Last month (September 2018) the New South Wales Public Accounts Committee delivered its findings following its inquiry into the delivery of healthcare services.
The Committee heard harrowing confidential testimony and received submissions from health consumers who had been misdiagnosed and mistreated as mentally ill when in fact they were having an adverse drug reaction precisely explained by pharmacogenomics.
These consumer stories led The Committee to seek testimony from Professor Ric Day, an internationally recognized clinical pharmacologist and expert in pharmacotherapy, drug reactions, and interactions.
Following his testimony, The Committee made two key recommendations, to employ more specialists (clinical pharmacologists) to improve safe prescribing practices and adverse drug reactions and to actively pursue and fund pharmacogenomic testing for patients with a mental illness.
Whilst these recommendations relate to mental health if implemented this is likely to have wide-ranging effects for not only those on mental health medicines but health consumers in general. The same principles apply and many adverse events mimic mental health conditions as the consumers testified.
But these are recommendations. The Government has six months to respond which means that we collectively have six months to lobby the NSW Government, and six months to use these recommendations.
You can read the full transcript of their report on medication management below.
- A significant theme emerging through the inquiry was the appropriateness of prescribed medication for mental illness and suggestions for the improved targeting of treatment options. Claims made in confidential submissions from former patients of psychiatric institutions and discussions with healthcare staff have highlighted a range of issues regarding the appropriateness and use of psychotherapeutic drug treatments in institutional settings.
- The Committee was informed of cases where, upon admission as psychiatric patients, individuals have been subjected to misdiagnosis and mismanagement resulting in adverse drug reactions and exacerbated clinical outcomes as a result of inadequate monitoring of their genetic profiles.
- In order to test these claims, the Committee invited a specialist clinician to give evidence at the final public hearing. Professor Ric Day, a clinical pharmacologist and recognized expert in pharmacotherapy and drug reactions and interactions, provided detailed comment on the impacts of drugs on pre‐existing psychiatric conditions. Professor Day is also a member of a Federal/State working party examining adverse medication events in mental health.
- According to Professor Day, the cost to the health system for inappropriate or erroneous prescribing is very high:
The cost internationally is calculated to be $42 billion annually. That is 1 percent of global health expenditure just on the cost side; forget the matters for the individuals. In our own hospitals, the rate of admissions for medication errors is very high and it is very hard to reduce it. On average, it is about 2 percent to 3 percent but the older you get with more comorbidities that number increases. In some studies in Australia up to almost 40 percent of reasons for admission is something to do with medicines.98
- As well as communication barriers in describing the effects of drugs by patients with a mental illness, another complicating factor in predicting drug efficacy and suitability is the existence of comorbidities. Professor Day described it in the following terms:
The other big hazard for people with mental illness is the comorbidities. It is much more common to have diabetes, hypertension and related metabolic problems because it is harder to look after their general health matters and some of the drugs used actually induce these problems—that is, they cause a tendency to eat more.
- There is also a hazard of what is called the prescribing cascade if something goes wrong. I give an example of an elderly person who has been taking a drug for dementia and it has effects on their bladder and leads to retention. They are then put on a drug to treat the bladder problem that actually was drug induced and there is this chain of drug two, drug three, drug four because the first problem is not identified as an adverse reaction.99
- A relatively recent development to individually tailor drug treatments to better predict their efficacy depending on each person's ability to metabolize and benefit from the active ingredients is known as pharmacogenomics. The Deputy Secretary, NSW Health, acknowledged that this was a promising area of further exploration.100
- Depending on the interactions between individual gene proteins and drugs in the body, the action of a drug may be beneficial, adverse or have what are described as "bizarre" drug reactions. Some examples of this relate to well-described syndromes affecting particular ethnic groups and drugs used to treat mental illness. Professor Day elaborated on developments in this area:
One of them is a drug we use for mood disorders—carbamazepine. The test really should be done to check if someone has the gene and marker and, if the person does, the doctor should see if there is an alternative drug. That does apply to an increasing number of drugs. We are still accumulating data, looking at populations and deciding when it is the right time to test. I would not say it is right for every drug at this point, but it certainly is for quite a lot of them… The cost of getting the panel of key enzymes done is dropping. In fact, you can get your whole genome done now. It is quicker and cheaper, so on and so forth. That is moving very fast.101
- Professor Day also made the observation that there is a lack of clinical pharmacologists and suitably trained medical practitioners to take full advantage of recent developments in the specific targeting of drugs based on individual genetic markers. As an example of an educational resource, reference was made to NPS MedicineWise, a not‐for‐profit organization funded by the Australian Department of Health, providing clinically reviewed independent information about medicines to doctors, pharmacists and other health professional. Many of these online materials related to new drugs or more complex grey‐areas in the prescription process.102
- The Committee shares the concerns expressed through the evidence provided that pharmacogenomics testing is not being adequately utilized in the public mental health system. Furthermore, there is a lack of appropriately qualified healthcare practitioners in the area of clinical pharmacology to provide accurate advice on the optimal use of medicines for mental health care patients.
The Committee recommends that NSW Health provides funding for clinical pharmacologists in each Local Health District to provide education about recent advances in drug therapy and adverse drug reactions, to better target pharmaceutical treatments for mental illness.
The Committee recommends that NSW Health actively pursues and funds the increased use of pharmacogenomic testing as a means of improving treatment for patients with a mental illness.
98 Transcript of Evidence, Professor Day, Clinical Pharmacology and Toxicology, 9 March 2018, p2
99 Transcript of Evidence, Professor Day, Clinical Pharmacology and Toxicology, 9 March 2018, p2
100 Transcript of Evidence, Dr. Lyons, NSW Health, 9 March 2018, p35
101 Transcript of Evidence, Professor Day, Clinical Pharmacology and Toxicology, 9 March 2018, p3
102 NPS MedicineWise, accessed at https://www.nps.org.au/, 2 July 2018