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Pharmacists in Medication
Adherence in Psychiatric
PatientsMamta Parikh, PharmD, BCPS, BCPP
Assistant Professor, Clinical and Administrative Sciences
Notre Dame of Maryland University
School of PharmacyFebruary 18, 2018
Disclosures
No Disclosures
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.
Objectives
PrevalenceVarying 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
Impact
Exacerbation of illness
Increased clinic and hospital visits
Compromise daily functioning and quality
of life
J Clin Psychiatry. (2002) 63:10
Violence Premature mortality Suicide
Patient Related Barriers
Young
Unmarried
Male
Lower education level
Mental Health Clinician. (2013) 2:7
Concomitant substance abuse
Medication Related Barriers
Side Effects
Dosing frequency and/or schedule
Efficacy
Mental Health Clinician. (2013) 2:7
Cost
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
Social/Environmental Barriers
Stability of living arrangement
Supervision of medication administration
Family support
Discharge planning and communication
Mental Health Clinician. (2013) 2:7J Depress Anxiety. (2015).4:2
Stigma
Mental Health Stigma
Corrigan PW, Person-Centered Care for Mental Illness: The Evolution of Adherence and Self – Determination. (pp 53 – 80)
Perceptions
Public
DangerousIncompetent
UnpredictableResponsible for disorder
Self
DangerousIncompetentResponsible for disorder
Low self –esteem and self – efficacy
Avoids treatment to avoid label
Mental Health Stigma
EducationContrast myths of mental illness with facts
MythPeople choose to be mentally ill because they are fundamentally weak.FactMental illness is largely a biological disorder; people are not to blame.
Address Self - StigmaDecrease self – stigma and promote personal empowerment
PsychoeducationReview facts about mental illness and injustices of stigmaDisclosureGroup identificationPeer SupportPeople with lived experience provide aid
Corrigan PW, Person-Centered Care for Mental Illness: The Evolution of Adherence and Self – Determination. (pp 53 – 80)
Strategies to Improve Medication Adherence
Psychoeducation
Cognitive Behavioral Therapy (CBT)
Motivational Interviewing
Psychoeducation
Patient+
Family
Individual or Group Counseling Sessions
Psychiatric diagnosesMedications
Audience Format Content
Mental Health Clinician. (2013) 2:7Neuropsychiatric Disease and Treatment. 2015.11:1077-90
Cognitive Behavioral Therapy
Rewarding
Cues
Skills Training
RemindersMental Health Clinician. (2013) 2:7Neuropsychiatric Disease and Treatment. 2015.11:1077-90
Motivational Interviewing
Expressing Empathy
Support Self – Efficacy
Develop Discrepancy
Rolling with Resistance
Asking open – ended questions
Affirm Self – Efficacy
Active Listening
Summarize patient’s narratives
Mental Health Clinician. (2013) 2:7Neuropsychiatric Disease and Treatment. 2015.11:1077-90
Medication Monitoring• Antidepressants
• Antipsycohtics
• Mood Stabilizers
Selective Serotonin Reuptake Inhibitors (SSRIs)
Adverse Effect(s) Recommendation(s)
Gastrointestinal: Nausea, vomiting, diarrhea
Symptoms usually resolve within 1 – 2 weeks
Sexual dysfunction Switch to Bupropion
Increased anxiety, agitation Lower dose and titrate slowly
Insomnia: Fluoxetine is most activating Administer in morning
Sedation: Paroxetine is most sedating Administer at bedtime
Antidepressants: SSRIs
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Adverse Effect(s) Recommendation(s)
Gastrointestinal: Nausea, vomiting, diarrhea
Symptoms usually resolve within 1 – 2 weeks
Sexual dysfunction Switch to Bupropion
Increased anxiety, agitation Lower dose and titrate slowly
Insomnia: All SNRIs Administer in morning
Increased blood pressure Lower doseSwitch to another antidepressant class
Antidepressants: SNRIs
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
Antidepressants: Other
Mirtazapine
Sedation• Administer at
bedtime
Increased appetite, weight
• Monitor BMI, weight, lipids, glucose
• Nutrition counseling
• Encourage physical activity
Bupropion
Insomnia • Administer before mid - morning
Gastrointestinal: nausea, constipation
• Resolve within 1 – 2 weeks
Seizures • Avoid alcohol• Avoid other
medications that lower seizure threshold
AntipsychoticsAdverse Effect(s) Recommendation
Motor symptomsExtrapyramidalsymptoms
• More common with FGAs• Monitor – Abnormal Involuntary Movement Scale (AIMS)• Add anticholinergic if appropriate• Switch antipsychotic
Cardiac arrhythmias • Monitor EKG
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
Mood Stabilizers
Lithium
Adverse EffectMonitoring
Parameter(s)
HypothyroidismThyroid function
tests
Abnormal T
WavesECG
Diabetes
insipidus,
dehydration
Renal function
Electrolytes
Leukocytosis WBC
Valproic Acid
Adverse Effect Monitoring Parameter
Hepatotoxicity Liver function tests
Hyperammonemia Ammonia level
Thrombocytopenia Platelet count
Weight gain Weight, BMI
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.
Sample CaseYou 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.
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?
References
1. Ehret MJ, Wang M. How to increase medication adherence: What Works?. 2003.2(8):230-2.
2. Chapman S CE, Home R. Medication nonadherence and psychiatry. 2013. 26(5): 446-51.
3. 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. 2002. 63(10): 892 – 907.
4. Alekhya et al. Treatment and Disease Related Factors Affecting Non-Adherence among Patients on Long Term Therapy of Antidepressants. J Depress Anxiety. 2015. 4(2): 1 – 6.
5. 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. 2015.11:1077-90
7. Stahl, S. M. (2014). Stahl's essential psychopharmacology: Prescriber's guide (5th ed.). West Sussex, UK: Cambridge University Press.
Pharmacists in Medication
Adherence in Psychiatric
PatientsMamta Parikh, PharmD, BCPS, BCPP
Assistant Professor, Clinical and Administrative Sciences
Notre Dame of Maryland University
School of PharmacyFebruary 18, 2018