Keywords

Introduction

Pharmacotherapy is the most common treatment used within mental health facilities with more than 90% of patients prescribed psychotropic medicines (Roughead et al., 2017). Due to their frequent use, they are associated with the highest incidence of errors and adverse events (Australian Commission on Safety and Quality in Health Care, 2017). It is believed that up to 50% of these incidences and adverse events are preventable (Australian Commission on Safety and Quality in Health Care, 2017). In 2019, the Australian Government declared quality use of medicines (QUM) and medicines safety as the tenth National Health Priority (Rigby, 2020). The basis of QUM and medicines safety is the judicious, appropriate, safe and efficacious use of all medicines (Rigby, 2020). The Medication Safety in Mental Health report published in 2017 by the Australian Commission on Safety and Quality in Health Care (ACSQHC) listed key recommendations to improve medicines safety within the mental health setting. The recommendations included adoption of clinical pharmacy services and medication reconciliation services (Roughead et al., 2017).

Pharmacy Services

Clinical pharmacy services within the Walker Unit aim to optimise health outcomes and improve patient safety throughout all steps of the medication management pathway. The medication management pathway begins with the decision to prescribe a medicine, followed by the dispensing, administering and monitoring medicine use. Due to the complex and multidisciplinary nature of medication management, all stages of the medication management pathway can involve medication-related problems (MRPs) and adverse medication events. Pharmacists are well positioned to reduce these errors and adverse events, and evidence demonstrates that implementation of clinical pharmacy services results in improved and safer health care (Australian Commission on Safety and Quality in Health Care, 2017; Roughead et al., 2017). Key evidence-based services offered by pharmacists shown to improve patient outcomes include documentation of best possible medication histories (BPMH), performing medication reconciliation and undertaking clinical medication reviews. Pharmacists also provide clinical recommendations regarding therapeutic drug monitoring, drug interactions, management of adverse drug reactions, psychopharmacology as well as interpretation and application of pharmacogenomic testing. These services support a collaborative approach between patients, carers and the multidisciplinary team to develop patient-centred medication management plans.

Transition points of care are highly prone to unintended medication changes, with more than 50% of MRPs occurring at transitions of care and approximately 33% of these have the potential to cause harm (Australian Commission on Safety and Quality in Health Care, 2017). This is particularly true during hospital admissions due to the lack of accurate medication histories on presentation (Roughead et al., 2017). Some of the errors that can occur include unintentional discontinuation of therapy, recommencement of ceased medications, inappropriate orders and failure to identify MRPs. The Guide for Hospitals published by the National Safety and Quality Health Service Standards (NSQHSS) recommends that a BPMH is documented as soon as possible on admission to hospital. This BPMH should then be reconciled against the prescribed medication orders to correct any discrepancies. Documentation of a BPMH followed by reconciliation against the prescribed medication orders on admission has been shown to reduce medication errors by 50% to 94% (Australian Commission on Safety and Quality in Health Care, 2017).

Pharmacist-led documentation of BPMH and medication reconciliation are conducted for patients as soon as possible upon admission to the Walker Unit. The key steps in obtaining a BPMH involve obtaining two independent sources of medication lists and history of medication allergies and adverse drug events, with one source ideally being the patient or carer (Rigby, 2020). This BPMH is then documented in the patient’s medication management plan on the electronic medical record to be accessible by the multidisciplinary team. The documented BPMH is then reconciled with the prescribed medication orders to identify and resolve MRPs and discrepancies such as omissions and duplications of therapy, and incorrect drug, dosages and frequencies. Similarly, the discharge transition point of care is also prone to unintended medication changes. Hence, a pharmacist-led discharge medication reconciliation process is also undertaken when patients are discharged from the Walker Unit. The discharge medication prescriptions are compared against the discharge plan and medication lists to ensure that changes are documented and unintended discrepancies are corrected.

Whilst documentation of BPMH and performing medication reconciliation greatly reduces MRPs, they have the greatest impact during transitions of care. On the other hand, well-structured clinical medication reviews ensure quality use of medicine (QUM) and medicines safety at all stages of the medication management pathway including when prescribing, dispensing and administering medications. Although clinical medication reviews are a multidisciplinary responsibility, the Society of Hospital Pharmacists of Australia indicates that pharmacists are expected to undertake clinical medication reviews within its Standards of Practice for Mental Health Pharmacy (Mahoney et al., 2009).

At the Walker Unit, pharmacist-led clinical medication reviews are conducted regularly for patients to detect and resolve MRPs, and to improve QUM and medication safety. These medication reviews include reviewing the current and newly prescribed medications, as well as previous medication use to optimise medication management. Outcomes of these medication reviews include clinical recommendations to improve therapeutic drug monitoring, management of drug interactions and adverse drug reactions, and advise on psychopharmacology and pharmacogenomics.

Therapeutic drug monitoring involves the measurement of drug concentration levels within bodily fluids to optimise efficacy, minimise toxicity and monitor adherence (Sansom, 2012). Therapeutic drug monitoring is employed for drugs with a narrow therapeutic index, defined therapeutic concentration range or established relationship between drug concentrations and clinical effect (Sansom, 2012). At the Walker Unit, medications that undergo therapeutic drug monitoring include lithium, valproate and clozapine. Monitoring and management of adverse drug reactions is an important role of mental health pharmacists. Over 80% of adult patients with psychotic illnesses experience some form of adverse drug reaction from their medications and approximately a third of these cause moderate to severe impairment (Roughead et al., 2017). Common adverse drug reactions handled by pharmacists at the Walker Unit include monitoring and management of metabolic side effects from antipsychotic use, as well as haematological and cardiovascular monitoring for clozapine patients. Management of adverse drug reactions may sometimes necessitate dosage reductions or cessation of therapy and the pharmacists are well situated to recommend strategies to avoid or minimise discontinuation syndromes.

With their expertise and training, pharmacists are also well equipped to improve QUM and medicines safety by providing advice on psychopharmacology. Pharmacists at the Walker Unit play a role in rationalisation of medication therapy, selection of medications, switching therapies and deprescribing. The increased accessibility of pharmacogenomic testing has provided mental health clinicians another tool to select the most appropriate medications for their patients particularly in cases of treatment resistance, or intense and unexpected adverse effects. Pharmacogenomic testing involves testing the genetic variances of a particular patient to better understand how they will respond to specific medications (Sansom, 2012). This allows for medication and dosage regimens to be individualised based on the patient’s genetic makeup, thereby optimising a medication’s effectiveness, and minimising the risk adverse reactions. However, the main challenges of utilising pharmacogenomics in the clinical setting are the training required to interpret genetic test results and the lack of guidelines on how to best modify therapy based on specific genetic variances (Sansom, 2012). Pharmacists are well equipped to overcome these challenges with their expertise in pharmacology and pharmacogenomics. They are also able to review the current literature to generate evidence-based recommendations on how to best individualise therapy based on genetic test results.

Additional clinical pharmacy services include facilitation of continuity of medication management through provision of updated medication lists as well as patient and carer medication counselling. Both activities align with the recommendations published by ACSQHC in their Guide for Hospitals. They recommend that health services should provide patients with sufficient information about their treatments and medications in a form appropriate to their level of health literacy (Australian Commission on Safety and Quality in Health Care, 2017). For these reasons, patients discharged from the Walker Unit are supplied an updated medication list and are counselled on their medication changes. The facility also offers its patients and carers access to the Choice and Medication website which provides a range of leaflets and fact cards on different mental illnesses and medications.

Pharmacotherapy

The practice of pharmacotherapy at the Walker Unit shares features in common with prescribing in acute child and adolescent mental health inpatient units, but there are some differences. For a start, if medication was the answer to a young person’s difficulties they would not need the support of a longer stay unit. We therefore understate rather than overstate the likely benefits of medication. This section will in particular seek to highlight the characteristics of pharmacotherapy that are distinct to longer stay intensive psychiatric care.

Owing to the severity and chronicity of their problems, most young people on entry to the Walker Unit are prescribed a combination of medications. In addition, most young people will have previously had adequate or inadequate trials of many other psychotropic agents. Some will be experiencing impairing side effects. An important early task, usually delegated to the psychiatrist in training, is to develop a timeline of all previous treatment documenting where possible duration, maximum dose and perceived benefits or harms.

Unlike acute units, the Walker Unit is not under time pressure to rapidly initiate or alter treatment. Medication would only usually be amended at the point of admission if there was toxicity, risk to the physical health in the context of a severe psychotic or depressive illness or ongoing severe risk taking behaviour requiring regular sedation. Changes to treatment are made, if indicated, after several weeks of observation and diagnostic clarification. Medications are selected to target specific and problematic symptoms or diagnoses. Not every symptom or diagnosis requires a medication. Some are better addressed by non-pharmacological treatment; others do not require treatment at all. Where possible, the treatment is simplified. This is an important consideration for young people discharged to rural and remote areas where there is no access to paediatric psychopharmacology expertise

PRN (pro re nata or medication as needed) is a reality in an inpatient unit managing high risk and severely unwell patients. On admission, most patients are routinely charted the following to be administered for agitation or behavioural disturbance where other measures articulated in the ‘de-escalation tree’ (see Chap. 3) have been ineffective:

  • lorazepam (oral)

  • quetiapine (oral)

  • midazolam (intramuscular)

  • ziprasidone (intramuscular)

PRN medication may be modified according to the patient’s circumstances and need. For example, in a patient routinely taking olanzapine, additional olanzapine may be preferable to administering quetiapine.

Especially for conditions relating to anxiety, depression and trauma the treatment emphasis is taken away from reliance on medication and redirected towards the importance of a healthy lifestyle including exercise and a balanced diet. Most patients have a one to two year history of slowly deteriorating illness, have not been attending school, socially isolating and been overly sedentary with unhealthy eating habits leading to unhealthy weight (too high or too low) which in return impacts their mental state.

In cases of early onset treatment resistant schizophrenia, some patients continue to deteriorate in their mental state despite being on therapeutic doses of clozapine or other antipsychotic medication. In these situations, time is taken to consider alterative medications and augmentation strategies leading to the least possible side effect profile. Parents may question the treatment and attribute the deterioration in mental state to the medication rather than the natural course of the illness. In these instances, psycho-education is of utmost importance to ensure the ongoing engagement of the family. In the most severe cases, it can take several months up to years before the illness stabilises and the patient can be discharged.

Conclusion

Thanks to the close collaboration on a weekly basis between the MDT and the pharmacist, the medication journey of the young person during their admission to the Walker Unit is optimised by reducing the side effect profile while increasing the efficacy of the medication regime. Every adjustment in medication is discussed with the young person and their family/carer to improve the compliance and awareness of the illness.