Damien O’Brien writes that pharmacists have the knowledge and skills to counsel patients on their condition and treatment, and make a positive impact on patient outcomes
Mental health is more than merely the absence of mental disorders. It is a state of mental wellbeing that allows individuals to cope with life stress, realise their potential, and contribute to their community. Mental health is defined as a basic human right by the World Health Organisation. It includes the biological, psychological, and social factors that make a contribution to a person’s mental state and ability to function within a community. In recent decades, mental health has been recognised, alongside physical health, as a vital component of the overall health of a person. Mental health is complex and is experienced differently for each individual. Mental health conditions exist that can cause significant distress and impairment in functioning. Individuals with mental health conditions are more likely to experience a lower level of mental wellbeing but this may not always be the case.
There are a lot of methods that individuals can use to improve their mental health and to reduce the risk of mental health disorders. Primary prevention focuses on promoting good mental health for everybody and stopping the development of mental health issues. This can include mental health awareness weeks and promoting self-care which is very important in both physical and mental health. Self-care can help reduce stress and lower the risk of illness. It must be noted that self-care is not a cure for mental illness but understanding what triggers symptoms and what coping techniques are effective can be very positive for a person’s mental health. Many different methods of self-care exist, and these include eating healthy food, getting regular exercise, getting enough sleep, and engaging in relaxing activities. Individuals can also stay connected with family and friends, practise gratitude, and focus on positivity. Secondary prevention of mental illness involves supporting individuals that are at a higher risk of suffering mental health issues. This may be due to characteristics they were born with or experiences they’ve had, and can include people who have experienced trauma and people with long-term physical health conditions.
Mental Health Disorders
A mental health disorder is characterised by a clinically significant disturbance in an individual’s cognition and behaviour, usually associated with distress and impairment in functioning. In 2019, it was estimated that one in every eight people was living with a mental health disorder, with depressive disorders and anxiety the most common conditions. There are a wide range of risk factors that can increase the risk of developing a mental illness, which can be both genetic or environmental. A history of mental illness in a family member and having a previous mental illness are risk factors. Traumatic experiences such as war, assault, or childhood history of abuse or neglect can increase the risk of developing a mental health disorder. Chronic medical conditions or traumatic brain injury can also be a risk factor for developing a mental health disorder. Excessive use of alcohol and recreational drugs, as well as stressful life situations are also significant risk factors. There are many different types of mental health disorders, and some are outlined below.
Depression
Depressive disorder is a common mental disorder that involves a low mood and aversion to activities for a prolonged period of time. Depression differs from regular mood fluctuations as it is persistent and can affect all aspects of life including relationships, work, and physical health. Depression can be categorised as mild, moderate, or severe – depending on the severity and number of symptoms and the impact on a person’s function.
Psychological symptoms of depression include continuous low mood, feelings of helplessness, low self-esteem, low motivation, irritable mood, anxiety, and having suicidal thoughts or thoughts of self-harm. Physical symptoms of depression can include low energy, loss of libido, changes in appetite, changes in weight, and sleep disturbances. Social symptoms of depression can also exist and include poor performance at work, avoiding social activities, and neglecting hobbies and interests. Different types of depression exist, which may develop due to specific circumstances:
Major depression includes symptoms of low mood that interfere with daily activities for at least two weeks;
Persistent depressive disorder may consist of less severe depressive symptoms that persist for at least two years;
Seasonal affective disorder is caused by change in the seasons, with symptoms usually starting in late autumn or early winter and are relieved in the spring and summer;
Perinatal depression occurs during or after pregnancy, with depression during pregnancy called prenatal depression and depression that begins after birth known as postpartum depression.
Anxiety
Anxiety is a feeling of unease and people will feel this at various stages in their lives. Individuals with anxiety disorders often experience worry that is excessive and intense. This worry is often accompanied with physical tension and behavioural symptoms. These are difficult to control, can persist for a long time, and cause significant distress. Anxiety disorders interfere with an individual’s daily activities and can impair functioning.
Psychological symptoms of anxiety disorders are varied but can include restlessness, a sense of dread, irritability, and difficulty concentrating. Physical symptoms associated with anxiety include trembling, excessive sweating, dry mouth, shortness of breath, dizziness, fast heartbeat, nausea and sleep disturbances. A wide range of different anxiety disorders exist and are outlined below:
Generalised anxiety disorder is persistent and excessive anxiety about many aspects of daily life and is very difficult to control;
Specific phobias are characterised by fear about specific objects or situations which they try to avoid. The fear is immediate and tends to be out of proportion to the actual danger;
Agoraphobia occurs when individuals are worried in certain circumstances that they feel that escape may be difficult. These individuals are anxious in two or more of the following situations: using public transportation; being in open spaces; being in enclosed spaces such as shops; standing in line; being in a crowd; or being outside of the home alone;
Other anxiety disorders include separation anxiety disorder, selective mutism, panic disorder, and substance-induced anxiety disorder.
Bipolar disorder
Bipolar disorder is characterised by alternating episodes of mania and depression. It is a chronic condition that affects about 1 per cent of the world’s population. The depressive symptoms of bipolar disorder are similar to the symptoms outlined above in depressive disorders. The symptoms of mania may include feelings of elation, talking rapidly, being easily distracted, being full of energy, feelings of self-importance, not sleeping, and engaging in risky actions. The pattern of mania and depression often varies, with periods of stable mood also possible between episodes.
There are three main categories of bipolar disorder, which all involve clear changes in mood and energy levels, and these are outlined below:
Bipolar I disorder is defined by manic episodes that lasts for a minimum of seven days or the manic symptoms are severe enough that immediate medical care is required. Depressive episodes generally occur, usually lasting at least two weeks;
Bipolar II disorder is characterised by a pattern of hypomanic episodes and depressive episodes, with hypomanic episodes being less severe than in manic episodes in bipolar I disorder;
Cyclothymic disorder is by characterised by hypomanic and depressive symptoms that are not intense enough to qualify as episodes.
Schizophrenia
Schizophrenia is a severe long-term disorder that is characterised by significant impairments in perception and behavioural changes. Schizophrenic patients may experience difficulties with cognitive functioning. Symptoms can be positive (changes in behaviour or thoughts), or negative (withdrawal or lack of function). Examples of positive symptoms of schizophrenia include hallucinations, delusions, and confused thoughts. Meanwhile, examples of negative symptoms of schizophrenia include lack of motivation, low concentration, lack of interest in daily activities, and feeling uncomfortable with people.
Treatment
There are several pharmacological and non-pharmacological treatment options for mental health disorders. Treatment depends on the disorder and the severity. Some drugs can be used to treat multiple conditions. A combination of pharmacological and non-pharmacological treatment is usually more effective than monotherapy in severe cases.
Pharmacological Treatment
Selective serotonin reuptake inhibitors (SSRIs)
SSRIs are antidepressants that are used as first-line pharmacological treatment of depression and numerous other psychiatric disorders due to their safety and efficacy. SSRIs exert their mechanism of action by inhibiting reuptake of serotonin and therefore increasing serotonin activity at the synapse. This is based on the theory that the cause of some psychiatric disorders is a deficiency of serotonin. SSRIs are used to treat a wide range of conditions including: major depressive disorder; generalised anxiety disorder; bulimia nervosa; panic disorder; obsessive-compulsive disorder; social anxiety disorder; and post-traumatic stress disorder. Fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, and escitalopram are all examples of commonly used SSRIs licensed for use in Ireland. SSRIs have a favourable adverse effect profile and reduced risk of overdose compared to other antidepressants. Some potential adverse effects include weight gain, sexual dysfunction, sleep disturbances, gastrointestinal pain, and dizziness. It is important to be aware of the risk of serotonin syndrome, particularly when co-administered with other drugs that may have serotonergic effects.
Serotonin norepinephrine reuptake inhibitors (SNRIs)
SNRIs are similar to SSRIs but they have the addition of inhibiting the reuptake of norepinephrine. Venlafaxine and duloxetine are the most commonly used SNRIs in clinical practice. They have a similar adverse effect profile to SSRIs but may not be as well tolerated. Additional adverse effects may include hypertension, headache, diaphoresis, and bone resorption.
Lithium
Lithium is a first-line treatment for bipolar disorder and tends to take one to three weeks to have an effect. Some patients may be not responsive to treatment, or only partial respond, which may mean titration of the dose is necessary. Lithium can have several adverse effects, and these are usually dose-related. The most notable adverse effects include nephrogenic diabetes insipidus, polyuria, polydipsia, bradycardia, confusion, memory problems, weight gain, thyroid problems, diarrhoea, and nausea. Taking lithium as a single dose at night-time can help to reduce adverse effects in stable patients. Lithium is a drug with a very narrow therapeutic index – where the therapeutic range is very close to the toxic level. Lithium toxicity can lead to interstitial nephritis, arrhythmia, sick sinus syndrome, hypotension, and bradycardia, with no antidote available. It is not recommended in patients with renal impairment and cardiovascular disease. Regular kidney function tests, thyroid function tests and an electrocardiogram are required for patients on lithium.
In 2019 it was estimated that one in every eight people was living with a mental health disorder, with depressive disorders and anxiety the most common conditions
Other Pharmacological Treatment Options
There are many other pharmacological treatment options that may be used as second-line treatment, or to control certain symptoms of mental health disorders. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) may be used for treatment-resistant depression. Atypical antidepressants, serotonin modulators, and antipsychotics are also potential therapeutic options for various mental health disorders. Benzodiazepines and beta blockers are potential treatment options for treating symptoms of mental health disorders. Alprazolam, diazepam and clonazepam are the most commonly used benzodiazepine in treating anxiety, with the most common adverse effects being drowsiness, confusion, nausea, vomiting, tremor, and respiratory depression. Extra caution should be exercised when co-administered with opioids due to the increased risk of sedation and severe respiratory depression. Propranolol is a non-cardio selective beta blocker and the most commonly used beta blocker in treating the physical symptoms of anxiety, which include increased heart rate and tremor. Common adverse effects include tiredness, headaches, cold fingers or toes, nausea, and vomiting.
Non-Pharmacological Treatment
There are many non-pharmacological methods of treating mental health conditions that can be very effective. They can be used as monotherapy or used in conjunction with pharmacological treatment. Cognitive behavioural therapy is one of the options that can be an effective treatment. It involves critically thinking about our thoughts and behaviours, which influences our feeling and habits. Electroconvulsive therapy is another option as well as other complementary and alternative treatments such as meditation and yoga.
Role of the pharmacist
Pharmacists are ideally placed in the community to promote positive mental health programmes. They can also interact with and assist in the caring of those with mental health disorders. Pharmacists should be aware of symptoms associated with mental illness and triage patients to the appropriate care provider. Pharmacists can also be an invaluable education resource for the community. As adherence to medication is a big issue in many mental health disorders, pharmacists can closely monitor adherence and make interventions if appropriate. Pharmacists have the knowledge and skills to counsel patients on their condition and treatment and make a positive impact on patient outcomes.
References on request
