Pharmacists in Medication Adherence in Psychiatric Patients

Transcription

1 Pharmacists in Medication Adherence in Psychiatric Patients Mamta Parikh, PharmD, BCPS, BCPP Assistant Professor, Clinical and Administrative Sciences Notre Dame of Maryland University School of Pharmacy February 18, 2018

2 Disclosures No Disclosures

3 Objectives 1. Identify barriers to medication compliance in psychiatric patients. 2. Discuss interventions to improve medication compliance in psychiatric patients 3. Review side effects for medications used in the treatment of psychiatric disorders.

4 Prevalence Varying estimates of medication non - adherence within the psychiatric patient population Major Depressive Disorder Anxiety Disorders Bipolar Disorder Schizophrenia 28 52% 57% 20 50% 20 72% Mental Health Clinician. (2013) 2:7

5 Impact Exacerbation of illness Increased clinic and hospital visits Compromise daily functioning and quality of life Violence Premature mortality Suicide J Clin Psychiatry. (2002) 63:10

6 Patient Related Barriers Young Unmarried Male Lower education level Concomitant substance abuse Mental Health Clinician. (2013) 2:7

7 Medication Related Barriers Side Effects Dosing frequency and/or schedule Efficacy Cost Mental Health Clinician. (2013) 2:7

8 Psychological Barriers Poor insight Denial of illness Negative attitude towards medications Lack of conviction that medication will prevent relapse Mental Health Clinician. (2013) 2:7

9 Social/Environmental Barriers Stability of living arrangement Supervision of medication administration Family support Discharge planning and communication Stigma Mental Health Clinician. (2013) 2:7 J Depress Anxiety. (2015).4:2

10 Mental Health Stigma Perceptions Public Dangerous Incompetent Unpredictable Responsible for disorder Avoids treatment to avoid label Self Dangerous Incompetent Responsible for disorder Low self esteem and self efficacy Corrigan PW, Person-Centered Care for Mental Illness: The Evolution of Adherence and Self Determination. (pp 53 80)

11 Mental Health Stigma Education Contrast myths of mental illness with facts Myth People choose to be mentally ill because they are fundamentally weak. Fact Mental illness is largely a biological disorder; people are not to blame. Address Self - Stigma Decrease self stigma and promote personal empowerment Psychoeducation Review facts about mental illness and injustices of stigma Disclosure Group identification Peer Support People with lived experience provide aid Corrigan PW, Person-Centered Care for Mental Illness: The Evolution of Adherence and Self Determination. (pp 53 80)

12 Strategies to Improve Medication Adherence Psychoeducation Cognitive Behavioral Therapy (CBT) Motivational Interviewing

13 Psychoeducation Audience Format Content Patient + Family Individual or Group Counseling Sessions Psychiatric diagnoses Medications Mental Health Clinician. (2013) 2:7 Neuropsychiatric Disease and Treatment :

14 Cognitive Behavioral Therapy Rewarding Cues Skills Training Reminders Mental Health Clinician. (2013) 2:7 Neuropsychiatric Disease and Treatment :

15 Motivational Interviewing Expressing Empathy Asking open ended questions Support Self Efficacy Affirm Self Efficacy Develop Discrepancy Active Listening Rolling with Resistance Summarize patient s narratives Mental Health Clinician. (2013) 2:7 Neuropsychiatric Disease and Treatment :

16 Medication Monitoring Antidepressants Antipsycohtics Mood Stabilizers

17 Antidepressants: SSRIs Selective Serotonin Reuptake Inhibitors (SSRIs) Adverse Effect(s) Gastrointestinal: Nausea, vomiting, diarrhea Sexual dysfunction Increased anxiety, agitation Insomnia: Fluoxetine is most activating Sedation: Paroxetine is most sedating Recommendation(s) Symptoms usually resolve within 1 2 weeks Switch to Bupropion Lower dose and titrate slowly Administer in morning Administer at bedtime

18 Antidepressants: SNRIs Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) Adverse Effect(s) Gastrointestinal: Nausea, vomiting, diarrhea Sexual dysfunction Increased anxiety, agitation Insomnia: All SNRIs Increased blood pressure Recommendation(s) Symptoms usually resolve within 1 2 weeks Switch to Bupropion Lower dose and titrate slowly Administer in morning Lower dose Switch to another antidepressant class

19 Antidepressants: TCAs Tricyclic Antidepressants Cardiac arrhythmias Monitor EKG Seizures Avoid alcohol Avoid other medications that lower seizure threshold Weight gain Monitor weight and BMI Anticholinergic side effects Monitor Switch to another antidepressant class

20 Antidepressants: Other Mirtazapine Bupropion Sedation Increased appetite, weight Administer at bedtime Monitor BMI, weight, lipids, glucose Nutrition counseling Encourage physical activity Insomnia Administer before mid - morning Gastrointestinal: nausea, constipation Resolve within 1 2 weeks Seizures Avoid alcohol Avoid other medications that lower seizure threshold

21 Antipsychotics Adverse Effect(s) Recommendation Motor symptoms Extrapyramidal symptoms Cardiac arrhythmias Monitor EKG More common with FGAs Monitor Abnormal Involuntary Movement Scale (AIMS) Add anticholinergic if appropriate Switch antipsychotic Sedation Administer at bedtime Weight gain Monitor BMI, weight, lipids, glucose, waist circumference Ziprasidone, lurasidone, and aripiprazole have lower incidence of metabolic side effects Weight management, nutrition counseling, encourage physical activity

22 Mood Stabilizers Adverse Effect Hypothyroidism Abnormal T Waves Diabetes insipidus, dehydration Leukocytosis Lithium Monitoring Parameter(s) Thyroid function tests ECG Renal function Electrolytes WBC Valproic Acid Adverse Effect Monitoring Parameter Hepatotoxicity Liver function tests Hyperammonemia Ammonia level Thrombocytopenia Platelet count Weight gain Weight, BMI

23 Sample Case MS is 25 year old female, who has been coming to your pharmacy for the past five years. Her physician calls to renew her prescriptions and a new prescription for Sertraline (Zoloft) 50mg po once daily. When MS comes to your pharmacy to pick up her medications, you note that she looks tired and has lost a significant amount of weight. She tells you that she wants all of her medications except for the Zoloft that her doctor ordered.

24 Sample Case You bring MS into the private consultation room to express your concerns and understand why she doesn t want her antidepressant. She acknowledges that she has not been eating properly and has been staying in bed for most of the day. She always feels tired, which has resulted in her missing some days at work. She is embarrassed to tell her family because she does not think they will understand her. During her visit, her physician told her that she has depression and prescribed an antidepressant. MS thinks she has been feeling this way because she is too weak to cope with some stressors that she has been dealing with. She does not understand how taking a pill will help her.

25 Sample Case What are some barriers that are preventing MS from seeking the appropriate care? What are some counseling points and recommendations that you can make at this time?

26 References 1. Ehret MJ, Wang M. How to increase medication adherence: What Works? (8): Chapman S CE, Home R. Medication nonadherence and psychiatry (5): Lacro JP, Dunn LB, Dolder CR, et al. Prevalence of and Risk Factors for Medication Nonadherence in Patients With Schizophrenia: A Comprehensive Review of Recent Literature. J Clin Psychiatry (10): Alekhya et al. Treatment and Disease Related Factors Affecting Non-Adherence among Patients on Long Term Therapy of Antidepressants. J Depress Anxiety (2): Corrigan PW, Bink AB (2015). How Does Stigma Impede Adherence and Self-Determination? In Corrigan PW, Person- Centered Care for Mental Illness: The Evolution of Adherence and Self Determination. (pp 53 80). Washington DC: APA. 6. El-Malakh P, Findlay J. Strategies to improve medication adherence in patients with schizophrenia: the role of support services. Neuropsychiatric Disease and Treatment : Stahl, S. M. (2014). Stahl's essential psychopharmacology: Prescriber's guide (5th ed.). West Sussex, UK: Cambridge University Press.

27 Pharmacists in Medication Adherence in Psychiatric Patients Mamta Parikh, PharmD, BCPS, BCPP Assistant Professor, Clinical and Administrative Sciences Notre Dame of Maryland University School of Pharmacy February 18, 2018