PSYCHIATRY OVERVIEW Pharmacy 421 October 24, 2002

1. PSYCHIATRY OVERVIEWPharmacy 421October 24, 2002 Albert Chaiet B.Sc.Phm., M.Sc.Phm., M.B.A. Beth Sproule B.Sc.Phm., Pharm.D Wende Wood B.A., B.S.P.

2. Beliefs about Mental IllnessWhat do YOU think?????

3. The Myths of Mental Illness(source: Canadian Mental Health Association) • People with mental illness are violent and dangerous • People with mental illness are poor and/or less intelligent • Mental illness is caused by a personal weakness • Mental illness is a single, rare disorder

4. The Myths of Mental Illness • More likely to be victims of violence • Can affect anyone regardless of intelligence, social class, income • Not a character flaw-an illness-cannot just snap out of it • A broad classification for many disorders

5. What is Mental Illness? • Mental illnesses are characterized by alterations in thinking, mood or behaviour (or some combination thereof) associated with significant distress and impaired functioning. • The symptoms of mental illness vary from mild to severe, depending on the type of mental illness, the individual, the family and the socio-economic environment

6. Mental Illnesses in Canada-An Overview • Mental illnesses indirectly affect all Canadians through illness in a family member, friend or colleague • 20% of Canadians will personally experience a mental illness during their lifetime • Mental illnesses affect people of all ages, educational and income levels and cultures • The onset of most mental illnesses occurs during adolescence and young adulthood

7. Overview continued • A complex interplay of genetic, biological, personality and environmental factors causes mental illnesses • Mental illnesses can be treated effectively • Mental illnesses are costly to the individual, the family, the health care system and the community • The economic cost of mental illnesses in Canada > $7.3 billion (1993)

8. Overview continued • 86% of hospitalizations for mental illness in Canada are in general hospitals • 3.8% of all admissions in general hospitals were due to anxiety disorders, bipolar disorders, schizophrenia, major depression, personality disorders, eating disorders and suicidal behaviour • The stigma attached to mental illnesses presents a serious barrier not only to diagnosis and treatment but also to acceptance in the community

9. What is Mental Illness? • Physical symptoms and illnesses • Concurrent disorders • Broad categories: • Mood disorders • Schizophrenia • Anxiety disorders • Personality disorders • Substance abuse

10. What is Mental Illness? Special issues: • Suicide • Special populations: • Children • Elderly • Developmental delay (dual diagnosis)

11. Mental Illness-Prevalence • 20% of Canadians will personally experience a mental illness during a one year period • 3% will experience profound suffering and persistent disablement

12. Mental Illness-Prevalence • Mental Illness One-Year Prevalence Mood Disorders • Major (unipolar) depression 4.1 to 4.6 % • Bipolar disorder 0.2 to 0.6 % • Dysthymia 0.8 to 3.1 % • Schizophrenia 0.30% • Anxiety disorders 12.2%

13. Mental Illness-Prevalence • Personality disorders 6.0 to 9.0 % (U.S.) • Eating disorders • Anorexia0.7 % women 0.2 % men • Bulimia 1 .5 %women 0.5 % men • Deaths from suicide 2 % of all deaths 24% of all deaths (15-24) 16% of all deaths (24-45) • Addictions • alcohol • 1 in 10 report problems • >6,500 alcohol-related deaths (1995) • >80,000 hospitalized for alcohol-related problems

14. Mental Illness-Prevalence • Addictions • alcohol • 1 in 10 report problems • >6,500 alcohol-related deaths (1995) • >80,000 hospitalized for alcohol-related problems • Smoking • 1in 6 deaths (34,700) related to smoking

15. Impact of Mental Illness • 58.8% admissions women • 50% admissions in age 25-44 • 25% admissions in age 45-64 • High rate in 15 –24 age group

16. Impact of Mental Illness • Onset of most mental illness during adolescence and young adulthood: • Educational achievement • Career opportunities • Personal relationships

17. Impact of Mental Illness • Suicide • Family impact • Economic impact-enormous $7.33 billion

18. Stigma and Discrimination • Superstition, fear, old stereotypes etc • Force people to remain quiet about their mental illness, often causing them to delay seeking treatment,avoid following through with recommendations, avoid sharing concerns with family, friends, colleagues.

19. Legal Framework • Legal framework for the care, treatment and hospitalization of those suffering from mental illness and those incapable of making their own life decisions • These laws are meant to balance the right to autonomy and self-determination with the right to care, protection and treatment as well as the safety of the community

20. Mental Health Act • Psychiatric facilities • Admitting • Retention • Access to records • Financial incapacity • Rights of patients to information • Community treatment orders

21. Health Care Consent Act • Informed consent prior to treatment or admission • Emergency situations • Capacity to provide consent • Substitute decision-makers (SDM) • Options re:improper SDM decisions

22. Substitute Decisions Act • Powers of attorney, guardianships • Continuing powers of attorney for property or personal care • Courts • Rules

23. DSM-IV-TR • Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision • American Psychiatric Association 2000 • Classification system for clinical, educational and research purposes • Categorical and subjective • Diagnostic criteria, course specifiers

24. Multiaxial System • Axis 1 Clinical Disorders • Axis 2 Personality Disorders/Mental Retardation • Axis 3 General Medical Conditions • Axis 4 Psychosocial and Environmental Problems • Axis 5 Global Assessment of Functioning

25. DSM-IV Major Depressive EpisodeCore Criteria 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).

26. Major Depressive EpisodeFull Symptom Criteria and represent a change  5 symptoms for 2 weeks from previous functioning: • depressed mood • loss of interest/pleasure •  appetite •  sleep • psychomotor agitation • fatigue must include 1 of these • worthlessness •  concentration • thoughts of death

27. Major Depressive EpisodeAdditional Criteria • Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. • Symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). • Symptoms are not better accounted for by Bereavement

28. Major Depressive EpisodeSpecifiers • Mild, moderate, severe • With psychotic features • With catatonic features • With melancholic features • With atypical features • With postpartum onset

29. Major Depressive Disorder • One or more major depressive episodes • Never had a manic episode • Course Specifiers: • With inter-episode recovery • With seasonal pattern

30. DSM-IV CLASSIFICATION Mood Disorders Psychotic Disorders Anxiety Disorders Sleep Disorders Childhood Disorders Substance Use Disorders Cognitive Disorders Eating Disorders

31. Mood Disorders • Major Depressive Disorder • Dysthymic Disorder • Bipolar I Disorder • Bipolar II Disorder • Cyclothymic Disorder

32. Anxiety Disorders • Panic Disorder • Specific Phobia • Social Phobia • Obsessive-Compulsive Disorder • Posttraumatic Stress Disorder • Generalized Anxiety Disorder

33. Psychotic Disorders • Schizophrenia • Schizoaffective Disorder

34. Sleep Disorders • Primary Insomnia • Primary Hypersomnia • Narcolepsy

35. Cognitive Disorders • Dementia • Alzheimer’s • Vascular Dementia • Amnestic Disorders • Delirium

36. Eating Disorders • Anorexia Nervosa • Bulimia Nervosa

37. Substance Use Disorders • Substance Dependence • Substance Abuse • Substance Induced Disorders • Intoxication • Withdrawal

38. Childhood Disorders • Learning Disorders • Developmental Disorders • Autistic Disorder • Attention-Deficit Hyperactivity Disorder • Conduct Disorder

39. THERAPEUTIC CLASSIFICATION Antidepressants Mood Disorders Mood Stabilizers Anxiety Disorders Sedative-Hypnotics Sleep Disorders Psychotic Disorders Antipsychotics

40. TCAs amitriptyline (e.g., Elavil) nortriptyline (e.g., Aventyl) imipramine (e.g., Tofranil) desipramine (e.g., Norpramin) clomipramine (e.g., Anafranil) MAOIs tranylcypromine (e.g., Parnate) phenelzine (e.g., Nardil) moclobemide (e.g., Manerix) SSRIs fluoxetine (e.g., Prozac) paroxetine (e.g., Paxil) sertraline (e.g., Zoloft) fluvoxamine (e.g., Luvox) citalopram (e.g., Celexa) Others nefazodone (e.g., Serzone) venlafaxine (e.g., Effexor) bupropion (e.g., Wellbutrin ) trazodone (e.g., Desyrel) mirtazapine (e.g., Remeron ) Antidepressants

41. Mood Stabilizers • lithium (e.g., Carbolith) • valproic acid (e.g., Epival) • carbamazepine (e.g., Tegretol)

42. Sedative-Hypnotics Barbiturates -          secobarbital (e.g., Seconal) Benzodiazepines diazepam (e.g., Valium) -          lorazepam (e.g., Ativan) -          clonazepam (e.g., Rivotril) -          alprazolam (e.g., Xanax) -          temazepam (e.g., Restoril) Non-Benzodiazepine Hypnotics zaleplon (Starnoc ) Buspirone (e.g., Buspar )

43. Antipsychotics Typicals haloperidol (e.g., Haldol) • chlorpromazine (e.g., Largactil) • perphenazine (e.g., Trilafon) • thioridazine (e.g., Mellaril) • pimozide (e.g., Orap) • fluphenazine (e.g., Moditen) Atypicals • clozapine (e.g., Clozaril) • risperidone (e.g., Risperdal) • olanzapine (e.g., Zyprexa) • quetiapine (e.g., Seroquel)

44. THERAPEUTIC CLASSIFICATION Mood Disorders Antidepressants Anxiety Disorders Mood Stabilizers Sleep Disorders Psychotic Disorders Sedative-Hypnotics Eating Disorders Substance Use Disorders Antipsychotics

45. Etiology of Mental Health Disorders • ???? • Biological Environmental • Neurotransmitter theories (NE, DA, 5HT) • Neuroendocrine theories • Membrane and cation theories • Second messenger theories

46. Concurrent Disorders • Substance use disorders and other mental health disorders • Very high comorbidity • Pharmacological Challenges: • Diagnosis (drug-induced?, self-treatment?) • Drug interactions • Compliance • Abuse of therapeutic agents

47. Guidelines • Canadian Network for Mood and Anxiety Treatments (CANMAT) • www.canmat.org • Depression • Ontario Program for Optimal Therapeutics • www.opot.org/guidelines • Anxiety

48. POTENTIAL AREAS FOR PHARMACIST CONTRIBUTION(Royal Pharmaceutical Society of Great Britain Mental Health Task Force Report September 2000) • Prevention • Recognition of undiagnosed illness • Responsibilities during active treatment • Support to patients, families and caregivers

49. PREVENTION • Raise awareness and help minimize stigma - posters, community lectures • Promote healthy lifestyles- health promotion leaflets • Liaise with other members of community mental health team and caregivers to improve quality of pharmaceutical care for service users • includes care planning for patient and professional development for team members

50. PREVENTION Ensuring the work environment and the workload placed on pharmacists and their staff is not detrimental to their own mental health!!