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 , 2 0 1 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

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

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

‘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

Global Mental Health Statistics

5

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)

Global Top 10 leading causes of years of life lived with disability

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

Serious cases receiving no treatment during the last 12 months

Developed countries Developing countries

0

10

20

30

40

50

60

70

80

Lower range Upper range Lower range Upper range

35%

50%

76%

85%

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

SUPPORTING PEOPLE IN THE AFTERMATH OF CRISIS EVENTS

Psychological First Aid

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

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.

MHPSS in Eastern Samar

House-to-house visits to find patients

Before and After MHPSS

7/8 RHUs 3 – Biliran Provincial Hospital

22/25 RHUs 3/5 District Hosp 3- Guiuan 2- Eastern Samar Provincial Hospital

24/24 RHUs 5/8 District Hospitals 2- Northern Samar Provincial Hospital 2 – Biri District Hospital 3 – Allen District Hospital

17/26

14/21 1/3 District Hosp 2- Southern Leyte Provincial Hospital

36/40 RHUs 2/2 CHOs

Excludes Regional Facilities RHUs only Beds in general hospital setting

MHPSS Essential Tools for Success

16

True or False

Mental, neurological and substance use disorders respond poorly to treatment

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

FALSE

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

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

‘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.

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

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

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

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

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

Management of Bipolar Disorder

MEDICATION Evidence base

TDM required? Available?

Physical monitoring

Teratogenic potential

Lithium +++ Lithium levels/ No

Renal function Thyroid function

Yes

Carbamazepine ? CBZ levels/ No

Liver function Yes

Valproate ++ No /NA Not essential Yes

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

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?

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

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

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

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!

FALSE

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

Salamat and Paalam