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Mental Health Care: The New Roles of Pharmacists Jun Ni, Ho, Faculty of Pharmacy, Taylor’s University, Malaysia An Overview on Mental Illnesses Mental illnesses are conditions whereby

disorder, Sluggish Cognitive Tempo (SCT),

individuals experience mild to severe disturbances

which is also known as the Second Attention

in thoughts, emotions, feelings and/ or behaviors,

Disorder or Concentration Deficit Disorder, 9 is

and are often incapable of dealing with life’s ordinar y routines and demands. 4Mental illnesses

children, and may persist to adulthood. It can be

can be defined as diseases of the brain, which comprise a range of disorders. Different mental d i s o r d e r s

characterized with symptoms such as “sluggish”

m a y h a v e d i ff e r e n t s p e c i fi c si gns an d

daydreaming and staring.10

symptoms, however, the overall hallmark

response to treatment of SCT are still not fully

features are the development of ner vousness,

comprehended, hence many studies are still on-

intense fear, peculiar behavior, illogical thinking

going and under thorough investigations.

or slow movement, lethargy, apathy, sleepiness,

and sudden mood changes. 5 There are various possible etiologies of m e n t a l d i s o r d e r s , i n c l u d i n g g e n e t i c factors (family history), 6biological factors (biochemical imbalances),

patterns), and psychological trauma (physical, emotional or sexual abuse). 7The cause of each medical case varies from one patient to another. Terminology and New Discovery of Mental Health disorders (panic disorder, obsessive- compulsive disorder, post- traumatic stress disorder and phobias), depression, bipolar disorder, schizophre nia, psychosis, personality disorders and eating disorders. 4-6 Borderline personality disorder and dissociative disorder are other examples of mental illnesses. Following a guideline suggested by the National Institute for Health and Care Excellence (NICE), the most common mental illnesses are anxiety disorders and depression.8 Recently, reviews have reported the emergence of a new mental disorder that has constantly raised concerns among the affected populations. This new

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Treatment Modalities of Mental Health Multiple treatment options are available for managing mental disorders, particularly those which involve pharmacotherapy and behavioral therapies. Pharmacotherapy is the treatment using pharmaceutical drugs, whereby patients are given medications to control, relieve and improve their symptoms. There are five main classes of medications commonly prescribed to patients with mental disorders- antidepressants, anxiolytics, stimulants, antipsychotics and mood stabilizers. The types and indications of these medications are summarized in the following table. 11 12


Drug Classes and Examples

Drug Indications

Antidepressants

Treatment of depression

Bupropion (Monoamine Oxidase Inhibitors (MAOIs •

Isocarboxazid •

Phenelzine

Tranylcypromine

(Selective Serotonin Reuptake Inhibitors (SSRIs •

Citalopram

Escitalopram Fluoxetine

Paroxetine

Sertraline

(Serotonin Norepinephrine Reuptake Inhibitors (SNRIs Duloxetine

Venlafaxine

(Tricyclic Antidepressants (TCAs •

Amitriptyline •

Imipramine

Nortriptyline Anxiolytics

Treatment of anxiety disorders

Benzodiazepines •

Alprazolam Diazepam Lorazepam

• •

Buspirone Centrally Acting Sympathomimetics

Treatment of ADHD

Non- Stimulants •

Atomoxetine Stimulants

Amphetamine

Lisdexamfetamine dimesylate

Methylphenidate Antipsychotics

Treatment of psychoses and schizophrenia

(First- Generation (Typical •

Chlorpromazine Haloperidol

Perphenazine

Fluphenazine

(Second- Generation (Atypical •

Aripiprazole Lurasidone

Olanzapine

Quetiapine

Risperidone Mood Stabilizers

• Treatment of bipolar disorder, mania and mood swings

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Antiepileptics Carbamazepine • Valproic acid

Lithium salts

Talking therapies include counselling, cognitive

as well as improving medication adherence in patients.

behavioral therapy (a therapy in which patients are guided on how to change the way of thinking and behaving), psychotherapy (a therapy in which patients are aided to understand more about themselves and their past experiences), family i n t e r v e n t i o n pro gram, an d drama therapy (a therapy in which patients are encouraged to apply drama or theatrical techniques such as role -playing, miming and stor ytelling to express

themselves).13Electroconvulsive

therapy is also applied as one of the mental disorders treatments, notably in improving severe symptoms of depression and mania. In most cases, patients are recommended to undergo ecotherapy. Ecotherapy is a range of nature- based pro grams wh ich en ab l e patients to get close with the natural environment. For instance, care farming, gardening, rock climbing, rafting, and animals petting (animal assisted interventions) assist patients to master self- development skill and relax mind.14 Community support programs are also well- known for their establishment and continuous advocacy in restoring patients’ health holistically, helping them to regain confidence and proceed with life. Roles of Pharmacists in Mental Health Care Provision

besides minimizing antipsychotic polypharmacy. It is essential for them to consistently screen for drug interactions, for instance serotonin toxicity, in order to maximize treatment and avoid other complications. Furthermore, mental health pharmacists should detect any adverse drug reaction (ADR) in a proactive manner, and report adverse drug event to the relevant authorities.16 As recording of ADR is conducted appropriately, pharmacists s h o u l d then be able to monitor medication administration, revise drug formulation, and improve its pharmacokinetic and pharmacodynamic properties. It is also their obligation to follow up and monitor their patients’ conditions to prevent any abuse or misuse of psychotropic substances. Medication review services must be provided by pharmacists to mental health patients, so that dose reduction or titration can be determined precisely, reducing patients’ exposure to toxicity risk. Commonly cited examples include Home Medicines Review (HMR) in Australia, Medicines Use Review (MUR) services in the UK and Medication Therapy Management (MTM) in the US. When it comes to medication adherence,

The Pharmaceutical Society of Australia (PSA)

pharmacists are encouraged to devise plans and

claims that pharmacists are the most accessible

solutions for patients with mental illnesses. They

health professionals whom a majority of con-

can help educate patients by providing oral and

sumers first consult to seek for medication advice. The main responsibility of mental health pharmacists is managing medications. Mental health pharmacists or psychiatric pharmacists play important roles in promoting safe medication use, as

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phone reminder), as well as applying pictograms or illustrations to enhance patients’ understanding. They can also improve patients’ medication compliance by involving patients in shared- decision making with other health prof e s s i o n a l s . T h i s m e t h o d e n a b l e s patients, pharmacists and


other healthcare givers to openly discuss issues of medication use, medication management, and medication adherence. As pharmacists engage actively in multidisciplinary team, they are able to communicate and collaborate with physicians, psychiatrists and nurses to optimize individual medication regimens. Patients who receive tailored drug therapy tend to maintain their conditions under good control. A holistic approach that comprises interdisciplinary teamwork is indeed required in mental health pharmacy practice to elevate the

They should learn how to give initial support to individuals experiencing mental health illnesse s, promote awareness of evidencebased medical, psychological and alternative treatments, and act dominantly whenever crisis situation arises- suicidal behavior, threatening psychotic behavior, panic attack, or overdose.19 Most importantly, mental health pharmacists should persevere with their continuing professional development (CPD), keeping themselves up-to-date to the latest pharmaceutical care knowledge and health care systems. 16 Below are the summaries of pharmacist roles as partners in mental health care, a framework designed by the PSA as guidelines for pharmacists.

quality of life of patients. When it comes to medication adherence, pharmacists are encouraged to devise plans and solutions for patients with mental illnesses. They can help educate patients by providing oral and written information (e.g. patient information leaflet, phone reminder), as well as applying pictograms or illustrations to enhance patients’ understanding. They can also improve patients’ medication compliance by involving patients in shared- decision making with other health professionals. This method enables patients, pharmacists and other healthcare givers to openly discuss issues of medication use, medication management, and medication adherence. As pharmacists engage actively in multidisciplinary team, they are able to communicate and collaborate with physicians, psychiatrists and nurses to optimize individual medication regimens. 16 Patients who receive tailored drug therapy tend to maintain their conditions under good control. A holistic approach that comprises interdisciplinary teamwork is indeed required in mental health pharmacy practice to elevate the quality of life of patients. There are a few pharmacy education programs which are available for pharmacists and pharmacy students to specialize in mental health. The More Than Meds program in Nova Scotia and the Bloom Program in Canada are founded to provide novel insights for ph ar macist s o n p ro cedu res of hand ling with the needs of mental health patients. 18 Pharmacists should take initiatives to sharpen skills, specifically effective communication skills and crisis management skills, by participating in courses and trainings to own hands- on experience.

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‘Medication Management Programmes’ (further reference): http://6cpa.com.au/medication-management-programs/]20

Mental Health Care in a Nutshell Pharmacists are guardians of all drugs. They should uphold professional ethics, values and standards to ensure mental health medications that are dispensed are safe, efficacious and of good quality. Besides providing patients with accurate information and rational advice, pharmacists play pivotal roles in encouraging patients to adhere strictly to medications and reviewing medications on regular basis. Practicing active listening and being empathetic also allow pharmacists to obtain patients’ details of history, backgrounds and reasons of their admission. It is important that pharmacists should never stigmatize or discriminate against patients with mental illnesses. As they are highly accessible health care and medication providers, they give a meaningful impact on mental health care in the community and clinical settings.

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References: 1. What is Mental Illness? American Psychiatric Association. https://www.psychiatry.org/patientsfamilies/ what-is-mental-illness. Updated 2017. Accessed December 10, 2017. 2. World health report. World Health Organization. http://www.who.int/whr/2001/media_centre/press_release/en/. Updated 2017. Accessed December 10, 2017. 3. Mental health status in Malaysia. Relate Malaysia. https://relate.com.my/mental-health-status-inmalaysia/. Published November 4, 2016. Accessed December 10, 2017. 4. What is Mental Illness? Mental Health Association in Forsyth County. https://www.triadmentalhealth.org/what-is-mental-illness/. Accessed December 10, 2017. 5. Warning Signs of Mental Illness. American Psychiatric Association. https://www.psychiatry.org/patients-families/warning-signs-of-mental-illness. Updated 2017. Accessed December 10, 2017. 6. Mental Disorders. National Institutes of Health MedlinePlus. https://medlineplus.gov/mentaldisorders.html. Updated December 11, 2017. Accessed December 10, 2017. 7. What is Mental Illness? Mental Health Resources for Carers. http://mhr4c.com.au/about-mentalillness/what-is-mental-illness/. Updated 2016. Accessed December 10, 2017. 8. National Collaborating Centre for Mental Health (UK). Common Mental Health Disorders: Identification and Pathways to Care. Leicester, UK: British Psychological Society; 2011. (NICE Clinical Guidelines, No. 123.) 2, COMMON MENTAL HEALTH DISORDERS. 9. Barkley RA. Sluggish Cognitive Tempo/Concentration Deficit Disorder. Oxford Handbooks Online. http://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780199935291.001.0001/oxfordhb9780199935291-e-9. Published February 2015. Accessed December 11, 2017. 10. Mueller AK, Tucha L, Koerts J, et al. Sluggish cognitive tempo and its neurocognitive, social and emotive correlates: a systematic review of the current literature. Journal of Molecular Psychiatry. 2014;2:5. https://jmolecularpsychiatry.biomedcentral.com/articles/10.1186/2049-9256-2-5. Published August 5, 2014. Accessed December 11, 2017. 11. Mental Health Medications. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml#part_149856. Accessed December 12, 2017. 12. Treatments for Mental Disorders. Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/treatment/mental-disorders. Updated May 4, 2017. Accessed December 12, 2017. 13. Talking Therapies- Types of Therapy. Rethink Mental Illness. https://www.rethink.org/diagnosistreatment/treatment-and-support/talking-treatments/types-of-therapy. Accessed December 12, 2017.

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14. Ecotherapy. Mind. https://www.mind.org.uk/information-support/drugs-andtreatments/ ecotherapy/types-of-ecotherapy/#.WjlCzlWWbIV. Published October 2015. Accessed 12 December 2017. 15. Pharmacists’ role in mental health. Mental Health Australia. https://mhaustralia.org/general/pharmacists-role-mental-health. Published June 12, 2014. Accessed December 15, 2017. 16. Standards of Practice for Mental Health Pharmacy. Journal of Pharmacy Practice and Research. 2012;42:2. https://www.shpa.org.au/sites/default/files/uploadedcontent/field_f_content_file/51._ ps_mental_health_pharmacy.pdf. Accessed December 16, 2017. 17. Rubio-Valera M, Chen TF, O’Reilly CL. New Roles for Pharmacists in Community Mental Health Care: A Narrative Review. Salvador-Carulla L, Rosen A, Sanchez AF, eds. International Journal of Environmental Research and Public Health. 2014;11(10):10967-10990. doi:10.3390/ijerph111010967. 18. Emberley P. The pharmacist’s role in mental health. Canadian Pharmacists Association. https://www.pharmacists.ca/news-events/cpha-blog/the-pharmacist-s-role-in-mental-health/. Accessed December 18, 2017. 19. Paola S. Pharmacy’s Role in Mental Health. Australian Journal of Pharmacy. https://ajp.com.au/news/pharmacys-role-mental-health/. Published October 11, 2016. Accessed December 18, 2017. 20. Medication Management Programs. 6th Community Pharmacy Agreement. http://6cpa.com.au/medication-management-programs/. Accessed December 20, 2017.

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Mental Health is OUR Concern Authors: Preda Olivia-Teodora (Contact Person IPSF – FASFR), Adam Patricia (Liaison Secretary – FASFR), Romanciuc Andreea (Student Exchange Officer – FASFR), Bîțu Iulia-Andreea (Censor - SSFB) Over the past 50 years, the role of pharmacists has evolved along with the health care needs of the population. Pharmacists are an integral part of the health care team and are among the most trusted and accessible of the health care professionals. In addition to dispensing medications and ensuring patient safety, today’s pharmacists are taking a larger role as medical counselors, educators and advocates 1. There has been an increased recognition of the fact that primary health care practitioners play an important part in the identification, zz and management of mental disorders. However, the clinical contribution of pharmacists has not been universally accepted or comprehensively defined. Mental, neurological and substance use disorders are estimated to affect more than 450 million people worldwide, yet only a minority receives even the basic treatment2. Medicines still represent the most used means of treatment for managing many mental illnesses and pharmacists are, therefore, well positioned to enhance mental health services with the potential to reduce the associated burden of mental disorders. However, one of the main obstacles to the provision of care for people suffering from these types of disorders is the stigma attached to mental illness. Stigma is defined as being a negative attitude, based on prejudice and misinformation that is triggered by a marker of illness. But it does not stop at illness: it marks those who are ill, their families across generations, institutions that provide treatment, psychotropic drugs, and mental health workers. Stigma makes community and health decision-makers see people with mental illness with low regard, resulting in reluctance to invest resources into mental health care. 3 An understanding of mental health and, more generally, mental functioning is important because it provides the basis to form a more complete understanding of the development of mental and behavioral disorders. Mental health has been defined variously by scholars from different cultures. Concepts of mental health include subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence, and self-actualization of one’s intellectual and emotional potential, among others. From a cross-cultural perspective, it is nearly impossible to define mental health comprehensively.42 These suboptimal attitudes towards mental illness and a lack of confidence to provide services to mental health patients highlights the need for different educational approaches in the mental health field. Research has identified the need for educational programs to move from the traditional focus of pharmacology and therapeutics of psychotropic medicines and adopt evidence-based approaches to reduce mental health stigma and improve pharmacists’ confidence in providing mental health services.5 While there is a variety of anti-stigma interventions that have shown to have an efficient outcome, facilitating personal contact with people with a mental illness has been found to be more likely to be successful. Fostering opportunities for students to experience contact in a safe, non-confrontational educational setting has proven to be an efficient method at reducing stigma and hence improving their willingness to provide health care services to mentally ill patients as pharmacists.6 What is more, patients with mental illness commonly have multiple mental illness or co-morbidities. They

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also have significantly poorer physical health than the general population. Pharmacists may see consumers with a mental health condition more regularly than any other health professional and have a unique opportunity to provide support to them in managing physical co-morbidities. 7 Asking someone how they are and having somewhere they feel comfortable to ask for advice can be very significant. Many psychotropic drugs cause adverse effects such as drowsiness or agitation at first. Patients should be given advice on managing side effects and be encouraged to persevere their medication and to discuss adverse reactions with their physician or pharmacist. 87 In recent decades government agencies and international institutions have supported and encouraged the introduction of pharmacists into multidisciplinary health care teams. As experts in pharmacotherapy, pharmacists can provide complementary skills to other health care professionals within a multidisciplinary team context. Specifically, pharmacists may contribute to health care teams by detecting and resolving or preventing drug related problems: helping to ensure the safe and efficient use of medicines; providing comprehensive drug information to patients and other health care professionals; promoting medication adherence; reinforcing primary prevention, health promotion and lifestyle modification activities in the community. 95 One study has explored health professionals and consumers attitudes to the role of pharmacists working as collaborative prescribers in mental health in secondary care. Both health professionals and consumers acknowledged the role of pharmacists as collaborative prescribers in mental health, as well as in medication management after assessment and diagnosis by a medical practitioner, and as an integral member of the multidisciplinary team.108 Pharmacists working in hospital and residential aged care settings may often have access to the patients’ clinical chart and also establish communication channels with other health providers. This facilitates the integration of pharmacists in caring for people with mental disorders in these settings.115 In mental health hospitals, there are pharmacists specialized in mental health practice who work closely with secondary care teams to tailor medications to individuals whose illness has relapsed, or who are experiencing a mental illness for the first time. They attend multidisciplinary team meetings, help patients choose the best medication for them, help simplify complex medication regimes, advise on therapeutic drug monitoring and provide education and training on medicines to staff, patients and nurses. Pharmacists are involved in ensuring that the treatment for a mental illness is not suddenly stopped and that the drugs that may worsen physical health or increase confusion are avoided. 127 While responsibilities vary among the different areas of pharmacy practice, the bottom line is that pharmacists help patients get well. Pharmacists practice in nearly all areas and specialties in healthcare – sometimes behind the scenes and not obvious to the public eye but as the medication expert on the healthcare team, pharmacists are necessary in all facets of healthcare. Generally, responsibilities of Pharmacist’s include a range of care for patients, from dispensing medications to monitoring patient health and progress to optimize their response to medication therapies. Pharmacists also educate patients on the use of prescriptions and over-the-counter medications, as well as provide population based care in institutional settings, while also educating and advising physicians, nurses, and other health professionals on medication therapy decisions. Pharmacists are medication experts who ultimately are concerned about their patients’ health and wellness.139Thus the role of Pharmacists in mental health care is unparalleled in importance.

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(Endnotes) 1. CVS Health. https://cvshealth.com/thought-leadership/the-role-of--pharmacists-in-a-changing-health-care-environment. Accessed December 14, 2017

2. The World Health Organization . Mental Health: New Understanding, New Hope. The World Health Organization; Geneva, Switzerland: 2001. 3. Sartorius N. Stigma and mental health. Lancet. 2007;370:810–811. 4. O’Reilly C.L., Bell J.S., Chen T.F. Consumer-led mental health education for pharmacy students: Impact on stigma and attitudes towards provision of pharmaceutical services. Am. J. Pharm. Educ. 2010;74

5. Rubio-Valera M, Chen TF, O’Reilly CL. New Roles for Pharmacists in Community Mental Health Care: A Narrative Review. Salvador-Carulla L, Rosen A, Sanchez AF, eds. International Journal of Environmental Research and Public Health. 2014;11(10):10967-10990.

6. Mental Health Australia. https://mhaustralia.org/general/pharmacists-role-mental-health. Accessed December 14, 2017. 7. Royal Pharmaceutical Society. http://blog.rpharms.com/royal-pharmaceutical-society/2017/01/25/the-role-of-pharmacyin-mental-health/. Accessed December 14, 2017. 8. Wheeler A., Crump K., Lee M., Li L., Patel A., Yang R., Zhao J., Jensen M. Collaborative prescribing: A qualitative exploration of a role for pharmacists in mental health. Res. Soc. Adm. Pharm. 2012;8:179–192. 9. The Pharmacy College Application Service (PharmCAS). http://www.pharmcas.org/preparing-to-apply/about-pharmacy/ role-of-a-pharmacist/. Accessed December 14, 2017.

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PRIMARY HEALTH CARE PHARMACISTS AND HOW THEY CAN SUPPORT EARLY DETECTION OF MENTAL ILLNESS IN NIGERIA Ozoude Chidi Victor1 Adebisi Yusuff Adebayo1,2Soyebo Abdul-Hammed1 1. Faculty of Pharmacy, University of Ibadan, Nigeria. 2. Research Department, Global Health Focus, Africa. The constitution of the World Health Organization (WHO) defined health “as a state of complete physical, mental and social well-being and not mere absence of disease or infirmity�. The major role of healthcare providers is to ensure good health and well-being (Sustainable Development Goal 3). Mental illness is one of the concepts that has been grossly misunderstood and an issue largely neglected in Nigeria.1-3 Mental well-being is one of the keys in the definition of health by WHO that means neglect of mental health of patients is tantamount to incomplete state of health. Mental health disorder is one of the health issues of increasing global importance which has made it imperative for pharmacists and other healthcare professionals to define their roles in tackling mental health issues and challenges in developing countries including Nigeria. There has been an increasing recognition that primary healthcare practitioners including the pharmacist’s role in mental disorder cannot be overemphasized. Surprisingly, the clinical contribution of pharmacists in mental health has not been comprehensively defined or accepted universally. Common mental illnesses in Nigeria are schizophrenia, anxiety disorder, personality disorder, depression, postpartum psychosis among others.4 generally. It is widely conceived that one is mentally ill when one is mad. The brain is treated as though it is immune from illnesses and irredeemable by medical means when it finally gets ill or malfunctions in any way. This makes the society resort to orthodox care or spiritual healing as a remedy for mental illness.3 According to a research carried out in South Western Nigeria,5there is a high level of social distance and stigmatization of mental illness and this might be linked to the fact that it is widely believed that mental illness is a result of curse or supernatural factor or as an outcome of the abuse of psychoactive substances and alcohol.3 On a sad note, even some mental health workers show significant negative attitude towards mentally ill patients.3 Because of the stigma attached to being mentally ill and the notion that there is no medical remedy, individuals in Nigeria with any form of mental illness do not voluntarily visit mental health care centers or any healthcare personnel to access the little services available. This is evident in the WHO statistics showing that 100% of patients in Nigerian mental hospitals are admitted involuntarily.6 Mental health services in Nigeria consist mainly of large government psychiatric hospital which are ill equipped with mental health professionals and facilities to serve the large population of the country.7 Less than 15% of people with severe mental illness access mental health care services.8 Nigeria which has a population of over 170 million people has only 8 federal neuropsychiatric hospitals and similar number of university teaching hospital psychiatric departments.8,9 Recent mental health campaign and awareness programs have made the country start developing community mental health services.8 However due to the problem of stigmatization and low level of knowledge that mental illness can not be treated with medication, a very small number of people receive appropriate care.10

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Community Pharmacy and Primary Health Care Primary health care is one of the core ways World Health Organization (WHO) has set out to achieve the ultimate goal of better health for all. 11 Primary care practices serve as the patient’s first point of entry into the health care system and principal point of continuing care for patients within health system.12 Health professionals such as physicians, nurses, pharmacist or clinical officer offer primary care services for patients. In Nigeria, apart from health care services offered by private(non-government owned) hospitals and clinics, the responsibility of health care is shared among the three tiers of governments which are the Local Government area, State government and Federal Government. The Local government focuses on the delivery of primary care and primary health care centers are relatively uniformly distributed throughout the Local Government areas in Nigeria.13, 14These centers are staffed by nurses, mid wives, community health officers, health technicians, community health workers and by doctors.14 Though many, if not all, of these health centers lack pharmacist, it will be erroneous in principle to assume that pharmacists are not involved in primary care in Nigeria. The service of primary care which include health education, health screening, infant care, disease prevention, counseling, diagnosis and treatment of acute and chronic illness are perform by community pharmacist in Nigeria.15 Also, community pharmacy is the most accessible or sole provider of health care services in most neighborhoods.16 This is because no prior appointment is needed to see a community pharmacist and because of the general public’s high level of trust in them. In this light, community pharmacists serve as the first contact of a patient with a health professional and are a good representation of primary care provider in Nigeria.17 In this vein, a community pharmacist can play an important role in supporting the early detection of mental illness. Pharmacists can help to create awareness and educate the patients they come in contact with. They should be able to make their patients understand that just like any part of the body such as the eyes can have problems and can be corrected medically, the brain and its function can also develop problems which can be taken care of medically. The stigma surrounding mental illnesses stop many individuals from seeking help. Primary care pharmacist should be able to detect any symptoms of mental illness such as recurrent hallucinations, delusions, consistent depression, anxiety or mood swings and let the patient know that it can lead to complete breakdown. Such patients should be enlightened that medications are the primary treatment and administered with drugs that can lower anxiety and sadness, so that the disorder will not grow to the level where they will run mad and become admitted into psychiatric hospitals. Community pharmacists should not only dispense medicine but also try to gain access to the lifestyle of the patients in their locality. This will make the pharmacist know the harmful and unhealthy practices of the patient which could lead to mental illness or mental breakdown. Pharmacists therefore, should possess the skills to gain the patient’s trust and have them open up about the issues they are facing. It would also be helpful if a primary care pharmacist can have a certified training program within the specialty of neurology and psychiatry.18 Many patients on antipsychotic drugs for their mental disorder are also on many other psychotropic drugs which increase their risk of drug-drug interaction. Apart from this, antipsychotic polypharmacy, this is concomitant use of more than one antipsychotic drug, prevalent with the rate between 20-50%. Thus, they are inclined to face more side effects than those on monotherapy. In a review done by Bell et al. among consumers with mental disorders, the review showed that the role of community pharmacists in medication

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use cannot be overemphasized.20 The roles include medication review to optimize the use of medicines and reduce the use of potentially inappropriate dugs, medication counseling and treatment monitoring services among others.21 Screening and risk assessment services performed in community pharmacies for conditions such as diabetes, hypertension or respiratory disorder should be performed also for mental illness such as depression.17,19 Screening has been proven to be a simple and cost effective way to detect depression.17 Depression screening and risk assessment can identify on time the signs and symptoms of depression, and the community pharmacist can thereby refer the patient to appropriate healthcare professionals if need be.17 This calls for multidisciplinary approach in the handling of mental illness. References 1. Suleiman DE. Mental health disorders in Nigeria: A highly neglected disease. Ann Nigeria Med 2016; 10:47-8. doi:10.4103/0331-3131.206214 2. Mental Health: The danger of Nigeria’s single story. http://nigeriahealthwatch.com/mental-health-thedanger-of-nigerias-single-story/ Published July 27, 2017. [Accessed on November 30, 2017] 3. Armiyau AY. A Review of Stigma and Mental Illness in Nigeria. J Clin Case Rep. 2015; 5:488. doi:10.4172/21657920.1000488 4. Common Mental Disorders Affecting Nigerians. https://www.nigerianbulletin.com/threads-amp/8-common-mental-disorders-affecting-nigerians.114256/[Accessed November 29, 2017] 5. Adewuya AO, Roger OA. Distance Towards People with Mental Illness in Southwestern Nigeria.http:// journals.sagepub.com/doi/abs/10.1080/00048670801961115?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed/ First Published January 1, 2008. [Accessed December 1, 2017] 6. Nigeria - World Health Organization. www.who.int/mental_health/evidence/atlas/profiles-2014/nga. pdf[Accessed November 26, 2017] 7. Increased rate of mental disorder among Nigerians worries experts. Premium Times. 2015.https:// www.premiumtimesng.com/news/headlines/192121-increased-rate-of-mental-disorder-among-nigerians-worries-experts.html/amp/ [Accessed on November 30, 2017] 8. Eaton J, Nwefoh E, Okafor G, Onyeonoro U, Nwaubani K, Henderson C. Mental Health Awareness in Nigeria. Int J Ment Health Syst.2017;11:66 DOI 10.1186/s13033-017-0173-z 9. Esan O, Abdulmalik J, Eaton J, Kola L, Fadahunsi W, Gureje O. Mental health care in Anglophone West Africa. Psychiatric Serv. 2014;65(9):1084–7. 10. Gronholm PC, Thornicroft G, Laurens KR, Evans-Lacko S. Mental health-related stigma and pathways to care for people at risk of psychotic disorders or experiencing first-episode psychosis. Psychol Med. 2017;47:1867–79. 11. Health topic: Primary Care. World Health Organization Website http://www.who.int/topics/primary_ health_care/en/ [Accessed November 29, 2017] 12. Alma –Ata. Primary Health Care. Geneva, World Health Organization. 1978 13. Abimbola S. How to Improve the Quality of Primary Health Care in Nigeria.https://nigerianstalk. org/2012/05/11/how-to-improve-the-quality-of-primary-health-care-in-nigeria/ Published May ll, 2012. [Accessed December 1, 2017] 14. Abdulraheem I, Olapipo A, Amodu M. O. Primary health care services in Nigeria: Critical issues and

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strategies for enhancing the use by the rural communities. J. Public Health Epidemiol. 2012;4(1): 5-13. doi: 10.5897/JPHE11.133 15. Bardach SH, Schoenberg NE. Primary Care Physicians’ Prevention Counseling With Patients With Multiple Morbidity. Qual Health Res. 2012 December ; 22(12): 1599–1611. doi:10.1177/1049732312458183. 16. Association of Community Pharmacists of Nigeria.https://www.medicalworldnigeria.com/company. php?jobs_at=Association_of_Community_Pharmacists_of_Nigeria&recordstart=5&recordstart=1&recordstart=1[Accessed November 26, 2017] 17. Rubio-Valera M, Chen TF, O’Reilly CL. New Roles for Pharmacists in Community Mental Health Care: A Narative Review. Int. J. Environ. Res. Public Health 2014; 11: 10967-10990. doi:10.3390/ijerph111010967 18. How do pharmacists help patients with mental illness and neurologic disorders through CPNP?https:// cpnp.org/faq/24912/how-do-pharmacists-help-patients-mental-illness-and-neurologic-disorders-through-cpnp[Accessed December 1, 2017] 19. Ayorinde, AA, Porteous, T, Sharma, P. Screening for major diseases in community pharmacies: A systematic review. Int. J. Pharm. Pract. 2013; 21: 349361. 20. Bell S., McLachlan A., Aslani P., Whitehead P., Chen T. Community pharmacy services to optimize the use of medications for mental illness: A systematic review. Aust. N.Z Health Pol. 2005;2 doi:10.1186/17438462-2-29. 21. Rubio-Valera M, Chen TF, O’Reilly CL. New Roles for Pharmacists in Community Mental Care: A Narrative Review . International Journal of Environmental Research AND Public HEALTH. 2014; 11(10): 1096710990. Doi:10.3390/ijerph111010967.

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The global status of pharmacists in the treatment of mental illness Zaira Zafroon Phuture Editor2017-2018

According to WHO‘s global status report on non-communicable diseases ,.2010 mental disorders are one of the leading causes of disability and represents the largest cause of lost economic output .Cost effective treatments in the form of drug therapy and counseling are available for patients but many patients do not utilize these treatments) .R .Kathryn McHugh, (2014Being a regular point of contact for medications ,pharmacists could naturally have a huge role to play in the care of the mentally ill patient but the opportunities they get to do so can be quite limited in many countries .Understanding the limitations of these opportunities can help us to empower pharmacists so that they can contribute to minimizing impacts of mental disorders on the lives of the patients. Mental health is an issue which is still shrouded in mystery to the public and often stigmatized. Thus ,people often do not understand how to deal with mental illness or mentally ill patients. The Pharmacy Education Committee of IPSF created a survey that was sent to members to learn about mental illness in various countries. Out of the 37 IPSF member organizations that participated in the survey 32.4 ,percent rated their country‘s understanding of mental illness below or 5 out of .10 This may represent the biggest barrier to providing mentally ill patients with the care they need .In theory ,pharmacists can play an active role in solving this problem. They are the most regularly contacted and readily accessible part of patient‘s health care team ,and they can help patients to understand the disease better while also increasing public understanding of mental health issues .However 5 ,out of 37 organizations say that there is no contact between mentally ill patients and pharmacists in their country of residence ,and 7 out of 37 organizations say only h o s p it a l ph a r ma ci sts co me into co nt ac t w ith menta l l y i l l patient s .

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munity-based pharmacists would be on the front lines of educating patients and the broader community ,so it is not ideal that most pharmacists do not interact with mentally ill patients in many countries .Another problem is the lack decision-making power that the pharmacists have in case of treatment of mentally ill patients .In the survey ,around 70.3percent of the countries had pharmacists as part of multidisciplinary team ,but only48.6 percent of the countries allow pharmacists to make decisions regarding mentally ill patient‘s therapeutic regimen .Only in 29.7 percent of the surveye d o r g a n i z a t i o n s s a i d t h a t their respective countries had recent uptake of pharmacist in mental health care teams .From this discussion ,it is evident that for pharmacists to have an effective role in the treatment of mentally ill patients, they need more decision-making power and more contact with mentally ill patients. According to WHO‘s global status report on non-communicable diseases ,.2010 mental disorders are one of the leading causes of disability and represents the largest cause of lost economic output .Cost effective treatments in the form of drug therapy and counseling are available for patients but many patients do not utilize these treatments) .R .Kathryn McHugh (2014 ,Being a regular point of contact for medications ,pharmacists could naturally have a huge role to play in the care of the mentally ill patient but the opportunities they get to do so can be quite limited in many countries .Understanding the limitations of these opportunities can help us to empower pharmacists so that they can contribute to minimizing impacts of mental disorders on the lives of the patients.


Mental health is an issue which is still shrouded in mystery to the public and often stigmatized. Thus ,people often do not understand how to deal with mental illness or mentally ill patients .The Pharmacy Education Committee of IPSF created a survey that was sent to members to learn about mental illness in various countries .Out of the 37 IPSF member organizations that participated in the survey 32.4 ,percent rated their country‘s understanding of mental illness below or 5 out of.10 This may represent the biggest barrier to providing mentally ill patients with the care they need. In theory ,pharmacists can play an active role in solving this problem .They are the most regularly contacted and readily accessible part of patient‘s health care team ,and they can help patients to understand the disease better while also increasing public understanding of mental health issues. However 5 ,out of 37 organizations say that there is no contact between mentally ill patients and pharmacists in their country of residence ,and 7 out of 37 organizations say only hospital pharmacists come into contact with mentally ill patients .Ideally ,community-based pharmacists would be on the front lines of educating patients and the broader community ,so it is not ideal that most pharmacists do not interact with mentally ill patients in many countries .Another problem is the lack decision-making power that the pharmacists have in case of treatment of mentally ill patients. In the survey ,around 70.3 percent of the countries had pharmacists as part of multidisciplinary team ,but only 48.6 percent of the countries allow pharmacists to make decisions regarding mentally ill patient‘s therapeutic regimen .Only in 29.7 percent of the surveyed organizations said that their respective countries had recent uptake of pharmacist in mental health care teams .From this discussion ,it is evident that for pharmacists to have an effective role in the treatment of mentally ill patients ,they need more decision-making power and more contact with mentally ill patients.

Fig ;Bar

graph

representing

mental

health

care

conditions

in

different

countries

Even though 35 out of 37 respondents believe that pharmacy education and training have a big role in the future of mental health care ,only 25 of them believe that21 st century pharmacists have the necessary tools to bridge the gap between mental health care and primary health care systems .Survey respondents gave suggestions to improve the education pharmacists receive .Some believe that patients often try to hide mental health issues from everyone ,so pharmacists need to be perceptive and have great communication skills .Some put emphasis on the need for a special certification program for pharmacists to deal with mentally ill patients and conferences and other training programs on the subject .Pre-

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dominantly ,all the respondents stated that physicians deal with mentally ill patients ,and the primary method of treatment is antipsychotic drugs .Since this class of drugs is known for having side effects ,alternative and patient-focused individualized treatments are a must .According to Peter Pratt ,NHS England and NHS Improvement head of mental health and learning disability medicine” Specialist mental health pharmacists can ,and should ,be using their skills and expertise to individualize treatments for best outcomes for service users) “Robinson(2017 , Fig

;Methods

used

to

treat

mentally

ill

patients

around

the

globe

Currently ,the Board of Pharmacy Specialties offers a BPS Board Certified Psychiatric Pharmacist )BCPP (program for pharmacists to specialize in mental health ,but according to the survey ,pharmacists in most countries are not aware of this certification .In New Zealand there are opportunities for pharmacists to be certified in mental health care after graduation ,and in Indonesia there are STRA) Surat Tanda Registrasi Apoteker (an SIPA) Surat Izin Praktek Apoteker (certificates for specialization .Sadly ,other countries said such programs and certification are exclusively available for doctors. Mental illness needs to be constantly monitored ,and as pharmacists are often the most frequent health professional in contact with the patient ,they are in an ideal position to treat these patients .Increased utilization of pharmacists would also allow doctors to focus on diagnosis of other complex cases and decrease the burden on hospitals .For this situation to become a reality ,more discussion is needed on the topic of mental health and the roles of pharmacist can play .An integrated syllabus ,more workshops and soft skill building sessions are welcome strategies that can equip pharmacists to provide better care for mentally ill patients .Increased awareness and availability of certificates in this specialty area would also help to increase pharmacist‘s ability to care for patients with mental health disorders. Phuture aims to shed light on the topic of mental illness more and aims to encourage student pharmacists and practicing pharmacists to take an interest in improving their countries ‘policies regarding pharmacist role ,education ,and treatment of mentally ill patients through this year‘s theme” Mental Health Care :The new role of Pharmacists.“ Special thanks to the PEC team and Tajana Iva Pejaković, member of committee for making this piece possible by designing the survey

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research subquestionnaire.


Mental Health in Croatia and How We Can Improve It Tajana Iva Pejaković, 5th Year Pharmacy Student, Faculty of Pharmacy and Biochemistry, University of Zagreb, Croatia Abbreviations WHO – World Health Organisation CPSA - Croatian Pharmacy and Medical Biochemistry Students’ Association Introduction In Croatia, the number of people in need of help because of mental illnesses is constantly increasing. If we take a look at the population of active workers (age 20-59) in 2002, mental health illness was the second cause of hospitalization, with alcohol being the leading cause for mental disorders1. In the following years, that number kept growing. Coupled with global instability, economic crisis and stress, there are more people taking drugs for mental disorders than ever before. According to WHO, mental illness accounts for almost 20% of the burden of disease in the WHO European Region. This number represents the fact that mental health problems affect one in four people at some time in their life. Additionally, they go on to mention that six out of the 20 countries with the highest suicide rates in the world are in the European Region2.

FIG :Leading groups of diseases and their share in hospitalization (age 20-59) in Croatia, 2002 . 1

WHO puts great focus on the effect of economic crisis on mental health. Both socioeconomic and environmental factors determine the mental health of the population. For example, loss of job security and social support at work, poverty, destabilisation of public service budgets ; all have an effect on the healthy functioning of families, communities, and therefore the whole society3,4. Mental health problems can have a significant impact on the economy of a country as well. One of the

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biggest problems that arise from this problem is loss of productivity. It is estimated that productivity of

workers in European Union (EU) countries can average to 3 - 4% of their gross national product. The age should also be taken into consideration with this problem because severe mental disorders in young adulthood often lead to the long-lasting loss of productivity 5.

FIG : Determinants of population mental health5. The most vulnerable groups that will be hit by mental health problems include children, young people, single-parent families, unemployed people, ethnic minorities, migrants and older people. Additionally, unemployment, family disruptions and debt are all linked to a greater risk of mental health problems such as depression, suicide and alcohol use5.

FIG: Ratios for risk of mental illness in people with increasing number of debts5. How we can help In his open letter to UN on the right of everyone to have the highest attainable standard of mental and physical health, Special Rapporteur Dainius Pūras wrote that „“the right to health includes more than access to health services; it is also the right to the underlying determinants of health, including equality and non-discrimination, protection against violence, participation, and safe and enabling environments for health and well-being“6. While very important, the efforts of individuals are not enough to improve mental health conditions in masses – the health and well-being of people should be a matter of national concern and interest. As it was mentioned before, some of the main causes of mental health illness in Croatia are stress, economic

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crisis and instability. WHO Regional Office for Europe suggests to focus on five key areas to mitigate the prob-

lems7: 1.

Active labour market programmes

These programmes are aimed at keeping and re-integrating workers in jobs. They include public employment services, labour market training, special programmes for youth in transition from school to work and labour market programmes to provide or promote employment for unemployed people and people with disabilities. In addition to that, they put focus on programmes that build mental health resilience. Cost–effectiveness evaluations of such interventions have reported increased rates of employment, higher earnings and fewer job changes. 2.

Family support programmes

Women and children gravely suffer the effects of an economic crisis. Families, those with low income especially, are hurt by cuts in health and education budgets. This in turn can lead to increases in violence within families and child negliegnce. Family support would include monetary support for children and other dependants, and for maternity and paternity leave, as well. 3.

Control of alcohol prices and availability impact of economic crises on mental health

Policy action to increase the price of alcohol reduces consumption, deaths from alcohol use disorders and the associated harm across the whole population. Controlling availability of alcohol is one of the most cost-effective policies. 4.

Primary care for the people at high risk of mental health problems

This is the main area of focus where pharmacist can take action. The primary care approach should increase access to mental health care and shift the focus to preventing mental health problems and detecting them early. Health services should modify their work to accommodate the population needs and providing psychological support. Promoting problem-solving and good mental coping skills may protect against depression and suicidal behaviour. 5.

Debt relief programmes

Debt relief programmes help people who are suffering from the stress of excessive debt, which may also improve their mental health. The stigma and discrimination against mental illnesses remains one of the biggest challenges to overcome and it may influence the willingness of public policy-makers to invest in mental health. We should also aim to demonstrate how investing in better mental health can have big economic benefits and generate savings in many sectors. For individuals to have universal access to mental health services, it is important to use our resources to strengthen and improve our primary health care facilities. Having high-quality information is an important factor in prevention of mental disorders, and inter-professional cooperation is one of the key factors in enabling the good education of the public2,7. What we’ve been doing so far Even though a lot of things in Croatia need to be improved in regards to mental health care, there are great examples of people fighting to increase the well-being of mentally ill patients. The mental health project in Osijek started by Ladislav Lamza, a social worker, is a one of those great examples. Lamza spent most of his career as a social worker, thinking that enclosed institutions are a part of life for

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people living with mental health challenges. His whole view changed when he went to Austria and met social workers assisting people living with mental health problems, who had been deinstitutionalized. While being there, he himself said that he couldn’t see the difference between the residents and the workers. He felt guilty because he had never seen anyone rehabilitated in Croatian institutions. Therefore, he decided to make “a transition from medical model to inclusive model” - he transformed apartments into a programme of organised housing with support and began moving many of its residents – or “beneficiaries” – into shared flats around the city. There psychologists and other experts would check up on the patients and see if the therapy is going well. This way, people who have been deinstitutionalized would have an opportunity to become independent again and to find jobs in the communityInitially he had little support from his employer, the Croatian ministry for health, and a lot of resistance from many of his own staff butthe majority are now convinced by the results they see. Most importantly, all of the residents started showing remarkable improvement in their conition and are now leading normal lives and enjoying their time outside of the asylums8.

FIG: Beneficiaries in shared flats in Osijek8. As future health workers, pharmacy students in Croatia are also taking a stand and fighting against the stigma of mental health illnesses. In 2016., CPSA organised one of its biggest public health campaigns, Break the Stigma. It was held in Maksimir Park, Zagreb and aimed to educate the public about mental disorders and how to prevent them. Moreover, the theme of CPSA’s 3rd National Congress in 2016. was Understanding the brain - challenges and therapy of mental disorders. Our focus was on raising the awareness about people who are stigmatized because of mental illnesses and educate our colleagues about the importance of mental health in this day and age9.

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FIG: CPSA’s 3rd National Congress. Understanding the brain - challenges and therapy of mental disorders9. Conclusion We as pharmacists have a big role in educating the public about mental health. WHO predicts that depression will be the second cause of disability by 2020;right after the cardiovascular diseases, and the leading cause by 2030. We should take rapid action in oder to make future pahrmacist competent enough to help their patients. References 1. Silobrčić Radić M, Hrabak-Žerjavić V, Tomić B. Mentalne bolesti i poremećaji u Republici Hrvatskoj. Hrvatski zavod za javno zdravstvo, 2004; 1: pages 2-3 https://www.hzjz.hr/wp-content/ uploads/2013/11/mental_bilten_2004.pdf Accessed Nov 29th, 2017. 2. WHO Regional Office for Europe. http://www.euro.who.int/en/health-topics/noncommunicable-diseases/mental-health/mental-health Accessed Nov 29th, 2017. 3. Fryers T et al. The distribution of the common mental disorders: social inequalities in Europe. Clinical Practice in Epidemiology and Mental Health, 2005, 1:14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1242241/ Accessed Nov 28th 4. Laaksonen E, Martikainen P, Lallukka T, et al. Economic difficulties and common mental disorders among Finnish and British white-collar employees: the contribution of social and behavioral factors. Journal of Epidemiology & Community Health, 2009; 63: pages 439-446. http://jech.bmj.com/content/63/6/439 Accessed Nov 28th, 2017. 5.

WHO Regional Office for Europe. Impact of economic crises on mental health, 2011; pages

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3-7 http://www.euro.who.int/__data/assets/pdf_file/0008/134999/e94837.pdf Accessed Dec 1st, 2017. 6. Pūras D. Open Letter by the Special Rapporteur on the right of everyone to the highest attainable standard of mental and physical health, 2015; page 2 http://www.ohchr.org/Documents/Issues/Health/SRLetterUNGASS7Dec2015.pdf Accessed Nov 30th, 2017. 7. WHO Regional Office for Europe. Impact of economic crises on mental health, 2011; pages 11-14 http://www.euro.who.int/__data/assets/pdf_file/0008/134999/e94837.pdf Accessed Dec 1st, 2017. 8. McVeigh T. ‘Sweet freedom’: remarkable recoveries in a mental health project in Croatia. The Guardian, 2017 https://www.theguardian.com/global-development/2017/nov/23/sweet-freedom-remarkable-recoveries-mental-health-project-croatia Accessed Dec 1st, 2017. 9. CPSA’s 3rd National Congress. Understanding the brain - challenges and therapy of mental disorders, 2016 http://usfmbh.wixsite.com/cpsa/copy-of-congress-2015 Accessed Dec 1st, 2017.

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MENTAL HEALTH: THE NEW ROLE OF PHARAMCISTS Tayanwa,Stephen Olumide. INTRODUCTION According to World Health Organization (WHO 1984), health is the extent to which an individual or group is able to realize aspirations and satisfy needs and to change or cope with the environment. Health is a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social or personal resources, as well as physical capacities. The above Organization also describes mental health as “a state of well-being in which the Individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” and n o t j u s t t h e a b sence of mental illness. Mental illness is described as ‘the spectrum of cognitive, emotional, and behavioral conditions that interfere with social and emotional well-being and the lives and productivity of people. Having a mental illness can seriously impair, temporarily or permanently, the mental functioning of a person.

STATISTICS From statistics available, a quarter of all adults who are 18 and over in the US are considered diagnosable with mental illness. Mental illness is the leading cause of disability in the US and Canada and also 1 in 4 people experience mental health difficulties each year in the UK. Examples include, schizophrenia, Attentive Deficit Hypersensitivity Disorder (ADHD), major depressive disorder, bipolar disorder, anxiety disorder, post-traumatic stress disorder and autism. Factors that contribute to mental Health problems are, divided into various categories: Biological factors (genes or brain chemistry), Life experiences, (trauma or abuse pressure from friends, sleeping disorders, Family history of mental health problems.) According to the National Bureau of Economic Research (NBER), mental health disorders are responsible for the consumption of 38% alcohol, 44% cocaine and 40% cigarrete. Self-medication has also been linked to cases of mental disorders, for example the use of marijuana to numb pain, consumption of alcohol due to social anxiety or the use of benzodiazepines by persons struggling with panic attacks. Commonly prescribed medications that have been abused include sedatives called the benzodiazepines, such as diazepam, clonazepam, hypnotics like zolpidem, stimulants used in the management of ADHD likeamphetamines(Adderall) and methylphenidate (Ritalin), with the latter having side effects like psychosis, seizures and cardiovascular complications.

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PSYCHOTHERAPY Over the years, there has been a drift in pharmacists’ roles from drug oriented practice to patient oriented practice. This shift demands more and extensive clinical skills, and additional roles, which includes; therapy monitoring, Drug information services and pharmacovilgilance, with the latter focused on records of adverse effects from drug use. Psychotherapy comprises a series of strategies targeted at achieving and sustaining recovery from mental attacks. Examples include: Cognitive Behavioral Therapy, Exposure Therapy, and Dialectal Behavioral Therapy. Medicines remain the major treatment strategy for many mental illnesses, which is hinged on suppression of symptoms, preventing relapse, improving quality of life. Pharmacists have got a great role in promoting rational use of antipsychotics, so as to ensure therapy is optimally achieved, and this includes (1) The role of the pharmacist in mental health care in multidisciplinary teams, which involves collaborative drug therapy management and in supporting early detection of mental illness through effective and efficient diagnoses.; (2) The pharmacists’ role in supporting quality use of medicines in medication review, strategies to improve medication adherence and improving compliance in cases of antipsychotic poly pharmacy. (3) Barriers and facilitators to the implementation of mental health pharmacy services with a focus on organizational culture and mental health stigma, through an effective rehabilitative services. Patients’ response to antipsychotic drugs is seen within 4 weeks of therapy and many of these medications especially those with narrow therapeutic window cause adverse effects such as drowsiness or agitation, extrapyramidal side effects (particularly common with first- generation antipsychotics), gynaecomastia, anxiety, weight gain, metabolic syndrome etc. Patients should be given advice on managing side effects and encouraged to compile with their medication and to discuss adverse effects with their prescriber or pharmacist.

GRADUATE PROGRAMS Graduate programs that allow for specialization in mental health are available across the world. The BPS Board Certified Psychiatric Pharmacist (BCPP) program is a credential for pharmacists to practice patient-centered care that ensures the safe, appropriate, evidence-based, and cost-effective use of medications in the treatment of persons with mental illness. Psychiatric pharmacists provide therapeutic drug monitoring especially for drugs with narrow therapeutic window, like clozapine so as to prevent its harmful outcomes. The purpose of the BCPP program is to validate that the pharmacist has the advanced knowledge and experience to optimize outcomes and recovery process for patients with mental illness which involves; designing, implementing, monitoring, and modifying treatment plans for patients and also educating patients and other health care professionals The National council of behavioral health and College of psychiatric and neurologic pharmacists among others, are professional institutions that train individuals to become licensed specialists in mental health therapy through q u a l i t y di a gn o s e a n d e f fe c ti ve i mple m e ntatio n o f ph ar maceut ical c are. Attendance at Global health submits, mental health conferences and commemorations should be encouraged

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among pharmacists, so as to reinforce their clinical skills in discharging quality pharmaceutical care necessary for effective mental healthcare delivery. Also pharmacists and other healthcare professionals should make sure that patients only have access to certain antipsychotic medications upon prescriptions to ensure adequate monitoring.

REFRENCES 1. “Part 1- Theory: Thinking About Health Chapter 1 Concept of Health and Illness”. Phprimer.afmc.ca. Retrieved 201606-22 2. World Health Organization. Regional Office for Europe (1984). Health promotion: a discussion document on the concept and principles: summary report of the working group on the concept and principles of health promotion, Copenhagen, 9-13, 1984. 3. Pilkington, Stephanie (August 7, 2013).”Causes and consequences of sleep deprivation in hospitalized patients” Nursing Standard. RCN Publishing. 27 (49): 35-42

Lastly, Governments and constituted authorities should also come up with strategies and policies necessary to control the use of narcotics and other dangerous drugs to reduce its abuse among citizens.

4. “Neuropsychiatric Pharmacy FAQ”. CPNP.org. Retrieved 23 April 2017 5. The Psychiatric Shortage: Causes and Solutions. National Council for Behavioral Health. March 28, 2017. P 52

A MENTALLY SOUND CITIZEN MAKES UP A HEALTHY COMMUNITY, WHICH THEN MAKES UP

6. Wiedenmayer K.S., Mackie R.S., Gous C.A., Andries G.S., Everard M., Tromp D. Developing Pharmacy Practice :A Focus on Patient Care Handbook. World Health Organization, International Pharmaceutical Federation, Gevena, Swithzerland.

A HEALTHY NATION

g 7. The Global Burden of Disease: 2004 Update. World Health Organization; Geneva, Switherland:2008 8. DaVanzo J., Dobson A., Koenig L., Book R. Medication Therapy Management Service: A Critical Review. American Pharmacists Association; Washington, DC, USA: 2005. 9. Barnes T.R., Paton C. Antipsychotic Polypharmacy in Schizophrenia: Benefits and risks. CNS drugs. 2001; 25: 383-399. 10. Ellenor G.L., Frisk P.A. Pharmacist impart on drug use in an institution for the mentally retarded. Am. J. Hosp. Pharm 1977; 34 :604-608.

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Alzheimer’s: new theories of prevention and treatment Mohannad Abd ElFattah About the disease: Alzheimer’s disease is a chronic neurodegenerative disease that usually starts slowly and worsens over time. It is the cause of 60% to 70% of cases of dementia affecting more than 40 million people worldwide. Dr. Alois Alzheimer the German psychiatrist first described it in 1901 when he noticed that a particular patient had some peculiar problems like difficulty in sleeping, disturbed memory, drastic mode changes and increasing confusion. When the patient died, he was able to do an autopsy and so he confirmed his theory that her symptoms were caused by abnormalities in her brain structure. After analyzing her brain tissues under microscope, he noticed visible differences in brain tissues in the form of misfolded proteins called “plaques” and “neurofibrillary tangles” These plaques and neurofibrillary tangles work together to break down the brain structure. Plaques arise when another protein in the fatty membranes surrounding nerve cells get sliced up by a particular enzyme, resulting in beta-amyloid proteins, which are sticky and have the tendency to clump together. That clumping of protein forms plaques. These clumps block the signaling and there for communication between cells, and also seem to trigger immune reactions that that cause the destruction of disabled nerve cells. Regarding the neurofibrillary tangles they are built from a protein known as tau. The brain nerve cells contain a network of tubes that act as a high way for food molecules among other things. Usually the tau proteins ensure that these tubes are straight allowing molecules to pass through freely. But in Alzheimer’s disease it collapses into twisted strands or tangles making the tubes disintegrate obstructing nutrients from reaching the nerve cell and leading to cell death. The destructive pairs of plaques and tangles starts in a region called the hippocampus, which is responsible for forming memories, that’s why the short memory loss is usually the first symptom of Alzheimer’s. The proteins then progressively invade other parts of the brain creating unique changes that signal various stages of the disease.

Is Alzheimer’s disease preventable? There has been a lot of recent press regarding the presence of cognitive impairment and even dementia in NFL players who have suffered repeated head trauma and concussions. But this is not a new story. Indeed, the observation that head trauma could cause dementia was first made in the 1920s when the term “dementia pugilistica” was coined to describe the occurrence of dementia in boxers who suffered repeated head trauma. In the modern era, head trauma (particularly with loss of consciousness) was recognized as a risk factor for Alzheimer’s disease more than 25 years ago.

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Other studies have shown that head trauma is associated with increased amyloid production and neurofibrillary tangles, the classic pathological hallmarks of Alzheimer’s disease, providing a scientific basis for the relationship. Beta-amyloid is produced in the brain in response to injury, and the “tangles” are markers of neuronal injury. Like other chronic diseases, there are multiple risk factors for cognitive decline and dementia from Alzheimer’s disease. Head trauma from any source, including all forms of athletics, is very likely one of these. Preventing head trauma, especially the kind associated with concussions, could help to prevent Alzheimer’s disease.

So, How to predict it? Researchers from Duke University Medical Center have identified three chromosomal regions that play a role in the onset of the disease. Variants in each genetic segment increase the risk of dementia during specific periods of life. Two of the regions described in this study had not been found in previous studies. One of the newly identified regions determines the risk of very late-onset Alzheimer’s, in which symptoms appear after the age of 80. The other increased susceptibility for early-onset disease--between the ages of 50 and 60. For the study, published in the November issue of The American Journal of Human Genetics, Margaret Pericak-Vance, the director of the Duke Center for Human Genetics, and colleagues screened 437 families that included at least two members with Alzheimer’s disease. Using a process known as ordered subsets linkage analysis, researchers were able to identify which stretches of DNA were linked to the disease and correlate age of onset with the genetic pattern. One area of chromosome 15 was linked to families with very late-onset Alzheimer’s; variations on a stretch of chromosome 2 were correlated with early-onset Alzheimer’s. The genes that influence late-onset (between 60 and 75) lie on chromosome 15, a region that had been identified in a previous Duke study.

New ways of treatment! Director of the Easton Center for Alzheimer’s Disease Research at the University of California and neurology professor Dr. Dale Bredesen tested a fresh, extensive therapeutic program that targeted sleep, diet, exercise and stress. They studied ten patients with enough memory loss that it had significantly disturbed their employment (or forced them to stop working entirely) and shattered their personal lives. The results were impressive: Of the ten participating patients, the memory and function of nine were significantly improved. The six patients who experienced such memory loss that they were struggling or forced to quit work were all able to return. The only patient who did not experience memory improvement had severe AD symptoms. Based on initial test results, this program incorporates 36 changes or points, with each point being personalized for each patient. Some points are:

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• Removing simple carbs, gluten and processed foods from the diet. • Incorporating yoga, meditation and exercise. • Adding more fruits, vegetables and fish to the daily diet. • Sleeping at least 7 to 8 hours every evening. • Taking methylcobalamin, vitamin D3, fish oil and CoQ10 daily. Nightly taking melatonin. • Taking hormone replacement therapy. • Fasting for 12 hours between dinner and breakfast; fasting 3 hours between dinner and bedtime. • Fasting for 12 hours between dinner and breakfast; fasting 3 hours between dinner and bedtime. Could making these changes, along with a comprehensive and personalized therapeutic system, really combat Alzheimer’s and memory loss? Of course there are issues to discuss. The study looked at cognitive decline, specifically. Since Alzheimer’s cannot be definitively diagnosed until autopsy, we cannot be sure how many of the subjects had true AD. About 25- 30% of new onset cognitive decline cases are NOT Alzheimer’s and may be treatable.So again, the numbers of true Alzheimer’s patients here are just not known. Also, how long do the benefits last? The study stretched to two plus years for some of the participants, but for a lifelong disease more follow up is needed before concluding wether this is a cure vs a remission or just a slowing down of the disease progression. However, one theory holds that Alzheimer’s is a “side effect” of chronic systemic inflammation and the whole approach listed above certainly addresses that from mouth to gut to hormones to stress to vitamin deficiencies. Clearly more extensive clinical trials are needed to determine if these changes will not only improve but actually reverse the underlying brain pathology associated with Alzheimer’s disease and cognitive impairment. But, overall, this is an exciting new study. All we have to do now is to stay tuned for more results and research regarding finding new ways to stop or prevent the disease from happening or progressing. Would it be in the near future? We hope so. References: Archer, D. (2014, October 24). A New Treatment for Alzheimer’s disease. Psychology today. Retrieved from https://goo.gl/W2V19c Fillit, H. (2009, October 19). Is Alzheimer’s Disease Preventable?. Psychology today. Retrieved from https://goo.gl/FZiFXa Allen, C. (2003, November 1). Predicting Alzheimer’s. Psychology today. Retrieved from https://goo.gl/ofDKby

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International Pharmaceutical Students’ Federation

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Profile for International Pharmaceutical Students' Federation

Phuture Issue #21: Mental Health  

Discover the #21 release of Phuture: Mental Health

Phuture Issue #21: Mental Health  

Discover the #21 release of Phuture: Mental Health

Profile for ipsf.org