The changing role of pharmacists in mental health

Over 100 pharmacists attended the United Kingdom Psychiatric Pharmacy Group’s (UKPPG) 24th annual and 6th international conference, which took place from October 8 to 10, 1999, in London. Among other matters discussed were the setting up of a College for Mental Health Pharmacists, neuroleptic discontinuation syndrome, pharmacy services for drug misusers and cognitive dysfunction

Neuroleptic discontinuation syndrome

Research was needed to explore the factors that predisposed certain patients to neuroleptic discontinuation syndrome and to determine the best methods for its treatment. So said Dr DAVID HEALEY (director of North Wales Department of Psychological Medicine).

The syndrome had been described in people with and without mental illness, Dr Healey explained. Its main features appeared to be acute and chronic motor and autonomic disturbances. Acute motor disturbances included dystonia, akathisia and dyskinesia, while chronic disturbances included tardive dyskinesia or tardive akathisia. Acute autonomic disturbances, such as nausea, vomiting or anxiety might last for up to one week. However, intermediate autonomic disturbances, including dysthymia, paraesthesia and temperature dysregulation, might last months to years. Neuroleptic discontinuation syndrome remained largely unrecognised and there were only a handful of reports in the literature discussing the phenomenon and the frequency of its occurrence. This was despite the fact that the first reports of the syndrome had appeared in the mid-1960s, following the introduction of neuroleptic drugs.

Dr Healey described some case histories of patients developing neuroleptic discontinuation syndrome on the antipsychotic medication trifluoperazine and the antidepressant Parstelin (which contained trifluoperazine and tranylcypromine). Some reports described cases associated with stopping dopamine blocking anti-emetics, using chlorpromazine to treat tuberculosis and the use of antidepressant-antipsychotic combinations in patients with affective disorders. The mechanism for neuroleptic discontinuation syndrome was unknown and Dr Healey felt that there were probably differences between the neuroleptics in their ability to cause the syndrome. Possible management strategies included the use of serotonin antagonists, such as cyproheptadine or calcium channel blockers, like verapamil.

Pharmacy services for drug abusers

Discussing the role that pharmacists had to play in the management of drug abusers, Dr JANIE SHERIDAN (National Addiction Centre, London) said that there were many opportunities for pharmacists to expand the service that they provided to this group of patients.

These opportunities might include working with other health professionals to help manage problems like benzodiazepine withdrawal, monitoring clients during their first few days on methadone, educating other health professionals, taking part in research and service development, being proactive members of the primary care team and advising at policy making level.

There had been recent reviews of the management of drug misuse that had highlighted the role of the pharmacist in this area, she said. In the Department of Health’s recently published “Orange Guidelines”, which had outlined the clinical management of drug misuse, pharmacists were identified as key partners in the care of patients (PJ 1999;263:199). The guidelines had defined the role of hospital and community pharmacists, emphasising the importance of communication between health professionals. In addition, the Royal Pharmaceutical Society had reviewed the role of pharmacists in managing substance misuse.

Dr Sheridan said: “Pharmacists already play an important role in managing the treatment of substance misuse and providing services for problem drug users”. She decribed a national survey of community pharmacies that had taken place in England and Wales in 1995. This had found that Controlled Drugs were dispensed in 50 per cent of pharmacies to manage substance misuse. It also appeared that 19 per cent of the community pharmacies sampled were involved in needle exchange.

As well as the roles highlighted by the survey, she said that community pharmacists might become involved in providing advice on safe prescribing, referral of drug users to appropriate services, supervised methadone consumption, and communication and liaison with other health professionals. It was important that community pharmacists had knowledge of the abuse potential of prescribed and over-the counter medication.

Hospital pharmacists were becoming more involved in service provision to drug users, both at the drug clinic level and in managing dual diagnosis clients. They might supply methadone to hospital inpatients and, where necessary, provide advice to doctors and other health professionals and develop admission and discharge policies for these patients.

Pharmacists specialising in the treatment of substance misuse might act as a resource for other health professionals, providing drug information, co-ordinating services between primary and secondary care and working with clients with complex drug regimes, Dr Sheridan concluded.

Cognitive dysfunction in schizophrenia and epilepsy

Cognitive dysfunction is a feature of both schizophrenia and epilepsy and its consequences in both diseases were discussed by speakers at the conference.

Professor TONY DAVID (Institute of Psychiatry, London) said that more research was needed into whether or not cognitive deficits led to relapses of schizophrenia. He believed that these deficits were a major contributor to the burden of care, as they affected the daily functioning and quality of life of the individual.

Schizophrenia had traditionally been regarded as a disease comprising hallucinations, delusions and thought disorder but without concomitant cognitive deficits. However, it had been shown recently that this was untrue.

Cognitive dysfunction was seen in more than 85 per cent of patients. It was generalised and pre-morbid, with some deficit usually present from childhood. People destined to develop schizophrenia were more likely to have a lower IQ than the average population and this could not be attributed to a prodromal psychosis. Brain scans of patients with schizophrenia showed a 5 to 10 per cent loss of brain tissue, especially in the left temporal lobes. When tested, these patients showed greater deficits across a range of cognitive functions, although it was possible that different domains of cognitive function were disproportionately affected. These domains included memory and “executive function” (generating and implementing plans or solving complex problems).

Concordance difficulties

Cognitive deficits could lead to difficulties in concordance with medication, said Professor David. Lack of insight into the illness meant that patients did not see the need for medication, and deficits in executive functions led to failure in organisational abilities. These patients might not be able to manage regular self-administration of drugs and often showed a lack of proper planning. Dysfunction of working memory could lead to an inability to keep track of sequences, so those individuals might also forget appointments or medication times.

Professor David admitted that medication could cause cognitive deficits, especially the older “typical” antipsychotics; anticholinergic drugs, such as procyclidine could affect memory and over-sedation could lead to cognitive impairment. However, cognitive deficits were widespread; they were not the result of “poor motivation” or side effects of neuroleptic medication, he said.

Discussing cognitive dysfunction in epilepsy, Dr PAM THOMPSON (National Hospital for Neurology and Neurosurgery, London) said that over the past 100 years, research had shown that the cognitive outlook for people with epilepsy was not as gloomy as was once thought. However, for some individuals, particularly those with complex epilepsy, the risk of cognitive disorders did remain high.

One in 200 people suffered from epilepsy, with approximately 10 per cent having more than one seizure per week. A range of cognitive disorders of varying severity was encountered in people with the disease. Cognitive deficits might be intermittent or transient and were related to seizure occurrence. Post-ictal deficits usually affected memory and had a variable recovery period. Transient cognitive impairment could also be related to subclinical seizures or even non-convulsive status, such as in absence status, where the sufferer might have prolonged attention deficits. Cognitive disturbances could persist between seizures, leading to chronic deficits.

The greatest causative factor in this case was the underlying brain pathology, including the location of the seizure. For example, memory deficits were common in temporal lobe epilepsy and the location within the temporal lobe determined the type of memory affected. The most common deficit was that of “remote memory”? the distant and personal memory.

Seizure frequency, severity and type were also influential factors in chronic deficits, along with psychosocial factors, such as mood and anxiety. Poor performance in cognitive testing was linked with female gender, temporal lobe epilepsy and a high seizure frequency.

Anticonvulsants and cognitive dysfunction

The treatment of epilepsy had been revolutionised by the advent of anti-epileptic drugs, with many of the new drugs being promoted on the basis of their cognition-enhancing effects, continued Dr Thompson. However, as usage became widespread and more experience was gained, negative effects had emerged.

Barbiturates seemed to be the worst for causing cognitive impairment; they decreased motor function and speed and also caused impaired attention, memory and problem solving abilities. Phenytoin had many cognitive side effects, whereas carbamazepine could increase cognitive function. Sodium valproate had received some bad press recently, which she felt was mostly undeserved. In a minority of cases, valproate had caused encephalopathy with increased ammonia levels, which had led to a global decline in cognitive functioning. One of the new anti-epileptic drugs, topiramate, had been shown to decrease verbal fluency in healthy volunteers. However, this cognitive dysfunction had to be balanced against its undoubted efficacy in decreasing seizure frequency.

Dr Thompson concluded that cognitive impairment was not inevitable in epilepsy and that anti-epileptic drugs had a vital role in the prevention of seizures, although this might only be achieved in some patients at the expense of cognitive function.

College of Mental Health Pharmacists

The UKPPG now has a mandate to set up a College of Mental Health Pharmacists, which will be financially linked to the group and will form a UKPPG practice subcommittee. Five founders are to be appointed through open competition, who will begin by constructing a constitution and developing the process of accreditation. At a later date, they will be replaced by an elected five-member executive.

The decision to set up the college was made following lively discussion of a proposal at the group’s annual general meeting. Presentations were given by UKPPG committee members (the proposers of the scheme) and from a representative of the College of Pharmacy Practice.

It was agreed that accreditation would be available to all UKPPG members and that, in order to achieve accreditation, pharmacists would be expected to show a high level of competence in mental health pharmacy. It was suggested that if, after two years, fewer than 25 specialists had been accredited, the function of the college would be reviewed.

Further information can be obtained on the UKPPG website www.ukppg.co.uk.