Professor Stephen Bazire is Consultant Pharmacist, Norfolk and Suffolk NHS Foundation Trust; Honorary Professor, School of Pharmacy, University of East Anglia, and was made a Fellow of the Royal Pharmaceutical Society of Great Britain in 2006.
His special interests include user and carer information and education on medicines, and he has been integral in the development of the groundbreaking www.choiceandmedication.org.uk website.
Here Prof. Bazire talks to us about patient empowerment, how to choose a medication and the availability of talking therapies…
Tell us about your position as a Consultant Pharmacist. What are your priorities in your role?
It started out as a wider brief but seems to have become dominated by eMMa, who isn’t a lady but our name for electronic Medicines Management and administration. Calling it electronic prescribing might have led people to think it was just prescribing rather than prescribing, clinical checking, dispensing and administration. I also do a lot of teaching and education sessions and answering our medicine telephone helpline.
Your Choice and Medication website (www.choiceandmedication.org) supports people to make informed choices about their medications. Do you think patients exercise sufficient choice at the moment and are they becoming more or less empowered?
I have definitely noticed a more assertive and empowered atmosphere over the last few years but I suspect this is still very patchy. To me the main problem is providing people with the information they need in a usable way. Our long-term aim with the website is to move much of the information into a Patient Decision Aid, which takes people through all the stages of decision-making. The missing part of the jigsaw is the data on how to answer the question “what are the chances of getting better if I have treatment?”. There are so many studies, all different and not comparing different treatments, many subject to “publication bias” (i.e. studies that show an effect are more likely to be published than those that don’t show an effect, and the latter often aren’t even written up) and other bias (e.g., people with vested interests). And as for the long-term effects…
What would your advice be to someone who is not satisfied with their medication (for example, because of negative side-effects or lack of effectiveness)?
There are a number of options: if a medicine is helping but the side-effects are a problem, then trying to minimise or manage those side-effects is the first thing to do, e.g. adjusting the dose, the timings of doses, how they’re spread across the day, and other actions to help the side-effects. If a medicine isn’t working then look at the options and try to compare them. Ask a professional you trust and who seems to know what they’re talking about to talk it through with you. I prefer to give people a number of options with the pros and cons of each, and sometimes put them in a possible order.
Do you think that atypical antipsychotics are preferable to typical antipsychotics, and would you advise someone taking typical antipsychotics to ask to try an atypical?
I have had a long-standing problem with the terms atypical and typical because they don’t really have a meaning. Atypical was an experimental term latched on to by the pharmaceutical industry so all new antipsychotics are now “atypical”, which implies they are similar. It’s illogical to think that clozapine, quetiapine, olanzapine, aripiprazole, risperidone and amisulpride are classed together in one group. It makes no sense in terms of side-effects, effectiveness or even how they work. And as for some drugs being called “partial atypical”… I think that we should consider them to be antipsychotics in their own right and be thought of as different to each other rather than members of two distinct groups. Anyway, the newer antipsychotics have different, rather than fewer, side-effects. So it’s whatever works for you that matters, not the marketing terms. I’ll get off my hobby horse now.
What do you think about the polarisation of talking therapies and medication in the debate about the treatment of serious mental illnesses?
I really don’t understand this. An open mind will recognise that they are different and frequently complimentary. As Kay Redfield Jamieson (a well-known figure with bipolar) once said: “lithium helps control the symptoms, therapy helps me live with them.” I know that many drug studies are criticised as being biased because the manufacturers did them, but fiddling studies is getting much more difficult and some failed or negative studies are inevitable. For instance, people have analysed the data on agomelatine and said that if you include all the studies it isn’t any better than anything else. True, but several of the studies were before they found out it really only works if taken at night. That’s why people do studies – to find this sort of thing out. There are only a couple of studies of talking therapies that would be good enough to get it a license if it was a medicine. I’m sure the evidence can be obtained but you’d never be allowed to include waiting list controls in a drug trial.
Recent studies have suggested that antidepressants are being over-prescribed. Do you agree?
There are numerous studies showing that antidepressants reduce the suicide rate, e.g. over 20 years (1980-2009) in each of 29 European countries (except Portugal) there was a close correlation between increasing antidepressant use and reducing suicide rates. The same has been found in USA, Japan and Scandinavia. I’m sure some people get prescribed antidepressants when they don’t need them, but with depression frequently unrecognised these are far outnumbered by the number that ought to but are not.
How would you like to see treatments for mental illness develop and improve in the future?
I have a grave concern about more resources being poured into crisis care whereas keeping people well should be our priority. I often feel we’re putting lines of ambulances at the bottom of a cliff to help people who fall off it rather than putting a fence at the top to stop it happening. With so few mental health medicines reaching the market and then being able to be used (and I think local area prescribing groups full of people who think they know all about mental health and then block new medicines are a huge factor here) I think we need more research on the best way to use the medicines we have. Resources such as the Big White Wall and Berkshire’s SHaRON could well be the key here to help keep people well by recognising early when wobbles are happening and supporting people early to avoid a full relapse or crisis.
Find out more about medications for mental illness @ www.mentalhealthwales.net/mhw/whole_medication.php