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Australian Journal of Pharmacy : October 2006
counselling casebook • approved CPE Dr Jenny Gowan PhD, FPS, FACPP, HMR Facilitator, Northern & North East Valley Divisions of General Practice, Melbourne, Consultant Pharmacist Associate Professor Louis Roller BPharm, PhD, FPS, FACPP, Department of Pharmacy Practice, Victorian College of Pharmacy, Monash University pharmacy Antipsychotic medicines: chemical restraint or not? T WENTY per cent of Australian adults are affected by mental illness at some time in their life. Episodes of men- tal illness can come and go throughout a person’s life. Some people experience their mental illness only once and then fully recover. Unfortunately, only about half of those affected by mental illness receive treatment.1 There are two main categories of mental illness: 1. Depression and anxiety disorders Depression affects about 16 per cent of adults and anxiety dis- orders affect about 10 per cent of adults at some point in their life. The conditions of depression, sadness, tension or fear, pho- bias, obsessive compulsive disorder are so disturbing they affect the person’s ability to cope with day-to-day activities. Conditions that can cause these feelings include anxiety disorders, for exam- ple, phobias, obsessive compulsive disorder, eating disorders and depression. 2. Psychotic illness The more serious psychotic illnesses include schizophrenia which affects about 1 per cent of Australian adults and bipolar disorder (previously called manic depressive illness) which can affect up to 2 per cent of the population. Psychosis causes changes in a person’s thinking, emotions and behaviour. People who experi- ence an acute psychotic episode lose contact with reality and may develop delusions or hallucinations. Other forms of psychosis include drug-induced psychosis and some chronic forms of depression. The causes are not fully understood but may include stressful life events, drug abuse and hormonal changes.1 Up to 10 per cent of people affected by mental illness commit suicide compared to an average of 1 per cent for the whole pop- ulation. With treatment and support, the majority of people with mental illness will recover well. Organisations such as SANE Aus- tralia (telephone 1800 18 SANE (7263) or www.sane.org.au) can offer support as well as local doctors and community mental health services.2 Clinical treatments Medications are the main form of treatment for people seriously affected by mental illness. Different types of medication treat dif- ferent types of mental illness: • Antidepressant medications. About 60 to 70 per cent of people with depression respond to initial antidepressant treat- ment. In addition to depression, these medications are now used (in combination with psychological therapies) to treat phobias, panic disorder, obsessive compulsive disorder and eating disorders. 78 ? THE AUSTRALIAN JOURNAL OF PHARMACY VOL.87 OCTOBER 2006 • Antipsychotic medications are used to treat psychotic ill- nesses (for example, schizophrenia and bipolar disorder) with variable results often due to low adherence. The first antipsychotic medications (chlorpromazine) were developed in the 1950s and allowed most people with a mental illness to live in the community rather than spending many years in a psychiatric hospital. The typical antipsychotic agents, such as phenothiazines, haloperidol and others, were effective but produced adverse effects such as extrapyrimidal and anticholinergic side effects, sedation, postural hypoten- sion, sexual dysfunction, neuroleptic malignant syndrome, retinal pigmentation, ECG changes and hyperprolactinaemia. Second generation antipsychotic medications have assisted further in management due to a lower adverse event profile. This group is not homogeneous and differ in pharma- cological properties, efficacy adverse effect profile but overall are better tolerated. • Mood stabilising medications are used for people who have bipolar disorder (previously known as manic depression). These include lamotrigine, lithium, sodium valproate, carba- mazepine and others.3 • Psychological therapies are based on the idea that some of the problems related to mental illness occur because of the way people react to, think about and perceive things. They can reduce the distress associated with symptoms and can even help reduce the symptoms themselves. Psycholog- ical therapies may take several weeks or months to show benefits. Different psychological therapies used in the treatment of mental illness include: • Cognitive behaviour therapy (CBT) examines how a per- son’s thoughts, feelings and behaviour can get stuck in unhelp- ful patterns. The person and therapist work together to develop ways of thinking and acting. Therapy usually includes tasks to perform outside the therapy sessions. CBT may be use- ful in the treatment of depression, anxiety disorders and psy- chotic disorders. • Interpersonal psychotherapy examines how a person’s relationships and interactions with others affect their own thoughts and behaviours. Difficult relationships may cause stress for a person with a mental illness, and improving these relationships may improve a person’s quality of life. This ther- apy may be useful in the treatment of depression. • Dialectical behaviour therapy is a treatment for people with borderline personality disorder (BPD) to help people to better manage their emotions and responses.