MENTAL HEALTH
Table 2. Initial treatments for dysthymia Treatment
Details Self-help programme
Computerised cognitive behavioural therapy (CCBT)
A treatment in which a person works through a book, often called a self-help manual. A healthcare professional will provide support and check progress either face to face or by phone.
A treatment based on cognitive behavioural therapy (CBT). The person works through a computer programme that helps
them understand depression and develop skills to deal with problems, including challenging negative thoughts and monitoring their own behaviour.
Physical activity programme A group exercise class.
Three sessions a week (lasting 45 minutes to an hour) over 10 to 14 weeks
According to NICE, an antidepressant of any kind should not be offered to a patient with dysthymia, however it may be helpful if the initial treatments are not successful, the condition has persisted for a long time or of the patient has had episodes of moderate or severe depression in the past(7)
.
It’s also important to note that patients who have diagnosed themselves with dysthymia may wish to self medicate. As a result, these patients may enquire about treatments, with St. John’s wort taking the lion’s share of these queries. It’s also worth noting that NICE have also provided advice on the use of this product, stating that it should not be recommended by health professionals, due in major part to it’s interaction profile, in addition to the lack of data on an effective dosage.
Psychosis As with other mental health conditions, discussed here and otherwise, each patient suffering with psychosis will present with their own set of symptoms, dependent on their experiences and circumstances. Most commonly however, there are four main symptomatic occurrences in psychosis: • Hallucination • Delusion • Confused thoughts • Lack of self-awareness
Each of these main symptoms can be broken down into further categories – for example, hallucinations may be visual, auditory, physically perceptive, gustative or olfactory. Such factors indicate the highly varied nature of this condition, and the necessity for personalised care for each patient who is suffering from this condition(8)
.
Yet again, our friends at NICE have provided very detailed information on how psychosis should be managed, and examination of this document crystallizes the fact that numerous factors are responsible for this condition, all of which should be addressed in the patient’s management strategy. In fact the guidance includes strategies for smoking cessation, lipid management
and blood glucose control, as an increase in physical health is critical in ameliorating the presenting condition.
The use of medication is often essential in the management of psychosis, acting to both alleviate the symptoms, and also prevent reoccurrence of psychotic episodes. As you’re probably aware, the most commonly used treatments for such a condition fall into two main camps, namely typical (e.g. chlorpromazine, flupenthixol, haloperidol, pimozide, trifluoperazine and zuclopenthixol) and atypical (e.g. clozapine, olanzapine, quetiapine and risperidone) antipsychotics. The choice of an appropriate medication is prescriber and patient dependent.
Current research suggests that all of these medications are equally effective in treating a first psychotic episode, however, each molecule will carry its own side effects, which must be considered so that patient compliance is facilitated as much as possible.
Amongst the most distressing of these side effects is tardive dyskinesia, which may occur months after treatment initiation. Pharmacists should be on the lookout for this occurring in their patients, and address this appropriately. Normally, the appearance of this effect results in modification of the treatment strategy, in order to prevent persistence or intensification(9)
. Pharmacists are
encouraged to familiarise themselves with these medications, and their use, so that they can fully assist patients who may be experiencing problems, and guidance on what to do next.
Behavioural disorders The term “behavioural disorder” is an umbrella heading which incorporates a number of conditions with differing appearances, symptom sets, and treatments. Yet again, space will constrain us within this article, but it is worthwhile making yourself aware of these conditions, and engaging in further learning so that you can assist patients should they be concerned that they have such a condition, or in the case that they are receiving a treatment for it(10)
.
Attention deficit hyperactivity disorder (ADHD) Definition: “A condition that impairs an individual’s ability to properly focus and control impulsive behaviours” Treatment: Behavioural therapy, stimulant or non-stimulant medications, parent education and support Extra info: ADHD is more common in males than females (males 2-3x more likely to have ADHD)
Emotional behaviour disorder Definition: “Affects a person’s ability to be happy, control their emotions or pay attention” Treatment: Cognitive behavioural therapy or traditional psychotherapy
Obsessive-compulsive disorder (OCD) Definition: “OCD is characterised by irrational thoughts that lead to obsessions, which in turn causes compulsions”. Treatment: Cognitive behavioural therapy, exposure and response prevention, selective serotonin reuptake inhibitors, dopamine blocking drugs
It’s no surprise to you that this list isn’t exhaustive, but the listed conditions are ones that you may have a greater degree of exposure to. Again, further study of these conditions will allow you to assist your patients further, but will also make you aware of various conditions or sub-conditions, which can be incorporated into your learning in the future.
Getting a head start You’d be forgiven for finding this article a little strange, due to the fact that it’s in a pharmacy publication, but makes very little mention to pharmacological treatments for what are very real conditions. However, this is due to the fact that the use of drugs for the treatment of these conditions makes up only a fraction of the treatment strategies available for the conditions mentioned, and the multitude of other mental health ailments which our patients can be afflicted by. As pharmacists, we are the experts on drugs, and have a good grounding in the various psychoactive
Duration
Up to 6 to 8 sessions over 9 to 12 weeks.
Between 9 and 12 weeks
drugs which are used both commonly and uncommonly. As a result, we should use our time wisely to learn more about the management of these conditions outside the realm of the active pharmaceutical ingredient, allowing us to offer holistic advice to our patient, and encourage them to engage in all of the types of therapy which may help them to overcome their malady.
Such assistance can involve offering advice about psychological techniques such as CBT, making recommendations about patients revisiting their doctor, or making patients aware of other support and advice groups which operate outside of the GP surgery. For example, the database of mental health initiatives in Northern Ireland compiled by the Public Health Agency (http://www.healthpromotionagency.o
rg.uk/resources/mental/pdfs/database. pdf) is a goldmine of ports of call which your patient can make use of.
If these steps are taken in addition to the provision of the advice which is staple to the pharmacy profession, we pharmacists can again cement our place at the forefront of patient care. n
References (1) The Guardian. Mental health is strongest taboo, says research. 2009; Available at:
http://www.theguardian.com/society/2009/feb/2 0/mental-health-taboo. Accessed 12/08, 2015.
(2) Mental Health Foundation. Fundamental Facts About Mental Health. 2015; Available at:
http://www.mentalhealth.org.uk/content/assets/ PDF/publications/fundamental-facts-15.pdf. Accessed 12/08, 2015. (3) Northern Ireland Executive. Hosital Statistics: Mental Health and Learning Difficulty. 2015; Available at:
http://www.northernireland.gov.uk/news- dhssps-030915-hospital-statistics-mental?WT.m c_id=rss-news. Accessed 08/12, 2015. (4) RefineNI. Mental Health Statistics. 2012; Available at:
http://www.refineni.com/mental-health- stats/4578563576. Accessed 12/08, 2014. (5) Mind. Anxiety and panic attacks. 2013; Available at:
http://www.mind.org.uk/information- support/types-of-mental-health-problems/anxiet y-and-panic-attacks/anxiety- symptoms/#.Vmb1csqNP08. Accessed 12/08, 2015. (6) Action on Depression. Dysthymia. 2013; Available at:
http://www.actionondepression.org/information/ depression/dysthymia. Accessed 12/08, 2015. (7) National Institute for Clinical Excellence. Treatments for mild to moderate depression. 2009; Available at:
https://www.nice.org.uk/guidance/cg90/ifp/chap ter/treatments-for-mild-to-moderate-depression. Accessed 12/08, 2015. (8) NHS Direct. Psychosis - Symptoms. 2014; Available at:
http://www.nhs.uk/Conditions/Psychosis/Pages/S ymptoms.aspx. Accessed 12/08, 2015. (9) CAMH. Treatments for Psychosis. 2015; Available at:
http://www.camh.ca/en/hospital/health_informa tion/a_z_mental_health_and_addiction_informat ion/psychosis/first_episode_psychosis_informatio n_guide/Pages/
fep_treatment.aspx. Accessed 12/08, 2015. (10)
Psychguides.com. Behavioral Disorder Symptoms. 2015; Available at:
http://www.psychguides.com/guides/behavioral- disorder-symptoms-causes-and-effects/. Accessed 12/08, 2015.
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