Pharmacotherapy for the Treatment of Hoarding Disorder

Hoarding disorder, which is characterized by difficulty discarding or parting with possessions, is common and potentially “disabling.” In fact, this behavior usually has some harmful effects, such as emotional, physical, social, financial, and even legal implications. Also, people who hoard often exhibit irrational behavior.

In some studies, hoarding has been listed as diagnostic criteria for obsessive-compulsive personality disorder (OCPD); however, some consider hoarding a disorder in itself. There are various routes of treatment for hoarding disorder, including both psychotherapy and pharmacotherapy. For the purpose of this assignment, I will focus more on the pharmacotherapy.

Since hoarding disorder is closely associated with OCD, pharmacotherapy for the treatment of hoarding disorder is similar to treatment of OCD. Studies have shown that OCD patients respond well to the use of selective serotonin reuptake inhibtors (SSRI’s), and some of these drugs have clinical effect in patients with hoarding behavior/disorder. In one study done by Sanjaya Saxena, it was concluded that the use of paroxetine (Paxil), which is an SSRI, improved hoarding symptoms, depression, and anxiety. Furthermore, venlafaxine has also shown good response with hoarding behaviors. In fact, venlafaxine had a trend for greater reduction in hoarding symptoms than that seen with paroxetine. New treatment strategies might also include cognitive enhancers, such as donepezil, to increase attention and executive functioning in patients with hoarding disorder.

In conclusion, hoarding disorder is a common and relevant problem that can tremendously affect someone’s life, but can be treated. Hoarding disorder, along with its signs and symptoms, can be improved by pharmacologic therapy (mostly the use of SSRI’s), psychological therapy, or a combination of both.

Saljoughian, Manouchehr. Hoarding Disorder: Diagnosis and Treatment. US Pharm. 2015:40(11):60-62.

Differential Impact of Selective Serotonin Reuptake Inhibitors on Platelet Response to Clopidogrel: A Randomized, Double-Blind, Crossover Trial

SSRIs and other antidepressant medications constitute one of the most commonly prescribed drug classes that pharmacists will see in the community setting. When taken alone, any one of these medications can be a good treatment option for patients experiencing depression; however, these drugs can cause a patient who is taking multiple drugs  to experience significant interactions with his/her other medications. For this reason, it is crucial to know how the effects of other medications can be altered through this therapy.  This study analyzed the effects of two SSRIs (citalopram and fluvoxamine) on the blood thinning medication clopidogrel. These medications all work on the same CYP enzyme (CYP2C19)  and have opposing effects. Researches tested these medications on healthy individuals and found that fluvoxamine was the only drug that caused significant inhibition of clopidogrel action.

I think this is important to note because these medications are commonly utilized by patients and thus there is a high likelihood that they may be taken together. As pharmacists, we should be able to provide adequate care in response to possible drug-drug interactions. To do this, we have to be able to recognize when there could potentially be a problem in medication therapy. By taking the proper precautions when these situations arise, pharmacists will be more likely to help patients avoid adverse medical events associated to drug therapy methods.

Association between guideline recommended drugs and death in older adults with multiple chronic conditions: population based cohort study

When prescribing medications for the initiation of  a new therapy in patients with multiple chronic diseases, physicians often look to guidelines to determine their recommended treatment option.  While this is considered good practice, it is important to not look at the disease state as a singular entity when choosing a therapy for the patient to follow due to the effects that certain conditions have on one another. This study looked to analyze the association between guideline recommended drugs and death in older adults with multiple chronic disease states. To do this, 8578 adults aged 65 and older were monitored though three years of treatment. Patients involved in the study had a variety of disease states including but not limited to atrial fibrillation, chronic kidney disease, depression, diabetes,  and hyperlipidemia. Results from the study showed that over 50% of the participants received guideline recommended drugs without the consideration of other disease states. Although 15% of the patients died during the course of the study, researchers were able to determine that cardiovascular medications were associated with a decrease in mortality. Other guideline medications analyzed in the study did not show an association with reduced mortality. Overall, it was determined that choosing medication therapy for patients should only be done after fully analyzing the patients other conditions.

I believe this study is important due to the fact that guideline recommended medications are commonly dispensed in the pharmacy setting. It is thus important for us to understand how guideline drugs interact with each other to protect a patient at the point of treatment initiation. By doing this, we will be able to avoid adverse drug effects that can result due to medication interactions. I believe that this is one of the most important roles of a pharmacist because it helps promote patient well-being and increases the likelihood of medication regiment adherence. The goal of our profession is to protect patients and advise them on how to find ways to live a healthy lifestyle. The easiest way to do this is by starting at the roots of the solution.

Tinoetti M, McAvay G, Trentalange M, et al. Association between guideline recommended drugs and death in older adults with multiple chronic conditions: population based cohort study. BMJ 2015; 351: h4984

Expanding Cessation Pharmacotherapy Via Videoconference Educational Outreach to Prescribers

According to studies that assessed current smoking rates among the population, it was found that people diagnosed with a mental illness are two to three times more likely to smoke than those who are not. For this reason, this study focused at providing these patients underutilized forms of smoking cessation pharmacotherapy to determine if a change could be made in this pattern. Researchers utilized two different forms of smoking cessation education methods in an attempt to determine the best way to deliver this information to patients. While the first method provided traditional group in-person cessation education sessions,  the second method aimed at determining if the use of videoconferencing technology would be an adequate alternative method for education. Members of the study analyzed the results by examining filled Medicaid pharmacotherapy claims along with the prescribers’ attitudes toward the different forms of education services. Although researchers hypothesized that in-person delivery of smoking cessation programs would be more effective than videoconferencing, they found that there were no significant differences between the two groups of patients receiving this service. They did note that patients receiving either form of this service were more likely to follow through with actions to quit smoking than those who did not.

I believe studies like these are important for future pharmacists to be aware of because it is our goal to make sure that patients are utilizing treatment options in an appropriate matter to ensure that they will receive the best health benefit. Since we are often the easiest person within the health care system for patients to approach with their issues, it is crucial that we know how to counsel them on these types of health-related concerns. Knowing that just providing some form of cessation education improves the likelihood that a patient will attempt to follow actions required to quit harmful behaviors is a positive sign that our work as professionals can have a significant impact on the people we are serving. It is for this reason that we should continually provided counseling services to patients at multiple stages in the treatment process, such as initiation of therapy and follow-ups. I believe that these actions will have a beneficial impact on patients and will make doing our job a much more fulfilling experience. I would be very interested to see how this type of study would show improvement in limiting the harmful impact that other health concerns have on the population.

Brunette MF, Dzebisashvili N, Xie H, et al. Expanding cessation pharmacotherapy via videoconference educational outreach to prescribers. Nicotine Tob Res. 2015;17(8):960-7.

Barriers to Effective Management of Hypertension in Older Populations

The leading cause of preventible death, not only in our own country, but worldwide, is hypertension. There is substantial evidence from robust trials for management of hypertension in older adults. The prevalence of hypertension seems to  increase with age, and therefore management of hypertension among older individuals through pharmacotherapy is essential to reach optimal health care for older populations. I study was conducted through the Journal of Pharmaceutical Policy and Practice to determine how exactly the prevalence of hypertension changes with age. The study also explored evidence regarding current pharmacological management in older adults for hypertension. The evidence from this study was then used to identify barriers that prevent older adults from receiving the best quality of care in the management of their hypertension.

The study found that the number of individuals struggling with hypertension increases significantly with age. At the age of 65 years or younger, 30% of the population has hypertension. But the age of 80 and over, this percentage of individuals with hypertension increased to 70% of the population. With the increase of the prevalence of hypertension with age, there is good evidence for the use of a number of medications to control blood pressures in older population.  However, despite good evidence for pharmacological management of hypertension in older adults, the quality of care available for treatment of hypertension in older adults is suboptimal. System, physician, and patient related barriers prevented older adults from reaching optimal blood pressure control.

J of Pharm Policy and Pract Journal of Pharmaceutical Policy and Practice 8.1 (2015): n. pag. Web.

Link to article

This study showed me the importance of open dialogue between patients and pharmacists. A pharmacist could easily prevent the patient-related barrier to the optimal treatment of hypertension in older adults. A pharmacist must make sure that each of his or her patients knows exactly how to adhere to his or her medication regimen. A pharmacist must also be able to advocate for his or her patients by expressing any concerns that they may have to the physician. Communication and a strong patient-pharmacist relationship are key to fixing the under treatment of hypertension in the older population.

Medical Marijuana and Migraine Headaches

Migraines are common headache disorders that range from being moderate to severe and from lasting hours to days. They are often accompanied by nausea, photophobia, and many other symptoms. Pharmacologic interventions can play a key role in reducing the severity, duration, and frequency of attacks and improving patients’ overall quality of life. There are no clinical trials that prove the effect of marijuana on migraines but the potential effects of cannabinoids on serotonin in the central nervous system imply that marijuana may be a pharmacological agent in treating migraines.

This article describes a study that was carried out as an observational chart review of patients seen at Gedde Whole Health. At this specific clinic, physicians specialize in applying the use of medical marijuana for various conditions. 121 adults with a diagnosis of migraine headache and a recommend migraine treatment with medical marijuana were reviewed and the number of migraines experienced and the amount of marijuana used each month were collected as data.

The primary outcome of this study was the number of migraine headaches per month with medical marijuana use and the results of this study demonstrated that headache frequency decreased from 10.4 to 4.6 headaches per month. The most common effects reported by patients were the prevention of migraine headache and decreased frequency of migraine headache. Many different types of marijuana were used and edible marijuana was found to have more negative effects compared to other types.

While many side effects persisted in this study, there was still a statistically significant decrease in the number of migraine headaches per month with the use of medical marijuana. Evidently, this is only one of the first studies done on the effectiveness of medical marijuana and further research is needed to investigate adverse effects and preferred delivery method and dose, verifying the effectiveness of medical marijuana as a prophylaxis and treatment for migraine headaches.

Pharmacists play a key role in the development of drug therapies and the treatment of sicknesses or diseases. As demonstrated with this case of migraines and medical marijuana, pharmacists’ knowledge of the body systems and the actions of chemicals on these systems can contribute immensely to the innovation of new drugs or therapies that could potentially treat or prevent many of today’s prevalent illnesses.

Rhyne, D. N., Anderson, S. L., Gedde, M. and Borgelt, L. M. (2016), Effects of Medical Marijuana on Migraine Headache Frequency in an Adult Population. Pharmacotherapy. doi:10.1002/phar.1673



Cognitive behavioural therapy as an adjunct to pharmacotherapy for depression

Depression can affect individuals for an acute or chronic period, but there has been little research done to examine the efficacy of antidepressants for over 1 year[1]. This recent article by Wiles et al.[2] examines the efficacy of cognitive behavioural therapy (CBT) in conjunction with pharmacotherapy for improving depression in treatment-resistant patients over a 3-5 year period. Depression is a mood disorder characterized by symptoms like decreased energy, difficulty sleeping, concentrating, or eating, loss of interest in activities, and suicidal thoughts. There are several classes of antidepressants such as SSRIs, SNRIs, and tricyclics available that function by affecting receptors of specific neurotransmitters. Cognitive behavioural therapy is a technique to change thinking and behavior patterns to assist the patient in taking action to solve problems.

248 individuals aged 18-75 year olds with substantial depression who had taken antidepressants for at least 6 weeks participated in this UK study from 2008-2010. Individuals were randomly assigned either normal care or CBT in conjunction with normal care. Severity of depression was scored based on the Beck Depression Inventory, where a lower score indicates less severe depression. The median follow-up period during treatment was 45 months. The group that received both pharmacotherapy and CBT had a mean score of 19 whereas the group that received only pharmacotherapy had a mean score of 23. After therapy ended the average follow-up period was 40 months. Cost-analysis showed that using both therapies in conjunction was cost-effective for the quality-adjusted life year (QALY) gain.

Since CBT in conjunction with pharmacotherapy has been shown to be effective in the long-term, how do you think pharmacists can increase the amount of patients who receive CBT?

  1. Uher R, Pavlova B. Long-term effects of depression treatment. The Lancet Psychiatry. 2016;3(2):95-96.
  2. Wiles, Nicola J et al. Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised control trial. The Lancet Psychiatry. 2016;3(2):137-144.