Pharmacists as a vital part of the mental health of the nation

Transcription

1 Pharmacists as a vital part of the mental health of the nation P H I L I P P I N E S P H A R M A C Y A S S O C I A T I O N C O N V E N T I O N A P R I L 2 5, B A C O L O D T R U D I H I L T O N P H A R M A C Y C O N S U L T A N T D I R E C T O R C O L L E G E O F M E N T A L H E A L T H P H A R M A C Y

2 Overview of Presentation Global Mental Health Picture Philippines Picture MH Psycho- Social Support mhgap training Region 8 revelations: E Samar Access to medicines Treatment Options Pharmacists as mediators of Mental Health

3 No health without mental health WHO Declaration 2013 Global mental health statistics of prevalence. - 1% psychosis; can be severe, chronic or acute - 3% per year with depression - 10% pregnancies lead to post-natal depression - Dementia the major global health burden by 2025 Philippines population: 1 million living with psychosis MISINTERPRETATION OF SYPMTOMS and STIGMA lead to failure to access healthcare

4 Global Mental Health Statistics

5 Global Top 10 leading causes of years of life lived with disability 1 Unipolar depressive disorders 10.9% 2 Hearing loss, adult onset 4.6% 3 Refractory errors 4.6% 4 Alcohol use disorders 3.7% 5 Cataracts 3.0% 6 Schizophrenia 2.7% 7 Osteoarthritis 2.6% 8 Bipolar affective disorder 2.4% 9 Iron-deficiency anaemia 2.2% 10 Birth asphyxia and birth trauma 2.2% (Both sexes, all ages) 5

6 Predictions for the leading causes of disability and mortality in 2030 World 1 HIV/AIDS 2 Unipolar depressive disorder 3 Ischaemic heart dis. High-income countries Unipolar depressive disorder 2 Ischaemic heart disease 3 Alzheimer Middle-income countries HIV/AIDS 2 Unipolar depressive disorder 3 Cerebrovascular Low-income countries 1 HIV/AIDS 2 Perinatal disorder 3 Unipolar depressive disorder

7 Serious cases receiving no treatment during the last 12 months 80 85% 70 76% % 30 35% Lower range Upper range Lower range Upper range Developed countries Developing countries

8 Mental Health Psycho-Social Support MHPSS in the Philippines Post Typhoon Yolanda, UK DfID funded WHO to support the affected region by providing MHPSS Psychological First Aid mhgap training Donated medicines BUILDING BACK BETTER

9 Psychological First Aid SUPPORTING PEOPLE IN THE AFTERMATH OF CRISIS EVENTS

10 What is PFA in disasters? Humane, supportive and practical assistance to fellow human beings who recently suffered exposure to serious stressors, and involves: Non-intrusive, practical care and support Assessing needs and concerns Helping people to address basic needs (food, water) Listening, but not pressuring people to talk Comforting people and helping them to feel calm Helping people connect to information, services and social supports Protecting people from further harm

11 Mental Health Gap Action Program; mhgap Community-based intervention, where there are no psychiatrists Raising awareness of mental illness by General Practitioners, midwives and community nurses Improving understanding of the diagnosis and treatment of a range of psychiatric conditions Initiating treatment with donated medicines Monitoring outcomes with mentoring from psychiatrists.

12 MHPSS in Eastern Samar House-to-house visits to find patients

13 Before and After MHPSS

14 24/24 RHUs 5/8 District Hospitals 2- Northern Samar Provincial Hospital 2 Biri District Hospital 3 Allen District Hospital 17/26 7/8 RHUs 3 Biliran Provincial Hospital 22/25 RHUs 3/5 District Hosp 3- Guiuan 2- Eastern Samar Provincial Hospital 36/40 RHUs 2/2 CHOs 14/21 1/3 District Hosp 2- Southern Leyte Provincial Hospital Excludes Regional Facilities RHUs only Beds in general hospital

15 MHPSS Essential Tools for Success

16 True or False Mental, neurological and substance use disorders respond poorly to treatment FALSE Most common mental, neurological and substance use disorders respond well to treatment. Up to 70% of persons with chronic psychosis can be stable and live symptom free with adequate treatment 16

17 Access to Medicines, DoH MAP-MH Free supply of medicines for people with mental illness - Everywhere - For as long as needed.. For life? National Centre for Mental Health, collaborating with NCPAM, procures the medicines. Clinical teams compile a list of patients Register as Access Sites, preferably with a pharmacy Place an order for prescribed medicines NCPAM provincial pharmacists optimising medicines

18 Treatment Options PNDF psychotropic list Guideline development Decision support Primary Care Formulary Evidence base - Philippino metabolic variation There are no cures, only chronic treatment options. Consistent, chronic administration is essential. NB No Special Licensed medicines required

19 Prescribing Decision Support in Psychiatry GOAL Safe, effective and cost-effective treatment Severe, enduring mental illness needs to be treated daily for many years The nature of the illness may affect adherence with treatment Tolerability of treatment often more relevant than efficacy. Patients are likely to be indigent. A Clinical Guideline describes pathways of care from diagnosis and treatment to monitoring outcomes.

20 Management of Psychosis Definition of Psychosis: delusions and hallucinations thoughts and perceptions - out of touch with accepted reality Many treatment options available: - 70% people benefit from the first treatment initiated - Tolerability more often dictates selection of agent - Typical vs Atypical relates to ExtraPyramidal Side effects (EPS) - Frequency of administration impacts on adherence

21 Properties of mhgap antipsychotics MEDICATION Sedating? EPS? Requires addition of biperiden to regime Chlorpromazine yes yes Haloperidol No yes Risperidone No No Fluphenazine No yes

22 Formulations and dosing MEDICATION Po/IM Frequency Duration of treatment Chlorpromazine Po 2-3 times daily indefinite Haloperidol Po Once indefinite Risperidone Po once indefinite Haloperidol IM When needed Repeated every 30 mins for disturbed behaviour Fluphenazine IM Every 4 weeks indefinite

23 Primary Care Formulary; Manual Section on Psychotropics : IMPORTANT revisions Avoid CHLORPROMAZINE IM injection - causes unpredictable dangerous hypotension RISPERIDONE LA injection not appropriate for use - costs Php7000 per injection - Requires refrigeration - Dry power for aqueous reconstitution ; 2 needles - Needs to be given every 2 weeks MISSING fluphenazine injection: First line

24 Management of Bipolar Disorder To prevent relapses into mania and depression which increase in frequency over time Initiated after first manic episode which adversely impacts on a person s life Needs to be taken regularly, without discontinuation to be effective Regular monitoring of medicines is required PRIMARY CARE FORMULARY includes carbamazepine and valproate, not lithium

25 Management of Bipolar Disorder MEDICATION Evidence base TDM required? Available? Physical monitoring Teratogenic potential Lithium +++ Lithium levels/ No Carbamazepine? CBZ levels/ No Renal function Thyroid function Liver function Valproate ++ No /NA Not essential Yes Yes Yes

26 Use of Valproate for Mania and Epilepsy Valproate has proven efficacy in bipolar disorder and epilepsy It can be administered without the need for regular monitoring of levels or organ function When used in women the high risk of damage to the unborn child must be taken into consideration they must be advised to avoid pregnancy while on treatment. MAP-MH provides valproate so it can be made available free of charge in all areas

27 Evidence Base for Prescribing in Psychiatry Large clinical trials carried out around the world Evidence for efficacy and information on tolerability available - Does the Philippino pharmacogenomic profile enable direct extrapolation of this data into local populations?

28 Mental Health Promotion by Pharmacists Psychological First Aid Screening for depression Supporting those who are suicidal Referrals for treatment Encouraging adherence to treatment Ensure appropriate monitoring available and accessible for narrow therapeutic medicines eg lithium

29 The Good News. Antipsychotic treatment with one tablet a day (Php 5) works! Intervention costs are low: economic gains are high People with chronic, untreated mental illness can be released from years of physical and mental restraint and become active, productive members of society. Mental illness is a chronic condition which benefits from the same approach to treatment as other chronic diseases. Mental Health Bill drafted for 2016 Session

30 True or False People with mental, neurological and substance use disorders are not capable of making decisions about their medical, financial, personal and social lives FALSE Many scientists, business people, artists, politicians, and people from different backgrounds have mental, neurological and substance use conditions and that do not stop them from making decisions that lead to great success!

31 CONCLUSION AND APPEAL Mental illness is treatable People with severe mental illness may need advocates they have no voice Medication is key to the success of interventions Consistent, continual supply of quality medicines is essential Good adherence reduces relapse as in all chronic conditions Pharmacists can improve the mental health of a nation

32 Salamat and Paalam