Hospital Pharmacists: what they are doing now
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[post_content] => With New South Wales recently expanding its pharmacy prescribing trial to include skin conditions, could other jurisdictions soon follow?
The NSW pharmacy prescribing trial has been a resounding success thus far, with thousands of women seeking treatment from their local community pharmacists since the rollout commenced in May 2023.
The number of participating pharmacies in the trial has ballooned from the initial 100 prescribing treatment for uncomplicated urinary tract infection (UTI) in the feasibility study to 1,100 following the expansion of the trial across the state – accounting for almost 60% of the state’s pharmacies.
‘It is fantastic to see that over 6,000 women have visited their community pharmacy to manage treatment for their UTI or extend their oral contraceptive,’ said President of the PSA NSW Branch Luke Kelly FPS.
[caption id="attachment_24351" align="alignright" width="233"]
NSW Minister for Health Ryan Park with PSA NSW Branch President Luke Kelly FPS[/caption]
‘Pharmacists are key to strengthening the healthcare system, and through the NSW pharmacy trial, patients have been able to access safe, quality treatment when and where they need it.’
NSW and Queensland have been at the forefront of pharmacy prescribing trials. The expansion and success of these trials could serve as a blueprint for what’s possible across the nation.
Australian Pharmacist looks at what will change and when, and why governments are increasingly relying on pharmacists to fill healthcare gaps.
What conditions will pharmacists be able to treat?
From March 2024, pending ethics approval, participating NSW-based pharmacists will able to prescribe medicines for the following skin conditions after a private consultation:
[post_title] => Pharmacy prescribing trial expands to include skin conditions
[post_excerpt] => With New South Wales recently expanding its pharmacy prescribing trial to include skin conditions, could other jurisdictions soon follow?
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[post_content] => With experts expecting a whooping cough outbreak next month, pharmacists can help to protect those most at risk through promoting testing and vaccination.
Australia is currently awash with respiratory symptoms. While many people will be infected with COVID-19, given we’re in the midst of our 8th wave, others will likely have whooping cough, said University of Sydney professor of paediatrics and child health, Robert Booy.
‘The rate of reporting of whooping cough in 2023 is three times higher than it was last year,’ he said. ‘Case numbers are rising all over Australia, particularly down the east coast in Queensland, New South Wales and Victoria.’
During the pertussis outbreak in 2015, case numbers reached 22,570. But there are several reasons to be concerned about a looming 2023 epidemic.
‘During COVID-19, people weren’t socially mixing, so germs such as whooping cough, weren’t spreading,’ said Prof Booy. ‘Now, the amount of immunity in the community is much lower.’
Childhood vaccination coverage also has slipped across all three coverage time points for children by up to 1–1.5 percentage points, said Margie Danchin, group leader of the Murdoch Children's Research Institute’s Vaccine Uptake Group.
‘We’re concerned about drops in childhood coverage, changes in immunity profiles through lockdowns and exposure to infections,’ she said. ‘As we're also anticipating the normal cyclical return of pertussis, a perfect storm is potentially brewing.’
‘We're due an outbreak and we're at the start of one right now, I believe,’ added Prof Booy.
What are the symptoms and who should get tested?
The classic symptoms of whooping cough in older children and adults include:
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[post_content] => Patients are being harmed because we are not talking about the adverse effects of mental health medicines.
Medicines prescribed for mental health can have disturbing adverse effects.
Sexual dysfunction can be a by-product and in turn adversely affect relationships. Weight gain can lead to non-adherence with prescribed medicines. Other detrimental physical ramifications from medicines to treat mental health conditions including schizophrenia, depression, bipolar disease and withdrawals from them can lead to dry mouth and thirst, tiredness, mood swings – even suicidal ideation.
Issues with medicine safety including the lack of recognition of such adverse effects of medicines prescribed for mental health conditions, a lack of understanding of the impairment that can result from these adverse effects on daily life are the subject of a new report commissioned by PSA.
The Medicine Safety: mental health care report1 launched this month also found people with mental health conditions were the subject of frequent changes in therapy. There was also little information on how to use medicines safely for these conditions and a failure to document past therapeutic failures and outcomes in many cases. Antidepressants and antipsychotics were also implicated in overdose deaths.1
A set-and-forget mentality for medicines prescribed for mental health conditions was found by the University of South Australia researchers, with little review for eventual tapering off or stepping up to a new dosage for more therapeutic effect. Patients may be locked into taking these medicines for long periods, which can significantly impede their quality of life.
Tellingly, the report found: ‘The [adverse] effects of most concern to health professionals are not necessarily those that concern the people taking medicines to treat mental health concerns, and the converse is also true.’
Master Mental Health First Aid (MHFA) Instructor and University of Sydney (USyd) Associate Professor Claire O’Reilly FPS says that with increased diagnoses comes heightened mental health medicine use year on year in Australia.
‘We’re getting better at treating mental illnesses,’ she says. ‘More people might be seeking help so medicines are prescribed.’
The report also found that one in two Australians will experience a mental health condition in their lifetime, says its lead author Dr Anna Kemp-Casey, a Research Fellow at the University of South Australia’s Quality Use of Medicines and Pharmacy Research Centre.
‘It will either be us or someone we love who is affected,’ she says.
Crippling adverse effects
Of crucial concern are the conversations that are not had between healthcare professionals and patients about adverse effects from mental health medicines.
The researchers found that people attending mental health facilities who were taking antipsychotics reported up to seven adverse effects each – most commonly daytime tiredness, weight gain and thirst.
One in four patients on antidepressants reported ‘very’ or ‘extremely’ bothersome adverse effects.
Of great concern is the statistic found that more than 40% of mental health facilities do not have any medicines handover at discharge.
Mental health-related hospitalisations usually last much longer than average hospital stays. In 2020–21 the national average stay in a public hospital with specialised psychiatric care was about 16 days compared to about 6 days.2
This is where pharmacists can step up. ‘Medicine reconciliations are important when a person has been recently discharged from a mental health facility,’ A/Prof O’Reilly told Australian Pharmacist.
‘Community pharmacists have a really important role to ensure ongoing supply of medicines, ensuring there is no confusion about old medicines and support with adherence. The first few months after discharge from hospital are a critical time. Pharmacists can have ongoing conversations and check-ins to ensure that patients are adjusting back into the community.’
Physical health care and monitoring other illnesses e.g. diabetes once they are discharged, should also take place.
Patients with adverse effects may also be good candidates for MedsChecks in the pharmacy or may need referrals for Home Medicines Reviews, A/Prof O’Reilly says.
‘Every patient visit for a repeat script is an opportunity to ask, “is the medicine working? Are there any adverse effects? Is there anything you want to ask me?”’
‘People talk about relationship breakdowns from sexual dysfunction,’ Dr Kemp-Casey points out. ‘They report this in surveys but are often too embarrassed to discuss it with prescribers. Women won’t mention sexual dysfunction to clinicians, unless they are asked directly,’ she stresses.
‘So this is important for addressing adverse effects [that] people find difficult to vocalise.’
A/Prof O’Reilly points to someone diagnosed with schizophrenia in their early 20s who starts on an antipsychotic and who might put on 10–20 kilograms in weight in the first 3–6 months.
As medicine experts, pharmacists can point to medicines less likely to cause particular adverse effects at a population level. This is an important role for GP pharmacists at the point of prescribing, or during monitoring after therapy initiation.
Therapeutic Guidelines are a good place to access good comparative information on mental health medicines,’ notes A/Prof O’Reilly. Pharmacists can have a conversation about the adverse effects patients are experiencing and can offer to contact the prescriber to discuss concerns.
Dr Kemp-Casey suggests it is helpful for prescribers to know what has or has not worked before and ‘also really helpful’ if people can explain their priorities. For instance, for some people a sedating medicine is much less concerning than sexual dysfunction, or the opposite might be true, she says.
‘For people who have lost substantial amounts of weight due to their mental health concern, a medicine that will lead to weight gain is not necessarily a problem. So it all comes down to the individual and what is tolerable for them.’
Pharmacists also have useful tips to reduce the severity of adverse effects.
‘With antipsychotics, pharmacists might say, “The dry mouth is worse for the first 6 hours. If you take it before you go to bed you might not notice it,”’ she says.
Medicine changes
One particular problem highlighted by the report is the high number of medicine changes for people who are inpatient admissions in psychiatric facilities.1
Some patients are already on multiple medicines. And the report noted there are no Australian studies on the extent of hospital admissions for mental health concerns due to problems with medicines.1
Average mental health hospitalisations involve 10 medicine changes, including dosage adjustments, adding new medicines and withdrawing others, according to one Australian study.3
‘Some people had up to 32 medicine changes during their admission,’ PSA’s report stated.
‘Four out of 10 charted medicine changes were not recorded at all in the clinical notes,’ it added, and no reason was recorded for 56% of medicine changes.
Clinical notes for patients with mental health problems are often not up to date, including the recording of adverse effects, or reasons for changes to medicines.
Tellingly, the report stated that only 4% of clinical notes on medicine changes mentioned adverse effects.1
Patients may also not receive adequate handover about medicine changes during transitions of care. This highlights the dearth of pharmacists in mental health wards to follow up on missing clinical notes or explain new medicine regimens to patients, says Dr Kemp-Casey.
‘There’s a need to train and embed more pharmacists in these facilities.’
The PSA report suggests pharmacist ‘participation in ward rounds in the mental health setting has been shown to lead to dosage adjustments’ for better results after pharmacist recommendations, as well as medicine initiation and discontinuation.
Pharmacists embedded in community mental health teams could also support the hospital discharge process and facilitate regular medication reviews within the service.
Community pharmacy relationships with these teams are also important.
Says A/Prof O’Reilly: ‘When case managers liaise with community pharmacies or collect DAAs, the pharmacy may be alerted directly by the hospital on discharge about changes to medicines in that process.’
Difficulty withdrawing
For a single episode of depression, an antidepressant should be used for 6–12 months.6
But the discontinuation effects of these medicines make it difficult to stop. ‘Withdrawal effects can mimic the condition patients are using the medicines for,’ says Dr Kemp-Casey.
The severity of withdrawal effects is often down to how medicines are metabolised. ‘There are around 150 different versions of the genes that make a liver enzyme responsible for metabolising antipsychotics and antidepressants,’ she says.7
‘Some people can discontinue medicines with no issues, whereas others are intensely sensitive.’
Genetic tests should soon allow prescribers and pharmacists to identify the medicines that render patients at higher risk of experiencing adverse and withdrawal effects.8
For now, as GP pharmacists’ roles continue to grow, they can help to reduce the impacts, says A/Prof O’Reilly.
‘They can monitor and support slow tapering of doses when patients change or come off antidepressants.’
Pharmacists can also help patients distinguish between a relapse in depression and withdrawal effects (see Box 1).
Box 1– Tips to distinguish between adepressive relapse and adverse effectsPhysical + psychological symptoms: If dizziness, ‘brain zaps’, headaches or nausea present together with mood changes, this is strongly suggestive of withdrawal rather than relapse. Timing: Withdrawal effects can occur within days of stopping antidepressants while relapse is likely to occur after weeks or months. Impact of restarting antidepressants: Commonly, withdrawal effects will cease within days of restarting antidepressants while relapse typically requires several weeks before symptoms improve. |
Too much prescribing
Clozapine in the community[caption id="attachment_24312" align="alignright" width="281"] Nick Logan MPS[/caption]
Sydney-based community pharmacy Nick Logan Pharmacist Advice supplies clozapine to 70 patients with treatment-resistant schizophrenia. Servicing this ‘disproportionately large’ cohort of patients is due to strong ties with the Assertive Outreach team at nearby Royal North Shore Hospital, says owner Nick Logan MPS.
Mr Logan describes clozapine as a ‘fabulous drug’ that has low extrapyramidal adverse effects, including less akathisia, tremor and little-to-no dystonia or rigidity.4
But due to potentially fatal complications – including agranulocytosis, neutropenia and myocarditis – the medicine is only indicated for patients who have tried and failed using other antipsychotics to manage their condition.4 After screening for cardiovascular problems, a weekly blood test that monitors white blood cell count and neutrophils is required for the first 18 weeks when clozapine is initiated.
Once stabilised, patients join the community clozapine system, with a blood test required every 28 days within 48 hours of medicine supply. Within clozapine monitoring software, there are green, amber and red ranges to inform pharmacists whether it’s safe [from blood test results] to supply.
In a ‘perfect world’, patients would always be in the green range. But there are always aberrations. ‘For example, if a patient is in the yellow range, bi-weekly blood tests are required and you can only supply enough clozapine to last the patient until the next test,’ says Mr Logan.
Clozapine patients usually drop into the pharmacy around once a week, which they consider a safe space. ‘One patient who has complete meltdowns sometimes freezes in the middle of the shopping village,’ he said. ‘Then she comes into the pharmacy and we offer her a seat and a glass of water, which usually helps her regain control.’
Three of Mr Logan’s clozapine patients managed to drastically improve their quality of life through the patient-pharmacist relationship. ‘They used to chain smoke, drink bourbon and smoke marijuana,’ he said. ‘But by forming relationships with the pharmacists, they had someone to ask about their blood glucose levels or why they were starting an oral hypoglycemic. We also gave them feedback on lifestyle changes and how to reduce their blood pressure.’
The patients have since quit cigarettes and alcohol, regularly go to the gym, and have significantly reduced their comorbidities. ‘It’s extremely satisfying from a pharmacist point of view, because you see those improvements,’ said Mr Logan. |
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[post_content] => With medicines being used more often than ever to treat mental health conditions, pharmacists’ quality use of medicines (QUM) expertise is vital to optimising therapy and preventing harm, says PSA’s newest medicine safety report.
One in two Australians will experience a mental health condition in their lifetime. With mental ill health on the rise, prescriptions for mental health medicines are soaring.
Almost one fifth of Australians (14.7 million, or 18%) filled a prescription for a medicine used to treat a mental health condition in 2021-2022. Yet there is a lack of QUM oversight from pharmacists to ensure these medicines are used appropriately and safely, found PSA’s Medicine Safety: Mental Health Care report, launched today (22 November 2023).
Wherever medicines are used there is a risk of medicine misadventure, said PSA National President Dr Fei Sim FPS.
‘Too often we hear of people stopping treatment altogether because of the effects of these medicines,’ she said. ‘This is where we believe there is significant opportunity for investment in pharmacist services to help support the safe and effective use of medicines.’
Patients using medicines for mental health conditions need access to pharmacists’ medicines expertise across the spectrum of care – whether in hospitals, community settings or private clinics.
The report’s recommendations, detailed below, address gaps in care across these junctures to ensure a movement away from the ‘set-and-forget’ approach that people using mental health medicines too often experience.
‘This is about ensuring patients have the support they need to get the most out of their medicines safely and effectively,’ said Dr Sim.
1. Upskilling pharmacy teams in emergency care
All members of the pharmacy team should receive funded Mental Health First Aid training. This includes pharmacists and support staff across all practice settings.
Equipping pharmacy teams with the right skill set will both help to reduce stigma and ensure an appropriate response to mental health challenges.
2. Timely screening to facilitate diagnosis
Early intervention in mental health conditions is key. As community pharmacists are the most accessible healthcare professionals, funding a mental health screening program using validated screening tools and evidence-based risk assessment methods will facilitate early intervention for people experiencing mental health symptoms. This will help to ensure referral to an appropriate health practitioner or service provider for further investigation and formal diagnosis.
3. Tailored support for patients starting new medicines
Implementation of a program that funds community pharmacists to provide three Mental Health Medicines Consultation Services will help to ensure patients on new and existing mental health medicines benefit from bespoke support.
4. Addressing overdose risk
To prevent harm or death from medicine overdose, community pharmacy services such as dose administration aids and staged supply should be promoted and funded for at-risk patients living with a mental health condition.
5. Testing to find the right therapy
A patient’s genetic profile can determine how effective a medicine will be and/or if adverse effects will be encountered. Funding for pharmacogenomic testing in primary care, including identification of patients who would benefit from this service, could help to avoid use of ineffective medicines to treat mental health conditions.
6. Activating credentialed pharmacists
Mental health service providers, such as community health services and private mental health clinics, should receive funding to access skilled services provided by credentialed pharmacists. These could include:
[post_title] => 9 recommendations to fix the mental health medicines crisis
[post_excerpt] => Pharmacists' QUM expertise is vital to optimising therapy and preventing harm, says PSA’s newest medicine safety report.
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[post_content] => The Australian Commission on Safety and Quality in Health Care Commission’s AURA 2023: Fifth Australian report on antimicrobial use and resistance in human health found that after a sharp reduction in 2020-21, antimicrobial prescribing has again surged.
To mark World AMR Awareness Week (18–24 November 2023) Australian Pharmacist sat down with the Commission's Senior Medical Advisor Professor John Turnidge AO for a Q&A session on new patterns of antimicrobial resistance and what pharmacists can do to help.
[caption id="attachment_24236" align="alignright" width="252"]
Professor John Turnidge AO[/caption]
AP: What are the key trends in antibiotic use highlighted in the report?
Prof. Turnidge: The most interesting trend was the rapid decline in antimicrobial Pharmaceutical Benefits Scheme (PBS) dispensings in 2020 and 2021.
COVID-19 lockdown measures, border closures, reduced access to GPs and the sudden drop in the number of circulating respiratory tract infections all played a role in that reduction.
There was a significant drop in prescribing of antibiotics for respiratory tract infections in 2020-21. However, there has been an uptick in antibiotic prescribing in 2022 – with a 10% increase over the previous 2 years.
Antibiotic prescribing is yet to reach the levels of 2019. We've never had a national campaign to help prevent a relapse in antibiotic prescribing – it would be helpful to ensure both prescribers and patients understand that antibiotics should only be used in very specific circumstances.
2022 highlights
|
Community pharmacists could ensure dosages on antibiotics on scripts align with Therapeutic Guidelines.
But an important first step is to establish a formal dialogue between GPs and pharmacists through local area health networks. They need to be able to sit around the same table and say, ‘These are the issues. How can we tackle antimicrobial stewardship together?
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[post_content] => With New South Wales recently expanding its pharmacy prescribing trial to include skin conditions, could other jurisdictions soon follow?
The NSW pharmacy prescribing trial has been a resounding success thus far, with thousands of women seeking treatment from their local community pharmacists since the rollout commenced in May 2023.
The number of participating pharmacies in the trial has ballooned from the initial 100 prescribing treatment for uncomplicated urinary tract infection (UTI) in the feasibility study to 1,100 following the expansion of the trial across the state – accounting for almost 60% of the state’s pharmacies.
‘It is fantastic to see that over 6,000 women have visited their community pharmacy to manage treatment for their UTI or extend their oral contraceptive,’ said President of the PSA NSW Branch Luke Kelly FPS.
[caption id="attachment_24351" align="alignright" width="233"] NSW Minister for Health Ryan Park with PSA NSW Branch President Luke Kelly FPS[/caption]
‘Pharmacists are key to strengthening the healthcare system, and through the NSW pharmacy trial, patients have been able to access safe, quality treatment when and where they need it.’
NSW and Queensland have been at the forefront of pharmacy prescribing trials. The expansion and success of these trials could serve as a blueprint for what’s possible across the nation.
Australian Pharmacist looks at what will change and when, and why governments are increasingly relying on pharmacists to fill healthcare gaps.
What conditions will pharmacists be able to treat?
From March 2024, pending ethics approval, participating NSW-based pharmacists will able to prescribe medicines for the following skin conditions after a private consultation:
[post_title] => Pharmacy prescribing trial expands to include skin conditions
[post_excerpt] => With New South Wales recently expanding its pharmacy prescribing trial to include skin conditions, could other jurisdictions soon follow?
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[post_content] => With experts expecting a whooping cough outbreak next month, pharmacists can help to protect those most at risk through promoting testing and vaccination.
Australia is currently awash with respiratory symptoms. While many people will be infected with COVID-19, given we’re in the midst of our 8th wave, others will likely have whooping cough, said University of Sydney professor of paediatrics and child health, Robert Booy.
‘The rate of reporting of whooping cough in 2023 is three times higher than it was last year,’ he said. ‘Case numbers are rising all over Australia, particularly down the east coast in Queensland, New South Wales and Victoria.’
During the pertussis outbreak in 2015, case numbers reached 22,570. But there are several reasons to be concerned about a looming 2023 epidemic.
‘During COVID-19, people weren’t socially mixing, so germs such as whooping cough, weren’t spreading,’ said Prof Booy. ‘Now, the amount of immunity in the community is much lower.’
Childhood vaccination coverage also has slipped across all three coverage time points for children by up to 1–1.5 percentage points, said Margie Danchin, group leader of the Murdoch Children's Research Institute’s Vaccine Uptake Group.
‘We’re concerned about drops in childhood coverage, changes in immunity profiles through lockdowns and exposure to infections,’ she said. ‘As we're also anticipating the normal cyclical return of pertussis, a perfect storm is potentially brewing.’
‘We're due an outbreak and we're at the start of one right now, I believe,’ added Prof Booy.
What are the symptoms and who should get tested?
The classic symptoms of whooping cough in older children and adults include:
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[post_content] => Patients are being harmed because we are not talking about the adverse effects of mental health medicines.
Medicines prescribed for mental health can have disturbing adverse effects.
Sexual dysfunction can be a by-product and in turn adversely affect relationships. Weight gain can lead to non-adherence with prescribed medicines. Other detrimental physical ramifications from medicines to treat mental health conditions including schizophrenia, depression, bipolar disease and withdrawals from them can lead to dry mouth and thirst, tiredness, mood swings – even suicidal ideation.
Issues with medicine safety including the lack of recognition of such adverse effects of medicines prescribed for mental health conditions, a lack of understanding of the impairment that can result from these adverse effects on daily life are the subject of a new report commissioned by PSA.
The Medicine Safety: mental health care report1 launched this month also found people with mental health conditions were the subject of frequent changes in therapy. There was also little information on how to use medicines safely for these conditions and a failure to document past therapeutic failures and outcomes in many cases. Antidepressants and antipsychotics were also implicated in overdose deaths.1
A set-and-forget mentality for medicines prescribed for mental health conditions was found by the University of South Australia researchers, with little review for eventual tapering off or stepping up to a new dosage for more therapeutic effect. Patients may be locked into taking these medicines for long periods, which can significantly impede their quality of life.
Tellingly, the report found: ‘The [adverse] effects of most concern to health professionals are not necessarily those that concern the people taking medicines to treat mental health concerns, and the converse is also true.’
Master Mental Health First Aid (MHFA) Instructor and University of Sydney (USyd) Associate Professor Claire O’Reilly FPS says that with increased diagnoses comes heightened mental health medicine use year on year in Australia.
‘We’re getting better at treating mental illnesses,’ she says. ‘More people might be seeking help so medicines are prescribed.’
The report also found that one in two Australians will experience a mental health condition in their lifetime, says its lead author Dr Anna Kemp-Casey, a Research Fellow at the University of South Australia’s Quality Use of Medicines and Pharmacy Research Centre.
‘It will either be us or someone we love who is affected,’ she says.
Crippling adverse effects
Of crucial concern are the conversations that are not had between healthcare professionals and patients about adverse effects from mental health medicines.
The researchers found that people attending mental health facilities who were taking antipsychotics reported up to seven adverse effects each – most commonly daytime tiredness, weight gain and thirst.
One in four patients on antidepressants reported ‘very’ or ‘extremely’ bothersome adverse effects.
Of great concern is the statistic found that more than 40% of mental health facilities do not have any medicines handover at discharge.
Mental health-related hospitalisations usually last much longer than average hospital stays. In 2020–21 the national average stay in a public hospital with specialised psychiatric care was about 16 days compared to about 6 days.2
This is where pharmacists can step up. ‘Medicine reconciliations are important when a person has been recently discharged from a mental health facility,’ A/Prof O’Reilly told Australian Pharmacist.
‘Community pharmacists have a really important role to ensure ongoing supply of medicines, ensuring there is no confusion about old medicines and support with adherence. The first few months after discharge from hospital are a critical time. Pharmacists can have ongoing conversations and check-ins to ensure that patients are adjusting back into the community.’
Physical health care and monitoring other illnesses e.g. diabetes once they are discharged, should also take place.
Patients with adverse effects may also be good candidates for MedsChecks in the pharmacy or may need referrals for Home Medicines Reviews, A/Prof O’Reilly says.
‘Every patient visit for a repeat script is an opportunity to ask, “is the medicine working? Are there any adverse effects? Is there anything you want to ask me?”’
‘People talk about relationship breakdowns from sexual dysfunction,’ Dr Kemp-Casey points out. ‘They report this in surveys but are often too embarrassed to discuss it with prescribers. Women won’t mention sexual dysfunction to clinicians, unless they are asked directly,’ she stresses.
‘So this is important for addressing adverse effects [that] people find difficult to vocalise.’
A/Prof O’Reilly points to someone diagnosed with schizophrenia in their early 20s who starts on an antipsychotic and who might put on 10–20 kilograms in weight in the first 3–6 months.
As medicine experts, pharmacists can point to medicines less likely to cause particular adverse effects at a population level. This is an important role for GP pharmacists at the point of prescribing, or during monitoring after therapy initiation.
Therapeutic Guidelines are a good place to access good comparative information on mental health medicines,’ notes A/Prof O’Reilly. Pharmacists can have a conversation about the adverse effects patients are experiencing and can offer to contact the prescriber to discuss concerns.
Dr Kemp-Casey suggests it is helpful for prescribers to know what has or has not worked before and ‘also really helpful’ if people can explain their priorities. For instance, for some people a sedating medicine is much less concerning than sexual dysfunction, or the opposite might be true, she says.
‘For people who have lost substantial amounts of weight due to their mental health concern, a medicine that will lead to weight gain is not necessarily a problem. So it all comes down to the individual and what is tolerable for them.’
Pharmacists also have useful tips to reduce the severity of adverse effects.
‘With antipsychotics, pharmacists might say, “The dry mouth is worse for the first 6 hours. If you take it before you go to bed you might not notice it,”’ she says.
Medicine changes
One particular problem highlighted by the report is the high number of medicine changes for people who are inpatient admissions in psychiatric facilities.1
Some patients are already on multiple medicines. And the report noted there are no Australian studies on the extent of hospital admissions for mental health concerns due to problems with medicines.1
Average mental health hospitalisations involve 10 medicine changes, including dosage adjustments, adding new medicines and withdrawing others, according to one Australian study.3
‘Some people had up to 32 medicine changes during their admission,’ PSA’s report stated.
‘Four out of 10 charted medicine changes were not recorded at all in the clinical notes,’ it added, and no reason was recorded for 56% of medicine changes.
Clinical notes for patients with mental health problems are often not up to date, including the recording of adverse effects, or reasons for changes to medicines.
Tellingly, the report stated that only 4% of clinical notes on medicine changes mentioned adverse effects.1
Patients may also not receive adequate handover about medicine changes during transitions of care. This highlights the dearth of pharmacists in mental health wards to follow up on missing clinical notes or explain new medicine regimens to patients, says Dr Kemp-Casey.
‘There’s a need to train and embed more pharmacists in these facilities.’
The PSA report suggests pharmacist ‘participation in ward rounds in the mental health setting has been shown to lead to dosage adjustments’ for better results after pharmacist recommendations, as well as medicine initiation and discontinuation.
Pharmacists embedded in community mental health teams could also support the hospital discharge process and facilitate regular medication reviews within the service.
Community pharmacy relationships with these teams are also important.
Says A/Prof O’Reilly: ‘When case managers liaise with community pharmacies or collect DAAs, the pharmacy may be alerted directly by the hospital on discharge about changes to medicines in that process.’
Difficulty withdrawing
For a single episode of depression, an antidepressant should be used for 6–12 months.6
But the discontinuation effects of these medicines make it difficult to stop. ‘Withdrawal effects can mimic the condition patients are using the medicines for,’ says Dr Kemp-Casey.
The severity of withdrawal effects is often down to how medicines are metabolised. ‘There are around 150 different versions of the genes that make a liver enzyme responsible for metabolising antipsychotics and antidepressants,’ she says.7
‘Some people can discontinue medicines with no issues, whereas others are intensely sensitive.’
Genetic tests should soon allow prescribers and pharmacists to identify the medicines that render patients at higher risk of experiencing adverse and withdrawal effects.8
For now, as GP pharmacists’ roles continue to grow, they can help to reduce the impacts, says A/Prof O’Reilly.
‘They can monitor and support slow tapering of doses when patients change or come off antidepressants.’
Pharmacists can also help patients distinguish between a relapse in depression and withdrawal effects (see Box 1).
Box 1– Tips to distinguish between adepressive relapse and adverse effectsPhysical + psychological symptoms: If dizziness, ‘brain zaps’, headaches or nausea present together with mood changes, this is strongly suggestive of withdrawal rather than relapse. Timing: Withdrawal effects can occur within days of stopping antidepressants while relapse is likely to occur after weeks or months. Impact of restarting antidepressants: Commonly, withdrawal effects will cease within days of restarting antidepressants while relapse typically requires several weeks before symptoms improve. |
Too much prescribing
Clozapine in the community[caption id="attachment_24312" align="alignright" width="281"] Nick Logan MPS[/caption]
Sydney-based community pharmacy Nick Logan Pharmacist Advice supplies clozapine to 70 patients with treatment-resistant schizophrenia. Servicing this ‘disproportionately large’ cohort of patients is due to strong ties with the Assertive Outreach team at nearby Royal North Shore Hospital, says owner Nick Logan MPS.
Mr Logan describes clozapine as a ‘fabulous drug’ that has low extrapyramidal adverse effects, including less akathisia, tremor and little-to-no dystonia or rigidity.4
But due to potentially fatal complications – including agranulocytosis, neutropenia and myocarditis – the medicine is only indicated for patients who have tried and failed using other antipsychotics to manage their condition.4 After screening for cardiovascular problems, a weekly blood test that monitors white blood cell count and neutrophils is required for the first 18 weeks when clozapine is initiated.
Once stabilised, patients join the community clozapine system, with a blood test required every 28 days within 48 hours of medicine supply. Within clozapine monitoring software, there are green, amber and red ranges to inform pharmacists whether it’s safe [from blood test results] to supply.
In a ‘perfect world’, patients would always be in the green range. But there are always aberrations. ‘For example, if a patient is in the yellow range, bi-weekly blood tests are required and you can only supply enough clozapine to last the patient until the next test,’ says Mr Logan.
Clozapine patients usually drop into the pharmacy around once a week, which they consider a safe space. ‘One patient who has complete meltdowns sometimes freezes in the middle of the shopping village,’ he said. ‘Then she comes into the pharmacy and we offer her a seat and a glass of water, which usually helps her regain control.’
Three of Mr Logan’s clozapine patients managed to drastically improve their quality of life through the patient-pharmacist relationship. ‘They used to chain smoke, drink bourbon and smoke marijuana,’ he said. ‘But by forming relationships with the pharmacists, they had someone to ask about their blood glucose levels or why they were starting an oral hypoglycemic. We also gave them feedback on lifestyle changes and how to reduce their blood pressure.’
The patients have since quit cigarettes and alcohol, regularly go to the gym, and have significantly reduced their comorbidities. ‘It’s extremely satisfying from a pharmacist point of view, because you see those improvements,’ said Mr Logan. |
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[post_content] => With medicines being used more often than ever to treat mental health conditions, pharmacists’ quality use of medicines (QUM) expertise is vital to optimising therapy and preventing harm, says PSA’s newest medicine safety report.
One in two Australians will experience a mental health condition in their lifetime. With mental ill health on the rise, prescriptions for mental health medicines are soaring.
Almost one fifth of Australians (14.7 million, or 18%) filled a prescription for a medicine used to treat a mental health condition in 2021-2022. Yet there is a lack of QUM oversight from pharmacists to ensure these medicines are used appropriately and safely, found PSA’s Medicine Safety: Mental Health Care report, launched today (22 November 2023).
Wherever medicines are used there is a risk of medicine misadventure, said PSA National President Dr Fei Sim FPS.
‘Too often we hear of people stopping treatment altogether because of the effects of these medicines,’ she said. ‘This is where we believe there is significant opportunity for investment in pharmacist services to help support the safe and effective use of medicines.’
Patients using medicines for mental health conditions need access to pharmacists’ medicines expertise across the spectrum of care – whether in hospitals, community settings or private clinics.
The report’s recommendations, detailed below, address gaps in care across these junctures to ensure a movement away from the ‘set-and-forget’ approach that people using mental health medicines too often experience.
‘This is about ensuring patients have the support they need to get the most out of their medicines safely and effectively,’ said Dr Sim.
1. Upskilling pharmacy teams in emergency care
All members of the pharmacy team should receive funded Mental Health First Aid training. This includes pharmacists and support staff across all practice settings.
Equipping pharmacy teams with the right skill set will both help to reduce stigma and ensure an appropriate response to mental health challenges.
2. Timely screening to facilitate diagnosis
Early intervention in mental health conditions is key. As community pharmacists are the most accessible healthcare professionals, funding a mental health screening program using validated screening tools and evidence-based risk assessment methods will facilitate early intervention for people experiencing mental health symptoms. This will help to ensure referral to an appropriate health practitioner or service provider for further investigation and formal diagnosis.
3. Tailored support for patients starting new medicines
Implementation of a program that funds community pharmacists to provide three Mental Health Medicines Consultation Services will help to ensure patients on new and existing mental health medicines benefit from bespoke support.
4. Addressing overdose risk
To prevent harm or death from medicine overdose, community pharmacy services such as dose administration aids and staged supply should be promoted and funded for at-risk patients living with a mental health condition.
5. Testing to find the right therapy
A patient’s genetic profile can determine how effective a medicine will be and/or if adverse effects will be encountered. Funding for pharmacogenomic testing in primary care, including identification of patients who would benefit from this service, could help to avoid use of ineffective medicines to treat mental health conditions.
6. Activating credentialed pharmacists
Mental health service providers, such as community health services and private mental health clinics, should receive funding to access skilled services provided by credentialed pharmacists. These could include:
[post_title] => 9 recommendations to fix the mental health medicines crisis
[post_excerpt] => Pharmacists' QUM expertise is vital to optimising therapy and preventing harm, says PSA’s newest medicine safety report.
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[post_content] => The Australian Commission on Safety and Quality in Health Care Commission’s AURA 2023: Fifth Australian report on antimicrobial use and resistance in human health found that after a sharp reduction in 2020-21, antimicrobial prescribing has again surged.
To mark World AMR Awareness Week (18–24 November 2023) Australian Pharmacist sat down with the Commission's Senior Medical Advisor Professor John Turnidge AO for a Q&A session on new patterns of antimicrobial resistance and what pharmacists can do to help.
[caption id="attachment_24236" align="alignright" width="252"] Professor John Turnidge AO[/caption]
AP: What are the key trends in antibiotic use highlighted in the report?
Prof. Turnidge: The most interesting trend was the rapid decline in antimicrobial Pharmaceutical Benefits Scheme (PBS) dispensings in 2020 and 2021.
COVID-19 lockdown measures, border closures, reduced access to GPs and the sudden drop in the number of circulating respiratory tract infections all played a role in that reduction.
There was a significant drop in prescribing of antibiotics for respiratory tract infections in 2020-21. However, there has been an uptick in antibiotic prescribing in 2022 – with a 10% increase over the previous 2 years.
Antibiotic prescribing is yet to reach the levels of 2019. We've never had a national campaign to help prevent a relapse in antibiotic prescribing – it would be helpful to ensure both prescribers and patients understand that antibiotics should only be used in very specific circumstances.
2022 highlights
|
Community pharmacists could ensure dosages on antibiotics on scripts align with Therapeutic Guidelines.
But an important first step is to establish a formal dialogue between GPs and pharmacists through local area health networks. They need to be able to sit around the same table and say, ‘These are the issues. How can we tackle antimicrobial stewardship together?
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[post_content] => With New South Wales recently expanding its pharmacy prescribing trial to include skin conditions, could other jurisdictions soon follow?
The NSW pharmacy prescribing trial has been a resounding success thus far, with thousands of women seeking treatment from their local community pharmacists since the rollout commenced in May 2023.
The number of participating pharmacies in the trial has ballooned from the initial 100 prescribing treatment for uncomplicated urinary tract infection (UTI) in the feasibility study to 1,100 following the expansion of the trial across the state – accounting for almost 60% of the state’s pharmacies.
‘It is fantastic to see that over 6,000 women have visited their community pharmacy to manage treatment for their UTI or extend their oral contraceptive,’ said President of the PSA NSW Branch Luke Kelly FPS.
[caption id="attachment_24351" align="alignright" width="233"] NSW Minister for Health Ryan Park with PSA NSW Branch President Luke Kelly FPS[/caption]
‘Pharmacists are key to strengthening the healthcare system, and through the NSW pharmacy trial, patients have been able to access safe, quality treatment when and where they need it.’
NSW and Queensland have been at the forefront of pharmacy prescribing trials. The expansion and success of these trials could serve as a blueprint for what’s possible across the nation.
Australian Pharmacist looks at what will change and when, and why governments are increasingly relying on pharmacists to fill healthcare gaps.
What conditions will pharmacists be able to treat?
From March 2024, pending ethics approval, participating NSW-based pharmacists will able to prescribe medicines for the following skin conditions after a private consultation:
[post_title] => Pharmacy prescribing trial expands to include skin conditions
[post_excerpt] => With New South Wales recently expanding its pharmacy prescribing trial to include skin conditions, could other jurisdictions soon follow?
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[post_content] => With experts expecting a whooping cough outbreak next month, pharmacists can help to protect those most at risk through promoting testing and vaccination.
Australia is currently awash with respiratory symptoms. While many people will be infected with COVID-19, given we’re in the midst of our 8th wave, others will likely have whooping cough, said University of Sydney professor of paediatrics and child health, Robert Booy.
‘The rate of reporting of whooping cough in 2023 is three times higher than it was last year,’ he said. ‘Case numbers are rising all over Australia, particularly down the east coast in Queensland, New South Wales and Victoria.’
During the pertussis outbreak in 2015, case numbers reached 22,570. But there are several reasons to be concerned about a looming 2023 epidemic.
‘During COVID-19, people weren’t socially mixing, so germs such as whooping cough, weren’t spreading,’ said Prof Booy. ‘Now, the amount of immunity in the community is much lower.’
Childhood vaccination coverage also has slipped across all three coverage time points for children by up to 1–1.5 percentage points, said Margie Danchin, group leader of the Murdoch Children's Research Institute’s Vaccine Uptake Group.
‘We’re concerned about drops in childhood coverage, changes in immunity profiles through lockdowns and exposure to infections,’ she said. ‘As we're also anticipating the normal cyclical return of pertussis, a perfect storm is potentially brewing.’
‘We're due an outbreak and we're at the start of one right now, I believe,’ added Prof Booy.
What are the symptoms and who should get tested?
The classic symptoms of whooping cough in older children and adults include:
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[post_content] => Patients are being harmed because we are not talking about the adverse effects of mental health medicines.
Medicines prescribed for mental health can have disturbing adverse effects.
Sexual dysfunction can be a by-product and in turn adversely affect relationships. Weight gain can lead to non-adherence with prescribed medicines. Other detrimental physical ramifications from medicines to treat mental health conditions including schizophrenia, depression, bipolar disease and withdrawals from them can lead to dry mouth and thirst, tiredness, mood swings – even suicidal ideation.
Issues with medicine safety including the lack of recognition of such adverse effects of medicines prescribed for mental health conditions, a lack of understanding of the impairment that can result from these adverse effects on daily life are the subject of a new report commissioned by PSA.
The Medicine Safety: mental health care report1 launched this month also found people with mental health conditions were the subject of frequent changes in therapy. There was also little information on how to use medicines safely for these conditions and a failure to document past therapeutic failures and outcomes in many cases. Antidepressants and antipsychotics were also implicated in overdose deaths.1
A set-and-forget mentality for medicines prescribed for mental health conditions was found by the University of South Australia researchers, with little review for eventual tapering off or stepping up to a new dosage for more therapeutic effect. Patients may be locked into taking these medicines for long periods, which can significantly impede their quality of life.
Tellingly, the report found: ‘The [adverse] effects of most concern to health professionals are not necessarily those that concern the people taking medicines to treat mental health concerns, and the converse is also true.’
Master Mental Health First Aid (MHFA) Instructor and University of Sydney (USyd) Associate Professor Claire O’Reilly FPS says that with increased diagnoses comes heightened mental health medicine use year on year in Australia.
‘We’re getting better at treating mental illnesses,’ she says. ‘More people might be seeking help so medicines are prescribed.’
The report also found that one in two Australians will experience a mental health condition in their lifetime, says its lead author Dr Anna Kemp-Casey, a Research Fellow at the University of South Australia’s Quality Use of Medicines and Pharmacy Research Centre.
‘It will either be us or someone we love who is affected,’ she says.
Crippling adverse effects
Of crucial concern are the conversations that are not had between healthcare professionals and patients about adverse effects from mental health medicines.
The researchers found that people attending mental health facilities who were taking antipsychotics reported up to seven adverse effects each – most commonly daytime tiredness, weight gain and thirst.
One in four patients on antidepressants reported ‘very’ or ‘extremely’ bothersome adverse effects.
Of great concern is the statistic found that more than 40% of mental health facilities do not have any medicines handover at discharge.
Mental health-related hospitalisations usually last much longer than average hospital stays. In 2020–21 the national average stay in a public hospital with specialised psychiatric care was about 16 days compared to about 6 days.2
This is where pharmacists can step up. ‘Medicine reconciliations are important when a person has been recently discharged from a mental health facility,’ A/Prof O’Reilly told Australian Pharmacist.
‘Community pharmacists have a really important role to ensure ongoing supply of medicines, ensuring there is no confusion about old medicines and support with adherence. The first few months after discharge from hospital are a critical time. Pharmacists can have ongoing conversations and check-ins to ensure that patients are adjusting back into the community.’
Physical health care and monitoring other illnesses e.g. diabetes once they are discharged, should also take place.
Patients with adverse effects may also be good candidates for MedsChecks in the pharmacy or may need referrals for Home Medicines Reviews, A/Prof O’Reilly says.
‘Every patient visit for a repeat script is an opportunity to ask, “is the medicine working? Are there any adverse effects? Is there anything you want to ask me?”’
‘People talk about relationship breakdowns from sexual dysfunction,’ Dr Kemp-Casey points out. ‘They report this in surveys but are often too embarrassed to discuss it with prescribers. Women won’t mention sexual dysfunction to clinicians, unless they are asked directly,’ she stresses.
‘So this is important for addressing adverse effects [that] people find difficult to vocalise.’
A/Prof O’Reilly points to someone diagnosed with schizophrenia in their early 20s who starts on an antipsychotic and who might put on 10–20 kilograms in weight in the first 3–6 months.
As medicine experts, pharmacists can point to medicines less likely to cause particular adverse effects at a population level. This is an important role for GP pharmacists at the point of prescribing, or during monitoring after therapy initiation.
Therapeutic Guidelines are a good place to access good comparative information on mental health medicines,’ notes A/Prof O’Reilly. Pharmacists can have a conversation about the adverse effects patients are experiencing and can offer to contact the prescriber to discuss concerns.
Dr Kemp-Casey suggests it is helpful for prescribers to know what has or has not worked before and ‘also really helpful’ if people can explain their priorities. For instance, for some people a sedating medicine is much less concerning than sexual dysfunction, or the opposite might be true, she says.
‘For people who have lost substantial amounts of weight due to their mental health concern, a medicine that will lead to weight gain is not necessarily a problem. So it all comes down to the individual and what is tolerable for them.’
Pharmacists also have useful tips to reduce the severity of adverse effects.
‘With antipsychotics, pharmacists might say, “The dry mouth is worse for the first 6 hours. If you take it before you go to bed you might not notice it,”’ she says.
Medicine changes
One particular problem highlighted by the report is the high number of medicine changes for people who are inpatient admissions in psychiatric facilities.1
Some patients are already on multiple medicines. And the report noted there are no Australian studies on the extent of hospital admissions for mental health concerns due to problems with medicines.1
Average mental health hospitalisations involve 10 medicine changes, including dosage adjustments, adding new medicines and withdrawing others, according to one Australian study.3
‘Some people had up to 32 medicine changes during their admission,’ PSA’s report stated.
‘Four out of 10 charted medicine changes were not recorded at all in the clinical notes,’ it added, and no reason was recorded for 56% of medicine changes.
Clinical notes for patients with mental health problems are often not up to date, including the recording of adverse effects, or reasons for changes to medicines.
Tellingly, the report stated that only 4% of clinical notes on medicine changes mentioned adverse effects.1
Patients may also not receive adequate handover about medicine changes during transitions of care. This highlights the dearth of pharmacists in mental health wards to follow up on missing clinical notes or explain new medicine regimens to patients, says Dr Kemp-Casey.
‘There’s a need to train and embed more pharmacists in these facilities.’
The PSA report suggests pharmacist ‘participation in ward rounds in the mental health setting has been shown to lead to dosage adjustments’ for better results after pharmacist recommendations, as well as medicine initiation and discontinuation.
Pharmacists embedded in community mental health teams could also support the hospital discharge process and facilitate regular medication reviews within the service.
Community pharmacy relationships with these teams are also important.
Says A/Prof O’Reilly: ‘When case managers liaise with community pharmacies or collect DAAs, the pharmacy may be alerted directly by the hospital on discharge about changes to medicines in that process.’
Difficulty withdrawing
For a single episode of depression, an antidepressant should be used for 6–12 months.6
But the discontinuation effects of these medicines make it difficult to stop. ‘Withdrawal effects can mimic the condition patients are using the medicines for,’ says Dr Kemp-Casey.
The severity of withdrawal effects is often down to how medicines are metabolised. ‘There are around 150 different versions of the genes that make a liver enzyme responsible for metabolising antipsychotics and antidepressants,’ she says.7
‘Some people can discontinue medicines with no issues, whereas others are intensely sensitive.’
Genetic tests should soon allow prescribers and pharmacists to identify the medicines that render patients at higher risk of experiencing adverse and withdrawal effects.8
For now, as GP pharmacists’ roles continue to grow, they can help to reduce the impacts, says A/Prof O’Reilly.
‘They can monitor and support slow tapering of doses when patients change or come off antidepressants.’
Pharmacists can also help patients distinguish between a relapse in depression and withdrawal effects (see Box 1).
Box 1– Tips to distinguish between adepressive relapse and adverse effectsPhysical + psychological symptoms: If dizziness, ‘brain zaps’, headaches or nausea present together with mood changes, this is strongly suggestive of withdrawal rather than relapse. Timing: Withdrawal effects can occur within days of stopping antidepressants while relapse is likely to occur after weeks or months. Impact of restarting antidepressants: Commonly, withdrawal effects will cease within days of restarting antidepressants while relapse typically requires several weeks before symptoms improve. |
Too much prescribing
Clozapine in the community[caption id="attachment_24312" align="alignright" width="281"] Nick Logan MPS[/caption]
Sydney-based community pharmacy Nick Logan Pharmacist Advice supplies clozapine to 70 patients with treatment-resistant schizophrenia. Servicing this ‘disproportionately large’ cohort of patients is due to strong ties with the Assertive Outreach team at nearby Royal North Shore Hospital, says owner Nick Logan MPS.
Mr Logan describes clozapine as a ‘fabulous drug’ that has low extrapyramidal adverse effects, including less akathisia, tremor and little-to-no dystonia or rigidity.4
But due to potentially fatal complications – including agranulocytosis, neutropenia and myocarditis – the medicine is only indicated for patients who have tried and failed using other antipsychotics to manage their condition.4 After screening for cardiovascular problems, a weekly blood test that monitors white blood cell count and neutrophils is required for the first 18 weeks when clozapine is initiated.
Once stabilised, patients join the community clozapine system, with a blood test required every 28 days within 48 hours of medicine supply. Within clozapine monitoring software, there are green, amber and red ranges to inform pharmacists whether it’s safe [from blood test results] to supply.
In a ‘perfect world’, patients would always be in the green range. But there are always aberrations. ‘For example, if a patient is in the yellow range, bi-weekly blood tests are required and you can only supply enough clozapine to last the patient until the next test,’ says Mr Logan.
Clozapine patients usually drop into the pharmacy around once a week, which they consider a safe space. ‘One patient who has complete meltdowns sometimes freezes in the middle of the shopping village,’ he said. ‘Then she comes into the pharmacy and we offer her a seat and a glass of water, which usually helps her regain control.’
Three of Mr Logan’s clozapine patients managed to drastically improve their quality of life through the patient-pharmacist relationship. ‘They used to chain smoke, drink bourbon and smoke marijuana,’ he said. ‘But by forming relationships with the pharmacists, they had someone to ask about their blood glucose levels or why they were starting an oral hypoglycemic. We also gave them feedback on lifestyle changes and how to reduce their blood pressure.’
The patients have since quit cigarettes and alcohol, regularly go to the gym, and have significantly reduced their comorbidities. ‘It’s extremely satisfying from a pharmacist point of view, because you see those improvements,’ said Mr Logan. |
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[post_content] => With medicines being used more often than ever to treat mental health conditions, pharmacists’ quality use of medicines (QUM) expertise is vital to optimising therapy and preventing harm, says PSA’s newest medicine safety report.
One in two Australians will experience a mental health condition in their lifetime. With mental ill health on the rise, prescriptions for mental health medicines are soaring.
Almost one fifth of Australians (14.7 million, or 18%) filled a prescription for a medicine used to treat a mental health condition in 2021-2022. Yet there is a lack of QUM oversight from pharmacists to ensure these medicines are used appropriately and safely, found PSA’s Medicine Safety: Mental Health Care report, launched today (22 November 2023).
Wherever medicines are used there is a risk of medicine misadventure, said PSA National President Dr Fei Sim FPS.
‘Too often we hear of people stopping treatment altogether because of the effects of these medicines,’ she said. ‘This is where we believe there is significant opportunity for investment in pharmacist services to help support the safe and effective use of medicines.’
Patients using medicines for mental health conditions need access to pharmacists’ medicines expertise across the spectrum of care – whether in hospitals, community settings or private clinics.
The report’s recommendations, detailed below, address gaps in care across these junctures to ensure a movement away from the ‘set-and-forget’ approach that people using mental health medicines too often experience.
‘This is about ensuring patients have the support they need to get the most out of their medicines safely and effectively,’ said Dr Sim.
1. Upskilling pharmacy teams in emergency care
All members of the pharmacy team should receive funded Mental Health First Aid training. This includes pharmacists and support staff across all practice settings.
Equipping pharmacy teams with the right skill set will both help to reduce stigma and ensure an appropriate response to mental health challenges.
2. Timely screening to facilitate diagnosis
Early intervention in mental health conditions is key. As community pharmacists are the most accessible healthcare professionals, funding a mental health screening program using validated screening tools and evidence-based risk assessment methods will facilitate early intervention for people experiencing mental health symptoms. This will help to ensure referral to an appropriate health practitioner or service provider for further investigation and formal diagnosis.
3. Tailored support for patients starting new medicines
Implementation of a program that funds community pharmacists to provide three Mental Health Medicines Consultation Services will help to ensure patients on new and existing mental health medicines benefit from bespoke support.
4. Addressing overdose risk
To prevent harm or death from medicine overdose, community pharmacy services such as dose administration aids and staged supply should be promoted and funded for at-risk patients living with a mental health condition.
5. Testing to find the right therapy
A patient’s genetic profile can determine how effective a medicine will be and/or if adverse effects will be encountered. Funding for pharmacogenomic testing in primary care, including identification of patients who would benefit from this service, could help to avoid use of ineffective medicines to treat mental health conditions.
6. Activating credentialed pharmacists
Mental health service providers, such as community health services and private mental health clinics, should receive funding to access skilled services provided by credentialed pharmacists. These could include:
[post_title] => 9 recommendations to fix the mental health medicines crisis
[post_excerpt] => Pharmacists' QUM expertise is vital to optimising therapy and preventing harm, says PSA’s newest medicine safety report.
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[post_content] => The Australian Commission on Safety and Quality in Health Care Commission’s AURA 2023: Fifth Australian report on antimicrobial use and resistance in human health found that after a sharp reduction in 2020-21, antimicrobial prescribing has again surged.
To mark World AMR Awareness Week (18–24 November 2023) Australian Pharmacist sat down with the Commission's Senior Medical Advisor Professor John Turnidge AO for a Q&A session on new patterns of antimicrobial resistance and what pharmacists can do to help.
[caption id="attachment_24236" align="alignright" width="252"] Professor John Turnidge AO[/caption]
AP: What are the key trends in antibiotic use highlighted in the report?
Prof. Turnidge: The most interesting trend was the rapid decline in antimicrobial Pharmaceutical Benefits Scheme (PBS) dispensings in 2020 and 2021.
COVID-19 lockdown measures, border closures, reduced access to GPs and the sudden drop in the number of circulating respiratory tract infections all played a role in that reduction.
There was a significant drop in prescribing of antibiotics for respiratory tract infections in 2020-21. However, there has been an uptick in antibiotic prescribing in 2022 – with a 10% increase over the previous 2 years.
Antibiotic prescribing is yet to reach the levels of 2019. We've never had a national campaign to help prevent a relapse in antibiotic prescribing – it would be helpful to ensure both prescribers and patients understand that antibiotics should only be used in very specific circumstances.
2022 highlights
|
Community pharmacists could ensure dosages on antibiotics on scripts align with Therapeutic Guidelines.
But an important first step is to establish a formal dialogue between GPs and pharmacists through local area health networks. They need to be able to sit around the same table and say, ‘These are the issues. How can we tackle antimicrobial stewardship together?
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[post_content] => With New South Wales recently expanding its pharmacy prescribing trial to include skin conditions, could other jurisdictions soon follow?
The NSW pharmacy prescribing trial has been a resounding success thus far, with thousands of women seeking treatment from their local community pharmacists since the rollout commenced in May 2023.
The number of participating pharmacies in the trial has ballooned from the initial 100 prescribing treatment for uncomplicated urinary tract infection (UTI) in the feasibility study to 1,100 following the expansion of the trial across the state – accounting for almost 60% of the state’s pharmacies.
‘It is fantastic to see that over 6,000 women have visited their community pharmacy to manage treatment for their UTI or extend their oral contraceptive,’ said President of the PSA NSW Branch Luke Kelly FPS.
[caption id="attachment_24351" align="alignright" width="233"] NSW Minister for Health Ryan Park with PSA NSW Branch President Luke Kelly FPS[/caption]
‘Pharmacists are key to strengthening the healthcare system, and through the NSW pharmacy trial, patients have been able to access safe, quality treatment when and where they need it.’
NSW and Queensland have been at the forefront of pharmacy prescribing trials. The expansion and success of these trials could serve as a blueprint for what’s possible across the nation.
Australian Pharmacist looks at what will change and when, and why governments are increasingly relying on pharmacists to fill healthcare gaps.
What conditions will pharmacists be able to treat?
From March 2024, pending ethics approval, participating NSW-based pharmacists will able to prescribe medicines for the following skin conditions after a private consultation:
[post_title] => Pharmacy prescribing trial expands to include skin conditions
[post_excerpt] => With New South Wales recently expanding its pharmacy prescribing trial to include skin conditions, could other jurisdictions soon follow?
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[post_content] => With experts expecting a whooping cough outbreak next month, pharmacists can help to protect those most at risk through promoting testing and vaccination.
Australia is currently awash with respiratory symptoms. While many people will be infected with COVID-19, given we’re in the midst of our 8th wave, others will likely have whooping cough, said University of Sydney professor of paediatrics and child health, Robert Booy.
‘The rate of reporting of whooping cough in 2023 is three times higher than it was last year,’ he said. ‘Case numbers are rising all over Australia, particularly down the east coast in Queensland, New South Wales and Victoria.’
During the pertussis outbreak in 2015, case numbers reached 22,570. But there are several reasons to be concerned about a looming 2023 epidemic.
‘During COVID-19, people weren’t socially mixing, so germs such as whooping cough, weren’t spreading,’ said Prof Booy. ‘Now, the amount of immunity in the community is much lower.’
Childhood vaccination coverage also has slipped across all three coverage time points for children by up to 1–1.5 percentage points, said Margie Danchin, group leader of the Murdoch Children's Research Institute’s Vaccine Uptake Group.
‘We’re concerned about drops in childhood coverage, changes in immunity profiles through lockdowns and exposure to infections,’ she said. ‘As we're also anticipating the normal cyclical return of pertussis, a perfect storm is potentially brewing.’
‘We're due an outbreak and we're at the start of one right now, I believe,’ added Prof Booy.
What are the symptoms and who should get tested?
The classic symptoms of whooping cough in older children and adults include:
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[post_content] => Patients are being harmed because we are not talking about the adverse effects of mental health medicines.
Medicines prescribed for mental health can have disturbing adverse effects.
Sexual dysfunction can be a by-product and in turn adversely affect relationships. Weight gain can lead to non-adherence with prescribed medicines. Other detrimental physical ramifications from medicines to treat mental health conditions including schizophrenia, depression, bipolar disease and withdrawals from them can lead to dry mouth and thirst, tiredness, mood swings – even suicidal ideation.
Issues with medicine safety including the lack of recognition of such adverse effects of medicines prescribed for mental health conditions, a lack of understanding of the impairment that can result from these adverse effects on daily life are the subject of a new report commissioned by PSA.
The Medicine Safety: mental health care report1 launched this month also found people with mental health conditions were the subject of frequent changes in therapy. There was also little information on how to use medicines safely for these conditions and a failure to document past therapeutic failures and outcomes in many cases. Antidepressants and antipsychotics were also implicated in overdose deaths.1
A set-and-forget mentality for medicines prescribed for mental health conditions was found by the University of South Australia researchers, with little review for eventual tapering off or stepping up to a new dosage for more therapeutic effect. Patients may be locked into taking these medicines for long periods, which can significantly impede their quality of life.
Tellingly, the report found: ‘The [adverse] effects of most concern to health professionals are not necessarily those that concern the people taking medicines to treat mental health concerns, and the converse is also true.’
Master Mental Health First Aid (MHFA) Instructor and University of Sydney (USyd) Associate Professor Claire O’Reilly FPS says that with increased diagnoses comes heightened mental health medicine use year on year in Australia.
‘We’re getting better at treating mental illnesses,’ she says. ‘More people might be seeking help so medicines are prescribed.’
The report also found that one in two Australians will experience a mental health condition in their lifetime, says its lead author Dr Anna Kemp-Casey, a Research Fellow at the University of South Australia’s Quality Use of Medicines and Pharmacy Research Centre.
‘It will either be us or someone we love who is affected,’ she says.
Crippling adverse effects
Of crucial concern are the conversations that are not had between healthcare professionals and patients about adverse effects from mental health medicines.
The researchers found that people attending mental health facilities who were taking antipsychotics reported up to seven adverse effects each – most commonly daytime tiredness, weight gain and thirst.
One in four patients on antidepressants reported ‘very’ or ‘extremely’ bothersome adverse effects.
Of great concern is the statistic found that more than 40% of mental health facilities do not have any medicines handover at discharge.
Mental health-related hospitalisations usually last much longer than average hospital stays. In 2020–21 the national average stay in a public hospital with specialised psychiatric care was about 16 days compared to about 6 days.2
This is where pharmacists can step up. ‘Medicine reconciliations are important when a person has been recently discharged from a mental health facility,’ A/Prof O’Reilly told Australian Pharmacist.
‘Community pharmacists have a really important role to ensure ongoing supply of medicines, ensuring there is no confusion about old medicines and support with adherence. The first few months after discharge from hospital are a critical time. Pharmacists can have ongoing conversations and check-ins to ensure that patients are adjusting back into the community.’
Physical health care and monitoring other illnesses e.g. diabetes once they are discharged, should also take place.
Patients with adverse effects may also be good candidates for MedsChecks in the pharmacy or may need referrals for Home Medicines Reviews, A/Prof O’Reilly says.
‘Every patient visit for a repeat script is an opportunity to ask, “is the medicine working? Are there any adverse effects? Is there anything you want to ask me?”’
‘People talk about relationship breakdowns from sexual dysfunction,’ Dr Kemp-Casey points out. ‘They report this in surveys but are often too embarrassed to discuss it with prescribers. Women won’t mention sexual dysfunction to clinicians, unless they are asked directly,’ she stresses.
‘So this is important for addressing adverse effects [that] people find difficult to vocalise.’
A/Prof O’Reilly points to someone diagnosed with schizophrenia in their early 20s who starts on an antipsychotic and who might put on 10–20 kilograms in weight in the first 3–6 months.
As medicine experts, pharmacists can point to medicines less likely to cause particular adverse effects at a population level. This is an important role for GP pharmacists at the point of prescribing, or during monitoring after therapy initiation.
Therapeutic Guidelines are a good place to access good comparative information on mental health medicines,’ notes A/Prof O’Reilly. Pharmacists can have a conversation about the adverse effects patients are experiencing and can offer to contact the prescriber to discuss concerns.
Dr Kemp-Casey suggests it is helpful for prescribers to know what has or has not worked before and ‘also really helpful’ if people can explain their priorities. For instance, for some people a sedating medicine is much less concerning than sexual dysfunction, or the opposite might be true, she says.
‘For people who have lost substantial amounts of weight due to their mental health concern, a medicine that will lead to weight gain is not necessarily a problem. So it all comes down to the individual and what is tolerable for them.’
Pharmacists also have useful tips to reduce the severity of adverse effects.
‘With antipsychotics, pharmacists might say, “The dry mouth is worse for the first 6 hours. If you take it before you go to bed you might not notice it,”’ she says.
Medicine changes
One particular problem highlighted by the report is the high number of medicine changes for people who are inpatient admissions in psychiatric facilities.1
Some patients are already on multiple medicines. And the report noted there are no Australian studies on the extent of hospital admissions for mental health concerns due to problems with medicines.1
Average mental health hospitalisations involve 10 medicine changes, including dosage adjustments, adding new medicines and withdrawing others, according to one Australian study.3
‘Some people had up to 32 medicine changes during their admission,’ PSA’s report stated.
‘Four out of 10 charted medicine changes were not recorded at all in the clinical notes,’ it added, and no reason was recorded for 56% of medicine changes.
Clinical notes for patients with mental health problems are often not up to date, including the recording of adverse effects, or reasons for changes to medicines.
Tellingly, the report stated that only 4% of clinical notes on medicine changes mentioned adverse effects.1
Patients may also not receive adequate handover about medicine changes during transitions of care. This highlights the dearth of pharmacists in mental health wards to follow up on missing clinical notes or explain new medicine regimens to patients, says Dr Kemp-Casey.
‘There’s a need to train and embed more pharmacists in these facilities.’
The PSA report suggests pharmacist ‘participation in ward rounds in the mental health setting has been shown to lead to dosage adjustments’ for better results after pharmacist recommendations, as well as medicine initiation and discontinuation.
Pharmacists embedded in community mental health teams could also support the hospital discharge process and facilitate regular medication reviews within the service.
Community pharmacy relationships with these teams are also important.
Says A/Prof O’Reilly: ‘When case managers liaise with community pharmacies or collect DAAs, the pharmacy may be alerted directly by the hospital on discharge about changes to medicines in that process.’
Difficulty withdrawing
For a single episode of depression, an antidepressant should be used for 6–12 months.6
But the discontinuation effects of these medicines make it difficult to stop. ‘Withdrawal effects can mimic the condition patients are using the medicines for,’ says Dr Kemp-Casey.
The severity of withdrawal effects is often down to how medicines are metabolised. ‘There are around 150 different versions of the genes that make a liver enzyme responsible for metabolising antipsychotics and antidepressants,’ she says.7
‘Some people can discontinue medicines with no issues, whereas others are intensely sensitive.’
Genetic tests should soon allow prescribers and pharmacists to identify the medicines that render patients at higher risk of experiencing adverse and withdrawal effects.8
For now, as GP pharmacists’ roles continue to grow, they can help to reduce the impacts, says A/Prof O’Reilly.
‘They can monitor and support slow tapering of doses when patients change or come off antidepressants.’
Pharmacists can also help patients distinguish between a relapse in depression and withdrawal effects (see Box 1).
Box 1– Tips to distinguish between adepressive relapse and adverse effectsPhysical + psychological symptoms: If dizziness, ‘brain zaps’, headaches or nausea present together with mood changes, this is strongly suggestive of withdrawal rather than relapse. Timing: Withdrawal effects can occur within days of stopping antidepressants while relapse is likely to occur after weeks or months. Impact of restarting antidepressants: Commonly, withdrawal effects will cease within days of restarting antidepressants while relapse typically requires several weeks before symptoms improve. |
Too much prescribing
Clozapine in the community[caption id="attachment_24312" align="alignright" width="281"] Nick Logan MPS[/caption]
Sydney-based community pharmacy Nick Logan Pharmacist Advice supplies clozapine to 70 patients with treatment-resistant schizophrenia. Servicing this ‘disproportionately large’ cohort of patients is due to strong ties with the Assertive Outreach team at nearby Royal North Shore Hospital, says owner Nick Logan MPS.
Mr Logan describes clozapine as a ‘fabulous drug’ that has low extrapyramidal adverse effects, including less akathisia, tremor and little-to-no dystonia or rigidity.4
But due to potentially fatal complications – including agranulocytosis, neutropenia and myocarditis – the medicine is only indicated for patients who have tried and failed using other antipsychotics to manage their condition.4 After screening for cardiovascular problems, a weekly blood test that monitors white blood cell count and neutrophils is required for the first 18 weeks when clozapine is initiated.
Once stabilised, patients join the community clozapine system, with a blood test required every 28 days within 48 hours of medicine supply. Within clozapine monitoring software, there are green, amber and red ranges to inform pharmacists whether it’s safe [from blood test results] to supply.
In a ‘perfect world’, patients would always be in the green range. But there are always aberrations. ‘For example, if a patient is in the yellow range, bi-weekly blood tests are required and you can only supply enough clozapine to last the patient until the next test,’ says Mr Logan.
Clozapine patients usually drop into the pharmacy around once a week, which they consider a safe space. ‘One patient who has complete meltdowns sometimes freezes in the middle of the shopping village,’ he said. ‘Then she comes into the pharmacy and we offer her a seat and a glass of water, which usually helps her regain control.’
Three of Mr Logan’s clozapine patients managed to drastically improve their quality of life through the patient-pharmacist relationship. ‘They used to chain smoke, drink bourbon and smoke marijuana,’ he said. ‘But by forming relationships with the pharmacists, they had someone to ask about their blood glucose levels or why they were starting an oral hypoglycemic. We also gave them feedback on lifestyle changes and how to reduce their blood pressure.’
The patients have since quit cigarettes and alcohol, regularly go to the gym, and have significantly reduced their comorbidities. ‘It’s extremely satisfying from a pharmacist point of view, because you see those improvements,’ said Mr Logan. |
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[post_content] => With medicines being used more often than ever to treat mental health conditions, pharmacists’ quality use of medicines (QUM) expertise is vital to optimising therapy and preventing harm, says PSA’s newest medicine safety report.
One in two Australians will experience a mental health condition in their lifetime. With mental ill health on the rise, prescriptions for mental health medicines are soaring.
Almost one fifth of Australians (14.7 million, or 18%) filled a prescription for a medicine used to treat a mental health condition in 2021-2022. Yet there is a lack of QUM oversight from pharmacists to ensure these medicines are used appropriately and safely, found PSA’s Medicine Safety: Mental Health Care report, launched today (22 November 2023).
Wherever medicines are used there is a risk of medicine misadventure, said PSA National President Dr Fei Sim FPS.
‘Too often we hear of people stopping treatment altogether because of the effects of these medicines,’ she said. ‘This is where we believe there is significant opportunity for investment in pharmacist services to help support the safe and effective use of medicines.’
Patients using medicines for mental health conditions need access to pharmacists’ medicines expertise across the spectrum of care – whether in hospitals, community settings or private clinics.
The report’s recommendations, detailed below, address gaps in care across these junctures to ensure a movement away from the ‘set-and-forget’ approach that people using mental health medicines too often experience.
‘This is about ensuring patients have the support they need to get the most out of their medicines safely and effectively,’ said Dr Sim.
1. Upskilling pharmacy teams in emergency care
All members of the pharmacy team should receive funded Mental Health First Aid training. This includes pharmacists and support staff across all practice settings.
Equipping pharmacy teams with the right skill set will both help to reduce stigma and ensure an appropriate response to mental health challenges.
2. Timely screening to facilitate diagnosis
Early intervention in mental health conditions is key. As community pharmacists are the most accessible healthcare professionals, funding a mental health screening program using validated screening tools and evidence-based risk assessment methods will facilitate early intervention for people experiencing mental health symptoms. This will help to ensure referral to an appropriate health practitioner or service provider for further investigation and formal diagnosis.
3. Tailored support for patients starting new medicines
Implementation of a program that funds community pharmacists to provide three Mental Health Medicines Consultation Services will help to ensure patients on new and existing mental health medicines benefit from bespoke support.
4. Addressing overdose risk
To prevent harm or death from medicine overdose, community pharmacy services such as dose administration aids and staged supply should be promoted and funded for at-risk patients living with a mental health condition.
5. Testing to find the right therapy
A patient’s genetic profile can determine how effective a medicine will be and/or if adverse effects will be encountered. Funding for pharmacogenomic testing in primary care, including identification of patients who would benefit from this service, could help to avoid use of ineffective medicines to treat mental health conditions.
6. Activating credentialed pharmacists
Mental health service providers, such as community health services and private mental health clinics, should receive funding to access skilled services provided by credentialed pharmacists. These could include:
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[post_content] => The Australian Commission on Safety and Quality in Health Care Commission’s AURA 2023: Fifth Australian report on antimicrobial use and resistance in human health found that after a sharp reduction in 2020-21, antimicrobial prescribing has again surged.
To mark World AMR Awareness Week (18–24 November 2023) Australian Pharmacist sat down with the Commission's Senior Medical Advisor Professor John Turnidge AO for a Q&A session on new patterns of antimicrobial resistance and what pharmacists can do to help.
[caption id="attachment_24236" align="alignright" width="252"] Professor John Turnidge AO[/caption]
AP: What are the key trends in antibiotic use highlighted in the report?
Prof. Turnidge: The most interesting trend was the rapid decline in antimicrobial Pharmaceutical Benefits Scheme (PBS) dispensings in 2020 and 2021.
COVID-19 lockdown measures, border closures, reduced access to GPs and the sudden drop in the number of circulating respiratory tract infections all played a role in that reduction.
There was a significant drop in prescribing of antibiotics for respiratory tract infections in 2020-21. However, there has been an uptick in antibiotic prescribing in 2022 – with a 10% increase over the previous 2 years.
Antibiotic prescribing is yet to reach the levels of 2019. We've never had a national campaign to help prevent a relapse in antibiotic prescribing – it would be helpful to ensure both prescribers and patients understand that antibiotics should only be used in very specific circumstances.
2022 highlights
|
Community pharmacists could ensure dosages on antibiotics on scripts align with Therapeutic Guidelines.
But an important first step is to establish a formal dialogue between GPs and pharmacists through local area health networks. They need to be able to sit around the same table and say, ‘These are the issues. How can we tackle antimicrobial stewardship together?
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
