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close this bookPartners for Mental Health - The Contribution of Professionals and Non-professionals to Mental Health (WHO, 1994, 110 p.)
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View the documentForeword
View the documentInternational Council of Nurses - ''The Current Status of Mental Health/Psychiatric Nursing and Some Future Challenges''
View the documentWorld Federation of Occupational Therapists - ''Occupational Therapy in Mental Health Care1''
View the documentWorld Organization of National Colleges, Academies and Academic Associations of General practice, Practitioners/Family Physicians (WONCA) - ''The Professional Role of General Practitioners in Mental Health''
View the documentWorld Psychiatric Association - ''The Now and Future Role of Psychiatrists''
View the documentCommonwealth Pharmaceutical Association - ''Pharmaceutical Services to the Mentally III and Mentally Handicapped''
View the documentInternational Union of Psychological Science - ''Psychology and Health''
View the documentInternational Sociological Association Working Group on Sociology of Mental Health - ''Sociology's Contribution to the Study of Mental Health''
View the documentWorld Federation for Mental Health - ''The Voluntary Sector: Passage to Empowerment for Volunteers, Consumers and Advocates''
View the documentNational Association of Psychiatric Survivors - ''Speaking for Ourselves: Former Psychiatric Patients organizing and speaking out''

Commonwealth Pharmaceutical Association - ''Pharmaceutical Services to the Mentally III and Mentally Handicapped''

Dave Branford

Unit Pharmacist, Glenfrith Unit/Hon. Principal Lecturer,
Leicester Frith Hospital, Leicester, England.

The Commonwealth Pharmaceutical Association

The Commonwealth Pharmaceutical Association was established in 1970 to represent the profession of pharmacy in all of its aspects. 3 7 national pharmaceutical associations are in full membership.

The principal purpose of the Association is to promote the science and practice of pharmacy throughout the Commonwealth and, in so doing, continuously develop the pharmaceutical component of health care. Its objectives include the maintenance and fostering of high standards of professional conduct, education, practice and research.

One of the Association's major activities during the next four years will be to promote the development of hospital pharmaceutical services, not least within psychiatric establishments.

There is no international data base on the activities of pharmacists in psychiatric care and the Association has not sought such information from its members which are mainly in developing countries. However, the developments which have occurred in Great Britain can be described and these will at least indicate the part that pharmacists can play.

1. Introduction

Prior to the 1950s psychiatric hospitals provided asylum for people with chronic and acute mental illnesses and mental handicap hospitals provided care for people with learning disabilities. Such hospitals were usually situated in isolated locations away from the city from where the inmates originated. Mostly they were locked facilities, frequently self-sufficient in the provision of food from an integral farm or equipment made in their workshops.

Many psychiatric and mental handicap hospitals received until the 1950s a limited range of medicines from dispensaries run by nurses and supervised by the medical superintendents. These dispensaries were often located in the centre of the hospital at the partition which divided the male and female parts of the hospital. A two hatch system usually operated so that the dispenser could supply the likes of paraldehyde draught to either side of the hospital without the requirement to unlock doors. In those pharmacies which did employ a pharmacist, that person was often responsible for a wide variety of stores functions such as drugs, surgical sundries, dressings, and occasionally fulfilling roles such as pulling teeth out and taking blood.

2. Developments in psychiatric care

Following the introduction in the 1950s of a wide range of drugs effective in the treatment of illnesses such as schizophrenia and depression, most psychiatric hospitals employed a pharmacist. Many such pharmacists worked in isolation from pharmacist colleagues and were primarily involved in the supply of drugs to wards and the dispensing of the medicines required to allow patients weekend leave from the hospital. The priority was to develop safe procedures for the supply, administration and storage on wards of medicines. Pharmacists were allowed to inspect wards every 3 months to ensure that such procedures were being adhered to, but were unlikely to be involved in the prescribing process. By the 1960s most hospitals insisted that the prescriber wrote the prescription on a prescription sheet and that medicines were locked in medicine cupboards. Concerns about the security of medicines on wards led to the development in some hospitals of individual supplies for patients rather than ward stocks, and of unit dose systems in others. The unit dose supply system fell out of favour during the 1980s and is now rarely used.

3. The Noel Hall report in the mid-1970s

Following a report called the 'Noel Hall' report, hospital pharmacy in Great Britain was reorganised and isolated pharmacists working within psychiatry or other specialties were brought within the span of control of area pharmacists. This provision of a career structure and satisfactory pay enabled hospital pharmacy to make enormous progress in service provision.

A survey carried out at the beginning of the 80s (1) indicated a very low staffing in many psychiatric hospital pharmacies with many pharmacists being responsible for in excess of 500 beds. A follow-up survey carried out in 1987 (2) showed a slightly reduced number of beds per pharmacist with 2.2 pharmacists and 1.6 technicians providing services to an average 580 bedded psychiatric hospital. Pharmacies that provided services to both psychiatric and mental handicap hospitals showed a staffing of 2.9 pharmacists and 2.4 technicians per 900 beds.

Prior to the 1970s pharmacists rarely left their dispensaries. However, at the beginning of the 80s a number of services were being developed in which, instead of the pharmacists trying to deal with the multitude of requests for assistance over the telephone, they started to visit wards on a regular basis to deal with the problems relating to individual patients' medicines. These services were described as 'Ward Pharmacy'.

It was only a short step then to doctors, nurses and pharmacists realising that, rather than the pharmacist spending much time persuading doctors to change prescriptions after the decision has been made, it made more sense for pharmacists to be involved with the decision in the first place. This process is part of what we now call 'Clinical Pharmacy'. (See Acute Prescribing below).

The development of clinical pharmacy in psychiatry was rather delayed because so few institutions employed more than one pharmacist, but between the mid 70s and mid 80s many pharmacy managers were able to make the case for more pharmacist support. Throughout this period hospital pharmacy made a quantum leap in service provision so that pharmacists working in Psychiatric hospitals were not only able to provide a better service but also had backup and support from the area or district managed services, such as drug information, production services, locum relief and training.

There have been a number of studies looking at the cost-effectiveness of clinical pharmacy services, including some within the arenas of mental illness (3, 4) and mental handicap (5). Most of these have shown that not only does the pharmacist have an impact on the medicines received by people, but that savings are generated by that impact by a reduction in the number of medicines received.

4. Community Care

Since the 1950s the population residing in psychiatric and mental handicap hospitals has been declining. Legislative changes and the development of effective psychotropic drugs has enabled people with such disabilities and illnesses to continue to live in the community in staffed homes or hostels, or in their own homes.

The aim now is for most institutions to be closed. This is resulting in the community pharmacist providing a service to people of a high dependency and with severe chronic mental illnesses, and needing to assist and advise the many carers who are supporting such people.

Within this period of rapid change, roles for three distinct types of pharmacist are emerging; the community pharmacists, the community services pharmacist and the psychiatric pharmacist.

The community pharmacist provides a readily accessible source of medicines and advice about medicines for both patients and carers. This service is currently being extended to include supplying medicines and related advice to residential homes and hostels, the keeping of medication records and the provision of domiciliary services to individual patient's homes. There is currently the opportunity to develop a more specialist supply role within community pharmacy by supplying registered drug addicts.

It is hoped that in the future community pharmacists will be able to develop specialist roles by involvement with local day centres, day hospitals and mental health centres, but currently there is no satisfactory method of remuneration to promote such a development. There are two pilot schemes underway to evaluate such a possible impact of community pharmacists.

Community services pharmacists are usually employed by Health Authorities to provide a liaison and inspectorate role for registered nursing homes, hostels and health centres. The number of such community based facilities is increasing rapidly with the closure of institutions for the elderly, mentally ill and mentally handicapped and standards need to be developed and maintained for the administration and storage of medicines.

Psychiatric pharmacy is one of many developing specialities within hospital pharmacy. As the role of the hospital pharmacist changes towards a more clinical involvement there is increasingly the opportunity for specialization.

5. Acute Psychiatry

Many of the acute psychiatric wards which were previously part of a psychiatric hospital have now been relocated to General hospital sites and represent a significant part of the pharmacy workload of such hospitals. Pharmacists are increasingly being seen as one of the members of the multidisciplinary team providing specialist advice to doctors, nurses, patients and other members of the team about the medicines prescribed. Activities include prescription monitoring for errors, incompatibilities, drug interactions and inappropriate prescribing, the taking of patient drug histories, the maintenance of prescribing records, advising on drug and dosage selection and pre-discharge counselling and training. (6-10) Pharmacists are also becoming involved in clinical audits of prescribing.

As the District General hospital increasingly becomes the focus for psychiatric medical care, it is hoped that such psychiatric pharmacists will be able to develop a wider role offering advice to non-hospital agencies by referral.

6. Chronic Psychiatry

With the change from institutional care to community based care there is the need to review the medicines of patients and prepare them for hospital discharge. Many such patients will have remained in hospital for many years. Pharmacists have been actively involved in the rehabilitation process, both in the review of medicines and in training to self-medicate (11). Programmes usually consist of an initial review based on the evidence of a drug history and clinical notes. Following the review, if there is any need to change the medicines, this is undertaken. Once a stable drug regime is agreed and the simplest regime is available, the patient increasingly takes responsibility for the medicines by firstly receiving one dose at a time and then slowly proceeding to controlling a week's supply of medicines. The ability to self-medicate will be a factor in deciding the style of accommodation and support required by the patient living in the community.

7. Community Teams

With the emphasis of community care being to maintain patients in the community, the role of the community team and the community psychiatric nurse are important. It is rare for pharmacists to be full members of community teams. A trial in Victoria, Australia, of appointing 'consultant pharmacists' as members of community teams was unsuccessful. Currently much of the specialist advice to community teams comes from hospital based pharmacists and the role in relation to community teams is yet to be established.

8. Day Hospitals and Day Centres

The extent to which pharmacists are involved depends largely on how active the prescribing process is. Increasingly day centres are being used by community nurses and psychiatrists as a way of gaining regular access to patients for the giving of depot antipsychotic injections and reviewing progress. Pharmacists are commonly asked to run discussion groups about prescribed drugs for attenders and advise carers.

Pharmacists are commonly involved with day hospitals in the review of medicines, the running of lithium and anticonvulsant clinics and counselling of patients.

9. Mental handicap (learning disabilities)

With very low pharmacy staffing available, the development of pharmaceutical services to the mentally handicapped has been minimal. This is regrettable as pharmacists have been shown to have significant impact in this area, both in the control of epilepsy and challenging behaviours (5, 12).

10. Training needs

The training needs of pharmacists are huge. Community pharmacists are relatively unfamiliar with mental illnesses and feel poorly equipped to assist such patients. Community services pharmacists have in the past been primarily involved with homes and hostels caring for the elderly and again are relatively unfamiliar with mental illnesses. Psychiatric pharmacy is a relatively new specialty within the District General Hospital. Most of the current expertise is within the psychiatric hospitals.

There is also a huge training need to inform other carers about drug treatments in psychiatry. Psychiatry is currently undergoing some degree of deskilling of care staff at a time when drug therapy is becoming more complex. Also, with care staff being scattered and employed by many agencies, they are in danger of becoming out of date with changing trends.

11. References

1. Benfield M, Griffiths G, Preskey D. Pharmacy in psychiatric hospital. Sandoz Publications, 1980.

2. Branford D. Pharmacy Services in Psychiatric hospitals. Pharmaceutical Journal, 1988, HS.24.

3. Cloete B, Heath P. Pharmacist participation in a psychiatric consultant ward round. Pharmaceutical Journal, 1987, 238:42-3.

4. Branford D. Four years of working with chronically disturbed mentally ill patients. Pharmaceutical Journal, 1989, HS32-4.

5. Inoue F. A clinical pharmacy service to reduce psychotropic medication use in an institution for mentally handicapped persons. Mental retardation, 1982, 20, 2:70-74.

6. Council Statement. Benzodiazepines. Pharmaceutical Journal, 1989, 243:220.

7. Ibid. Survey shows wide variation in the teaching of psychiatric pharmacy. Pharmaceutical Journal, 1990, 245:591.

8. Ibid. Pharmacists to control safe use of new schizophrenia drug. Pharmaceutical Journal, 1990, 244:48.

9. Psychiatric Pharmacy Group. Advice to pharmacists in psychiatry. Pharmaceutical Journal, 1989, 242, HS17.

10. Psychiatric Pharmacy Group. Benzodiazepines - advice for hospital pharmacists. Pharmaceutical Journal, 1990, 244:197.

11. Pratt P, Dunnett. Self administration of medicines: a rehabilitation project. Pharmaceutical Journal, 1985, 234:172-173.

12. Branford D. Assessing the drug needs of the mentally handicapped. British Journal of Pharmaceutical Practice, 1984, 6,5:158-170.