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Pharmacy Services Director
Norfolk Mental Health Care NHS Trust
Schizophrenia, which usually starts in someone’s teens, is for many sufferers a devastating illness. However, if we manage to find the right drug and right dose, the person can become as normal as the next person, if not more so. Getting the right drug at the right dose usually involves a deal of trial and error, but making the most of any medicine is vital, and pharmacists have a significant role to play in all these aspects.
Medication is important but should only ever form part of an overall strategy, which should also include the person looking after themselves and social and cognitive help and support. If we get the drug aspect wrong, then the other components of care won’t work optimally either.
Choice of drug is a complex issue and won’t be dealt with here, but dose is almost as important. A person will tend to receive high initial doses (to help them manage an acute crisis), which are then often continued in the community. Since the probable mode of action of antipsychotics is predominantly dopamine receptor blockade, each dose taken is “topping up” the existing blockade. Many studies have shown that, once stabilised, dose reduction by 20–30% actually improves efficacy and reduces side-effects, with no increase in relapse. The maxim with antidepressants that “the dose that gets you right keeps you right” doesn’t apply to antipsychotics in schizophrenia. Pharmacists should help publicise this.
Antipsychotics have got a bad name in many sectors of the care services, due to the use of sometimes unnecessarily high doses and the poor availability and use of other strategies. One role pharmacists have is in educating carers, relatives, professionals, voluntary helpers, social workers and others about the appropriate role of medication in schizophrenia. Everyone needs to know the evidence for the usefulness of various drugs and interventions, the positive and negative effects of drugs (including how and why they work), how and when they should be used for optimal effect, and individuals’ roles in getting the overall management (including drugs) right. This can be by giving education sessions for these groups on a regular basis: for example, on request, volunteering, and helping the user organisations (in the UK these include MIND and Rethink [formerly NSF]).
In many countries, the mental health advocate movement is gaining momentum. Advocates, the majority of whom are ex-service users, help current patients to stand up for themselves. Advocates thus also need to know the role of drugs, and how to seek advice and support, rather than potentially being “antidrugs” out of prejudice or lack of education.
Educating patients (service users)
The people who really need to know about medication are the people who take it! This is sadly often missed out. In Norfolk we run pharmacist-led, twice-weekly medication education (MedEd) sessions on acute psychiatric wards for patients. The patients who have been through these MedEd sessions know about dopamine (and the effect of imbalances), how the antipsychotics are thought to work, the how and why of side-effects, the need for long-term compliance, and the issues of dependence and tolerance. It is also possible to use this knowledge to explain, for example, why smoking cannabis when you have schizophrenia is not a wise idea, as the dopamine released may exacerbate the symptoms.
The MedEd sessions take about an hour twice a week per pair of acute wards. Not a lot of time in itself, and they’re hard work to do, but not beyond the reach of those daring enough to try something really clinical. Interestingly, we often get asked to do extra sessions for nurses as the patients know more about the drugs than they do! Remember that information alone has never been shown to do anything positive – education is the key.
Switching drugs has inherent risks, and so optimising a current drug by managing its side-effects is another vital role we play. This can include such things as altering formulations, adjusting doses (total, frequency, timings), monitoring plasma levels to optimise dose, and adjunctive therapies, as well as more specific strategies. Being open about such effects and trying to help is better than ignoring them or trivialising the effects on the user. Practical advice through taking side-effects seriously is nearly always appreciated. The feeling that nothing is being hidden from the user is also vital – too often they know they’re having things hidden and know why they’re hidden, building up mistrust. Weight gain is a classic case – what could be worse than developing schizophrenia, then taking a drug that unremittingly piles on the pounds and ruins what little self-esteem you had left? We should be weighing, warning (with practical advice) and watching.
This is something that tends to get talked about, but not routinely done. We really should be routinely doing baseline weight, prolactin and glucose for anyone going onto any antipsychotic. A pharmacist should be in a position to start insisting these simple measures are done.
Choice of drugs
In England, NICE (the National Institute for Clinical Excellence) has ruled that atypicals should be considered in the choice of firstline drugs in schizophrenia. It also recommends that “The choice of antipsychotic drug should be made jointly by the individual and the clinician…” based on informed discussion of relative benefits and side-effects. I am not aware that this happens routinely anywhere yet, but it is an area where pharmacists should be leading the way just now. We are indeed starting along that road.
People with schizophrenia, and their carers, are often left with little support about drugs in the community. Provision of a telephone helpline and the backup of comprehensive written information (websites and books) is relatively simple but hugely appreciated and popular. Schizophrenics are real people. We shouldn’t ever forget that.
UK Psychiatric Pharmacy Group
Has lots of useful information, although you’ll have to join the UKPPG to get access to the MedEd page
Norfolk Mental Health Care NHS Trust pharmacy site
Ideas on ways to teach about how drugs work