Self-care counseling for patients with psychiatric disorders

OTCs Today

According to the National Institute of Mental Health, 1 in 17 adults has a serious mental illness and, of those, almost one-half have two or more disorders.1 About 18% of adults have anxiety,2 3% have bipolar disorder,2 and between 5% and 10% are depressed.3 In addition to psychiatric illnesses, many patients have a range of chronic medical conditions (e.g., hypertension). Pharmacists can provide valuable self-care counseling to these individuals.

General counseling considerations

Pharmacists should ask patients with psychiatric disorders about their smoking status and, if needed, encourage smoking cessation. Patients with depression are more likely to smoke than those who are not depressed (29% vs. 19%).4 This finding also has been identified with bipolar disorder and schizophrenia. Multiple approaches (e.g., nicotine replacement therapies) are available OTC and should be discussed.

In a survey of more than 2,000 adults, 53% of those with depressive symptoms used complementary and alternative medicine (CAM), especially St. John’s wort and 5-hydroxytryptophan.5 Other supplements such as valerian, kava, melatonin, and omega-3 fatty acids often are used by individuals with mental health issues. Counsel patients that supplements are not well regulated, may not be safer than prescribed drugs, and should never replace prescription therapy.

Selective serotonin reuptake inhibitors

Selective serotonin reuptake inhibitors (SSRIs) are a commonly prescribed class of antidepressants. Although safe, the development of serotonin syndrome is a serious concern when used with other serotonergic agents. Dextromethorphan possesses serotonergic activity and is present in many cough preparations. Natural products (e.g., St. John’s wort, 5-hydroxytryptophan, S-adenosyl-l-methionine) also are serotonergic and should be avoided in individuals using an SSRI or antidepressants, including duloxetine and venlafaxine.

SSRIs (and serotonin–norepinephrine reuptake inhibitors) may increase the risk of bleeding, especially if taken with prescription antithrombotic agents. Patients should avoid OTC ibuprofen, naproxen, and analgesic dosages of aspirin to reduce the risk of bleeding and instead use acetaminophen.


Anticholinergic effects may occur with bupropion use, so patients should be counseled to avoid OTC drugs with anticholinergic effects (e.g., diphenhydramine, dimenhydrinate, meclizine). When a patient presents with cough and cold symptoms, products to recommend include second-generation antihistamines, decongestants, and throat lozenges. Patients should avoid combination OTC cold products, as they most likely contain anticholinergic agents.


Lithium remains a primary treatment for many patients with bipolar disorder. Self-care counseling should focus on any activity that would change lithium concentrations. Most importantly, changes in sodium ingestion, specifically sodium restriction, will increase the renal tubular reabsorption of lithium and result in lithium toxicity. Advise patients with concomitant bipolar disorder and hypertension to maintain adequate sodium and fluid intake. Patients taking lithium also should avoid the use of ibuprofen and naproxen, both of which can increase the renal reabsorption of lithium, resulting in increased concentrations. Tell patients to use acetaminophen for pain instead of NSAIDs.


  1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617–27.
  2. National Institute of Mental Health. The numbers count: mental disorders in America.…. Accessed April 11, 2013.
  3. Centers for Disease Control and Prevention. An estimated 1 in 10 U.S. adults report depression. Accessed April 11, 2013.
  4. Sanderson Cox L, Feng S, Cañar J, et al. Social and behavioral correlates of cigarette smoking among mid-Atlantic Latino primary care patients. Cancer Epidemiol Biomarkers Prev. 2005;14(8):1976–80.
  5. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51(1):8–19.
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