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Australian Journal of Pharmacy : June 2005
mental health_june05.qxd 10/05/2005 2:35 PM Page 444 mental health Newer antipsychotics more effective long term S TUDIES in the US indicate that schizophrenia patients taking newer atypicals stay on treatment for longer than those taking older, typical antipsychotics. The studies were presented at the International Congress on Schizophrenia Research held recently in Savannah, Georgia. According to report in American Journal of Psychiatry(2004;161:692–699) almost 60 per cent of people with schizophrenia do not take their medications as prescribed by their doctors. Recent observational studies conducted in Australia found that as the incidence of people using the new atypicals rose, the average costs of hospitalisation decreased by almost one-third. (Schizophrenia Care and Assessment Program). undergraduate pharmacists to deal with people with mental health disorders, as pharmacists are often reluctant to discuss depression with patients. According to Dr Crockett, studies have revealed that patients welcome the interaction with pharmacists, and mostly a prompt is often all that is required to start a discussion. The report also identified the need to co-ordinate the various roles of the health professionals involved, in order to move towards a more holistic model of mental health care management and provision in rural communities. The main recommendation from the report was that the results were sufficiently positive to justify a larger research project over at least an 18-month time frame. Dr Crockett said: ‘Given that this pilot study was relatively small, we were only able to follow patients over a two month period, which was not long enough to monitor any change in depression levels. ‘Similar international studies have continued over a longer time frame. But we believe the evidence is there to support a longer study with preferred follow-up at six, nine, 12 and 18 months. ‘Patient feedback was outstanding from the vast majority of the 119 patients that included men and women, although it was predominantly women, with an average age of 46 years for participants.’ Dr Crockett believes this is the first time a study like this has been undertaken in Australia. Dr Crockett was assisted by pharmacist Dr Susan Taylor, senior lecturer in rural pharmacy at the University of Sydney Faculty of Pharmacy, and two project officers, pharmacist Anita Grabham and mental health nurse Pam Stanford. Where to for SSRIs? Professor Patrick McGorry, professor of psychiatry at the University of Melbourne, believed the adolescent depression issue certainly needs more research, following reports about the risk of suiciderelated behaviour to adolescents and children posed by selective serotonin reuptake inhibitors (SSRIs). Professor McGorry claimed that due to lack of funding for research into this area, it is likely that many young patients will not receive appropriate treatment. The reports followed an analysis by the US Food and Drug Administration from studies—‘many of which have not been published’—that showed a significant increase in suicidal thinking and suicide attempts linked to SSRIs. ‘I have a problem linking children with adolescents because children are quite different to adolescents in relation to mental disorders. Adolescents are more similar to adults, especially older adolescents.’ Professor McGorry said while there does appear to be an increased risk in suicidal behaviour, there has been no increase in mortality or completed suicides. ‘This black-and-white idea that justifies a ban or restriction on the use of this class of drugs is a totally dichotomous way of responding, which means that the 99 per cent of patients who are helped by taking these medications are deprived of benefit, compared to those who might be harmed. There has to be a risk-benefit analysis and Benefits for CT C ognitive therapy (CT) may be as effective as medical therapy for the initial treatment of moderate to severe depression, according to results from a US study reported in the Archives of General Psychiatry, but the degree of effectiveness is dependent on the expertise of the therapist. Reports from another study suggested that CT has an enduring effect similar to that of maintenance medical therapy. this has not been done,’ Professor McGorry said. SSRIs, he said, should not be considered as a first line treatment in depressed young people. ‘These patients should be receiving counselling, psychotherapy and cognitive behaviour therapy (CBT) first. If the condition persists or is severe, then it is necessary to prescribe an SSRI as the next step. What are you going to do if a patient is not getting better, let them stay severely depressed?’ Professor McGorry said the risk of suicide in a small percentage of patients could be managed by monitoring, or by prescribing one of the new anti-psychotic drugs, such as quetiapine, in low doses to help reduce anxiety and agitation. ‘Psychological and social forms of treatment and self-help strategies, such as staying active, exercise and trying herbal remedies like St Johns wort, can help depression if it is not too severe, but once the disorder becomes moderate-to-severe then antidepressants are necessary.’ According to Professor McGorry, an estimated one-third of those with depression do not respond to initial treatment; but after a series of steps the figure falls to about 20 per cent. ‘The figures are similar to schizophrenia. While most respond well to treatment, there is a subgroup that don’t, and are very treatmentresistant.’ An experimental treatment showing promise in the treatment of depression is transcranial magnetic stimulation (TMS), a non-invasive technique that Professor McGorry said uses an electromagnet to alter brain activity. s THE AUSTRALIAN JOURNAL OF PHARMACY VOL.86 JUNE 2005 444