Mental Health PHAR3821

2011

Tutorial Case 1A/Prof Tim Chen

Mr. Thomas (44 years old) enters your pharmacy and appears to be very upset. He tells you that he has just been to see the doctor who was too busy to listen to him properly. He presents two prescriptions, one for Stilnox 12.5mg CR nocte and the other for Temaze 10mg 1-2nocte. He is very withdrawn and tearful and mentions under his breath that he can’t see any point to life right now.

http://farm4.static.flickr.com/3187/2888275881_06ec23f6ea.jpg

Tutorial Scenario-Part 1.• You dispense Mr Thomas’ prescriptions and take him into your

private counselling area. He explains the following information: • Recently he has been quiet, withdrawn and tearful. • He has been eating and drinking very little. • He reports feeling worthless and tells you that there is no point

to life. • One month ago his partner and only close friend died after a

serious motor vehicle accident. They had just moved back to Australia after a period of almost 5 years working in the UK. Mr Thomas had been working on and off in the creative arts fund raising area, and his partner as a well-remunerated IT consultant.

Tutorial Scenario-Part 1.• Currently Mr Thomas is unemployed, as the company he was set to join in

Australia, is no longer taking on new staff, and in fact others from the same business have been retrenched.

• Mr Thomas is an only child. His parents are no longer alive. His father died of a heart attack at the age of 45 years.

• All of his (distant) relatives work in regional Australia in the farming industry. They have been hit hard by the long-standing drought and also the global financial crisis. His extended family faces a very challenging financial situation. Although Mr Thomas kept in touch for the first year whilst in the UK, he has not been in direct contact with his relatives for the past four years.

• Although he is Australian, and is now living in Australia, he feels very alone. All of his close friends live in the UK.

• Mr Thomas (now) lives by himself in a sixth floor inner-city apartment. His apartment is new and luxurious. The view from the open balcony is spectacular. As was the case for their time in the UK, it was usual for his partner to meet most of the financial commitments they shared. He does not know how he is going to afford the rent for the apartment.

Tutorial Scenario- Part 1.• He feels that there is no point to life. Although he would never have

thought about this before, he has had thoughts about jumping off the balcony.

• Today, Mr Thomas saw a doctor at the local medical centre. The consultation was very short and he was able to get two prescriptions, one for Stilnox 12.5mg CR nocte and the other for Temaze 10mg 1-2 nocte.

• His doctor told him to try one of the tablets for sleep, and if it didn’t help, to try the other.

• He also tells you that he has been very tired but he has not been sleeping.

• Mr Thomas, aged 44 years, has no previous mental health history and until this year has been physically well.

• The only prescribed medicine he takes on a when required basis is Zomig 2.5mg PRN for migraine.

Lectures to support this case

• Medication review (Tim Chen)• Depression 1 and 2 (Tim Chen)• 5HT (Mary Collins)• Dopamine and 5HT (Tina Hinton)• Antidepressant drugs 1 & 2 (Tina Hinton)• Anxiety disorders (Tim Chen)• Amino acids 2 GABA (Graham Johnston)• Benzodiazepines 1&2 (Mary Collins)• Hypnotics, sedatives and Anxiolytics (Graham Johnston)• Clinical use of Hypnotics (Peter Carroll)

References to support this case

• Psychotropic guidelines• Cardiovascular guidelines• Endocrinology Guidelines• AMH 2011• References provided onBlackboard• Reference links in this powerpoint

presentation

Learning Outcomes

• Critically examines scientific evidence – both quantitative and qualitative – in order to arrive at evidence based conclusions

• Outlines pathophysiology associated with disease states of the central nervous system

• Demonstrates a working understanding of fundamental concepts and techniques of chemistry necessary for understanding drug delivery, drug action and therapeutics

• Demonstrates an understanding of the pharmacological mechanisms of action and the properties drugs display as biologically active molecules in living systems

Learning Outcomes

• Communicates effectively with patients, families, carers and other health care professionals

• Applies a systematic reasoning process to address a range of health and drug-related problems that present in Pharmacy

• Provides prescription medicines and appropriate advice and counselling

• Provides patient education in relation to medicines and therapeutic and monitoring devices

• Demonstrates appropriate attitudes and values in personal and professional dealings and business practice

• Works effectively and cooperatively as a member of a learning group/team

Information Gathering Prior to Tutorial 1

• WHAT ARE THE DIFFERENT CLASSES OF SEDATIVE HYPNOTICS AND HOW DO THEY DIFFER?

• ARE THERE ANY ADVANTAGES OF USING ONE SEDATIVE OVER ANOTHER?

• CAN YOU CO-PRESCRIBE THESE DRUGS?

Information Gathering Prior to Tutorial 1

• Before your tutorial you should read the following articles as well as do further research to answer these questions.– http://www.nps.org.au/__data/assets/pdf_file/

0006/82392/NPS_News_67.pdf– http://www.nps.org.au/__data/assets/pdf_file/

0011/59888/Zolpidem_position_statement_To_print.pdf

Information Gathering Prior to Tutorial 1

• WHAT IS SLEEP HYGIENE?

• Before your tutorial find out what this means and be ready to report this in class

Information Gathering Prior to Tutorial 1

• WHAT IS GABA?• WHAT ARE THE TYPES OF GABA RECEPTORS?• AT WHICH SPECIFIC GABA RECEPTORS DO

BENZODIAZEPINES ACT?• WHAT IS AN LIGAND-GATED ION CHANNEL?• WHAT IS A G-PROTEIN LINKED RECEPTOR?

• Before your tutorial refer to your lecture notes and chemistry texts to answer these questions.

Information Gathering/Processing Prior to Tutorial 1

• WHAT ARE YOUR CONCERNS REGARDING THE PRESCRIPTIONS FOR MR THOMAS?

• WHAT ARE IMPORTANT PRINCIPLES WHEN PRESCRIBING/DISPENSING BENZODIAZEPINES?

• Before your tutorial record your thoughts on any issues you have regarding his prescriptions- what would you do?

Information Gathering/Processing Prior to Tutorial 1

• WHICH BENZODIAZEPINES ARE SHORT ACTING AND WHICH ARE LONG ACTING? WHY?

• DOES THEIR HALF LIFE EFFECT TOLERENCE?

• Before your tutorial create a table listing all benzodiazepines etc and their length of action – Be prepared to copy this to the white board for discussion during class

Information Gathering Prior to Tutorial 1

• WHAT IS FLUMAZENIL AND HOW DOES IT WORK?

• Before your tutorial research this drug and its place in therapy.

Information Processing Prior to Tutorial 1

• WHICH SYMPTOMS EXPERIENCED BY MR THOMAS ARE CONSISTENT WITH DEPRESSION?

• ARE THERE ANY ASSOCIATED RISK FACTORS?

• Before your tutorial list the common signs and symptoms associated with depression and the major concerns regarding depression.

Information Gathering Prior to Tutorial 1

• WHAT IS MENTAL HEALTH FIRST AID?

• Before your tutorial refer to the following websites.– http://www.mhfa.com.au/ – http://www.mhfa.com.au/downloads.shtml– http://www.mhfa.com.au/documents/guidelines

/8191_MHFA_suicide_guidelines.pdf

Information Gathering/Processing Prior to Tutorial 1

• WHAT WILL YOU DO FOR MR THOMAS?

• Before your tutorial read the following papers. Be prepared to role play with Mr Thomas, telling him what he can do and where he can get help– http://www.sane.org/images/stories/information/fa

ctsheets/0902_info_antidepressant.pdf– http://www.plosmedicine.org/article/info:doi/10.13

71/journal.pmed.0050045– http://www.nice.org.uk/nicemedia/live/12329/4589

0/45890.pdf• Also think about STRENGTHS AND LIMITATIONS

of the PLOS article

Tutorial Scenario-Part 2.• Two weeks later Mr Thomas goes back to the local medical

centre to get another prescription for Stilnox CR 12.5mg nocte.• He sees a different doctor this time. • He also tells you that the doctor prescribed a new medicine for

his symptoms of depression and a pain medicine for migraine. • He can’t recall any specific information provided to him about

these medicines. • He asks for his prescriptions to be dispensed (Aropax 20mg daily

and Tramal SR 100mg twice daily). • He is still withdrawn and seems quite down. He has not taken an

antidepressant medicine previously.

Information Gathering/Processing Prior to Tutorial 1

• HOW LONG SHOULD HE TAKE ZOLPIDEM FOR?

• Before your tutorial comment on the recommended duration of treatment of Zolpidem and the sleep related events associated with its use – Refer to previous reading materials from NPS.

• WHAT IS THE STRENGTH OF THE EVIDENCE?

Information Processing/Delivery Prior to Tutorial 1

• WHAT WILL YOU TELL MR THOMAS ABOUT AROPAX?

• Before your tutorial review the CMI for Aropax. Be prepared to counsel Mr Thomas on this medicine

Information Processing Prior to Tutorial 1

• ARE THERE ANY DRUG RELATED PROBLEMS WITH HIS PRESCRIPTIONS IN PART 2?

• Before your tutorial document any findings and recommendations you have at this time.

During tutorial 1.• You will be asked to complete an on-line survey

• You may be asked to present interesting insights from your placement

• The tutor will ask for answers to pre-work questions

• You may be asked to record your benzodiazepine table on the whiteboard

• A role play with Mr Thomas using mental health first aid principles will occur

• A role play with Mr Thomas using the Aropax CMI will occur

• There will be discussion regarding the appropriateness of medication choices

• END OF TUTORIAL 1.

Tutorial Scenario-Part 3.• Six weeks later Mr Thomas comes by the pharmacy. • You find out that he did take the Aropax for about 4 weeks and

that he did start to feel a little better. Although he can’t really remember the details, he does thank you for taking time out the last time he was in the pharmacy and for your concern and empathy.

• His insomnia and other symptoms of depression improved after taking the Aropax for about 4 weeks. However you also find out that Mr Thomas decided not to continue to take the Aropax because he wanted to reserve it for when he was “really feeling down”.

• For the past two weeks he has had symptoms of nausea, dizziness, anxiety and headache. He tells you that he took the Tramal for headaches, and started taking the Temaze for anxiety.

• He wonders whether he is getting depressed again.

Information Gathering before Tutorial 2

• WHAT SORT OF QUESTIONS ARE ASKED TO ASSESS DEPRESSION?

• Before tutorial 2 go to the following website and complete this assessment (Kessler Psychological Distress Scale K10)– http://www.beyondblue.org.au/index.aspx?link_id

=89.678

Information Gathering/Processing before Tutorial 2

• WHAT IS SSRI DISCONTINUATION SYNDROME?• COMMENT ON PAROXETINE AND DISCONTINUATION

SYNDROME• IS DISCONTINUATION SYNDROME DIFFERENT FOR

DIFFERENT SSRIs?• HOW LONG SHOULD A PATIENT TAKE AN

ANTIDEPPRESANT?

• Before tutorial 2. review your psychotropic TGs and AMH and lecture notes to answer these questions

Information Processing before Tutorial 2

• ARE THERE ANY DRUG RELATED PROBLEMS YOU CAN IDENTIFY IN PART 3 OF THE CASE

• Before tutorial 2, document your findings and recommendations in a table for part 3 of the case

Tutorial Scenario-Part 4.• Mr Thomas has now been a regular in your pharmacy for the past

decade. • He comes into the pharmacy almost every other month. • He is now 54 years old. • He has been working for a charity organisation for the past 9 years,

first in a voluntary capacity, but now as an employee. • He enjoys this work and this has helped him form a small group of

close friends. • He is busy at work and although he enjoys the challenge, finds it quite

stressful at times. • For the past 12 months he has been stabilised on Cipramil 20 mg 2

daily. • He has developed hypertension (BP 145/90 mmHg) and his doctor

told him that he now has pre-diabetes. • He is referred to you for a Home Medicines Review.

Information Gathering/Processing/Delivery before Tutorial 2

• CONDUCT AN HMR

• Before tutorial 2. review the HMR referral form on Web CT. Complete your initial findings and recommendations based on the documentation you have.

Information Gathering/Processing/Delivery before Tutorial 2

• CONDUCT AN HMR

• Consider the following issues (and others)– What is the difference between citalopram and escitalopram?– What is his CV risk?– Comment on his alcohol intake (NHMRC guidelines)– Metformin and renal function?– Would you like other blood tests?– Is Metoprolol a good choice?– Others

Information Gathering/Processing/Delivery before Tutorial 2

• CONDUCT AN HMR

• Be prepared to interview Mr Thomas in class and complete the review

During tutorial 2.

• You may be asked to present interesting insights from your placement.

• The tutor will ask for answers to the pre-work questions.

• You will Interview Mr Thomas.

• You will complete the doctors HMR report.

• You will case-conference with the doctor.

Other references

• Psychiatry – 2nd Edition, Wiley-Blackwell (Burton)• The Maudsley Prescribing Guidelines – 10th Edition, Informa

Heathcare• Case Studies in Practice – Medication Review: A Process Guide

for Pharmacists – 2nd Edition, Pharmaceutical Society of Australia, (Chen, Moles, Nishtala, Basger)