APTI ijopp - Indian Journal of Pharmacy Practice

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Indian J. Pharm. Pract. 1(2), Jan-Mar, 2009Overall, there now appears to be ample evidence that theprovision of clinical pharmacy services in the psychiatriccontext is justifiable, both form an economic point ofview, and more important, to help assure safe andeffective drug therapy for patients affected by mentalillness. The challenge is for practitioners to develop andsustain a practice model that can allow the delivery ofthese services, both in hospitals and in the communitysector. Inherent to this challenge is the need to devisepersuasive business cases that can be used in influencepayors and governmental bodies, so that these servicescan eventually become routinely available where needed.A framework for the delivery of clinical pharmacyservices in psychiatryAlthough other systems have been proposed, theconceptual framework that had its foundations in thework relating to the pharmaceutical care model has beenwidely embraced as a basis for the work of clinicalpharmacists in many settings. Strand et al. define amedication-related problem as 'any undesirable eventexperienced by the patientthat involves or is suspected toinvolve drug therapy and that actually or potentially29interferes with a desired patient outcome'. Using thismodel, pharmacists can base their clinical practicearound the prevention, detection, documentation andresolution of drug-related problems (DRPs). Theoriginal eight categories of DRP proposed in this systemare outlined with examples in Table 2.The current and active set of clinical pharmacy practicestandard from the Society of Hospital Pharmacists of30Australia (SHPA) was disseminated in 2004, anddescribes clinical pharmacy practice as the practice ofpharmacy in the context of multidisciplinary healthcareteam, directed at achieving quality use of medicines.Each of the clinical pharmacy functions outlined in theSHPA practice standards are directly applicable in thecontext of psychiatry, and include, but are not limited to:active participation in the management of individualpatientsassistance with the application of the best availableevidence in daily clinical practicecontribution of clinical knowledge and skills to thehealthcare teamidentification and reduction in risks associated withmedicines useinvolvement in the education of patients, carers, andother health professionals and involvement inresearch.The guidelines provide information about a range ofactivities that are components of contemporary clinicalpharmacy practice. These include those activities that areoriented towards the management of DRPs for theindividual patients – measures such as obtaining anaccurate medication history, assessment of currentmedication management, clinical review, therapeuticdrug monitoring, ward round participation, provision ofmedicines information to health professionals andpatients, adverse drug reaction management and others.In addition, the guidelines outline other aspects ofclinical pharmacy practice that although not focusedupon individual patient outcomes, still have directrelevance for psychiatric pharmacy practice. Theseinclude clinical research, teaching and quality assuranceactivities.Practical implementation of clinical pharmacyservices in psychiatryParticularly, if a practitioner has not had experience in thefield of psychiatry, the implementation of clinicalpharmacy services in a psychiatric unit can prove to be adaunting task. If there is no existing base to build upon,the best advice would be to start with modest aims, andwork steadily to build relationships with clinicians andpatients. Take every opportunity to participate ininterdisciplinary meetings, and to learn from theexperience and wisdom of medical, nursing andparamedical colleagues. Listen actively and carefully toinformation presented in multidisciplinary meetings, andunderstand that a holistic approach to patient care mustbe used to underpin the provision of clinical pharmacyservices. It is important to be able to acknowledge that insome cases, drug therapy (although possibly important)is not the only way to approach the management ofpsychiatric illnesses: psychological therapy, communitybased support, counselling, and the provision of practicalassistance in difficult times can be vital to the success ofoverall treatment.In some cases, it may be necessary to prioritise andprogressively implement clinical pharmacy services in away that is commensurate with the resources available.Under these circumstances, it is vital to ensure that basicfunctions with high impact upon patient outcomes areafforded the highest priority. Medication chart review,assistance through the provision of high quality druginformation, adverse drug reaction and drug interactionscreening, and work directly at ensuring the patients havean adequate understanding of their medications are themost important functions,as well as making sure thatthere are adequate supplies of medication available to thepatient, and that the patient has the insight and motivation4
Indian J. Pharm. Pract. 1(2), Jan-Mar, 2009In many cases, enlisting the support of family or closefriends of the patient can assist with these objectives. Aspractitioners begin to accumulate increasing experiencein psychiatric clinical pharmacy practice, they developgreater understanding of the special challenges involved:these include communicating with the mentally impairedpatient, recognising a patient who might be a danger tothemself or to others, dealing with issues relating tosubstance abuse (more common amongst patients withsevere psychiatric illness), and problems in helpingpatients to adhere to the prescribed therapy. Althoughclinical pharmacy practice in psychiatry is challenging,it is certainly rewarding in equal measure. In choosing towork in this field, a pharmacist chooses to deal withpatients who are often both chronically and severelyphysically and mentally unwell. There is extensivepolypharmacy with drugs of low therapeutic index.Serious adverse drug reactions and drug interactions arecommon. Mentally ill patients are amongst thevulnerable and underprivileged in any society: arguablythere is no higher calling in clinical pharmacy thanworking for the protection and assistance of these people.Table 4.1Key findings of epidemiological studies of mental illnessStudy Setting Key findingsGlobal Burden of Disease Worldwide Unipolar depression leading cause of disabilityBurden of Disease & Injury inAustraliaNational Survey of Mental Healthand Wellbeing of AdultsMental Health Disorders inAustralian VeteransMental Health: Report of theSurgeon GeneralMental Health Supplement to theOntario Health SurveyNational Psychiatric MorbidityNetherlands Mental Health Surveyand incidence studyTaiwan PsychiatricEpidemiological ProjectAustraliaAustraliaAustraliaUSACanadaBritainNetherlandsTaiwanMental disorders account for 30% of non-fataldisease in Australia. Depression and dementiasforemost causes of disability caused by mentalillness18% of Australians affected by key mentalillnesses Health and during the preceding 12months. 34.5% Wellbeing of adults experienceddisability.GAD, PTSD, Depression and alcohol abuse mostVeteran Community (Veterans) common. PTSDaccounts for > 50% of accepted mental healthclaims.One-year prevalence of diagnosable mental illnessapproximately 22-23%. Prevalence for anxietydisorders and mood disorders 16.4% and 7.1%respectively.18.6% affected, 14.2% with one disorder, 4.5%two or more disorders. Anxiety disorders (12.2%),affective disorders (4.5%) and substance usedisorders (5.2%) most prevalent.16% of subjects met screening criteria for mentaldisorders Surveys of Great Britain. No differencesamongst geographical regions of Great BritainLifetime prevalence of 41.2% and 12-monthprevalence 23.3% for psychiatric disordersLifetime prevalence estimates of 16-28%depending upon setting.5
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APTI ijopp - Indian Journal of Pharmacy Practice

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