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