Abstract
Defining the problem
The appropriate prescribing of medications in mental health is part of both the skill and art of psychiatric practice. Psychiatrists commonly consider the evidence base and adverse reaction of medications in discussing the options with patients, while being aware of other factors, including those relating to patient preference. One such factor is patient preference surrounding dietary restrictions, a consideration of increasing importance in contemporary multicultural Australian society. Dietary restrictions can be generally split along those based on religious grounds (most commonly Hinduism, Judaism and Islam), those on medical grounds (lactose and gluten intolerance) and those based on ethical or personal preference (vegan and/or vegetarianism). The most recent National Nutrition and Physical Activity Survey data from the Australian Bureau of Statistics (ABS) (2014) suggests that some 7% of the Australian population avoid food types for cultural, religious or ethical reasons with a further 17% avoiding a food type related to allergy or intolerance. Accordingly, up to one in five Australians may wish to have the dietetic component of their medications included in the decision-making process. Psychiatrists’ engagement with this new dimension in prescribing will be increasingly vital to promote consumer engagement.
There is a paucity of information currently available to practitioners. At present, there is no obligation todisclose the source of componentsin standard product information provided to the Australian Register of Therapeutic Goods. As such, thisinformation may be difficult to source for patients and clinicians alike. Furthermore, the authors found a dearth of clear information relating to the presence or absence of animal products, gluten and lactose in mental health medications literature. Likewise, the latest 2015 ‘Maudsley Prescribing Guidelines in Psychiatry 12th edition’ do not give guidance to prescribers. There is a narrow amount of writing on this topic, and certainly none that we could find relating to the Australian context.
Among psychiatric literature, the single dietary restriction of vegetarianism was raised over 15 years ago in a letter to the editor of the British Journal of Psychiatry (Singsit and Naik, 2001), and more recent ongoing discussion, including one article reviewing the suitability of psychiatric medications for vegetarians in the United Kingdom (McAllister-Williams and Ramplin, 2009). In the broader literature, there is again a paucity of factual guidance provided regarding these special dietary groups; there are, however, some articles which raise similar concerns with an ethical focus such as a recent paper by Eriksson et al. (2013) entitled, ‘Animal derived products may conflict with religious patient’s beliefs’, which explores the duty of the physician to expose and discuss possible conflict.
Addressing the problem
A list of the most commonly prescribed psychiatric medications was obtained from the PBS (Pharmaceutical Benefits Scheme). Thereafter, a readily identifiable brand name of that medication was identified. The medical information departments of key manufacturers of the medications to be included in the reference table were approached using a pro forma data request. Questions were posed in a direct manner, e.g. ‘Does this medication preparation contain lactose?’, rather than enquiring as to whether it is suitable for lactose-intolerant people. Data were collected from April to June 2016. If a clear response was not readily forthcoming, follow-up email and phone contact were undertaken.
It was endeavoured to produce a clear, simple and quick reference for clinicians of the most commonly used mental health medications. There are many names and manufacturers for each medication preparation; for example, olanzapine may be prescribed by the physician in a generic manner but the patient may be dispensed Zyprexa™ from Eli-Lilly, Olanzapine-APO™ by Apotex or a myriad of others, and each manufacturer’s process will vary. Therefore, the commonly prescribed medications with their associated brand name are presented. This method was chosen so that, should the prescriber wish to have definite faith in the prescription, they could write the brand name on the prescription and stipulate ‘not for substitution’.
A summary table
Table 1 shows the suitability of proprietary preparations of select mental health medications. The data demonstrate that 82.6% (i.e. 19 of the 23) of mental health medications listed contain animal products, common excipients including gelatine, animal-derived magnesium stearate, glycerol and lactose. Furthermore, 30.4% contained gluten and 78.2% included lactose. Fortunately, despite these seemingly high numbers, the results also show that agents are available for each of the special dietary requirement groups.
Content of selected proprietary mental health medications.
Explanation of the terms used and manufacturer’s response to the listed preparation:
‘
‘
‘?’ unclear or the preparation is produced in a factory which also manufacturers products containing the item of concern.
Animal-derived contents refer to contents of medications produced directly from an animal such as gelatine.
Animal products refer to components derived from animal by-products such as lactose from milk.
Uncertainty regarding the 0.5 mg tablet preparation and meat product content.
The main limitation of the table is that it is not an exhaustive reference list. It is designed as a guide to allow an open discussion between psychiatrist and their patient. Not all patients with dietary restrictions or avoidance will identify with the sub-choices that are represented (i.e. the different religious persuasions were not specifically requested nor were different subsections of vegetarianism/veganism). Furthermore, no enquiry as to whether adherence to strict codes of preparation was undertaken (e.g. Islamic religious codes such as Halal, Jewish dietary codes such as Kosher and Hindu dietary codes). It also should be noted that information presented is accurate as of the time of writing; however, as manufacturers change their practices regularly this is, of course, subject to change also.
While we acknowledge that the relationship between food-type avoidance and medication non-compliance is complex, our results show that a majority of commonly prescribed proprietary medications contain products unsuitable for numerous patient groups with special dietary requirements. The table is presented without any assignment of religious or moral preference. The clinician and patient are instead empowered to present the fact of what is contained in the medication, and they may interpret this accordingly. It is anticipated that this table will give a further tool to the clinician in discussing medications with patients surrounding these concerns. We note that patients may seek information or guidance from sources other than the clinician, indeed the table may be shared with the patients, their carers and religious leaders or organisations.
Other countries have debated improving medicine labelling to improve patient knowledge of their contents. By increasing knowledge, patients are more likely to engage with medical practitioners in informed choices. A revealing UK study found that over 40% of an inner city population had special dietary requirements (Vissamsetti et al., 2012). Within this group, nearly one quarter were unwittingly taking drugs containing animal products, of which they were unaware. Is this occurring everyday in Australia? If so, it is prudent for manufacturers to explicitly state whether their products are suitable or not for all four of the patient groups addressed in this paper not just for vegetarians which is the predominant focus of the limited literature in this area. We need better labelling in Australia, but until then, we hope that this table will assist psychiatrists in best practice for their patients.
Footnotes
Declaration of Conflicting Interests
Dr Murphy was funded via the NSW Institute of Psychiatry Research Fellow (2016).
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.