicide
2 % of all deaths
24% of all deaths (15-24)
16% of all deaths (24-45)
Mental Illness-Prevalence
Addictions
alcohol
– 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
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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 achievement
Career opportunities
Personal 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
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Psychiatric facilities
Admitting
Retention
Access to records
Financial incapacity
Rights of patients to information
Community treatment orders
Health Care Consent Act
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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
• Axis 2
• Axis 3
• Axis 4
• Axis 5
Clinical Disorders
Personality Disorders/Mental
Retardation
General Medical Conditions
Psychosocial and Environmental
Problems
Global Assessment of Functioning
DSM-IV Major Depressive Episode
Core 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 Episode
Full Symptom Criteria
 5 symptoms for 2 weeks and represent a change
from previous functioning:
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depressed mood
loss of interest/pleasure
 appetite
 sleep
psychomotor agitation
fatigue
must include 1 of these
• worthlessness
•  concentration
• thoughts of death
Major Depressive Episode
Additional 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 Episode
Specifiers
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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
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Sleep Disorders
Childhood Disorders
Cognitive Disorders
Substance Use Disorders
Eating Disorders
Mood Disorders
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Major Depressive Disorder
Dysthymic Disorder
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
Anxiety Disorders
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Panic Disorder
Specific Phobia
Social Phobia
Obsessive-Compulsive Disorder
Posttraumatic Stress Disorder
Generalized Anxiety Disorder
Psychotic Disorders
• Schizophrenia
• Schizoaffective Disorder
Sleep Disorders
• Primary Insomnia
• Primary Hypersomnia
• Narcolepsy
Cognitive Disorders
• Dementia
– Alzheimer’s
– Vascular Dementia
• Amnestic Disorders
• Delirium
Eating Disorders
• Anorexia Nervosa
• Bulimia Nervosa
Substance Use Disorders
• Substance Dependence
• Substance Abuse
• Substance Induced Disorders
– Intoxication
– Withdrawal
Childhood Disorders
• Learning Disorders
• Developmental Disorders
– Autistic Disorder
• Attention-Deficit Hyperactivity Disorder
• Conduct Disorder
THERAPEUTIC CLASSIFICATION
Antidepressants
Mood Disorders
Mood Stabilizers
Anxiety Disorders
Sedative-Hypnotics
Sleep Disorders
Psychotic Disorders
Antipsychotics
Antidepressants
TCAs
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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
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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 )
Mood Stabilizers
• lithium (e.g., Carbolith)
• valproic acid (e.g., Epival)
• carbamazepine (e.g., Tegretol)
Sedative-Hypnotics
Barbiturates
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 )
Antipsychotics
Typicals
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
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clozapine (e.g., Clozaril)
risperidone (e.g., Risperdal)
olanzapine (e.g., Zyprexa)
quetiapine (e.g., Seroquel)
THERAPEUTIC CLASSIFICATION
Mood Disorders
Antidepressants
Anxiety Disorders
Sleep Disorders
Psychotic Disorders
Mood Stabilizers
Sedative-Hypnotics
Eating Disorders
Substance Use Disorders
Antipsychotics
Etiology of Mental Health
Disorders
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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:
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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)
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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 comorbidity 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 nonpsychiatric 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 longterm 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.
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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!!!
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