Consultant pharmacist Dr Siobhan Gee PhD speaks to Kathy Oxtoby about a new report from the Lancet Psychiatry Physical Health Commission looking in depth at the holistic prevention and management of physical health side effects from psychotropic medication, and its importance for clinical practice.
The landscape of managing mental illness is constantly evolving and recent years have seen new formulations enter the market that are having a positive impact on patient care.
‘We now have many more options for long-acting antipsychotic injections (LAIs) and very long-acting antipsychotic injections (VLAIs), says Dr Siobhan Gee PhD, consultant pharmacist and deputy director of pharmacy at South London and Maudsley NHS Foundation Trust, as well as clinical director of the Mind and Body Programme at King’s Health Partners and honorary senior lecturer at King’s College London.
‘The comparison to oral antipsychotics in terms of outcomes has become much clearer: that long-acting antipsychotic injections are much more effective in preventing relapse and inpatient hospital admissions.’
Understanding the nature of clozapine induced blood dyscrasias has also developed. ‘Critically, it is about the better identification of clozapine induced agranulocytosis being distinct from non-clozapine related clinically insignificant neutropenias,’ she says.
Often these two conditions have been ‘blurred into one’, Dr Gee explains. ‘There is an assumption that any neutropoenia in a person taking clozapine is a dangerous agranulocytosis. That assumption has meant that a lot of people have had their clozapine needlessly stopped, or they’ve never started it in the first place due to having low neutrophils at baseline. Many of these patients are from Black ethnic groups and so this results in inequity of access to treatment.’
However, a better understanding of the difference between the two conditions has led to a relaxation in the requirements for mandatory full blood count monitoring in Europe.
‘We’re hoping [this] is going to increase access to clozapine for people who need it,’ Dr Gee says. ‘We are hopeful that the Medicines and Healthcare products Regulatory Agency (MHRA) will follow suit in the UK.’
Physical health monitoring and support in mental health
Acknowledgement of the need to concurrently support the physical health of people with mental illness is also driving changes to the treatment landscape.
The first report of the Lancet Psychiatry Physical Health Commission in 2019 provided a blueprint for this. It highlighted the importance of moving away from fragmented care for people with mental illness to focus on protecting both physical and mental health.
This September, the Commission published its second report, looking in depth at the holistic prevention and management of physical health side effects of psychotropic medication.
Co-led by clinical experts from King’s College London, the University of Oxford and the University of Queensland, the Commission calls for people taking psychiatric medications – such as antidepressants, antipsychotics, and mood stabilisers – to receive ‘proactive, ongoing physical health monitoring and support’.
While these psychotropic medications are essential in the treatment of many mental health conditions, they can cause significant physical side effects, such as diabetes, weight gain and high blood pressure. These complications are often under-recognised and undertreated in routine care.
Side effects can impact physical health and quality of life and lead to non-adherence, compromising the associated benefits of treatment, the report says.
As such, the Commission systematically reviewed the available evidence across 11 major side-effect domains, including metabolic, cardiovascular, renal, sexual and neurological complications.
‘Out of that systematic review came proposals for core monitoring and management strategies, all of which begin with a comprehensive physical health assessment at the point of prescribing,’ says Dr Gee, who co-authored the new report.
This pre-treatment assessment is followed by early monitoring, for example, weight checks within four weeks, and long-term follow-up of cardiometabolic markers, such as blood sugars, cholesterol and blood pressure.
Actionable advice for adverse effects of psychotropic medication
The report ‘pulls together all of the existing literature into one place’, Dr Gee explains. ‘It gives an overview of the current evidence base and summarises that for clinicians.’
And it includes details and actionable advice for the prevention and management of adverse effects, which pharmacists can use as a helpful tool in their practice. Indeed, Dr Gee says: ‘Pharmacists are dedicated to making sure that patients get the best outcomes from medicines. A large part of that is in preventing and managing side effects.’
For many expert mental health pharmacists, the content of this Commission, ‘is not going to be a surprise’. However, for non-specialists, including members of the wider multidisciplinary team, the report acts as a crucial one-stop resource. This is enhanced by the fact that it is grouped by side effect profile, rather than by psychotropic drug type. ‘That makes it practically very useful, and more accessible if you’re a non-specialist,’ says Dr Gee.
The report includes information on prevention, monitoring and intervention. ‘It’s precisely instructive,’ she explains. ‘It tells you what to do and when to do it. It’s not “you should just monitor”, or “you should treat the blood pressure”. It tells you how, with what drug, with what dose, and how to follow the patient up.’
It also features a heat map ranking for antidepressants and antipsychotics, which shows how likely a drug is to cause different side effects. ‘It’s a helpful visual tool for reference, and a great aid to thinking about the importance of the different side effects for the individual patient,’ Dr Gee says.
Person-centred care and service optimisation
Person-centred care, shared decision-making and individualised prescribing of psychotropic medicines are crucial and therefore the report notes that its content was ‘guided by people with lived experience of mental illness and incorporates their perspectives, experiences and preferences in relation to psychotropic prescription and side-effect management’.
The heat maps can also be used during consultations to help patients as well as healthcare professionals. ‘If you’re having a discussion with a patient about medicine options, those sorts of visual tools can be really handy,’ Dr Gee says.
More broadly, she says the report provides an opportunity for individual services and Trusts to consider whether they are providing a standard of individualised care that meets the cutting-edge approach that it sets out and to identify areas in which improvements can be made.
‘It’s important to identify the gaps, because that’s where we need to focus work in the future,’ Dr Gee says, adding that she hopes the report will ‘provide an evidence base to underpin individualisation of medication use, and that it will become the best practice standard’.
Shifting towards implementation
An overview of the steps that should be taken to implement best practice in clinical care are outlined in the Lancet Psychiatry Physical Health Commission’s third report.
‘The third report talks about the challenge of implementation as we have an implementation gap,’ Dr Gee explains. ‘The benefits of the interventions are well established. We need to shift towards implementation research, and that’s about how to embed those interventions as core clinical practice. The third report is a call to action for implementation research in the field.’
Implementation will require input from other specialties. ‘Collaboration between mental and physical healthcare providers is essential to deliver shared decision-making, and individualised and optimal care of the whole patient – that holistic care goal,’ she says. ‘Without working across specialisms, we are never going to have truly integrated care. Then we will never fully address the mortality gap for serious mental illness.’
This mortality gap is something that has existed in serious mental illness for decades and Dr Gee says it has not yet been addressed.
‘Patients with serious mental illness continue to fall through the gap between services, so system change is important,’ she says. ‘Our patients with serious mental illness are, in effect, living in the 1950s in terms of life expectancy. That’s an urgent inequality gap that needs some focus. There should be people shouting about it. This is a vulnerable group of people who often don’t have a very loud voice. We owe it to them to be that voice.’
System-level change has to be informed by evidence and patients themselves, and the Lancet Psychiatry Physical Health Commission’s reports go some way to achieving that.
Getting the psychotropic medication basics right
For Dr Gee, it is important to ‘get the basics right’ in terms of evidence-based psychotropic treatment options.
In a healthcare landscape increasingly focused on prevention, she highlights the need for greater recognition of the ‘very strong association’ between the effective treatment of mental health conditions and reduced physical health mortality.
‘Optimising the treatment of the mental health condition has a big impact on physical health outcomes,’ she says. ‘Side effects are one thing, but actually just getting the mental health treatment right reduces mortality itself. The link between those two things is not well recognised.’
Her longer term hopes for the management of psychotropic medications and mental illnesses themselves include ‘access to clozapine for everyone who needs it, so reducing the inequalities of care that currently persist; increased use of long-acting antipsychotic injections, as these are the formulations that are most effective in preventing relapse; and the reduction of stigma around mental health medication’.
Unsurprisingly, improved recognition of the link between good mental healthcare and physical health outcomes is also on her wish list, and pharmacists have a role in supporting this.
‘Use this report,’ she concludes. ’It will give you confidence.’