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Prescribing in mental illness: a practice pharmacist’s perspective

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Chris Johnson

Chris Johnson is a primary care specialist mental health pharmacist and advanced prescribing support pharmacist with NHS Greater Glasgow & Clyde (NHSGGC). Chris has been telling Pharmacy in Practice, that patients are best served by treating physical illness and mental illness as two sides of the same coin.


Practice pharmacists are involved supporting the needs of their patients and practices in different ways. I see myself as a generalist first with an interest in mental health.


You cannot truly separate mental health and physical health. For instance, with a long-term condition like COPD, if a person’s respiratory condition is poorly controlled that creates anxiety which in turn affects their breathing and vice versa. We also need to consider that people who have long-term mental health conditions commonly die prematurely; 20 years earlier for those with schizophrenia than somebody without it.


We also know that people with mental health conditions commonly have multimorbidity and lifestyle risk factors. Therefore, we can only truly address avoidable premature mortality or somebody’s multimorbidity if we treat the whole person, not simply the mental health condition or their common physical health conditions separately.


Pharmacy in practice


At a practice level, my work has mainly focused on antidepressant, anxiolytic and hypnotic use. Antidepressant work has involved identifying people who have been prescribed the same anti-depressant for two years or more, enabling GPs to review ongoing need.


Since 2009, this has enabled more than 180 of 260 NHSGGC practices to review more than 8,000 people receiving long-term antidepressants. Of those reviewed, one in four people needed to change: switch, increase/reduce the dose or stop their antidepressant altogether.


Overall, this achieved a 10% reduction in antidepressants prescribing (as defined daily doses) but, more importantly, created an opportunity for review. This continues as an NHSGGC prescribing indicator for practices to participate in.


Other antidepressant work includes academic detailing and education and highlighting the limitations of the selective serotonin reuptake inhibitor (SSRI) doses for the treatment of depression. SSRI doses are commonly on average 40-50% higher than current evidence supports, as SSRIs demonstrate a flat dose-response curve for the treatment of depression: ‘20’s plenty’ for fluoxetine/citalopram/paroxetine (20mg daily) and ‘50’s enough’ for sertraline (50mg daily) to achieve their optimum effect for depression, with higher doses commonly causing more adverse effects.


However, this work has not all been about drugs. I have been involved in developing local depression guidelines for primary care considering non-pharmacological and non-medicalised options to support people with depression such as exercise referral to local council gyms, or gardening or walking groups.


Part of my role includes sharing information with other practice pharmacists, such as Black Dog videos, which can be helpful in explaining depression, or advising on accessing ASIST suicide intervention training which can be accessed via the Choose Life website.


The Z factor


Since 2005, I have also been involved as a prescriber running anxiolytic and hypnotic reduction clinics in practice for people receiving long-term benzodiazepines and/or z-hypnotics (B&Zs) which commonly achieves a 20-30% reduction in a practice’s defined daily doses.


Polypharmacy issues are also addressed during these reviews, as this helps to provide the reviewer with insight into a patient’s other conditions, symptoms and appropriateness for the potential for gradual reduction and stopping B&Zs.


Over the years this work has mushroomed in NHSGGC with other practice pharmacists getting involved, and by demonstrating to GPs it can be done successfully, which has enabled more people to be reviewed – achieving health gains and reducing avoidable drug-related risks for patients.


We also involve GPs in reviewing, reducing and stopping B&Zs as this achieves greater sustainability and minimises the chance of prescribing increasing back to pre-intervention levels. In some of the localities, this has led to groups of practices tackling B&Z use, sharing experiences and learnings on what worked well and did not. We have also used some of the more recent price increases, for instance for temazepam, as an opportunity to encourage reviews.


I have also led on quality improvement work for Community Mental Health Teams (CMHT) and general practices psychotropic medicines reconciliation, improving reconciliation accuracy across this interface as well as addressing safety, quality and cost-effective prescribing issues.


Pharmacy future 


A future model I am interested in developing is specialist mental health pharmacists with split CMHT and general practice commitments in specific localities. I think this would first of all help patients, but also general practices and practice pharmacy teams with the challenges of reviewing and ensuring appropriate psychotropic medicines use and cardiometabolic monitoring to address and minimise avoidable drug-related harms.


Ideally, that would mean you always have somebody who you’re working really closely with whose knowledge you can dip into. No individual can know everything but, by working together, asking questions and showing a willingness to engage with the challenges, you’d have a primary care team that is more than the sum of its parts.



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