PSNZ CE by Keith Crump Focusing on Mental Health for Auckland Pharmacists

1. Mental Health Review
PSNZ Auckland Branch

2. Topics
 Review of mental health
 What role does stigma play
 Supporting consumers, what is their perspective
 Update on medicines
 Brand switches

3. We live in troubled times
Geopolitical instability
 Terrorism
 Potential conflict in Asia
 Changes in governments overseas
 The rise of nationalism
New Zealand and Auckland
 Comparatively stable country
 Stresses on the Health Care System
 Huge issues re access to stable
social housing
 Increased use of harmful
substances; methamphetamine,
synthetic cannabis, huffing,
alcohol
 Increase in suicide rate

4. The impact of stress
 Individuals with underlying mental illness can experience relapse
 Increased substance use (self medication)
 Pressure on family and social support structures
 Increase in rates of depression and anxiety
 New cardiovascular guidelines consensus statement includes screening for
anyone with a serious mental illness: Schizophrenia, Bipolar disorder,
Schizoaffective disorder, Major depression and/or addiction

5. The Link Between Stress and
Mental Health/Illness
 From time to time, everyone faces things in life that cause
stress – we will all move up and down this continuum
 Sometimes, people’s normal coping skills are not enough to deal
with these stress events, leading to developing symptoms
 In any one year, for 25% of the population, 33% of Primary Care
attenders, life stressors will be causing a mental health or drug
alcohol condition – or in our lifetimes this figure is 66%
Increasing intensity of stressors
Stress Chronic Stress
Emotional Disorders
(Depression, anxiety,
alcohol and drug problems)

6. Awareness and Recognition:
Symptoms of Chronic Stress
Constant worry
Racing mind
Illogic
Can’t concentrate
Impatience
Depression
Loneliness
Churning stomach
Backache
Palpitations
Chest tightness
Poor sleeping habits
Rapid speech
Reckless driving
Excessive drinking
Easily distracted
Uncertainty
Forgetfulness
Poor memory
STRESS AND
YOUR MIND
STRESS AND
YOUR FEELINGS
STRESS AND
YOUR ACTIONS
STRESS AND
YOUR BODY
Irritability
Anxiety
Anger
Low self-esteem
Fatigue
Headaches
Diarrhoea
Poor eating habits
Drug use
Excessive smoking

7. How do you manage stress

8. Ways for managing stress
Helpful
 Lifestyle balance: don’t take work
home, turn of phones
 Exercise, relaxation techniques,
yoga, mindful practices
 Net working, families, community
work, worship
Less helpful
 Over compensating
 Short term self soothing, over
eating, shopping
 Self medicating: alcohol, tobacco,
cannabis etc

9. How do you recognise mental health
issues in practice?

10. Recognising mental health issues
 For a pharmacist we can assess by what medicines dispensed (be cautious
about off label use)
 Use of good communication skills to establish what the client understands
what the medicine is prescribed for
 For individuals who are not on a medicine presentations can be vague, may
have a medical focus

11. PH2 (can be modified for anxiety as well
as depression)
Other Rating scales
Kessler, PHQ9

12. Stigma: have you experienced or
observed stigma?

13. Stigma
 A mark of disgrace associated with a particular circumstance, quality or
person
 Pervades a culture via media, social media and personal interactions
 Some of threads that appear in popular literature and social media associated
with stigma
 Weakness a failing, lazy, no backbone, failing the family
 Weird, wacky unusual, drama queen/king, self obsessed
 Dangerous, a potential murderer
 Low IQ, not able to work, a burden
 A drug addict
 A sexual deviant

14. Consequences
Fear
Ignorance
Effects of
stigma
Silence
Failure to access services
Fear of discrimination
Increased stress and anxiety
Failure to invest in
mental health services
Family stress, increased stress on children/parents
Loss of income and livelihood
Loss of hope and self esteem
Loss of reputation
People who help don’t access it
Family breakdown

15. Internalised stigma

16. How to support clients
 We need to reflect on our own beliefs
 Discuss the issue with colleagues
 Be aware that some clients may feel shame and embarrassment
 Have supportive material and literature available
 Endeavour to treat each person with respect
 Use your own personal skill kit of and be genuine

17. Jan Gordan-Waters
Client Perspective

18. The 2 x biggest questions …
 What benefit can I expect ?
 What risks am I taking ?
Jan Gordan-Waters

19. Aspirations
“To take the
lowest dose
possible to
keep me well”
“To keep me
out of hospital”
“To be able to
get on with my
life”
“To be able to be
part of the
community”
“To feel more
confident to
manage my
life”
“To get more
enjoyment out
of life”
“To reduce the
symptoms”
“To have to take them
for as short a time as
possible”
“To feel more
in control”
Jan Gordan-Waters

20. Advantages
“Keeps me
stable”
“Reduces
symptoms”
“Helped me
get my life
back”
“Changed my
life”
“Saved my
marriage”
“I am
holding
down a job
now”
“Improves my
concentration”
“Balances
my
thoughts”
“I can keep
my cool”
“A life saver
for me”
Such a relief
when the right
meds/right
dose is found”
Jan Gordan-Waters

21. Challenges
“Feeling
‘different’ or
‘other’ for
having to take
medication”
“Feeling
discriminated against
for having to take
medication”
“Feeling like a
‘chemically
engineered’ person
rather than a ‘real’
person”
“Privacy
compromised by
need to disclose”
“Side effects”
“Being taken
advantage of"
“Clash of
psychiatric meds
with other meds”
“Clash of
psychiatric meds
with alcohol &
recreational drugs”
“Accepting that I
need them,
possibly forever
…”
“Being sidelined for
opportunities
because I need
psychiatric meds”
“Seen as a sign
of weakness”
Jan Gordan-Waters

22. Side Effects
The
“shakes Salivation
Lockjaw
Poor
memory
Weight
gain
Sexual
Dysfunction
Depression
Lack of
concentration
Constipation
Breast
milk
Muscle
stiffness
Demotivation
Anxiety
Palpitations
Feeling
suicidal
Extreme
tiredness
Lethargy

23. Ambivalence
 Simultaneous & contradictory feelings
 Continual fluctuation between one
thing and its opposite
 Uncertainty as to which approach to
follow
Jan Gordan-Waters

24. Communication is the key
“I need to be
honest, not say
what someone
else wants to
hear”
“Must be
able to talk
issues
through”
“I expect to
be listened
to”
“I need to feel
comfortable
asking questions
“My concerns
should be taken
seriously, not
brushed aside”
“I want
straight
answers to
my
questions”
“I want the pros
and cons fully
explained to me
by a real person
(not a piece of
paper inside the
box)”
“This is a big
decision that will
seriously impact
my life. Of
course I want to
fully discuss it !”
Jan Gordan-Waters

25. Key Relationships
Psychiatrist
Pharmacist
Pharmacy
Assistant
Keyworker
G.P.’s
Receptionist Supportive
People
NurseG.P.
Jan Gordan-Waters

26. The Pharmacist’s tool kit
 In depth knowledge of medicines (know how people respond to medicines, the
benefits and the adverse effects)
 A strong health science background (stick to the facts)
 Tools to support adherence: blister packaging, medicines reconciliation,
follow up
 Part of a wider health care team

27. Know your pharmacology
 Have a basic working knowledge of the commonly prescribed medicines
 Be able to identify how the medicines have there beneficial effects and adverse
effects, the time frames for medicines to have an effect
 Understand the dosing bands, basic pharmacokinetics, therapeutic blood
monitoring and the monitoring and screening for significant adverse effects

28. SSRIs: fluoxetine, sertraline,
escitalopram, citalopram, paroxetine
 Flat dose response
 Most daily dosing (apart from
sertraline)
 Similar efficacy
 As with most antidepressant may
take 2-3 weeks for a response
 Safe in overdose
Adverse effects
 Agitation, anxiety and sleep issues
 Narrow emotional band width
 Increased sweating
 Sexual dysfunction
 Discontinuation syndrome
 Serotonergic syndrome
 QT prolongation
 Caution in pregnancy

29. SNRI: venlafaxine
 More variable dose repose from
75mg daily to 300mg
 May have effecicay for poor
responders
Adverse effects
 Similar to SSRIs
 Increase in BP, and possible cardiac
toxicity
 Marked discontinuation syndrome

30. Other agents: mirtazapine,
moclobemide, phenelzine, bupropion
 Mirtazapine useful new agent
 Moclobemide not commonly used
 Phenelzine old MAOI
 Bupropion, of licence but has a
role
 Sedation weight gain low sexual ADR
 Low SE but effecicay limited
 MAOI diet
 Sleep disturbance

31. TCAs
 Often used for chronic pain, sleep
or anxiety
 For an antidepressant effect dose
needs to be titrated up,
nortriptyline 75mg, amitriptyline
150mg, doxepin 75mg, dothiepin
150mg
 Anticholinergic SE
 Risk in overdose
 Sedation, postural hypotension

32. Mood stabilisers: lithium, valproate,
lamotrigine, carbamazepine
 TDM is important (esp lithium)
 Difference in efficacy for acute
mood disorder versus prophylaxis
 Lithium: renal ADR , low
therapeutic index, thyroid
 Valproate: sedation Poly Cystic
Ovaries, weight gain
 Lamotrigine: skin ADRS
 Carbamazepine: rash and blood
dsycrasia

33. Antipsychotics (atypical) risperidone,
quetiapine, amisulpride, aripiprazole,
olanzapine, paliperidone, clozapine
 Differing properties relating to high
potency (risperidone, paliperidone,
olanzapine, aripiprazole)
 Low potency: quetiapine
amisulpride, clozapine
 Motor side effects
 Metabolic side effects
 Sedation
 Clozapine high risk medicine: blood
dsycrasia, potentially toxic to the
bowel (toxic megacolon), acute
myocarditis

34. Issues with generics changes
 Medicine specific issues
 Marked discontinuation syndromes
 Well identified dose response
features
 Formulation of the generic
 Pharmacokinetics
 Client specific issues
 Poor tolerance to medicines,
history of adverse effects
 Strong brand allegiance
 Previous conflicts with treatment
team in terms of treatments

35. Venlafaxine
Known to have marked
discontinuation syndromes
Often a second line so clients
may have less resilience
New formulation has some
cosmetic disadvantages

36. How best to mange
 Liaise with prescriber
 Discuss with client outlining the possible risks, reinforce the dose will not
change but the client may experience some perceptual changes
 If things get bumpy persevere if possible (sometimes a short cause of
benzodiazepine may help)

37. Consider LTC for clients with significant
mental health diagnosis (schizophrenia,
bipolar, severe depression) and other
comorbidities
 Adherence, adherence, adherence
 Medicines reconciliation, liaising with prescribers
 Supporting ongoing monitoring, TDM, lipids, HbA1C, prolactin, thyroid
 Medicines education

38. Suicide Risk Factors
(Presence indicates increased risk)
 Severity of current depression and hopelessness
 Previous attempt(s)
 Alcohol/Drug abuse
 Social isolation
 Family History of suicide
 Medical co-morbidity
 Agitation
 Clusters especially among younger people
 Being an older male
 Recent significant loss(es)

39. What can pharmacists to reduce suicide
risk
 Listen to your clients and if concerned ask, “have you a plan or are you
thinking about harming yourself”, and be prepared to support the person if
indicate they are at risk
 If you are concerned contact GP, case worker and family and if risk is
imminent the police
 Dispense medicines and sell OTCs based on risk and knowledge of your
patient

40. Helpful tips
 Have resources available including links to websites Health Navigator, Beyond
the Blue
 Discuss issues with your colleagues, use shared learning
 Self reflect on interactions with clients, what worked and what seemed not to
be useful
 If appropriate obtain the clients GP contact details, mental health team,
community support workers
 Document your interventions