Compounding Pharmacists Fill an Essential Role When Patients Decide to Stop Psychiatric Medications
After being on four psychiatric medications for years, Jeremy lost his health insurance and discovered he couldn’t afford to pay for refills. Since he had been stable and felt good, he decided it was time to stop his meds, which he proceeded to do without consulting his doctor. Two days later a psychotic episode landed him in the hospital, where he spent the next six months trying to regain equilibrium. He wasn’t aware of discontinuation syndrome. Compounding pharmacists who reach out with medication management can make a difference for patients who abruptly stop psychiatric medications.
Mental Health Prevalence and Self-Discontinuation of Psychiatric Medications
You don’t need a rundown of all the different types of psychiatric disorders to understand the depth of the problem. Let’s just start with depression, which is the most common disorder. It occurs in 8 percent of adults, accounts for 8 million visits to the emergency room, and results in 41,000 yearly suicides.1 When all types of mental illness—not including developmental disabilities and drug abuse—are considered, the prevalence rate is 18 percent of American adults or an estimated 43.6 million people.2
Medication noncompliance is rampant in people taking psychiatric medications. A retrospective study of more than 22,000 patients taking selective serotonin reuptake inhibitors found that only 43 percent adhered to their antidepressant therapy.3 A systematic review reported that 74 percent of patients taking antipsychotics for schizophrenia stopped taking their medication within 18 months.4 Roughly half of bipolar patients are non-adherent and after discharge from a psychiatric hospital, 70 percent of patients discontinue their psychotropic meds.5 You can be sure that many of these patients went to their neighborhood pharmacy at least once to fill the initial prescription, which means that pharmacists are positioned to bridge the gap with medication management.
The Seriousness of Discontinuation Syndrome
Abruptly stopping psychiatric medications can cause severe and sometimes long-lasting symptoms, including rebound back to pre-treatment levels of the disorder. Discontinuation syndrome is more likely to occur in patients who have been on meds four weeks or longer, who take higher doses, and in those taking meds with a shorter half-life. You can distinguish the symptoms from other causes because they appear within a few days of stopping the medication.6
While any type of psychiatric medication can cause discontinuation syndrome, patients have an increased risk if they take atypical antipsychotics, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and norepinephrine-acetylcholine serotonin reuptake inhibitors. Symptoms associated with antidepressants include flu-like symptoms, dizziness, fatigue, headache, insomnia and anxiety. Discontinuation of antipsychotics, especially benzodiazepines, may cause excessive anxiety, panic attacks, palpitations, labile mood, restlessness and perceptual disturbances. In rare cases, stopping antipsychotics can lead to seizures and psychosis.
Roles for Compounding Pharmacists
Tapering psychiatric medications or following a step-down approach that introduces a replacement medication while eliminating the old medication require slow titration of doses over the course of weeks or months, depending on the type of medication and how long the patient was treated.
- Compounding is the best way to achieve accurate yet ever-smaller doses, especially when the medications are compounded into liquid form. Don’t hesitate to contact the prescribing physician to recommend this option.
- Be aware that even with tapering, patients can still experience discontinuation symptoms. Screen patients for problems every time they pick up newly titrated meds.
- About 30 percent of patients taking SSRIs will experience discontinuation syndrome. Set up a system to track patients taking these and other psychiatric meds. Call them personally when they fail to refill their prescription. Develop a telemedicine protocol to assess why they didn’t get their medication and to determine whether they might need emergency attention.
Mental Health Outreach Improves Adherence
Compounding pharmacists who choose to proactively manage psychiatric medications are forging a new path because mental health patients aren’t commonly targeted for outreach. This is a large group of patients—future customers—who are in great need for medication guidance. After they see a physician, who is often their primary care physician rather than a psychiatrist, most mental health patients must wait months, sometimes years, to get the services they need in addition to medication. Then a new problem arises when they decide to stop taking their meds.
Costs and lack of insurance can factor into the decision, but intolerable side effects are one of the most common reasons patients stop taking meds. Some start to feel better and think they don’t need medication; others have taken multiple meds for a long time and they just want to stop. When compounding pharmacists step in, adherence improves, which is vital, but there’s more at stake. Twenty-two percent of patients taking antidepressants discontinue meds without supervision from their doctor and they’re not the only ones making the decision on their own.7 As a result, they may not be aware of discontinuation syndrome.
Tips for Mental Health Outreach: You don’t have to be a mental health expert to reach out to patients. As a compounding pharmacist, you have the advantage of approaching them based on the neutral ground of medication management. Once that door is open, it’s natural to discuss side effects and whether they’ve thought about stopping meds. When you counsel mental health patients, be prepared with brochures or print-outs that list local programs and service providers and provide info about discontinuation syndrome.
Here are a few other ideas for mental health outreach:
- Anticipate other health needs associated with discontinuation syndrome or side effects from psychotropic medications. For example, these patients often have a hard time sleeping, so talk to them about natural, compounded options to help them sleep.
- Reach out to primary care practitioners prescribing psychotropic medications. PCPs increasingly treat mental health disorders and may welcome collaboration with a medication expert.
- Take advantage of national awareness campaigns and use them to advertise free consultations and products in your pharmacy. For example, May is Mental Health Month and Suicide Prevention Week is in September, but many other conditions have health observance dates.8
Compounding Pharmacists Bridge the Gap to Improve Outcomes
Compounding pharmacists may be the only health care professional accessible to mental health patients, especially those who have decided to discontinue meds without expert advice. You have a vital opportunity to protect their health, so don’t let them slip through the gaping cracks in a mental healthcare system struggling to provide adequate and timely services. All you need is the willingness to listen and to offer nonjudgmental advice—even if the best advice is something they don’t want to hear, like “consult a doctor.”
Pharmaceutica North America provides high-quality bulk pharmaceutical ingredients and custom compounding kits to support the diverse needs of mental health patients. Contact us today to learn about how we can help you deliver effective personalized medications to your patients.
- “Depression,” July 2015, http://www.cdc.gov/nchs/fastats/depression.htm ↩
- “NIMH: Any Mental Illness Among US Adults,” 2014, http://www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-ami-among-us-adults.shtml ↩
- “Adherence and Health Care Costs,” February 2014, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934668/ ↩
- “Medication Adherence in Schizophrenia: Factors Influencing Adherence and Consequences of Nonadherence, a Systematic Literature Review,” August 2013, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805432/ ↩
- “Medication Discontinuation in Patients After Discharge From a Psychiatric Hospital,” October 2015, http://www.ncbi.nlm.nih.gov/pubmed/26160969 ↩
- “Abrupt Stop: Managing Discontinuation Syndrome Associated with Psychoactive Medications,” September 2010, http://www.academia.edu/318081/Abrupt_Stop_Managing_Discontinuation_Syndrome_Associated_with_Psychoactive_Medications ↩
- “Antidepressant Self-Discontinuation: Results From the Collaborative Psychiatric Epidemiology Surveys,” May 2015, http://www.ncbi.nlm.nih.gov/pubmed/25930223 ↩
- “2016 National Health Observances,” February 2016, http://healthfinder.gov/NHO/nho.aspx ↩