These commentaries by John Macgill represent his opinions only and not those of any Ettrickburn client.

Three Perspectives on Pharmacy and Mental Health

Pharmacy and the New GP Contract

Bordering on Problematic

Recognised by the Queen and her community

VACANCY Reporter/Researcher: Health and Care Policy in Scotland

Prescribing in Mental Illness – A Practice Pharmacist’s Perspective

What Matters to You? Communication in Pharmacy

Prescribing in Mental Illness – A Patient’s Perspective

Focusing the Vision: Dr Rose Marie Parr on the new strategy for Scottish pharmacy

All the things that could go wrong - looking ahead to the SNP conference

Ask Once, Get Help Fast? Pharmacy and Mental Health

Automation and Delegation in Pharmacy: Understanding the Moving Parts

Initiatives Highlight Potential of Community Pharmacy

Pharmacy First in Forth Valley One Year On

Trying to concentrate on the day job

Health and the Local Elections – a strange silence

The Pharmacist Will See You Now – The Growth of GP Pharmacy

Montgomery’s Review – Dr Brian Montgomery answers questions on access to new medicines in Scotland

An afternoon with SMC

Pharmacists at SMC

SMC – are drug firms voting with their feet?

Radical Surgery on the Horizon for Scotland’s NHS

The Future’s Bright – in General Practice

Community Pharmacy in a Changing Environment

Disclosing payments to doctors – has Sir Malcolm done the pharma industry a favour?

Health and Care in the First Minister’s Programme for Government

CMO: Scotland’s pharmacists “absolutely ideally placed” to practice Realistic Medicine

Profile: Maree Todd – MSP and Pharmacist

Scottish Parliament Health Committee Work Programme

Scotland’s new NHS – a Summer of Speculation

Scotland’s New Health Committee

Two million voices in Scotland – is integration the big opportunity to listen?

Medicines – levelling the playing field

Key appointment raises the bar for health & social care partnerships

What did our new MSPs do before?

SMC says no then NICE says yes – three times

SNP promises single formulary and a review of Scotland’s NHS

More Generous than the CDF – but less transparent

Comparison of Funds: New Medicines v Cancer Drugs

Bonfire of the Boards? SNP signals NHS Review

A tribute to five retiring MSPs

New Medicines Review - Health Committee sends findings to Government

Medicines New & Old in the Scottish Cancer Strategy

Great Ambitions, Slow Progress – New Models of Care in Scotland

Scottish Minsters Demand Up-Front Medicine Price Negotiation

Opportunity and Disappointment: MSPs Investigate New Medicines Access

Scottish NHS Strategy calls for 'Realistic Medicine'

The Scottish Model of Value for Medicines: Taking Everything into Consideration

When SMC Says No: An Access to Medicines Lottery

Reviewing the Review: Access to New Medicines in Scotland

A day of psephology and kidology

Insulting the Lifesavers

Worthy of Mention – Health and Science in the Honours List

News Silence from North of the Border

A Christmas PPRS Present from Pharma

Thursday, January 11, 2018: Prescribing in Mental Illness – A Practice Pharmacist’s Perspective

This article was first published on Pharmacy in Practice www.pharmacyinpractice.scot

A multidisciplinary conference this month will examine how Scotland can put patients with mental health conditions at the centre of medicines decisions and innovation. Chris Johnson is a primary care specialist mental health pharmacist and advanced prescribing support pharmacist with NHS Greater Glasgow & Clyde (NHSGGC). He will lead a seminar on the role of the Practice Pharmacist in improving care. Chris has been telling Pharmacy in Practice, that patients are best served by treating physical illness and mental illness as two sides of the same coin.  

Practice pharmacists are involved supporting the needs of their patients and practices in different ways. I see myself as a generalist first with an interest in mental health. You cannot truly separate mental health and physical health. For instance, with a long-term condition like COPD, if a person’s respiratory condition is poorly controlled that creates anxiety which in turn affects their breathing and vice versa. We also need to consider that people who have long-term mental health conditions commonly die prematurely; 20 years earlier for those with schizophrenia than somebody without it. We also know that people with mental health conditions commonly have multimorbidity and life-style risk factors. Therefore, we can only truly address avoidable premature mortality or somebody’s multimorbidity if we treat the whole person, not simply the mental health condition or their common physical health conditions separately. 

At a practice level, my work has mainly focused on antidepressant, anxiolytic and hypnotic use. Antidepressant work has involved identifying people who are prescribed the same antidepressant for two years or more, enabling GPs to review ongoing need. Since 2009, this has enabled more than 180 of 260 NHSGGC practices to review more than 8000 people receiving long-term antidepressants. Of those reviewed, one in four people needed to change: switch, increase/reduce dose or stop their antidepressant altogether. Overall, this achieved a 10% reduction in antidepressants prescribing (as defined daily doses) but, more importantly, created an opportunity for review. This continues as a NHSGGC prescribing indicator for practices to participate in. 

Other antidepressant work includes academic detailing and education, and highlighting the limitations of selective serotonin reuptake inhibitor (SSRI) doses for the treatment of depression. SSRI doses are commonly on average 40-50% higher than current evidence supports, as SSRIs demonstrate a flat dose response curve for the treatment of depression: ‘20’s plenty’ for fluoxetine/citalopram/paroxetine (20mg daily) and ‘50’s enough’ for sertraline (50mg daily) to achieve their optimum effect for depression, with higher doses commonly causing more adverse effects. However, this work has not all been about drugs. I have been involved in developing local depression guidelines for primary care considering non-pharmacological and non-medicalised options to support people with depression such as exercise referral to local council gyms, or gardening or walking groups. Part of my role includes sharing information with other practice pharmacists, such as Black Dog videos, which can be helpful in explaining depression, or advising on accessing ASIST suicide intervention training which can be accessed via the Choose Life website. 

Since 2005, I have also been involved as a prescriber running anxiolytic and hypnotic reduction clinics in practice for people receiving long-term benzodiazepines and/or z-hypnotics (B&Zs) which commonly achieves a 20-30% reduction in a practice’s defined daily doses. Polypharmacy issues are also addressed during these reviews, as this helps to provide the reviewer with insight into a patient’s other conditions, symptoms and appropriateness for potential for gradual reduction and stopping B&Zs. Over the years this work has mushroomed in NHSGGC with other practice pharmacists getting involved, and by demonstrating to GPs it can be done successfully, which has enabled more people to be reviewed – achieving health gains and reducing avoidable drug related risks for patients. We also involve GPs in reviewing, reducing and stopping B&Zs as this achieves greater sustainability and minimises the chance of prescribing increasing back to pre-intervention levels. In some of the localities this has led to groups of practices tackling B&Z use, sharing experiences and learnings on what worked well and did not. We have also used some of the more recent price increases, for instance for temazepam, as an opportunity to encourage reviews.

I have also led on quality improvement work for Community Mental Health Teams (CMHT) and general practices psychotropic medicines reconciliation, improving reconciliation accuracy across this interface as well as addressing safety, quality and cost effective prescribing issues. 

A future model I am interested in developing is specialist mental health pharmacists with split CMHT and general practice commitments in specific localities. I think this would first of all help patients, but also general practices and practice pharmacy teams with the challenges of reviewing and ensuring appropriate psychotropic medicines use and cardiometabolic monitoring to address and minimise avoidable drug related harms. Ideally that would mean you always have somebody who you’re working really closely with whose knowledge you can dip into. No individual can know everything but, by working together, asking questions and showing a willingness to engage with the challenges, you’d have a primary care team that is more than the sum of its parts. 

Mental Health in Scotland – Putting the Patients at the Centre of Medicines and Innovation takes place on Thursday 25th January 2018 at Stirling Court Hotel and Conference Centre, University of Stirling. Places are free for healthcare professionals. Register now at www.pharman.co.uk/events

The conference has been organised by Pharmacy Management and is sponsored by Sunovion Pharmaceuticals Europe. The agenda has been arranged by a steering group from within NHSScotland. The conference is non-promotional and the sponsor had no input to the agenda.