Guest Editors: Kiran Hewitt (Research Portfolio Holder, CMHP) and Ciara Ni Dhubhlaing (Past President, CMHP)
Psychological wellbeing and psychotropic medication use in people living with serious mental illness in Australia
Amanda J Wheeler1, Jack C Collins2, Jie Hu1, Sara S McMillan1, Claire O’Reilly2, Sarira Elden2, Ricki Ng2, Theo Theodorus3
1Griffith University, Southport, QLD, Australia
2University of Sydney, Camperdown, NSW, Australia
3Metro South Mental Health Services, Brisbane, QLD, Australia
Introduction: People living with severe and persistent mental illness (SPMI) may experience high levels of psychological distress resulting from complexities with managing their mental health, co-existing physical conditions, medication regimens, stigma and social disconnection. Higher levels of psychological distress are associated with increased mortality; of particular concern for the SPMI population with higher risks of reduced life expectancy compared to the general population. Increased psychological distress may also indicate worsening SPMI.
Aims and Objectives: To explore psychological distress levels using the Kessler (K6) scale and psychotropic medication management (focusing on polypharmacy and high-dose prescribing) in an adult cohort experiencing SPMI living in the Australian community between September 2020 and July 2021.
Method: As part of a randomised controlled trial (RCT), community pharmacists recruited people living with SPMI taking antipsychotics or mood stabilisers from three Australian states/territories. Participants completed an electronic survey including the K6 and a medication review with a pharmacist who was asked to provide a distress report when participants recorded ‘very high’ (⩾19/30) K6 scores; a convenience sample of reports for the first 150 recruited participants was explored. All psychotropic medications were recorded and reviewed for alignment with clinical guidelines.
Results: In total 326 participants recruited from 51 community pharmacies had baseline data for analysis: mean age 47 years, 53% female, 60% reported ⩾2 mental health conditions (predominantly moderate-severe mood (57%) and/or anxiety disorders (45%)), 45% ⩾2 physical health conditions, 22% a hospital admission in previous 6-months. Participants were prescribed an average of two psychotropic medications (range: 1–6); 84% ⩾1 antipsychotics, 69.5% ⩾1 antidepressants, 46% ⩾1 mood stabilisers, 18.5% 1–2 benzodiazepines. Polypharmacy within a medication group was recorded for less than 20% of participants; highest rates occurred with mood stabilisers (19%) and antipsychotics (18%). High-dose treatment was recorded for 19% of participants. At baseline, 25% of participants reported ‘high’ (14–18/30) and 34% ‘very high’ (⩾19/30) K6 scores. Amongst the first 150 participants, 59 reported ‘very high’ K6 scores, and although 25 exhibited signs of psychological distress, none indicated acute mental health crisis. Precipitating factors included family/personal circumstances, medicines changes/adverse effects, substance use.
Discussion: Experiencing high/very high levels of psychological distress was common for more than half (59%) of this community-dwelling participant population. In comparison, the 2020–21 Australian National Study of Mental Health and Wellbeing found 15.4% of the general population reported high/very high levels.1 With recent research demonstrating increased mortality among those with high distress,2 there is a critical need to identify those at risk and reduce distress with tailored holistic healthcare. Overall, psychotropic prescribing did not diverge greatly in terms of polypharmacy and/or high dose prescribing compared to published literature. However, it highlights the importance of regular medication reviews and strengthened communications with consumers and prescribers in community mental healthcare settings.
Conclusions: Community-based, pharmacist-led services are well placed to address medication-related problems and improve health and wellbeing and provide engagement opportunities to reduce distress, and hence, premature mortality for people living with SPMI.
References
1. Australian Bureau of Statistics. National Study of Mental Health and Wellbeing 2020–21. Canberra, Australia: ABS; 2022.
2. Barry V, Stout ME, Lynch ME, et al. The effect of psychological distress on health outcomes: A systematic review and meta-analysis of prospective studies. J Health Psychol. 2020;25(2):227-39.
(Funding acknowledgement: The PharMIbridge RCT received funding from the Australian Government Department of Health and Aged Care).
Dosing accuracy of direct-acting oral anticoagulants in a mental health hospital
Xander Man1, Siobhan Gee2
1King’s College London, London, UK
2South London and Maudsley NHS Foundation Trust, London, UK
Introduction: Four direct-acting oral anticoagulants (DOACs) are licensed in the UK – apixaban, edoxaban, rivaroxaban, and dabigatran. Dosing of DOACs is individualised by indication, renal function, weight, age, and concurrent prescriptions. Published data show up to one in five medical inpatients are prescribed incorrect doses.1 Underdosing may result in treatment failure (thrombosis), overdosing may cause serious bleeding. There are no published studies examining the accuracy of DOAC dosing in psychiatric inpatients.
Aim: To examine the dosing appropriateness of DOACs in a mental health hospital.
Audit Standards: 100% of doses should be prescribed as indicated in the relevant summary of product characteristics.
Method: Pharmacy dispensing records were used to identify inpatients at South London and Maudsley NHS Foundation Trust (SLaM) prescribed a DOAC in a 12 months period. Clinical notes were manually searched for patient demographics (sex, age, weight, ethnicity, mental health diagnosis), serum creatinine, dose and indication of DOAC, past medical history, and concurrent medication.
Results: A total of 91 patients were prescribed a DOAC in the audit period. Of these, 63% were male (n = 57), the majority were White (n = 51, 56%), and mean age was 60 years (range: 25–85). Mental health diagnoses were categorised as psychotic disorder (n = 40, 44%), mood disorder (n = 33, 36%), cognitive disorder (n = 12, 13%) or ‘other’ (n = 6, 7%). The majority of patients were prescribed rivaroxaban (n = 43, 53%), and the most common indication was prevention of embolism in atrial fibrillation (n = 35, 40%). In total, 86% of patients received correct doses of DOACs (n = 78), and 11% (n = 10) of patients were incorrectly dosed. Dosing for the remaining three patients (3%) could not be categorised – in two cases, serum creatinine levels were not recorded, and one patient received rivaroxaban for an unlicensed indication. Of the 10 incorrect doses, half were overdosed, and half were underdosed. Incorrect dosing was due to a contraindication (uncontrolled severe hypertension, n = 1), incorrect dose for the indication (n = 4), incorrect dose for the patient’s weight (n = 1), and failure to adjust the dose following initial loading doses (n = 4).
Discussion: In this audit of DOAC prescribing in mental health inpatients, more than 1 in 10 patients were prescribed incorrect doses. This is a lower error rate compared with prescribing in medical inpatients.1 Nonetheless, given the potential consequence of either under or overdosing, improvement in prescribing is needed. Prescribers were informed of the audit results, and pharmacy staff reminded of the importance of carefully checking doses. This audit was conducted prior to the introduction of electronic prescribing (ePMA), and as part of the implementation of change following the audit, the role of ePMA prompts to improve the accuracy of prescribing is being investigated. A repeat audit is planned to assess the impact of these improvement measures.
Conclusions: Dosing errors for DOACs are common for both medical and psychiatric inpatients. Particular care should be taken when prescribing. Evaluation of the role of electronic systems to increase safety should be undertaken.
References
1. Sanghai S, Wong C, Wang Z, et al. Rates of potentially inappropriate dosing of direct-acting oral anticoagulants and associations with geriatric conditions among older patients with atrial fibrillation: The SAGE-AF study. J Am Heart Assoc. 2020;9:e014108.
Burnout and resilience of pharmacy professionals in the United Kingdom post COVID-19 pandemic: A mixed-methods, cross-sectional survey
Amy King1
1North East London NHS Foundation Trust, London, UK
Introduction/Background: Post COVID-19 pandemic, increased demand on healthcare services and levels of workplace stress and burnout have been reported.1 Burnout, an occupational phenomenon resulting from chronic occupational stress, may lead to psychological exhaustion, cynicism, and reduced workplace efficacy and is a concern for professionals and service users. Burnout research in healthcare has generally focused on professionals outside of pharmacy. An international systematic review1 and meta-analysis discussing the mental health impact of the COVID-19 pandemic on healthcare professionals identified 70 studies published up until October 2020, none had been conducted on pharmacy professionals. Research continues to emerge after the pandemic. A subsequent systematic review2 identified 19 articles investigating burnout of pharmacists and found increased workload and burnout related to the pandemic was associated with medication error and likelihood to leave current employment. However, the review2 excluded pharmacy technicians and assistants and did not identify any data from the UK. Research examining burnout in the pharmacy workforce that is inclusive of all pharmacy professions, job roles and healthcare sectors is limited.
Aims and Objectives: The research aimed to survey the wider pharmacy workforce in the UK including different pharmacy professions, job roles and sectors addressing previous gaps in burnout research. The objectives were to measure prevalence and severity of burnout alongside resilience in pharmacy professionals and describe factors that support and inhibit perceived wellbeing.
Method: An online questionnaire was distributed via Microsoft Forms® comprising demographic and job role information and two validated scales. The Copenhagen Burnout Inventory3 was used to measure burnout in three domains; Personal Burnout, Work-related Burnout and Client-related Burnout. The Connor-Davidson Resilience Scale4 was used to assess resilience of respondents. Challenges and supportive factors during the COVID-19 pandemic were explored using free-response questions.
Results: 285 responses were received from multiple pharmacy professions and sectors. Most respondents reported moderate or high levels of Personal Burnout and Work-related Burnout alongside low levels of resilience. Client-related Burnout was reported as low by most respondents. Staffing levels, workload, organisational change, and work–life balance were significant workplace challenges. Remote working, digital growth and teamwork were positive changes reported. Shared experience of colleagues, flexible working and effective leadership were perceived as major supportive factors.
Discussion: There were interesting findings when burnout level and type were compared between demographic, job role and sector groups. Personal Burnout was highest for females, parents and carers. Work and Client-related burnout were highest for single people and those without parental or caring responsibilities. Business owners and retail sector professionals in retail reported highest burnout scores in all subscales. Narrative given regarding supportive and inhibitive factors also produced interesting themes. Pharmacy assistants and technicians requested increased management support whilst managers cited needing more staff. Flexible working was valued more by pharmacists and managers than peers in more technical and operational roles.
Conclusions: After tackling the challenges of the COVID-19 pandemic, pharmacy professionals may now be experiencing concerning levels of burnout. Reported support needs differ between professionals and further research should focus on deepening understanding of these needs.
References
1. Marvaldi M, Mallet J, Dubertret C, et al. Anxiety, depression, trauma-related, and sleep disorders among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Neurosci Biobehav Rev. 2021;126:252-64.
2. Dee J, Dhuhaibawi N, Hayden JC. A systematic review and pooled prevalence of burnout in pharmacists. Int J Clin Pharm. 2022;6:1-10.
3. Kristensen TS, Borritz M, Villadsen E, et al. The Copenhagen burnout inventory: a new tool for the assessment of burnout. Work Stress. 2005;19:192-207.
4. Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). Depres Anxiety. 2003;4:76-82.
Mental health simulation training for pharmacy workforce in secondary care
Simmy Daniel1, Michaela-Hinson Raven1, Iffah Salim1, Fabio Serra1, Emma Walker2
1East London NHS Foundation Trust, London, UK
2NHS England Workforce, Transformation and Education, London, UK
Background: Simulation involves life-like scenarios followed by reflection within a facilitated debrief and is widely used in healthcare education. The NHS Long Term plan1 and Health Education England (HEE)2 highlight the need for pharmacy workforce in different practice settings to be confident and competent in providing care for people with mental health illnesses. Similarly, North-East London Integrated Care Service (NEL ICS) are prioritising parity of esteem and bridging gaps between services through an improved workforce.3
Aims: To increase the pharmacy workforce’s confidence in supporting and caring for patients with mental health illnesses and empower staff to provide a safe, effective, and equitable service.
Objectives: To be more familiar with mental health conditions including within a substance misuse and learning disabilities context. To improve effective communication (verbal and non-verbal). To build confidence in formulating treatment plans, talking to patients in distress and taking appropriate history within a mental health context.
Method: Twenty-nine participants included medicines management pharmacy technicians (MMPT) and pharmacists who volunteered from East London NHS Foundation Trust (ELFT) and Barts Trusts (NEL ICS). Training delivery format included pre-reading clinical material, simulation scenarios which were co-produced with service users (informed consent obtained), teaching by multi-disciplinary team and pharmacy colleagues, and debriefs. Ethical approval was not required as training did not directly affect patient care and informed consent was obtained from service users involved in the process. Quantitative and qualitative data were gathered via pre- and post-simulation questionnaires (two validated scales and course specific questionnaire) to assess confidence and perception of communication improvements. The validated scales used were the Jefferson Empathy scale4 and The Mental illness: Clinicians’ Attitude Scale (MICA-4).5
Results: The whole group showed a statistically significant increase in empathy and improvement in attitudes towards people with mental health illness from pre- to post-simulation training. The 15 measures (course-specific questionnaire) and the qualitative feedback indicated that all the learning objectives were met. 100% of participants either strongly agreed or agreed that the simulation training helped improve their communication skills and found the debrief and service user participation valuable. A pharmacist’s feedback was as follows: “Gained confidence in speaking to patients with different forms of mental health conditions and patients who are in distress”
Discussion: Simulation training is novel and innovative, and despite being unfamiliar to the participants, was well received. They emphasized the effectiveness of the debrief technique, delivery format and service user contributions during debriefs. The project demonstrated improved communication and confidence within a mental health context, particularly in talking to patients in distress. Participants became more familiar with mental health conditions too. It was pioneering to assess the use of mental health simulation training within secondary care between two different practice settings.
Conclusions: These findings support the use of simulation in increasing pharmacy workforce confidence in caring for those with mental illness including within a learning disabilities and substance misuse context. In addition to improving clinical knowledge and skills, simulation training can also help improve pharmacy staff perceptions, attitudes, and work towards addressing stigma and hence contribute towards a high-quality patient care service. This project indicates potential value of training the pharmacy workforce on a wider scale, regardless of sector, in collaboration with MDT and service users.
References
1. NHS England. The NHS Long Term Plan [Internet]. NHS England. 2019. Updated August 21, 2019. Accessed February 20, 2023. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf
2. Tyrrell A. A review of innovative and extended roles within mental health pharmacy. Health Education England. 2020. Accessed March 2, 2023. https://www.hee.nhs.uk/sites/default/files/documents/Pharmacy%20Extended%20Roles%20Report.pdf
3. NEL Health and Care Partnership. Purpose statement and priorities [Internet]. NEL Health and Care Partnership. 2023. Accessed March 2, 2023. https://www.northeastlondonhcp.nhs.uk/wp-content/uploads/2023/05/NEL-Interim-integrated-care-strategy-31-January-2023-final.pdf
4. Hojat M. The Jefferson Scale of physician empathy: development and preliminary psychometric data. Educ Psychol Meas. 2001;61(2):349-65. doi:10.1177/00131640121971158
5. Gabbidon J. Mental illness: clinician’s attitudes (MICA) scale psychometric properties. Psychiatr Res. 2013;206(1):81-7.
