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