Medicines optimisation is all about enabling people to get the best possible outcomes from their medicines. It is about talking to and engaging with individuals to understand their beliefs and concerns about their treatment and finding out what they would like their medicines to achieve for them. It is also about ensuring that the medicines chosen are clinically appropriate, safe and effective while supporting people to use them in a way that fits with their lifestyle and meets their expectations.
To make medicines optimisation meaningful we need to engage with people and involve them in decisions about their treatment. This may mean stopping medicines or providing non-medical treatment advice as well as starting medicines (PJ 2014;292:48).
The medicines optimisation briefings we have produced are for pharmacists working in all sectors of healthcare. We believe that, as experts in medicines and their use, pharmacy professionals are well placed to support patients to get the most from their medicines.
Medicines for schizophrenia
The briefing distributed with this week’s issue of The Journal focuses on medicines that are used for schizophrenia. This is the fourth in a series of briefings that complement and build on each other. The content is not intended to be exhaustive; the aim is to improve your approach to and understanding of people who have schizophrenia. (Pharmacists should be aware that patients may have more than one condition and be on a variety of medicines.)
Schizophrenia is a serious, distressing and disabling mental illness that causes severe disruption to people’s lives and can have a major adverse impact on family and friends. During an episode of schizophrenia, a person’s experience and interpretation of the outside world are disrupted — they may lose touch with reality, see, hear or believe things that others cannot or do not, and act in unusual ways in response to such hallucinations and delusions. An acute episode of schizophrenia can last for several weeks and can be frightening because the hallucinations and delusions are real to the person experiencing them. A diagnosis of schizophrenia carries significant stigma.
A major health inequality is that people with schizophrenia have a significantly higher risk of dying earlier than those in the general population. (This has been estimated by the Schizophrenia Commission Report “Schizophrenia — the forgotten illness” [November 2012] to be 20 years earlier than people without a diagnosis of schizophrenia).
People with mental illness are entitled to receive the same level of support as people with any other long-term condition; however, for various reasons this does not always happen. Poor physical health can arise as a side effect of antipsychotics (for example, weight gain, cardiovascular disease and increased risk of developing diabetes) and as a result of a chaotic lifestyle, self-neglect, poor diet and high levels of smoking.
Healthcare professionals involved must ensure that people’s physical health is regularly kept under review and opportunities to encourage improvements in lifestyle are maximised. Refer to our previous advice about cardiovascular disease (PJ 2014;292:212) and type 2 diabetes (PJ 2014;292:272).
The easy access of community pharmacy provides an opportunity for them become much more involved in supporting people with mental illnesses such as schizophrenia.
The recovery model
In mental health, recovery does not always refer to complete recovery from a mental illness in the way that people may recover from a physical health problem. For many people, the concept of recovery is about staying in control of their life despite experiencing a mental illness.
The recovery model encourages people to move forward, set new goals and do things and develop relationships that give their lives meaning. Putting recovery into action means focusing care on supporting recovery and building resilience, not just on treating or managing symptoms. It requires a more positive approach, rather than just correcting the negative.
Community mental health teams
Most mental health services are based within the community. Community-based mental health teams (CMHTs) operate differently in different areas, depending on the policies of the local NHS mental health trust. Find out how services are structured in your area by contacting the medicines management team at your local mental health NHS trust.
However services are structured, people with schizophrenia should have a key healthcare worker who works with them to develop their care plan, personal goals and targets, and should involve that person in decisions about their care, including medicines, support, self-management and follow-up. If you are supporting a person with schizophrenia in your pharmacy ask if they would like you to be part of this team so you can feedback if they are having problems with their medicines or are not collecting their repeat prescriptions.
There are several national support groups such as Mind, Rethink Mental Illness, SANE, Mental Health Matters and Hafal (Wales), as well as local groups that you can signpost people to for specialist support. Keep their contact details at hand and have leaflets on display.
In addition there are several websites containing useful information for people with mental illness and their families and friends such as NHS Choices (www.nhs.uk/conditions/schizophrenia) or mental health care (www.mentalhealthcare.org.uk) and the Royal College of Psychiatry (www.rcpsych.ac.uk/healthadvice.aspx).
Tips for pharmacists to support people with schizophrenia include the following:
Medicines will usually be initiated by mental health services professionals: you can encourage people to take their medicines regularly and as prescribed. During the first few weeks doses will often be titrated and adjusted to manage symptoms versus adverse effects.
When antipsychotics are initiated people with schizophrenia may not be able to take in all the information on offer, so ongoing input from pharmacy professionals could be valuable. Was the person offered a choice of medicine? Is there any other information that he or she would like to know? Would the person like to review his or her options and share the decision making?
Engage in conversation with the person, allow for trust to build over time and do not assume that just because people say they do not have any questions the first time you ask they will not ever want any information.
Every time you speak to the person you have an opportunity to make a difference. You just need to start the conversation. It is about building a relationship, becoming a familiar face and listening. It is also good practice to check people understand what you have told them, but do not assume that because they have a mental illness they will have difficulty in understanding what you say.
It may take some time for antipsychotics to be effective, so encourage people to keep taking their medicines as they are being titrated and emphasise the need to continue taking them regularly even when their symptoms have improved in order to reduce the risk of relapse.
Explain the risks of suddenly stopping and restarting antipsychotics without retitration, which greatly increases the risk of adverse effects and a poorer long-term outcome. Emphasise that, in the case of clozapine, this may be potentially hazardous for the person’s physical health.
If people have a chaotic lifestyle ensuring adherence can be challenging, so aim to link medicine-taking with a regular daily event. For example, advising people to take their medicines in the morning may lead to non-adherence if the person does not get up until after midday. The aim is for medicines to be taken regularly at a time that suits the person’s lifestyle to improve effectiveness.
People may obtain some of their medicines from secondary care, for example clozapine or long-acting antipsychotic injections. It is important to be aware of all the medicines that the person is taking so that you can carry out complete drug interaction checks when other medicines are prescribed or advice is provided about over-the-counter products. This is especially important because there are several significant drug interactions with antipsychotic drugs that could be missed.
Side effects — supporting people
Contact your local mental health trust medicines management team to find out what patient information resources they use and they will tell you how to access them. For example they may subscribe to the “Choice and medication” website (www.choiceandmedication.org). This website allows medicines information leaflets to be printed to support people with schizophrenia.
Offer people information about their medicines in a form that suits them — in writing, verbally or both. Encourage people to ask questions and request more information if they need to.
Explain to people what side effects may occur, how long they are expected to last, how they may be managed and what to do to minimise them. Taking antipsychotics regularly as prescribed can reduce the length of time that some of the more transient side effects are experienced. For example, sedation, tachycardia or postural hypotension are more likely if the antipsychotic is stopped and started without titration. Are people who take clozapine receiving a regular faecal softener and a stimulant laxative? More people die as a result of constipation and bowel perforation caused by clozapine than neutropenia.
Advise people to speak to you, their CMHT or their key worker if side effects last longer or are worse than they expected or are impacting negatively on their lifestyle. Reassure people that there may be alternative choices of medicines available if they do not get on with what has been prescribed for them.
Keep stocks of leaflets about schizophrenia and medicines used to treat it to reinforce the information you have provided verbally. Make sure that people on depot antipsychotics have received the appropriate patient information leaflet.
People with schizophrenia will benefit from support and encouragement with lifestyle changes that will reduce the impact of the adverse metabolic side effects of many of the antipsychotics. Weight gain will occur with most antipsychotics therefore it is best for people to take measures to avoid or minimise that from the start. With the person’s permission liaise with the CMHT or key worker in order to provide consistent and reinforcing healthcare messages.
Simple healthy living and dietary advice such as healthy eating, increasing exercise or reducing alcohol intake can be beneficial. Check if exercise prescriptions are available in your area since these may be a helpful way of engaging people in regular exercise.
Tips for losing weight could include advising people to drink a glass of water before eating and to wait 10 minutes before eating to see if they still feel hungry, and to avoid carbonated and sugary drinks.
When offering smoking cessation advice be mindful of the effects that changes in smoking can have on the metabolism of certain antipsychotics such as clozapine and olanzapine. Specialist smoking cessation support may be required as well as advice from the mental health trust.
Regular, ongoing physical health monitoring is vital for people with schizophrenia. Do people understand the reasons for monitoring and what it means?
Contact your local mental health trust and see if you can attend their wellbeing clinic or equivalent. Generally these clinics are where people’s blood pressure and weight checks are done, depot antipsychotics are administered and advice is provided. People have lots of questions about their general health as well as their mental health so a community pharmacist would be well placed to help with the information that people want.
Familiarise yourself with the National Institute for Health and Care Excellence quality standard for service user experience in adult mental health (www.nice.org.uk/qs14), the NICE pathway “Psychosis and schizophrenia” (pathways.nice.org.uk/pathways/psychosis-and-schizophrenia) and the NICE “Psychosis and schizophrenia in adults: treatment and management clinical guideline 178” (http://guidance.nice.org.uk/CG178).
Speak to your commissioners about introducing public health services such as a smoking cessation service, an alcohol brief advice service or health checks. Have you thought about operating a healthy living pharmacy?
Acknowledgement Thanks to the College of Mental Health Pharmacy for its help in preparing this article and the associated medicines optimisation briefing.
Citation: The Pharmaceutical Journal, 22/29 March 2014, Vol 292, No 7802/3, p342 | URI: 11136046