Medicines Management

Medicines management is not the sole responsibility of the GP or the pharmacist. It is something that should involve, and be owned by, primary care professionals of every discipline and managers. That is not to exclude the patient himself, who should be empowered and enabled to take a far more active role in his medication

Dr Michael Dixon OBE FRCGP
Chair, NHS Alliance

Medicines management is a broad term which encompasses several aspects:

• Rational prescribing and prescribing support
• Repeat prescribing
• Patient information
• Access to medicines

Modernising Medicines Management is a guide published by the National Prescribing Centre (see Resources section for a direct web link) aiming to support NHS professionals, managers and organisations in the development and delivery of effective medicines management services. This publication is available in two parts:

Introduction

Schizophrenia is usually a chronic disorder with acute relapses.

In acute episodes, the main treatment aim is to control the symptoms as quickly and effectively as possible. This is usually best achieved with antipsychotic medication.

In chronic schizophrenia, the main aim is to avoid relapse. This can be done with antipsychotic medication, talking treatments or both together.

A variety of other treatments may have a role in people with particular problems.

What are the different treatments?

Antipsychotic medication can be classified as old (typical) or new (atypical). Some of the older antipsychotics are also available as injectable depot preparations, which only need to be taken every two to four weeks.

All the talking treatments tend to include relatively frequent meetings with a therapist, general support and illness education; as well as other elements more specific to each type of treatment.

The talking and other treatments have generally been evaluated in patients who are also taking antipsychotic medication. Much of the benefit from such treatments may arise from increasing knowledge of the illness and improving compliance with antipsychotic medication. Stopping antipsychotic treatment to receive a talking treatment may increase the chances of a relapse and may reduce the chances of benefit from a talking or other treatment.

The National Institute for Clinical Evidence (NICE) has recommended to the NHS in England and Wales that newer, (atypical) antipsychotics should be considered alongside the existing traditional medicines as a one of the first choice options to treat people with newly diagnosed schizophrenia. (Guidance on the use of newer (atypical) antipsychotic drugs for the treatment of schizophrenia: Technology Appraisal No.43 June 2003).

The choice of antipsychotic drug should be made jointly by the individual and the clinician responsible for treatment based on an informed discussion of the relative benefits of the drugs and their side effect profiles. The individual’s advocate or carer should be consulted where appropriate.

The Guidance recommends that the oral atypical antipsychotic drugs amisulpride, olanzapine, quetiapine, risperidone and zotepine are considered in the choice of first-line treatments for individuals with newly diagnosed schizophrenia.

Psychiatrist - Patient Relationships

Drug treatment should always be based on a collaborative relationship between prescribers and patients. This means that:

(a) People should always be fully informed about the likely effects of their drug treatment. There is no evidence that informing patients about side effects deters them from accepting treatment. questions about their treatment, and their questions should be answered as fully as possible.

(c) People's attitudes, side effects and response to treatment should be monitored at regular intervals .There area number of simple standardised scales designed for this purpose. There is evidence that a good collaborative relationship between prescriber and patient results in a better outcome for the individual in the long term.

A Collaborative Approach to Medication

Mental health service users should be able to make appropriate choices about their own medication.

Prescription has traditionally been seen as a process in which doctors make the decisions and patients follow. We recommend that professionals take a more collaborative stance, which enables service users to play a more active role.

Specific approaches that may be useful include:

(a) Giving people information about the benefits and hazards of treatment.

(b) The use of simple behavioural strategies such as diaries and reminders to help people remember when to take their drugs.

(c) 'Compliance therapy' is based on the approach known as 'motivational interviewing' which is often used in substance misuse services. A recent study of this approach found that it led to improved adherence with medication and a better outcome in terms of global functioning.

However, others have argued that such approaches do not sufficiently take into account the fact that not everyone benefits from medication. Each individual needs to be able to make an accurate appraisal for him or herself of the benefits and costs of taking medication.

(d) Other drugs may be prescribed in addition to or instead of antipsychotic drugs.In some parts of the world, it is common to offer people short courses of benzodiazapine medication (e.g.valium) in order to reduce anxiety in the short term prior to determining whether treatment with a neuroleptic necessary. Antidepressant medication may also be prescribed if appropriate.

(e) If, having considered all the relevant information, the service-user decides not to use medication, this decision should be respected and he or she should continue to be offered support by mental health services. We view with considerable concern the practice adopted by some clinicians of equating such a decision with 'refusing treatment' and withdrawing support as a result.