PharmMedCommunity: 2016

Medical and Ethical debate – why it is so important?

( Readers to whom I dedicate this to, thank you all for your patience, will update you on weekly schedule soon)

It is interesting studying on a course with fellow healthcare professionals- we all seem to be fighting the same battles, united by our challenges, and desires to do well in the course- understand the material and pull through to become the great healthcare professionals we aim to be.

Sometimes, it is easy to forget that behind the grades, the numbers, we still remain to be people. We are still very much different in how we perceive life and in essence how despite equal acquisition of knowledge, how we would still act differently when placed in the same situation.

The reason for this lies in our beliefs. Our core beliefs those that we tenaciously hold onto whatever circumstance we face are those that inform our everyday decisions. These core valued will reflect who we are in our defining moments and therefore are a very significant part of healthcare practice and by extension our lives.

So what determines them- these core beliefs? Sometimes you might find yourself in an argument, debating something so vehemently, until you lose your momentum. An unexpected loophole and the whole, neatly constructed idea collapses into a pile of rubble. That’s when you might come to the realisation that the belief that you previously held, really had no backing.

It is a dangerous place to be. Without consciously forming beliefs, they begin form by default. Without careful evaluation, accurate research and reliable evidence, heresy directs your core values. As a healthcare professional, as any person in fact, this should never happen.

Lack of self-analysis, means leaving your fate in the hands of someone else. In the case of health, it means being more susceptible to fear mongering and other poor practices conducted by those aiming to serve a dubious agenda.

As I see it, medical debate can be an invaluable tool in debunking the fallacies surrounding important matters. Practicing a reflective attitude, may even give rise to the analytical thinking necessary to find solutions to the challenges we face in medical healthcare. If that is an overly aggrandised claim, well at least it would serve the imperative role, of preventing us from becoming victims of poorly informed decision-making.

For the healthcare professionals, forever and always, this echoes the highly prevalent, fast-held initiative to empower the patient. The Realising the value programme building on the NHS Five Year Forward View is just another project recognising the value in patient making their own decision. How better to reach this, than by forming our own concrete arguments, before objectively delivering them, for the patient to make the ultimate decision.

This is a preliminary to what I hope to be a series of brief introductions to various contentious issues, we now face in the world of healthcare.

Till next time.

https://www.england.nhs.uk/2014/11/realising-value/ a

Basic guide - 8 ways to get more involved in pharmacy

Entering first year many students do not know what to expect as they embark on the journey which comes with studying pharmacy. There will be the days of 'back to basics' lectures, through to paired lab work and then, there will be those OSCE days, dreaded by many. Amongst, exam revision, coursework assignments and deadlines, it's also important to take a break, and remind yourself, why it was, that you decided that pharmacy was the field for you.

There are many ways to do this, and a great way to do so is by getting more involved with pharmacy outside of the standard 'classroom' setting. This applies to students across the course from first to final and even after pre-registration year. Many students and qualified pharmacists alike are not aware of the breadth of opportunity that awaits them and just how much there is to explore.

So here it goes- a few quick ideas of how to get more involved in pharmacy.

1. CPPE training

Conducted often by pharmacists, CPPE training events are there to support the training and continual development of pre-registration and qualified pharmacists. Students are also welcome and encouraged to come along. Many topics are covered from clinical knowledge to professional skills. By participating in debate and discussion, this is often a great environment to learn from those more experienced in the field and prepares you for the world of pharmacy practice. Examples of titles are epilepsy and dementia friends - focal point training .

2. Local Practice Forum Events

Each region has its own Local Practice Forum which you are encouraged to join - this can be found on the Royal Pharmaceutical Society website. The conferences are a great opportunity to network with like minded people and hear top speakers talk passionately about healthcare matters . The events are always reflective of the challenges or current affairs faced in pharmacy and the healthcare system today. For instance a recent South London meeting at Kings' University was on the subject of pharmacists in General Practices, exploring the benefits and obstacles faced with the development of such positions in healthcare.

3. British Pharmacy Student Association- National/International

Many conferences and events are organised throughout the year, directed particularly at pharmacy students to help support their development as aspiring healthcare professionals. Simply by attending an event such as a conference or competition is enough to win a 'PDS" point. These points add up, so if a student were to collect 5 in one year, they would be sent a bronze certificate, followed by a silver, platinum and gold, in the subsequent years. But if you still require further incentive, these events are great for networking with pharmacy students across the UK and learning about real challenges faced by pharmacists in practice. For instance the BPSA Southern area conference was on the subject addiction. Topics covered were from the pharmacological and psychological treatment, covering the angle from current published pharmacy guidelines, to physiological models, real ethical dilemmas and advice from pharmacy support. Aside from conferences, BPSA representatives have recently held the Johnson&Johnson competition supporting students with their OSCE practice, honing key skills when responding to symptoms.

If these events seem of interest to you, maybe consider applying for a representative position. For the first round of applications the window opens at the beginning of June and closes somewhere mid-summer. However, this is variable from year to year, so if interested check with a BPSA representative at your university.

4. TeamUp Volunteering events

NHS Education England host an annual event usually early autumn time and recruit student healthcare professionals from various settings from nurses and dentists to doctors and pharmacists. Students have the opportunity to speak to various organisations about their various healthcare and well-being projects and enlist to take part with their development for the deprived demographic of our society. Working alongside allied professionals, builds not only key team work skills, it gives a great insight and appreciation of the unique role that each healthcare sector plays in the collaborative process of providing patient-centred care. You also learn about medicine from a different angle and expand your current depth of knowledge surrounding the healthcare system.

5. Placements

Take advantage of summer placements! This is directed at the students. Apply early-Boots has one for first and second years. There are also a range of placements available for third years from Lloyd's community to Hospital Placements. Also, if you have placements as part of your university course, make the most of them. This is an opportunity to see your pharmacy knowledge put into practice and work on key skills in order to become a competent pharmacist.

6. Global/National Campaigns

As a pharmacist, you are first and foremost a healthcare specialist. When you enter a field such as this, there are endless points that may spark your interest - what drew you to this healthcare. Find what it is and become passionate about it. Was it challenging mental health stigmatisation or finding the cure for a rare genetic disorder? Global and National campaigns help raise awareness surrounding a myriad of different healthcare matters. One of such campaigns which is currently receiving worldwide notice is antibiotic awareness. This particular event is an opportunity to support antibiotic stewardship and learn more about the reasons behind the movement.

7.University Pharmacy Association

Most pharmacy courses will have their own pharmacy association. The common challenge amongst most students, is once they sign up to these organisations, is to actually stay organised and committed enough to attend. Events held by such pharmacy associations would often tell you all the ideas, that I have shared here. Student life though may seem tough, does not last forever, so do not take this for granted and take advantage of this society for professional development. Explore how you can get more involved as a pharmacy student at your university. You might even be able to get a role in your university pharmacy association committee and have your say surrounding the events the society would run.

8. Pharmacy Defence Association

There are many pharmacy support groups one of which is the pharmacy defence association or otherwise known as PDA. Since, many students are taking on, part-time pharmacy job roles, there is a risk of error attached to this. The PDA organisation is in place to support the student, where for instance such an error may have brought on harm to the public. The PDA will work to prevent fitness to practice measures from being filed against the accountable student/pharmacist and work to resolve the situation to benefit all parties involved.

So here are my 8 basic ways to get more involved in pharmacy. This is a question that had often run through my mind and I hope students and qualified pharmacists , would find this to be an equally useful, quick reminder.

Thank you for reading my post!

If you agree/disagree with anything I have said or have anymore ideas to add on
- how to get more involved in pharmacy-
please leave a comment below!

Pharmacy and Social Media

Sometimes, when we strive together towards a common goal, we may still find something to be lacking on a day to day basis. A sense of community. This can definitely be felt amongst the corporate companies. It is my biggest fear and regret that eventually, the same will come to be said for pharmacy. However, I can honestly say that recently, I have come across evidence that would prove the contrary to be true.

Let me take you back to me in first year - an unsure, sceptical pharmacy student paving her path in an unknown field. I wanted to connect, to discover and share. The most suitable platform to me at the time seemed to be online blogging. But as I started, a heavy sense of doubt descended on me. It was not the familiar telling signs of fear when placed before a “blank sheet” of paper. It was something utterly different. Ethics and practice, a module that we had come to cover at university, had raised many concerns in my mind. I was taught that being a student pharmacist meant a stark distinction to any other degrees in science - you are an accountable, representative for the face of the profession. And herein lies the core concern. As a student pharmacist would I be judged by content? What were my restrictions? What could I post? Was I allowed to take a side in a debate, or was I forced to remain impartial and portray myself as an objective professional in the eyes of the public?

It was years before my worries were put to rest. This year many would be glad to know that the newest edition of the Medicines, Ethics and Practice sets out the guidelines regarding this matter for both practising and student pharmacists. For me this was the perfect example of indispensable, forward thinking and was reflecting the current advancing state of affairs in pharmacy. With everything moving to digital platforms it made logical sense to publish such a guide. For that I must thank the MEP writers! The quality and timing could not have been better.

To summarise what the guidelines said:

It’s important to recognise the necessity that those using social media uphold the same standards as in “real-world interactions”. The issues that were covered under the umbrella of social media included maintaining confidentiality, ensuring online activity does not tarnish the reputation of the profession, showing respect and not undermining professional boundaries. But most fitting for me, I thought was the parting message. When teaching or providing information ensure that it is impartial, accurate and that you do not mislead or make claims that you cannot justify.

This applies to any pharmacist who interacts online via blogpost, web forums, facebook, twitter or any other social networking. This guidance will ensure that we all do so in the best way to serve the public and fellow pharmacists. So let’s continue to unite as a community, in sharing our experiences, furthering healthcare advancement and learning from others.

Let me know if agree with me in the comments below. Thank you for reading!

Pharmacy- What does it have to offer?

There was promise that pharmacy would be the new frontline face of the NHS and now with government cuts, we are forced to contemplate where exactly do we stand? This years’ seemingly innocuous 6% cut means a substantial £170m reduction in pharmacy funding. A grim future comes to mind, with this potentially meaning a decline in pharmaceutical services and pharmacy closures leading to reduction in access to healthcare advice with mounting pressure on GPs and hospitals. This loss builds sure grounds for a self-fulfilling prophecy – reaffirming the perpetuated image of pharmacists as mere suppliers of medication. The disparity between public perception and the actual job role is wherein lies the core of the problem.

It saddens me that media and public fall prey to this impression .The prevailing attitude that a Pharmacist does no more than order and supply, is at the very least disheartening. These healthcare professionals are equipped with the clinical knowledge to deliver crucial information of medication safely and preclude potential patient harm. Underpinning the significance of their role, was the resounding protest reflected in the flood of petitions signed by the public. The Department of Health received 30,000 objections a day in the campaign to "Support your Local Pharmacy".

Many still believe pharmacies to be part of the fabric of quality frontline health service and yet there are those that enter the arena, and question with obvious irritation, what pharmacists even do. In this era with the precarious economic and political climate, it is easy to discredit our most valued fields. Pharmacy like medicine, had always been the forefront of care, but with recent cuts, and reaffirmed devaluation, it has began to seem less so.

As a pharmacy student, and a passionate one at that, I feel it is my duty, to put these preconceptions to straits. Its surprises me even more, that pharmacy students themselves, feel so influenced by current held beliefs, that they too begin to believe that there is nothing more to pharmacy than dispensing. Once again, this horrifies me, nothing could be further from the truth.

Pharmacy is a field with much to offer and that is besides the stable and yet very honourable positions at both community and hospital settings. Aside from the most well known, there are other opportunities that stem from being a pharmacy specialist. Such settings include positions in teaching, regulation , research, public health, military, prison, publishing, GP, hospices, and independent prescribing.

In aid of this, below I have made a brief introduction to some of the the main pharmacy settings:

Regulatory pharmacy-MHRA/GPhC safeguard public health, committed to maintaining an excellent track record for safe delivery of services and care. The GPhC is a regulator of the pharmacy profession, whilst The MHRA is a regulator of medicines and devices, ensuring safety before they are marketed to the public.

Veterinary pharmacy-Here pharmacists provide a valuable contribution to animal welfare supporting pet owners and farmers in rural settings branching out into roles in teaching, industry or a government body such as the Veterinary Medicines Directorate.

Pharmacist in the military- Army Medical Services (AMS) offer rewarding challenging roles, recognised first-class training with pharmacists employed in support of the Royal Navy (RN) or Royal Air Force (RAF). The overarching role is that of medical supply distribution, provision of pharmaceutical care and advising the commanding officer.

Pharmacists in academia-From drug design through to the provision of pharmacy services, there is a diverse range of areas of research to embark upon. Both a rewarding and satisfying field, finds many continue to explore careers in teaching, industry or clinical practice.

Pharmacists in industry- Pharmacists here witness and play a role in the development of cutting edge technologies, medicines and strategies for safe and quality care. This encompasses a critical quality checking processes; where pharmacists are essential in auditing a range of criteria to ensure viability of medicines on the market.

Pharmacists in community- Here pharmacists aid the public by offering patient tailored advice for lifestyle change and management of a broad range of conditions. Many undertake clinical roles including management of asthma and diabetes as well as blood pressure testing.

Pharmacists in Hospital- Here pharmacists play a vital role in a interdisciplinary team focusing on pharmacovigilance, vital in monitoring patient outcomes, attend regular ward rounds ,more involved in selecting treatments , manufacturing of sterile medicines, providing medicine information and managing the medicine procurement for the whole hospital.

Pharmacists in Primary care- Here pharmacists are fundamental in the management of medicines, carrying out a strategic role, to optimise benefit and minimise risk of medicines, with a focus on prevention rather than cure. They run medication review clinics, maintain close working relationships with GPs as well as playing a significant role in Practice Based Commissioning (PBC) improving quality and access of services for patients.

Pharmacists in GP –Here pharmacists have a role in streamlining practice processes, medicines optimisation, minor ailments, and long term condition management. More recently a funding boost from NHS England, means by 2020, over 1500 pharmacy positions may open in GP surgeries. This advancement was further supported by the royal college of general practitioners who declared this “as perhaps the most significant piece of news for our profession since 1960s”.

Pharmacists in Publishing- The leaders in pharmacy publishing, pharmaceutical press have a role in establishing authoritative, independent guidance on management of a range of conditions, best practice measures with clinically validated drug information. Here pharmacists utilising the latest resources produce drug monographs encompassing specialist information on uses, cautions, contra-indications, side-effects, doses as well as guidance on prescribing monitoring, dispensing and administering medicines. With a range of publications seeing regular update, pharmacists are the forefront establishing guidance for both existing and newly licensed drugs.

As a final point, there is no question that the current era is that of austerity . We find ourselves in a time, when value is not to be assumed but proven, and it is a time like no other, to take a stand and revolutionise what is fast becoming a discredited profession. We owe it to our patients, to work harder than ever before, to break through the limiting supermarket service model, forever a contender for cutting government cost but simultaneously undermining the pharmacy role. The attitude of marginalising pharmacists in the clinical role is becoming more and more atavistic.And with dedicated advocates we can feel secure in the knowledge that as surely as the apothecary, this challenge is soon to become a thing of the past.

Teaching in science

“To be a successful nation in a competitive world, and to maintain a cohesive society and a rich culture, we must invest in education to develop our greatest resource, our people.”
The Dearing Report (1997)

With this in mind, it becomes a true paradox, that to prosper and to meet the criteria for a higher ranking teaching, one must first distance themselves from the very field in which they aspire to grow. Similarly, it seems counter intuitive, to practice less of the field in which you hope to become more proficient. It was mentioned that if one was to leave teaching it brings about opportunity in academia such as research or instructing pedagogy on a global scale. But I must confess, that I do not claim to be an expert in the matter, and describe what I observe.

Being a teacher, does not equate to good teaching and it seems today there are very few establishments that recognise the distinction. The valuation of the profession has become diminished, as opposed to the core undeniable belief that teaching is instrumental in the advancement of our future through the next generation.

Recently, a national teaching excellence conference was held, hosted by exemplary lecturers in pharmacology and physiology. Guest speakers and the audience alike, contended to bring the truth to surface. In reality, it was found that there is a no size fits all approach, each teacher must use the method that best fits their personality. Confidence in your methods, demands confidence in your teaching.

And yet, as simple as this formula is, there are many for whom lecturing and teaching does not come so naturally. To develop an alternative pedagogic styles take time, and the likelihood of failure is high, as with any attempt at trying something new. This leaves many teachers forced using safe methods, which are not always effective. But the harsh reality is that when it comes to promotion, teachers, if effective, do not get recognised or rewarded, and thereby fall behind in the criteria of expectations, to the detriment of their career, without recompense.

Drug abuse and Alcoholism- Can we see beyond the obvious?

If I would go up to you and ask what you think of liver disease, increased CHD risk, and reduced mortality, you would probably look to me as though I was mad. The answer is so self-evident, it doesn’t bear questioning. Of course, these conditions are terrible, disabling diseases which we would think we would avoid at all costs. And yet alcohol and drug abuse is as prominent as ever. To make matters worse, there is a prevalent demographic of children, subject to addiction, becoming younger and younger.

However, when we think about alcoholism, and drug abuse, the connotations that arise are those of heavy drinkers, in solitude, who seemed to have brought it on themselves. We don’t even think to associate addiction and abuse with social events when young adults are out to have a good time. We are cultured to believe that this is the norm, and it’s all in good fun.

Clinging onto this traditional attitude is calamitous. Blinded by these beliefs, many don’t see what lies beyond. It’s no secret that aside from multi-organ failure, associated with substance abuse, in many cases the user becomes a criminal. A burden on society and family, and consequently addiction leads to destructive behaviour, unemployment, and failure to see reason or a way out.

As children, they are most susceptible. Psychologically and chemically their brains are still undergoing critical development. This can easily be impeded with the inappropriate consumption of drug substances, leading to irreversible and detrimental alterations to brain chemistry. Pregnancy in this state can lead to a condition known as foetal alcohol syndrome. With a inbalance in the regulation of dopamine, comes the demon of addiction.With altered brain chemistry, it becomes a question whether the user is at liberty to stop? Are they a criminal or are they a victim of their cravings?

Current, statistical analysis depicts that cannabis followed by alcohol are the the leading substances of addiction in the youth. Much drug abuse and alcoholism is found to stem from co- morbidity. One of the main conditions being a poor mental state (depression), the belief that there’s an inability to cope with the worlds demands. This is remedied by “medicating” away the troubles with psychoactive drugs including alcohol, cannabis etc. This is found very commonly with those holding the cultural ideologies that to have a relaxing time with friends, alcohol or drug taking is a prerequisite.

Addiction insidious, in that it robs the user of control over their choice. It’s an illness, even though; it still carries with it an unrelenting stigma, which calls scorn upon the victim.

It’s fundamental that this vicious cycle brought to an end. People deserve to be treated with dignity, and be given all viable sources of therapy to aid their treatment. Seeing these people as patients rather than criminals leaves us with a way to eliminate the problem.

Many attribute this problem to destitution, lack of education and lack of inculcation of the core values, some to a deeper issue such as mental health whilst others, adopt a more condemning outlook, blaming the user. This traditional, fast held belief, lays the grounds for a self-destructive pattern- an addict sees his path as one with no return, which essentially does not help anyone. In actual fact, we understand brain chemistry, and we know that most people do not relish in the idea of being a burden, or a dysfunctional member of society.

Status quo, and much of current legislation likes to view users through a criminal lens, its disparaging and in no way, effective in ending the vicious cycle that is addiction. The key is to transform this issue into a public health issue. This is where we can help. Health professionals can raise awareness, of these issues by campaigning at schools- impressing upon children the significance of prevention early on. Providing mental health support, confidentiality, and other support for youth and addicts, is also critical to rid ourselves of this epidemic.

By realising this, it is my hope that with a more compassionate approach, it will welcome more opportunities for treatment of those affected. This should not be an elephant in the room, or a reason to shun or shame another. By completely shifting the paradigm of the preconceptions held about recreational drinking and drug taking and then consequential addiction, this would massively improve the health of our society. Seeing alcoholism or drug taking as a choice and self-inflicted is to miss the point entirely. There is always a deeper reason, if only we recognise the cry for help for what it is.

https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-LG0Cl09b7re9q5U_GgHiNGKJDW7VaNZCF7xFLpFPQf_boPcRNPjweogB0Oj5LmD81c_chigBMXhJzgYIyfZfAyu9__kQpTtosFtoOqq-ARPi68V4K3YVF2lrc0upXqSd3ukTjQ2YMr4r/s320/Signs-Symptoms-and-Help-for-Alcoholism-and-Alcohol-Use-Problems.jpg

https://www.theguardian.com/society/2015/apr/04/my-mother-the-alcoholic-living-with-foetal-alcohol-syndrome

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/462885/drug-misuse-1415.pdf

Euthanasia- has it really come to this?

We are in the era of austerity ;the NHS being stretched to its limits, the climate of our underfunded healthcare seeming to plummet to its depths, and yet the need to address mental health issues can be felt more than ever before. With the suicide numbers climbing but lack of resources to meet demand, the prospects for the younger demographic looks all the more grim. Reflected in today's statistics, England possess the highest suicide rate since 2004. But this goes further, as a more global pandemic. WHO predicts incidence of mental health will soar from ¼ to ½ by 2020 .

Our brightest lights are being put out, and I do not just speak of Robin Williams, but this 2016, will be a year commemorating the death of 18 year old Edward Mallen. A stellar, prodigious student with prospects in university of Cambridge, took his own life, after battling depression, having started on anti-depressants.

This is an awakening, like nothing else, that something must be done.

For me, I am a mental health enthusiast. I see that many people still try to deny that stigmatisation exists. That in part is the problem. By denying a problem exists, we remove our ability to change it, we stagnate, and fail in the face of the public. Aforementioned, Edward Mallen, has become yet another victim of the system. Suicide rates are ever increasing. However, we can make the difference. Our word is more potent, than just mine. I am a single, person, I know that simple recognition is a vacuous achievement in the face of the stark reality; that is people are counting on healthcare professionals to take a stand. We save lives, by building an environment, where “excellence in clinical care would flourish” and I am simply quoting the 7^th pillar of the community pharmacy contractual framework . I know you believe this too.

A great many people, still don’t have access to mental health support. Times are changing, and the 21^st Century is seeing advancements in the sector. Furthermore, I had the fortune to experience a placement at mile end , mental health hospital and needless to say, it surpassed my expectations incontrovertibly . However, more than ever before, the fact has become abundantly evident, that NHS is really struggling. The underfunding, has taken a tow on staffing, I feel this is where pharmacists, have the opportunity to step in, stronger than ever before.

Adopting this principle, we can only imagine what benefit can be wrought if we use this ideology in our professional practices. Pharmacists role, is moving forward, and I am proud, of the achievements of the field. No longer, seen as mere dispensing profession, we see the multifaceted opportunities and the value its position represents. The amplitude and scope ever-growing to new heights- reaching out to consultant, GP clinics and research. With the necessary training, community pharmacy can be the frontline to mental health treatment. We already address the issues of many other minor ailments. Here lies that answer for mental health. It will reduce the number of issues, engendered by lack of appointment availability, having to delay, urgent referrals. This in many cases is deadly as with Edward Mallen.

You would think that the news of this, was startling enough, what could be worse than teenage suicide rates increasing? Euthanasia- assisted suicide. Until recently, I was not aware that it was even legal. As a health professional – abiding by the standards of conduct, ethics and performance to put the patient first and implicitly do no harm, to even considered this, goes against all instinct.

To go beyond this point of contention, I may concede that certain conditions may call for this; certain terminal cancers at a stage where death may be a mercy.To find that the same approach was proposed for mental health sufferers, was at the very least worrying.

The rudimentary characteristic of psychiatric conditions is that it robs the victim of a rational state of sound mind. It therefore baffles me that we can even consider this to be a viable alternative offered in patient care. After having researched this procedure, legalised in Belgium, the psychiatry consultant discusses how all possible mental health treatments must first be exhausted before, this is proposed. But this in no way mitigates the glaringly obvious fact that this is assisted suicide. In primitive terms, this can be tantamount to saying, “ we have no other treatments available for you, and it seems wrong to leave you in pain, so …. Would you consider suicide?”. Euthanasia is a glamorous, word for the very thing that we go to such lengths to avoid. It negates the effort many ; years of mental health research, and funding towards improving mental health research, becomes meaningless. Why does it come to this? As some struggle in the “battlefields” searching for a solution, others have tragically been handed a solution with no return.

Clearer than ever before, is the revelation that stigmatisation needs to end. This is not fear mongering, this heralds the need to end denial, and realise that by admitting there is an issue, there can be a means to end of this suffering.

Dr Brock Chisholm, first director WHO legendary quote that “without mental health there can be no true physical health” rings true, more than ever before. If we are to make a change in the status quo, we must address existing, attitude dynamics towards mental health in society. Mental health must be seen to be encompassed within a mind-body dichotomy, inextricably linked and not separate issue. It needs to be recognised and addressed rather than avoided or worse, made to seem terminal. When I had joined Kings Volunteering, I had learnt many values but one seems to be are embedded in my memory forever. If volunteers by their just their presence could succeed in improving mental health and clinical outcomes- What is the limit to what we can achieve?

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/2014registrations#suicide-rates-by-country

http://www.bbc.co.uk/news/uk-england-cambridgeshire-36536297

http://themindedtrust.org/contact/

http://www.who.int/bulletin/volumes/91/1/12-115063/en/

https://www.mentalhealth.org.uk/sites/default/files/Mental_Health_Strategic_Partnership_LHW.pdf

http://euthanasia2016.com/

http://www.befrienders.org/suicide-statistics

https://www.youtube.com/watch?v=SWWkUzkfJ4M

https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHBCdBVhlPOFhGfrInP8IJsM0sgWqgKhzbdt22pUPcFULqCzsatT9BpYcXKqJee9y8o4eu5bzskU1ugU7wR6vYuKQsBMSVWcLZ-9z6Wbje93auvbUbcKQNH7TK8BhSCpZRd3pe-1F59N2p/s320/mental-health-thumbnail.jpg
http://www.kingsfund.org.uk/sites/files/kf/field/field_related_document/volunteering-in-health-literature-review-kingsfund-mar13.pdf

Asthma - quick update

Key points to remember for asthma management

-Importance of inhalation technique for effective dosing
- to follow this series of actions: shake, prime, shake, exhale ( to increase capacity for drug intake), spray, inhale
- default inhalation rate is variable and therefore its essential to match the product to meet the specific needs of the patient.
-With MDIs- instruct the patient to use Slow and steady inhalation technique ( encourage drug to enter deep areas of lungs and not impact the back of the throat accumulating there due to high speed- 20% Vs 5% reaching deep lungs with poor inhaler technique. Deposition increases chances of developing ADRs such as oral thrush). -Spacers can also help control the rate of gas particles released per dose thereby improving administration. ( optimum inspiratory flow)
-With DPIs- instruct the patient to use Fast and deep inhalation technique
- Finally, In-check inspiratory flow meter can help determine natural/default inhalation rate as a basis for recommending the most suitable inhaler for a certain patient.

Please see: https://pharmacyinpractice.org/2016/03/08/the-importance-of-inhaler-technique-a-pharmacistgp-collaboration/

Depression management

For those who requested to see my notes on the subject- Enjoy.

There are two conditions which present with depression an these are:(2)
Bipolar ( depressive and manic episodes)

Depressive (unipolar) disorders- low state + sadness, lack energy, self worth, guilt etc

Two types:(2)

Major Depressive disorder-severe pattern depression= disabling but NOT caused by drugs or general medical condition.
Dysthymic disorder ( dysthymia)-less disabling BUT longer lasting ( chronic)

Number one difficulty-diagnosis
Wide variety of symptoms, difficult to distinguish when normal FLUCTUATIONS in mood become depression and No single objective test to establish diagnosis.

Since: based on interview using diagnostic criteria (2):
-DSM-IV ( Diagnostic Statistical Manual by American Psychiatric Association)
-Example- depressed mood nearly every day either by subjective report or observation made by others. Plus, diminished interest almost in all activities.
-ICD-10 International Classification of Disease ( WHO)
-Example-typical symptoms- depressed mood, anhedonia, reduced energy
-common symptoms- reduced concentration, self-esteem ( confidence), ideas of guilt/unworthiness, negative/pessimistic views on the future, ideas of self hamr/suicide, disturbed sleep, diminished appetite
Example of a screening question ( clinical interview)- during the past moneth have you often been bothered by feeling down, depressed or hopeless.( /little interest/plesure in doing things)

Patients normally affected
Gender- twice as many women ( up to 25% W, 12% M)
Age-1st episode late adolescence or early adulthood, but onset is decreading in recent years- life more stressful/diagnosing more with depression?

Important Factors ( Suicide/Comorbidity)
Suicide thoughts common in patients-20% attempt, 10% severe depressives commit
Commonly comorbid with i.e drug abuse

Comorbidity
Terminal/Chronic illness ( pain), Thyroid dysfunction, Neurological disease, Stroke, Drug abuse, Parkinsons, anxiety ( i.e common comorbidity- manifest more severe symptoms, less responsive to treatment, higher risk of suicide... which one cause which?)

Causes
Genetic predisposition-first degree relative (20%), monozygotic ( up to 50%), general population(3.2)
Environ- Loss/stressors/social isolation
Neurobiological factors
- deficit NT NoA and serotonin ( i.e with reserpine) but elevating this alleviates depression ( i.e MAOI)
- Lack of neurogenesis ( new nerve cells not produced) ( i.e rodent sub-ventricular zone/dentate gyrus or from stress hormone studies)

Treatment options consist of the four main types (4)

Psychological treatment
-CBT:aiding recognition & change negaitive cognitive processes thus improve mood/counterproductive behaviours
-Interpersonal therapy:assumes depression multi-factorial but interpersonal difficulties play central role in depressive symptoms.
MAOI ( First generation AD)
- catalysis breakdown on DA, 5-HT, NoA ( located in nerve terminal/liver/intestine+ vesicular MA protected from MAO)
- irreversible inhibiton i.e phenelzine, tranylcypromine & isocarboxazid
-ADRs: high incidence= CNS stimulation (i.e insomnia), postural hypotension, hypertensive crisis ( after ingestion of certain foods* cheese effect*= reversal of effects take 2 weeks until NEW ENZYME formation ( hence don't start new AD until 2 weeks after MOAI
-Cheese effect*=MAO in gut inhibited, dietry amines cheesei.e high conc tyramine get into circulation acts as indirect sympathomimetic displacing NoA from vesicles.
-MOA subtypes
-A: metabolises 5-HT & DA
-Both:metabolise tyramine & DA
-Where? ( A= intestine), B ( striatum= caudate, putamen,accumbens)
- Selective: older, non= phenelzine, tranylcyp&isocarb. BUT selective: A ( clorgyline), B ( selegiline)
-Reduced tyramine, "cheese effect": with reversible inhibitors ( RIMA i.e moclobemide)
TCA ( 2nd generation AD)
-inhibit monoamine reuptake
-those with secondary amine group show greater selectivity for inhibiting NA VS 5-HT i.e. desipramine, nortriptyline, protriptyline
- tertiary amine group show greater selectivity for 5-HT VS NA i.e imipramine, amitryptaline, doxepin
N.B. DA not inhibited as much as NA & 5-HT
-ADRs: anticholinergic i.e dry mouth, blurred vision, consitipation, tachycardia, cardiac arrhythmia ( lead to orthostatic falls), tremour, weight gain ( neuroendocrine effects), lower seizure threshold ( contraindicate in epileptics?), TOXIC in overdose ( self poisoning common, hyperpyrexia, cardiac problems, seizures, coma)
SSRIs ( 3rd generation AD)
-MORE selective 5-HT reuptake blockade than TCA.
-For example: Paroxetine, Fluoxetine ( Prozac), Fluvoxamine, Setraline, Citalopram
-ADRs (2)- 5-HT2 mediated ( Headache, Agitation/nervousness, sexual dysfunction), 5-HT3 mediated ( nausea, vomiting, reduced appetite)
-NB: Safer in overdose than TCA + devoid of MUSCARINIC effects
SSRI ( NICE recommends)in synapse, more selevtive in the molecules to which they bind, don't bind to receptors on other classes of neurons ( hence less ADR)
More recent ADS SNRIs
-Seratonine &NorAdrenaline reuptake inhibitors i.e duloxetine
- combined SERT inhibition & 5-HT2 receptor antagonist i.e nefazadone
-5HT2/3 & NA a2 antagonist- i.e Mirtazapine

Overview- AD advancement
- reduced ADRs+ less toxicitiy in overdose
- speed of action & proportion of patients who respond hasn't changed
- need to be given 4-6 months after symptoms disappear & may require lifetime treatment
Example: ( overdose 10^6 .... 14,12 , 2 ( MOAI, TCA, SSRI)
Current treatment Limitations:4-6 wks for clinical effect, don't work for everyone, ADRs, some not better than placebo, some increase suicide rates
ADRs- Dry, Urinary Ret., Blurred, Constip, Sed, Sleep disrupt, Wt Gain, Headache, NAusea, GI dist./diarr., Abdominal pain, loss of libido ( inability orgasm/erection), agitation/anxiety
children/adolescents- increased suicide rates on paroxetine

Pathophysiology- 5HT pathya- raphe nuclei ( from brain stem to frontal cortex)
DA pathway ( nigrostriatal): Substantia Nigra to Stiatum.
DA pathway ( mesolimbic): ( Brain stem to hypothalamus to frontal cortex)
ventricles?

Presynaptic autoreceptors- negative feedback get diagram- terminals/cell bodies.SSRIs reduce 5-HT neuronal firing via 5HT1A receptors

5-HT autoreceptor control of cell firing/ release toeards Post synaptic 5HT1A Receptors ( control raphe cell firing) B/D control 5HT release at terminals

Overall- SSRI augmentation with 5HT (Pindolol) antagonists work in some not all i.e sustained response diff btwn groups taking SSRI & placebo
Better than placebo- major significance in those with severe depression