1 December 2011 CMHP Bulletin Reflecting on a year of change Message from the Immediate Past President This has been a year of significant change and many of us have had to cope with a degree of uncertainty unprecedented in our professional careers. Old familiar structures are going or have gone and in many cases we are still unclear what will replace them. Against this background it would be easy to despair for the future. However, despite the “doom and gloom”, the annual CMHP conference was once again a major success. In particular, the Saturday morning session, where a succession of pharmacists showcased their forward-thinking initiatives was, for me, the highlight of the weekend. The success of the annual conference is the result of hard work by a team of people behind the scenes. Space does not permit me to name all the individuals who contributed but it would be remiss of me not to pick out three individuals for special mention. First: Dave Branford, who acted as co-ordinator during the final stages of planning. Second: Graham Newton who single-handedly negotiated with the venue and the exhibitors, and ensured the event ran smoothly over the weekend, to mention just some of his input. Last, but by no means least: Denny Humphries, who has organised conference applications and registration for as long as I have been a member. She is completely unflappable and is always at hand throughout the weekend offering timely advice and reminders. Her presence at the conference this year was particularly appreciated by Council members. Of course, the conference would not be a success without delegates — the individual members (especially those who self-fund!) who give up their weekend to attend and the chief pharmacists who continue to find funds in their training budget to support their staff members’ attendance. Without the members — it all means nothing. As I first mentioned in March’s CMHP Bulletin, three Council members stood down over the course of the year – Marion Walker, Clare Mundell and Steve Bazire. I make no apologies for thanking them again. Their direct input into Council meetings will be sorely missed by current Council members. Finally, since I have now handed over to Denise Taylor at November’s Council meeting, I would just like to add that it has been a pleasure and an honour to lead the CMHP through the change from the UKPPG into the new, charitable CMHP. Stephen Guy (HELDER ALMEIDA / DREAMSTIME.COM) From the new President Hello everyone. It is a nerve-wracking business taking over any role that has been vacated by a respected colleague who has performed at the highest level. I am glad that Stephen Guy, as Immediate Past President, will be helping to guide me and the wider Council. We are looking forward to the challenge of ensuring that the CMHP remains at the forefront of any policy decisions that include medicines in the area of mental health, no matter what the sector. To help the CMHP attain this goal our Council members will be working hard to fulfil their designated roles and responsibilities. A list of Council members and their positions is included on p2. Denise Taylor In this issue... Welcome to December’s CMHP Bulletin. In this issue, we bring you news about the CMHP, including details of the new Council (p2). Some highlights from September’s conference are on p3. Our featured article reports an audit performed to assess compliance with a point of good practice in the use of CTO11 forms (p4). A round-up of mental health pharmacy news from around the globe can be found on p6. Updates for pharmacy technicians and from the Prescribing Observatory for Mental Health are included on p7, and the CMHP Bulletin closes with Stephen Bleakley’s popular “Top texts” (p8). If you would like to contribute to the CMHP Bulletin, please contact Denise Taylor ([email protected]). Clinical Pharmacist The CMHP Bulletin is now being produced by the staff at Clinical Pharmacist (PJ Publications) in collaboration with the CMHP. Two pages of highlights from the Bulletin appear in December’s issue of Clinical Pharmacist. Issue 7 December 2011 page Audit of community treatment order forms C M H P B u l l e t i n www.cmhp.org.uk ISSN 2045-838X
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1
December 2011 CMHP Bulletin
Reflecting on a year of changeMessage from the Immediate Past President
This has been a year ofsignificant change andmany of us have had tocope with a degree ofuncertaintyunprecedented in ourprofessional careers.Old familiar structuresare going or have goneand in many cases weare still unclear what
will replace them. Against this backgroundit would be easy to despair for the future.However, despite the “doom and gloom”,the annual CMHP conference was onceagain a major success. In particular, theSaturday morning session, where asuccession of pharmacists showcasedtheir forward-thinking initiatives was, forme, the highlight of the weekend.
The success of the annual conference isthe result of hard work by a team ofpeople behind the scenes. Space does notpermit me to name all the individuals whocontributed but it would be remiss of menot to pick out three individuals for specialmention. First: Dave Branford, who actedas co-ordinator during the final stages ofplanning. Second: Graham Newton whosingle-handedly negotiated with the venueand the exhibitors, and ensured the eventran smoothly over the weekend, tomention just some of his input. Last, butby no means least: Denny Humphries, who
has organised conference applications andregistration for as long as I have been amember. She is completely unflappableand is always at hand throughout theweekend offering timely advice andreminders. Her presence at the conferencethis year was particularly appreciated byCouncil members.
Of course, the conference would not be asuccess without delegates — the individualmembers (especially those who self-fund!)who give up their weekend to attend andthe chief pharmacists who continue to findfunds in their training budget to supporttheir staff members’ attendance. Withoutthe members — it all means nothing.
As I first mentioned in March’s CMHPBulletin, three Council members stooddown over the course of the year – MarionWalker, Clare Mundell and Steve Bazire. Imake no apologies for thanking themagain. Their direct input into Councilmeetings will be sorely missed by currentCouncil members.
Finally, since I have now handed over toDenise Taylor at November’s Councilmeeting, I would just like to add that it hasbeen a pleasure and an honour to lead theCMHP through the change from theUKPPG into the new, charitable CMHP.
Stephen Guy
(HELDER ALMEIDA / DREAMSTIME.COM)
From the new PresidentHello everyone. It is a nerve-wracking business taking over any role that has beenvacated by a respected colleague who has performed at the highest level. I am gladthat Stephen Guy, as Immediate Past President, will be helping to guide me and thewider Council. We are looking forward to the challenge of ensuring that the CMHPremains at the forefront of any policy decisions that include medicines in the area ofmental health, no matter what the sector. To help the CMHP attain this goal ourCouncil members will be working hard to fulfil their designated roles andresponsibilities. A list of Council members and their positions is included on p2.
Denise Taylor
In this issue...Welcome to December’s CMHP Bulletin.In this issue, we bring you news aboutthe CMHP, including details of the newCouncil (p2). Some highlights fromSeptember’s conference are on p3. Ourfeatured article reports an audit performedto assess compliance with a point of goodpractice in the use of CTO11 forms (p4). Around-up of mental health pharmacy newsfrom around the globe can be found onp6. Updates for pharmacy techniciansand from the Prescribing Observatory forMental Health are included on p7, andthe CMHP Bulletin closes with StephenBleakley’s popular “Top texts” (p8). Ifyou would like to contribute to theCMHP Bulletin, please contact DeniseTaylor ([email protected]).
Clinical PharmacistThe CMHP Bulletin is now beingproduced by the staff at ClinicalPharmacist (PJ Publications) incollaboration with the CMHP. Two pagesof highlights from the Bulletin appear inDecember’s issue of Clinical Pharmacist.
Issue 7 December 2011
page Audit of community
treatment order forms
CMHP
Bulletin www.cmhp.org.uk
ISSN 2045-838X
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2 NEWS + EVENTS
CMHP Bulletin December 2011
Who sits on CMHP Council?November 18 saw the first CMHP Councilmeeting following the annual generalmeeting that was held at the conference.
Denise Taylor was elected as President andMichael Marven as Vice President. StephenGuy is Immediate Past President,supporting the new Council. All other formalpositions will be decided at February’sCouncil meeting, along with the newCouncil’s aims and objectives for the nextyear. Council members are listed below:
• Dr Denise Taylor (President) • Mr Michael Marven (Vice President) • Mr Stephen Guy (Immediate pastPresident)
• Dr Dave Branford • Mr Stephen Bleakley (Registrar) • Ms Ann Andrews (Pharmacy TechnicianRepresentative)
• Ms Wendy Ackroyd• Mr Andy Down • Mrs Katherine Delargey • Ms Trudi Hilton • Mr Ian Maidment • Ms Michele Sie • Ms Anita Solanki • Prof David Taylor• Prof Stephen Bazire (British Associationfor Psychopharmacology liaison)
Denise Taylor comments: “With the currentand continual changes in health and fiscalpolicy, we will be seeking our members’advice and support to ensure that we leadin medicines optimisation in mental health.Watch this space for the opportunity toadvise on and shape our future together.”
Date for the diary The next “Psych 2”course will take place on 20–21 April2012. Visit www.cmhp.org.uk for moredetails.
DENISE TAYLOR, CMHP PRESIDENT
Accreditation
Registrar’sreportThis year 10 members have beenaccredited — congratulations go toCaroline Parker, Denise Taylor, HannahMacfarlane, John Lawton, Jules Haste,Patricia Mabeza, Ray Lyon, SalwaMorcos, Corina Young and AmandaGulbranson.
This brings our current accreditedmembership to 67. Five members werere-accredited — congratulations to KateMasters, Dave Branford, Michele Sie,Stephen Guy and Amanda Parkinson. Thefull list of accredited members has beenupdated and is available atwww.cmhp.org.uk.
All 18 viva vignettes have now beenreviewed and I am indebted to theaccreditation panel — David Taylor andthe team at South London and MaudsleyNHS Foundation Trust — for theirinvaluable help with this.
• Thursday 27 September, BarcelóHinckley Island Hotel, Leicestershire(deadline for portfolio submission, 10 August)
A huge thank you must go to all thecurrent accreditation panel members —Michele Sie, Kyra Sycamore, LynnHaygarth, Helen Shaw, Ian Maidment,Priti Ved and Amanda Kelso. Withoutthem accreditation would not be possible.
As part of our commitment to supportingthe professional development ofpharmacists specialising in psychiatricpharmacy practice, an email discussiongroup has been established, which ismoderated at “yahoogroups” by GrahamParton.
By joining this group you will be able tocontact all fellow group members bysending a message to just one emailaddress. Thus, if you have a question,comment, query or idea, you can askadvice or share it with colleaguesrapidly, easily and cheaply. To join, youneed to either:
• Send an email to [email protected]; please includeyour name and address, CMHPmembership number and any otherrelevant details; or
• Visit www.yahoogroups.com/group/cmhpuk; your subscribe emailwill be sent automatically to themoderator (email [email protected]) who will then senda confirmation of joining
CMHP matters
We are currently looking for volunteers tohelp review a forthcoming NICE guidelineabout autism spectrum disorder in adultsand conduct disorders in children. Pleaseemail Stephen Bleakley (see Registrar’sreport, adjacent, for contact details) if youwould like to help — it looks good on theCV! — or if you would like to beconsidered to review any future guidelines
New clinical eventThe CMHP has agreed to support the ClinicalPharmacy Congress, being held on 20–21April 2012 at the London ExCeL (note thatthese are the same dates as “Psych 2”). Asdescribed by Dave Branford: “The congressis an exciting and innovative opportunity forclinical pharmacists from any specialism orsector to learn more about mental health andfor mental health pharmacists to not onlyimprove their knowledge about mental healthproblems and treatments but also learn aboutother areas of medicine.” Registration formsare available to download at www.pharmacycongress.co.uk — please indicate on theform that you are a CMHP member.
Volunteers soughtfor NICE guideline
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CONFERENCE 3
December 2011 CMHP Bulletin
Conference award winners announcedOver 200 delegates attended the annualconference at Hinckley Island,Leicestershire, from 30 September to 2 October 2011. Highlights from theweekend are too numerous to report fullyon this page and details of thepresentations given, together with morephotographs taken at the event, areavailable on our website, www.cmhp.org.uk.
Here we list our award winners. We shouldpoint out that help from colleagues wasinvaluable in undertaking much of the workfor which awards were won, but it is themain authors only who are detailed below.
Fellowship Helen Shaw, Oxfordshire andBuckinghamshire Mental HealthPartnership NHS Foundation Trust, andMargaret Davies, Somerset PartnershipNHS Foundation Trust, were named as the2011 Fellows of the CMHP in recognitionof their significant contribution topsychiatric pharmacy.
Service development poster award DavidTait, Coventry and WarwickshirePartnership NHS Trust won the servicedevelopment category for “Benchmarking
how mental health trusts manage andprescribe medicines — A West Midlandsmental health chief pharmacist’sapproach”. Runner up was Andy Down,West Midlands mental health clinicalpharmacist, for “Development of a MentalHealth Training Package”.
Audit poster award Graeme Brown,Birmingham and Solihull Mental Health NHSFoundation Trust, won the audit categoryfor “Audit of the antipsychotic prescribingin older adults”. Runner up was AoifeDavis, St John of God Hospital, Stillorgan,Dublin, Ireland, for “From pen to patient:improving prescription-writing practice in apsychiatric teaching hospital”.
Preregistration bursary award The winnerof the CMHP preregistration bursary awardwas Lorna Hand (pictured, right), MilbrookMental Health Unit, Sutton-in-Ashfield, for“An audit of clozapine use in assertiveoutreach teams”. Runner up was SarahWarda, Central and North West LondonNHS Foundation Trust, for “An audit ofCT011 form attachment to drug charts”.(The feature on p4 reports the findings ofthis audit.)
Undergraduate bursary award EleanorBevan, Medway School of Pharmacy, wonthe CMHP undergraduate bursary awardfor “Community pharmacists’ recognitionand response to symptoms ofdepression”.
STEPHEN GUY PRESENTS THE PREREGISTRATIONBURSARY AWARD TO LORNA HAND
Positive practice
Do pharmacists take“positive risks”?Pharmacists should take more positive risks. If they do so,patient care as well as their own career progression can benefit.These were among the conclusions from a discussion sessionchaired by Roy Lilley, who relentlessly questioned the Councilmembers who were presenting as to how they could movemental health pharmacy forward in the current climate ofunprecedented change in the NHS.
The work of two mental health pharmacists who had clearlytaken “positive risks” was also presented at the conference.Pharmacist Salwa Morcos, formerly of Kent and Medway NHSand Social Care Partnership, saw her role very much as being acore member of a crisis team. Although remodelling services inthis way might not currently be feasible for all trusts, some ofthe resources developed by Ms Marco and colleagues to makemedicines recording safer, in particular the patient groupdirections and the “orange forms”, were potentially readilytransferable.
Mike Leonard, from Tees, Esk and Wear Valleys NHSFoundation Trust, outlined how he independently prescribes forpatients at complex medicine clinics, and how he has kept theservice running when cover from psychiatrists was hard tocome by. Retaining the role when more “psychiatrist time”became available was not without its challenges, he explained.
Dementia
Person-centreddementia careAlthough environmental factors are important, genetics alsoplay a large part in determining who is at a higher risk ofdeveloping dementia, explained Julie Williams, professor ofpsychological medicine at Cardiff University.
Research to identify and analyse the key genes involved indementia has also highlighted several potential diseasemechanisms, particularly those involving endocytosis, immuneresponse and lipid processing, she continued.
Person-centred care for those who have dementia, which takesinto account an individual’s background, lifestyle, personalityand other health issues, is a current focus of improvingtreatment, particularly in care homes, explained SimonManchip, consultant in old age psychiatry, Avon and WiltshireMental Health Partnership NHS Trust.
Knowing when not to prescribe, as well as when to prescribe, isalso key, according to Clive Ballard, professor at the WolfsonCentre for Age Related Disease, King’s College, London. This isparticularly the case for antipsychotics, which studies haveshown can actually worsen a patient’s quality of life, he added.Guidance for managing dementia, and how this is to beincorporated into the “WHELD” study, was also discussed byProfessor Ballard.
Highlights from Hinckley
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4 FEATURE
CMHP Bulletin December 2011
Community treatment orders and CTO11 forms
CTO11 forms are used to specifyall of the psychotropicmedicines (and medicines usedto treat the side effects of
psychotropic medicines) included in thecare plans of patients who are the subjectof a community treatment order (CTO).Community treatment orders wereintroduced by changes to the MentalHealth Act (MHA) in 2007 and provide a
framework to allow patients to continuepsychiatric treatment in the community,rather than in hospital, under appropriatesupervision (known as supervisedcommunity treatment)1 — see Box below.
The code of practice that accompanies theMHA2 states that: “As a matter of goodpractice, a copy of the certificate relatingto medication should be kept with the
patient’s medicine chart (if there is one) tominimise the risk of the patient being giventreatment in contravention of theprovisions of the Act.” While adherence tothe code of practice is not a legalrequirement, it is to be encouraged toreduce the likelihood of mental healthmedicines that are not part of a patient’scare plan being prescribed for them.
At Central and North West London NHSFoundation Trust a baseline audit wasperformed to determine the extent ofadherence to this aspect of good practice.The audit also sought to determinewhether patients’ prescribed psychotropictreatment corresponded to that outlined intheir CTO11s.
MethodsThe records of nine community mentalhealth teams (CMHTs) within Central andNorth West London NHS Foundation Trustwere reviewed for the audit. Local MHAofficers identified all patients at the trustwho were the subject of a CTO. Therecords of these patients were thenchecked on the local electronic patientrecord system to identify which (if any)psychotropic medicines were prescribedfor them.
Data relating to patients who were notprescribed psychotropic medicines; who
(HELDER ALMEIDA / DREAMSTIME.COM)
All the mental health medicines included in the care plan of patients who are thesubject of a CTO of at least a month’s duration must be approved by a second opinionappointed doctor (SOAD) appointed by the Care Quality Commission (CQC). TheSOAD must then produce a certificate in the form of a “CTO11”, which specifies thepsychotropic medicines (either by drug name or BNF code) included in the care plan,together with any medicines to treat the side effects of psychotropics — eg, hyoscinehydrobromide for clozapine-induced hypersalivation and antimuscarinics forextrapyramidal side effects. Medicines for concomitant medical illnesses need not beincluded.
These requirements apply regardless of whether a patient consents to treatment. Useof a CTO11 is similar to the use of T2 (Certificate of consent to treatment) and T3(Certificate of second opinion) forms for detained patients at inpatient units.
Psychotropic prescribing for a patient who is the subject of a CTO is limited to thosemedicines detailed on his or her CTO11, regardless of whether such prescribing is by apsychiatrist, GP or non-medical prescriber.
What are community treatment orders and CTO11 forms?
Audit
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had been the subject of a CTO for lessthan one month at the time of the audit; orwhose prescribed medicines were notprovided by the mental health trust (eg,they were provided by their GP or anotherexternal service) were excluded.
Psychotropic medicines were categorisedas: “depot antipsychotics”, “clozapine”and “other oral psychotropics”. Forclozapine and other oral psychotropics,repeat outpatient prescription charts heldat hospital pharmacy departments at thetrust were reviewed.
For depot antipsychotics, prescriptioncharts held at the offices of the localCMHTs were reviewed. The pharmacydepartments and CMHT premises werethe only locations where prescriptioncharts would be held if the trust wascontinuing to prescribe for a particularpatient.
Data were collected over a period of fivedays in November 2010 by pharmacystaff.
Results At the time of the audit, 75 patients, underthe care of 24 different consultantpsychiatrists, were the subject of a CTO ofat least one month’s duration. Electronicrecords confirmed that 69 of thesepatients were prescribed psychotropicmedicines, although it was clear that onepatient was receiving an oral psychotropicfrom his or her GP and his or her datawere therefore excluded from the audit.The audit results are summarised in theTable below.
Discussion Data obtained in this audit showed thatCTO11 forms were attached to just over afifth of the prescription charts that were
located. All of these charts were for depotpreparations and were from a singleCMHT. The relatively small proportion ofprescription charts found with CTO11forms attached suggests thatadministrative processes may need to beredesigned and/or a programme of stafftraining implemented.
It is encouraging that, where CTO11 formswere attached, there were no discrepanciesbetween the medicines that had beenprescribed for patients and those thatwere listed on the CTO11 forms.
Electronic records Importantly, it shouldbe noted that an electronic copy of eachcompleted CTO11 form is stored on therelevant electronic patient record and isaccessible to all healthcare professionalsinvolved in that patient’s care. A “legalalert” is highlighted on the main page ofthe electronic record where MHA issuesare relevant. For patients treated in thecommunity such an alert can only be for aCTO.
This system is in place to ensure that allhealth professionals involved in a patient’scare are aware of his or her current statusunder the MHA. It was designed tocounter the concerns of the CQC, whopreviously identified that lack ofcommunication between hospital teamsand CMHTs was a national issue, resultingin some patients being discharged fromhospital on a CTO without the relevantCMHTs being made aware of this,potentially leading to subsequentproblems with patient care.3
Despite these electronic records and legalalerts being in place, without a hard copyof the CTO11 form being attached toprescription charts, there is a risk thatprescribing errors may unwittingly occur.
Limitations The implications of these auditresults are limited by the small samplesize. In particular, approximately half ofthe prescription charts for patients knownto be the subject of a CTO were notlocated (n=35).
It is likely that these patients were actuallyreceiving their prescriptions from their GP(although this could not be verified fromthe electronic records), and their datawould therefore have been excluded fromthis audit.
Alternatively, for depot antipsychotics, it ispossible that the chart was actually in useby members of the CMHTs at the time ofthe audit (eg, to administer the medicine).Checking CTO11 records held in GPsurgeries was beyond the remit of thisaudit but could potentially be the focus ofa future audit.
ConclusionThe majority of prescription chartsidentified for patients who were thesubject of a CTO had no CTO11 formattached.
All of the prescription charts that had aCTO11 form attached were for depotantipsychotics and all of the psychotropicmedicines prescribed on them werecompliant with the approved treatmentplan.
Administrative processes need to berobustly designed and implemented toensure that these forms are attached toprescription charts to minimise the risk ofunintentional prescribing errors.
Conflict of Interests None
Ethical approval Not required because thestudy was approved as an audit
By Alexandra Cain, advanced specialistpharmacist, Sarah Warda, rotationalpharmacist (and preregistration traineeat the time of the study), and CarolineParker, consultant pharmacist, all at StCharles Hospital, Central and North WestLondon NHS Foundation Trust
1. Department of Health. Mental Health Act 2007Chapter 12. London: The Department; 2007.
2. Department of Health. Code of Practice: MentalHealth Act p214. London: The Department; 2008.
3. Bartlett K. CQC annual report highlights concernsover the use of CTOs. Mental Health Law Briefing161; Radcliffes Le Brasseur; January 2011.Available at www.rlb-law.com (accessed 23 May2011).
Audit results
Type ofpsychotropicmedicineprescribed
Number ofpatientsprescribedmedicine type
Number ofprescriptioncharts located
Number ofcharts withCTO11 formattached
Number ofchartscompliant withCTO11 form
Depotantipsychotic
37 21 7 7
Other oralpsychotropics
20 1 0 N/A
Clozapine 11 11 0 N/A
Total 68 33 7 7
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6 PRACTICE UPDATES
CMHP Bulletin December 2011
YorkshireYorkshire pharmacy in psychiatry held itsannual general meeting on 28 June, atwhich the current chair, Ruth Setchell,announced her intention to serve one moreyear in the role and then stand down. PaulHardy was retained as group secretary.
October saw the first meeting of the2011/2012 season, with two casepresentations. The first considered thechoice of mania prophylaxis for a womanintending to start a family — interestinglyan individual whose bipolar disorder firstmanifested after exposure to antimalarialprophylaxis some years before. Thesecond described the convoluted butultimately futile attempts to maintainclozapine supplies for someone whowished to take an extended retreat to amonastery in the Balkans. At November’smeeting, Robert Flanagan discussedclozapine therapeutic drug monitoring.Future meetings are scheduled for thesecond week of the month.
Republic of IrelandSeveral pharmacists who work in“approved centres” joined consultantpsychiatrists and senior nurses for apsychiatric medicines management dayat Farmleigh House, Dublin, in October. Apresentation from Aoife Davis from theIrish Medication Safety Networkhighlighted the benefits of having clinicalpharmacists in multidisciplinary teams.Current medication charts were reviewedand a start was made to design anational template chart for psychiatryinpatients. The new design should beavailable in January 2012.
I was delighted to be asked to present atthe second Mental Health Liaison Nurseconference in Tullamore also in October.Again, the benefits of close workingrelationships between nurses and clinicalpharmacists were among the themesdiscussed.
New ZealandKia ora. As ever it has been a busy time!Our special interest group (SIG) wasrecently involved in updating the mentalhealth component of the national
pharmacy intern training days. Thisupdated training was delivered withexcellent feedback this year and last andwill hopefully be published soon.
The 2011 SIG seminar was held inDunedin in August. Our keynote speakerwas associate professor Chris Aldermanfrom University of South Australia,Adelaide. He spoke about post traumaticstress disorder, issues relevant to medicalco-morbidities in depression and thepharmacological management of bipolaraffective disorder. Hot topics discussedincluded the optimal use of clozapine,especially with respect to GP prescribing.
Corina Young (who recently became anaccredited CMHP member — see p2)remains our SIG co-convenor, along withGuna Kanniah from Waikato. I havestepped down as I am returning to theUK, so this will be my last missive fromAotearoa. E noho ra to my SIG whanau.
SussexOver the past couple of months, financialpressures have suddenly become the keyfocus for our trust and all the directoratesare listening to our recommendations onhow best to save money. In anticipationof quetiapine becoming generic next yearwe are actively moving away fromquetiapine XL and over to the immediate-release preparation. One stumbling blockwe have found is that patients whom wehave initiated on once-daily immediate-release products are returning for reviewhaving been prescribed the XLpreparation elsewhere — and so we areworking with PCTs to resolve this.
However we don’t just want to talk aboutmoney. A half-day medicinesmanagement update for non-nursemental health staff has been extremelypopular, such that we are looking atfinding capacity to increase the numberof training sessions we can offer. It is vitalthat all of those acting as careco-ordinators have a basic understandingof medicines and what sorts of side effectstheir patients may be troubled with.
Our Brighton team are welcoming twovisitors from Sweden at the end ofOctober. They will be joining us after a fewdays with Celia Feetam in the Midlands.
It will be interesting to see what theythink of our well developed medicinesmanagement technician services.
WalesSo, what is happening in Wales? The AllWales Medicines Strategy Group providesadvice on new medicines and decideswhich medicines should be used in Wales.On its list for drugs not recommended foruse, we have quetiapine XL for majordepressive episodes in bipolar disorder,oral paliperidone and olanzapine depot.Intramuscular paliperidone is to bediscussed next week. There are no plansto discuss asenapine and individualhealth boards will need to decide forthemselves whether or not they want touse this drug.
The “Wales 1000 lives plus” campaignseeks to improve the quality of patientcare and reduce avoidable harm acrossNHS Wales. Of the 14 components, oneto provide better treatment for peoplesuffering with a mental health disorder(including ensuring that those withdementia in care homes do not receiveinappropriate antipsychotic treatment)has just started. Another component is toprovide risk assessments for venousthromboembolism (VTE). A pilot projectto determine how this can best beapplied in mental health inpatient units isabout to start.
USAThe College of Psychiatric andNeurologic Pharmacists (CPNP) wasofficially founded in 1998, but actuallystarted in the early 1970s as a specialinterest group within the AmericanSociety of Health-system Pharmacists.Currently we have 1,170 members.
In October, we launched our manifesto inwhich we publicly declare our principles,beliefs, intentions and visions for thefuture relating to psychiatric pharmacy tothose inside and outside of our profession.It makes interesting reading and can befound at www.cpnp.org/about/manifesto.
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PRACTICE UPDATES 7
December 2011 CMHP Bulletin
What is new for pharmacy technicians?It is now nearly six months since theregistration of pharmacy techniciansbecame mandatory. What does this meanfor us? The title “pharmacy technician” isnow protected and pharmacy techniciansare now recognised as members of ahealthcare profession. In line with othersuch professional groups, the requirementto register ensures that only those qualified,competent and under a duty to maintainhigh standards are able to practise aspharmacy technicians. Patient safety andcare will ultimately be enhanced.
CPD Registration has also madecontinuous professional development(CPD) mandatory. For some, the prospectof completing nine mandatory records in a12-month rolling period seemed daunting.But CPD should build on previousknowledge, skills and experience andshould form part of pharmacy technicians’personal development plans (PDPs). Itshould also help support careerdevelopment and increase job satisfaction.
It is important to take responsibility fordeveloping and monitoring our own CPDand PDPs. Take the time to ask yourselfthe following questions:
• What training and/or courses have Iundertaken recently?
• Which of my skills am I currently using? • Do I possess all the necessary skillsand competences to do my job as
well as I would like? If not, what can Ido about it?
Training opportunities The answer to “whatcan I do about it?” often involves exploringeducation and training opportunities. Aswell as addressing any gaps in yourknowledge, the right kind of training canexpand your skill set, which might beinstrumental in you acquiring moreresponsibilities. Here are some trainingcourses to look out for:
• The CMHP’s “Psych 1” course is runannually as a three-day residentialcourse and is available to pharmacytechnicians who are at band 5 andabove (see www.cmhp.org.uk)
• Certain modules of Aston University’sdistance learning packages andpostgraduate courses are available to
pharmacy technicians. Details areavailable at www.aston.ac.uk
• The University of Bath runs anintroduction to mental health as adistance learning course with a two-dayface-to-face event. Visitwww.bath.ac.uk for more information
• Several universities and colleges offercertificates in medicines managementfor pharmacy technicians, as well asfoundation degrees. These coursesusually require part time attendance —eg, day release
Competence Another development forpharmacy technicians has been theintroduction last year of the “General levelpractice framework for pharmacytechnicians in medicines management”,which has since been renamed as the“Framework for pharmacy technicians”.Created by the Competency Developmentand Evaluation Group, this providesguidance about evidence of competence,together with a checklist.
I hope that this overview has been helpful.In my role as pharmacy technicianrepresentative on Council, I am working onyour behalf. So if there is anything youwould like the CMHP Council to consider,please email me. It is only by having avoice that we will begin to make changes.
Update from AstonUniversityNine pharmacists were awarded the PostgraduateCertificate in Psychiatric Therapeutics this year.Congratulations go to: Nigel Barnes, CarolineMollison, Malcolm Griggs, Christine Rowe, CarolineHynes, Ameen Saleem, Patience Kuwana, RebeccaTindall and Gurdeep Major. A further 12 pharmacistswere awarded the Postgraduate Diploma inPsychiatric Pharmacy. Congratulations go to:Alexandra Cain, Claire Gordon, Sally Jordan,Caroline Chiu, Anne Cole, Roisin McCanney, LucyCornell, Laura McKee, Aoife Davis, Matthew Reeve,Catherine Edwards and Abbie Young.
Catherine Edwards, of St Andrew’s Healthcare,Northampton, was awarded the Helen Tennant prizeas the best overall diploma student of 2010/11. Shewas presented with her prize at the CMHP annualconference.
Benchmarked reports
Prescribing Observatory for Mental HealthTrusts should by now have received their benchmarked reports for 6c —the assessment of side effects in patients prescribed a depotantipsychotic — from us at the Prescribing Observatory for Mental Health.Data collection is almost complete for 7c — lithium monitoring — and yourreports should be with you early in the new year.
We are now currently recruiting for the 2012 programme, which includes anew quality improvement programme (QIP) to address prescribing forpeople with personality disorder. The dates for the regional workshops canbe found on the POMH website, as can the date and details for the POMHlearning event that will be held early next year. As ever, a huge thank yougoes to all who support and champion POMH QIPs at your trusts.
We hope participation helps to improve the way in which medicines aremanaged and keeps medicines on trust boards’ agendas.
Contributed by Carol Paton, Oxleas NHS Foundation Trust, Kent [email protected]
Education + training
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CMHP Bulletin December 2011
Updated BAP practice guidelinesOur esteemed colleagues from The British Association forPsychopharmacology (BAP) have recently produced twoupdated evidence-based guidelines — one for schizophreniatreatments and the other for antidementia drugs. Both (Barnes etal, Journal of Psychopharmacology 2011;25:567; O’Brien J et al,Journal of Psychopharmacology 2011;25:997) should be high onyour reading list.
Another fantastic Cipriani study . . .. . . this time on antimanic drugs. This delightful multiple-treatments meta-analysis included 68 randomised control trials,with studies lasting between two and six weeks. Data relating to14 antimanic drugs, versus placebo and against each other,were evaluated. The study ranked haloperidol, risperidone andolanzapine top for efficacy and olanzapine, risperidone andquetiapine top for acceptability. Gabapentin, lamotrigine andtopiramate were found to be no more effective than placebo(Cipriani A et al, Lancet 2011;378:1306).
Lithium better than valproate in bipolar disorderThis large observational study reviewed the national Danishregister of people with bipolar disorder from 1995 to 2006. Itadds to the body of evidence favouring the use of lithium.Those receiving valproate (n=719) had significantly higher ratesof switching (HR=1.89) and of hospital admissions (HR= 1.33)than those receiving lithium (n=3,549) (Kessing L et al, BritishJournal of Psychiatry 2011;199:57).
Should we switch everyone to aripiprazole?The CAMP (Comparison of antipsychotics for metabolicproblems) study investigated patients being treated witholanzapine, risperidone or quetiapine and who had a body massindex of ≥27 and who either continued with their existing drug orwere switched to aripiprazole (n=215, 24 weeks). The“aripiprazole switchers” had improved metabolic parameters buthad a higher rate of discontinuing their treatment (Stroup T et al,American Journal of Psychiatry 2011;168: 947).
A new atypical antipsychoticThis six week, randomised control phase 3 study compared twodoses of lurasidone (40mg or 120mg) with placebo or with anolanzapine control group (n=478). Both doses of lurasidone andolanzapine were more effective than placebo at six weeks butthere was no difference between either of the lurasidone dosesand olanzapine. Note: lurasidone is an atypical antipsychoticwhich was launched in the US in February 2011 and is predictedto be launched in the UK in 2013 (Meltzer H et al, AmericanJournal of Psychiatry 2011;168:957).
What dose of flupentixol decanoate should we use?According to this review, to prevent relapse in patients withschizophrenia, no more than 50–60mg of flupentixol decanoateshould be used every four weeks because there is no evidenceof increased survival rates with doses above this. Unfortunatelythough, the evidence base is poor with only eight long-termstudies (duration of 24 weeks to 18 months, n=247) having beenpublished between 1974 and1990 (Reed P et al, The Psychiatrist2011;35:293).
No improvement in depression in Alzheimer’sDisappointingly, neither sertraline (150mg/day) or mirtazapine(45mg/day) were shown in this multi-centre, double-blind,randomised, placebo-controlled trial to improve depression inpatients with Alzheimer’s disease after 13 weeks of treatment(n=111 on control and 107 on active treatment) (Banerjee S et al,Lancet 2011;378:403).
Brush up on PTSDFor a well written, succinct overview of post traumatic stressdisorder (PTSD) look at: Bleakley S et al, The PharmaceuticalJournal 2011;287:295. Can’t beat a bit of self promotion!
Another fine example of our members’ good work Carol Parton and her inspirational team at the PrescribingObservatory for Mental Health have recently published themedicines reconciliation audit data. As expected, pharmacyteams were shown to discover 62–80% of all discrepancies onadmission (Paton C et al, Therapeutic Advances inPsychopharmacotherapy 2011;1:101).
Equipped to QIPPThe recently published mental health medicines use efficiencyschemes (or “Tips to help you QIPP”) — from the QIPPmedicines use and procurement workstream — wereco-ordinated by David Branford and presented at conference,prompting much discussion (available at www.cmhp.org.uk).
And finally . . .. . . look out for the following, which have been published recentlyor are shortly to be made available:
• The 2012 Psychotropic Drug Directory (ISBN 10:0956915604)
• The new Maudsley Prescribing Guidelines, 11th edition (ISBN 10:0470979488)
Contributed by Stephen Bleakley. Feel free to email any suggestionsfor future “top texts” to [email protected]
Toptexts
CMHP Bulletin is produced quarterly on behalfof the College of Mental Health Pharmacy byClinical Pharmacist (PJ Publications). PJPublications is a division of Pharmaceutical
Press, a wholly ownedsubsidiary of the RoyalPharmaceutical Society,1 Lambeth High Street,
London SE1 7JN (tel 020 7572 2425; [email protected]). The contentof and information contained in this publicationis the responsibility of the College of MentalHealth Pharmacy. The content is not influencedby advertising and it is produced independentlyof the pharmaceutical industry. For editorialenquiries contact Denise Taylor (email
