Positive evidence for clinical pharmacist interventions during interdisciplinary rounding at a psychiatric hospital

Development and validation of a feasible questionnaire to assess pharmacists' attitudes to documenting and classifying pharmaceutical interventions in hospital settings

BACKGROUND

Significant efforts have been directed towards systematically documenting and classifying pharmacist interventions (PIs), generating relevant data for professionals' practice and improving the quality of patient care and health outcomes. However, the paucity of PI evaluation tools hinders data generation, harmonisation and sensible application.

AIM

This study aimed to develop and validate a comprehensive questionnaire to assess pharmacists' opinions and practices concerning documenting and classifying PIs in Portuguese hospital settings.

METHOD

The tool development underwent face, content, construct validity procedures and scale reliability calculations grounded in the attitudinal framework. An exploration of the instrument dimensionally was accomplished through factor analysis. Face validity, content validity, construct validity and scale reliability were the selected validation parameters.

RESULT

A 37-item scale was developed comprising an initial sociodemographic section (8 items) and three explanatory attitudinal-based domains: Cognitive (6 items), Behavioural (14 items), and Affective (9 items). The scale showed adequate overall psychometric properties. Within the Affective domain, factor analysis revealed three latent explanatory factors: Process (4 items), Outcome (3 items) and Satisfaction (2 items).

CONCLUSION

This newly developed tool can contribute to assessing pharmacists' perspectives and routines in documenting and classifying PIs within hospital environments.

Deprescribing psychoactive drugs in older orthogeriatric patients: findings from the GIOG2.0 Italian survey

BACKGROUND

Psychoactive drugs represent a major contributor to falls in older people. This study aims to evaluate the prescribing practice of psychoactive drugs in older people hospitalized for hip fracture (HF) and to explore independent correlates of deprescribing.

METHODS

Multicenter prospective observational study including patients with HF admitted to 13 Orthogeriatric wards of the Italian Group of Orthogeriatrics (July 2019-August 2022). Patients underwent a comprehensive geriatric assessment. The use of psychoactive drugs associated with a higher risk of falls was assessed using a dedicated checklist. Deprescribing was defined as any reduction in the number of psychoactive drugs upon discharge, and independent correlates of deprescribing were explored using logistic regression analyses. Cluster analysis by Partitioning around Medoids was also performed in the hypothesis that selected clusters of characteristics could be associated with deprescribing.

RESULTS

One thousand eight hundred fifty-four older individuals (mean age 84 years, 77% females) were studied; 1190 (64%) were not prescribed any psychoactive drug, while 474 (26%), 129 (7%), and 61 (3%) took 1, 2, 3 or more psychoactive drugs, respectively. Among 664 patients on psychoactive drugs on admission, 177 (27%) had fewer prescriptions at discharge, mainly anxiolytics from 89 to 10 (50-6%), antipsychotics from 49 to 12 (28-7%) and antidepressants from 98 to 28 (55-16%). On the other count, 51 (8%) were prescribed more psychoactive drugs, mostly antidepressants from 25 to 45 (49-88%) and antipsychotics from 7 to 17 (14-17%). Functional autonomy (ADL aOR 0.87 [95%CI 0.78-0.97] p < 0.001), polipharmacy (aOR 1.15 [95%CI 1.03-1.29] p < 0.001) and the occurrence of post-operative delirium (aOR 1.71 [95%CI 1.09-2.66] p < 0.017) were independent correlates of deprescribing. More specifically, the clustering procedure could not improve the characterization of deprescribing; conversely, the deprescribing propensity significantly depended upon the center-specific prescriptive practice, not explained by other clinical-epidemiological factors.

CONCLUSION

Only a small proportion of patients hospitalized for HF undergoes deprescribing of psychoactive drugs, with considerable heterogeneity among centers, suggesting that the physician's attitude rather than patient-related factors affects deprescribing.

Effectiveness of a pharmacist-led tele-psychiatric clinic in managing drug-related problems

Background

The study aimed to evaluate the effectiveness of telepsychiatry combined with the expertise of psychiatric clinical pharmacists in identifying and addressing drug-related problems (DRPs) associated with psychotropic medications. Additionally, the research assessed physicians' acceptance of pharmacists' recommendations for managing these DRPs.

Methods

A cohort retrospective study was conducted at a leading tertiary care hospital in Saudi Arabia spanning from January 2023 to January 2024 in a psychiatry setting. The study comprehensively examined all instances of interventions for DRPs facilitated through patient-initiated telepsychiatry encounters with psychiatric clinical pharmacists. Detailed and meticulously recorded notes from patient chart reviews, documented by the pharmacist in the Electronic Health Record (EHR), during each encounter, were reviewed. These notes provided significant information on psychiatric diagnosis, identified DRPs and the specific interventions and recommendations proposed by the clinical pharmacist to the attending physician. The Krska classification was utilised to classify and analyse the identified DRPs, ensuring a structured and systematic approach to the study's findings.

Results

A total of 259 pharmacist interventions were made, and the results revealed a remarkably high acceptance rate of 98.5% among physicians. The most common intervention (16.21%) involved targeted education to improve medication adherence. Additionally, substantial efforts were directed towards rectifying inappropriate dosage regimens, accounting for 13.51% of DRPs resolved by the pharmacist. Noteworthy interventions also encompassed the identification and management of potential or suspected adverse reactions, comprising 12.35% of the interventions, along with interventions addressing concerns regarding potentially ineffective therapy, which constituted 11.59%.

Conclusion

The study underscores the critical role of pharmacists in psychiatric care, with high physician acceptance of their interventions. The diverse range of DRPs highlights the need to expand clinical pharmacy services and integrate pharmacists into psychiatric teams. Our findings clearly demonstrate that integrating pharmacists into psychiatric care settings is beneficial. This approach enhances DRP identification and management, ultimately enhancing patient care and treatment outcomes.

Impact of psychotropic pro re nata prescription-monitoring programme on prescriptions for inpatients with psychiatric disorders: a retrospective observational study

BACKGROUND

Pro re nata (PRN) medication is used "as needed" for symptoms such as agitation and insomnia, in addition to regular daily pharmacotherapy of mental disorders. However, there is no high-quality evidence on the effectiveness of psychotropic PRN medications and concerns have been raised about their potential to contribute to polypharmacy. This study introduced a psychotropic PRN prescription-monitoring programme for psychiatric inpatients with the aim of examining the change before and after the implementation of the programme.

METHOD

This study included 389 patients admitted to the psychiatric department between 1 July 2021 and 30 June 2023. The psychotropic PRN prescription-monitoring programme was implemented in July 2022, and the participants were classified into monitoring and non-monitoring groups. Demographic data (age, sex, and diagnosis), regular prescriptions before admission and at discharge, psychotropic PRN prescriptions before admission and at discharge, and the total number of psychotropic PRN prescriptions during hospitalisation were compared between the two groups. Data on psychotropic prescription were collected by psychotropic category. The significance level of 5% was set at 1.67 × 10-3 using the Bonferroni correction for multiple testing.

RESULTS

The psychotropic PRN prescription ratio at discharge in the monitoring group was 9.3%, which was significantly lower than the 28.1% in the non-monitoring group. The percentage of patients with a PRN prescription during hospitalisation in the monitoring group was 29.8%, which was significantly lower than the 64.5% in the non-monitoring group. In the non-monitoring group, there was no statistically significant difference in the number of psychotropic drugs prescribed regularly before and after admission. However, in the monitoring group, the number of psychotropic drugs in the regular prescriptions at discharge was 1.87 ± 1.24, which was significantly lower than 2.47 ± 1.90 in the regular prescription before admission.

CONCLUSIONS

Our findings suggest that a psychotropic PRN prescription-monitoring programme may contribute to the elimination of polypharmacy, including regular prescriptions. Further research is required to optimise psychotropic PRN prescriptions and reduce polypharmacy.

Improving the provision of clinical pharmacy services in low- and middle-income countries: a qualitative study in tertiary health facilities in Tanzania

Background

The provision of clinical pharmacy services (CPS) in low- and middle-income countries is still low. The reported challenges in providing CPS include healthcare structures, public policies, resources, workforce, culture and education inequalities. This study aimed to explore the strategies to improve the provision of CPS in tertiary health facilities in Tanzania.

Methods

This study was conducted between August and September 2021. We adopted an exploratory qualitative study to conduct 14 in-depth interviews with hospital administrators and 10 focus group discussions (FGDs) with healthcare providers. A purposeful sampling technique was used to recruit 97 participants, including 45 pharmacists, 31 medical doctors and 21 nurses across five tertiary healthcare institutions. Of those, 14 hospital administrators participated in 14 IDIs and 83 healthcare workers divided into 10 FGDs. Analysis was done using a qualitative thematic approach.

Results

The study identified several strategies that fall under four major themes: (i) strengthen preservice training by reviewing the Bachelor of Pharmacy training curriculum to include clinical pharmacy components; (ii) improve continuing professional training through regular provision of on-job training to pharmacists; (iii) revise the scope of work for pharmacists to include CPS provision in the job description; and (iv) improve operational environment by ensuring availability of guidelines, policies, and adequate number of pharmacists and good inter-professional communication skills.

Conclusions

This study's findings highlight that improving CPS provision requires strengthening pharmacists' training, scope of work and operational environment. The latter calls for multifaceted engagement from pharmacists, training institutions, policymakers, regulatory bodies and health systems for sustainable progress.

Clinical pharmacist recommendations in daily interdisciplinary ward rounds at a psychiatric hospital: a retrospective pre-post study on drug-related problems focused in somatic comorbidities

Objective

One potential strategy to address inadequate screening for somatic comorbidities among patients with mental disorders is to integrate a clinical pharmacist into the inpatient team for daily interdisciplinary ward rounds. This approach remains under-researched in psychiatric hospitals. This study aimed to evaluate the impact of a clinical pharmacist on drug-related problems (DRPs) during daily ward rounds within an interdisciplinary team in a psychiatric hospital.

Methods

A retrospective observational pre-post study was conducted at the Ormož Psychiatric Hospital in Slovenia, including patients treated between 2019 and 2020, during which clinical pharmacists offered recommendations during daily ward rounds. The primary outcomes assessed the difference in the total number of DRPs observed at the time of hospital discharge compared to previous stage, as well as the recommendations and their continuation rate after three months. The secondary outcomes evaluated adherence to treatment guidelines.

Results

The study included 186 patients (mean age: 58.1 years, SD=17.0). During ward rounds, 280 recommendations related to DRPs were conducted (1.5 recommendations per patient). Regarding the nature of DRPs, 154 (55.0%) were identified as expressed DRPs, while 127 (45.0%) were deemed potential DRPs. Following pharmacist recommendations, 133 (86.4%) of the expressed DRPs were successfully resolved. The majority of DRPs pertained to treatment effectiveness (N=179, 63.9%), followed by unnecessary treatments (N=86, 30.7%) and patient safety (N=15, 5.4%). Initially, the acceptance rate of recommendations was 88.9% (N=249) at discharge, declining to 63.2% (N=177) three months after discharge. The acceptance rate for somatic conditions at discharge was 87.8% (N=122), declining to 59.0% (N=82) three months after discharge. Adherence to treatment guidelines for somatic comorbidities increased (p < 0.05).

Conclusions

The results indicate that this approach led to fewer DRPs, a high rate of acceptance, and better adherence to treatment guidelines. This is the first retrospective pre-post study in the European Union to include this collaboration in daily rounds at psychiatric hospitals, focusing on somatic comorbidities. However, the study also has significant limitations, such as its non-randomized design and short monitoring period, which should be addressed in future research.

Phytochemicals in the treatment of patients with depression: a systemic review

Background

Depression is a complex mental disease whose incidence increases every year; 300 million people worldwide currently suffer from it. Women are more likely to suffer from depression, twice the rate as men. It is one of the few illnesses that can lead to suicide, which makes it very dangerous - currently, 700,000 people die from suicide and it is the 4th most common cause of death in people aged 15-29. The treatment strategies for depression is a big challenge for physicians, pharmacists, scientists and classic remedies cause many side effects. Therefore, natural phytotherapy with herbs can prove to be a good solution. Phytotherapy is a popular treatment method used for centuries in Chinese medicine or Ayurveda.

Materials and methods

The study conducted a comprehensive database search PubMed, ClinicalKey and MedNar covered the years 2015 - 2024 to provide the most up-to-date data. 13 randomized controlled trials and 1 meta - analysis were included in the systematic review.

Results

Many plants show anti-inflammatory, antioxidant and cognitive enhancing effects, which are particularly important in depression. In the treatment of depression, plants such as Crocus sativus L. stigma, Lavandula angustifolia, Hypericum perforatum L. and Curcuma longa L. have proven to be effective. They show good effectiveness in human studies and alleviate the symptoms of depression. Herbal products can support classical pharmacotherapy, but this requires further research. Non-commercial clinical trials in the future should provide answers to research questions: at what stage of treatment of patients with MDD will the use of phytochemicals be most appropriate in terms of therapy efficacy and safety for the patient.

Conclusions

Crocus sativus L. stigma, Lavandula angustifolia, Hypericum perforatum L. and Curcuma longa L. in modern medicine can help improve the well-being of patients with depression. The use of herbs as an intervention was associated with a decrease in the concentration of proinflammatory cytokines and an overall improvement in the mood of patients. Further research should be undertaken into combining both therapies in order to improve patients' quality of life and reduce treatment costs.

Prevalence and solving strategies of drug-related problems in adult psychiatric inpatients - a systematic review

Introduction

Most psychiatric inpatients receive psychopharmacological treatment indicated for their mental diseases. The aim of this systematic review is to give clinical pharmacists and physicians a comprehensive summary of common drug-related problems (DRPs) in adult psychiatric inpatients and of potential interventions to solve them in clinical practice.

Methods

Six databases and registers were searched for English, German and French articles published between 1999 and 2023 with content regarding the prevalence and/or type or interventions to solve DRPs in adult psychiatric inpatients. Studies were categorized based on types of DRPs and clinical interventions. The prevalence rates of DRPs and subtypes were compared quantitatively and the tested interventions were summarized qualitatively.

Results

A total of 88 articles with an overall sample of over 95.425 adult psychiatric inpatients were included in this review. DRPs were reported with a prevalence range of 0.32 to 9.48 per patient. The most frequently reported DRPs were caused by prescribing errors (1.91 per patient), the most frequent subtype was drug interaction (0.77 per patient). Clinical pharmacists were involved in interventions in 7 of 13 included articles. Interventions consisted of clinical pharmacy services on the ward, educational classes, medication reviews, and the implementation of digital tools such as dispensing cabinets and prescribing tools.

Discussion

The included studies were heterogeneous. The most frequent DRPs in psychiatry are related to prescribing errors and drug interactions. Clinical pharmacists may support the drug therapy by identifying and effectively solving DRPs in psychiatric inpatients using interdisciplinary approaches.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022354958.

A case report of mental disorder caused by shunt blockage after hydrocephalus surgery

Introduction

Hydrocephalus is a form of communication hydrocephalus syndrome characterized by ventricular enlargement and normal intraventricular pressure. The primary clinical manifestations include gait disturbances, cognitive dysfunction, urinary incontinence, and either elevated or normal intracranial pressure. This paper presents a case of a mental disorder resulting from inadequate drainage following a ventriculoperitoneal shunt procedure for hydrocephalus. The case report aims to enhance clinicians' understanding of such organic brain lesions, which are prone to misdiagnosis and inappropriate treatment, thereby improving differential diagnostic skills.

Case presentation

This case report describes a 34-year-old male with a 16-year history of depressive disorder, previously managed with 150 mg of venlafaxine daily, 7.5 mg of zopiclone every night, and 2.4 g of piracetam every day. The patient underwent a ventriculoperitoneal shunt procedure for hydrocephalus, leading to the development of a mental disorder attributable to poor drainage from the shunt tube. Initial symptoms consisted of low mood, decreased interest, and cognitive impairment. Despite psychiatric consultation and antidepressant treatment, there was no improvement in his condition. The final diagnosis was an organic mental disorder. Following an increase in shunt drainage and the administration of a low dose of olanzapine, the patient's psychiatric symptoms showed significant improvement.

Conclusion

Reporting this case seeks to enhance clinicians' awareness of the psychiatric manifestations of organic brain lesions, expand the differential diagnostic approach for psychiatrists, and improve diagnostic accuracy. Additionally, it emphasizes the need for cautious use of psychiatric medications, appropriate symptomatic management, and timely referral when necessary.

Assessment of clinical pharmacist interventions using a web-based application in a Saudi Arabian Tertiary Hospital

Objectives

Medication-related problems are a top concern of clinical pharmacists. Medication-related problems can cause patient harm and increase the number of visits, hospital admissions, and length of hospital stay. The objective was to assess clinical pharmacy medication-related problem-related interventions in a tertiary care setting.

Methods

A retrospective cohort study was conducted at King Fahad Armed Forces Hospital in Jeddah (Saudi Arabia) between June 2021 and June 2022. The data were extracted monthly from a new web-based Microsoft Excel application documenting medication-related problems during any stage of the medication use process.

Results

A total of 5310 medication-related problem-related interventions in 1494 patients were performed. The departments associated with the highest frequency of medication-related problem-related interventions were the critical care unit (26.9%), intensive care unit (23.8%), anticoagulation clinic (17.1%), medical ward (11.3%), and nephrology unit (6.8%). The most common type of medication-related problem-related interventions included inappropriate dosage regimens (25.6%), monitoring drug effect or therapeutic drug monitoring (24.4%), requirement of additional drug therapy (21.9%), and inappropriate drug selection (14.1%). The proposed interventions were accepted by physicians in 97% of the incidents. The most frequent medication classes associated with medication-related problem-related interventions were cardiovascular agents (47.6%), antimicrobial agents (27.2%), and nutrition and blood substitute agents (11.4%). The most frequent medication groups associated with medication-related problem-related interventions were anticoagulants (25.6%) and antibiotics (25.2%).

Conclusions

The current findings characterize the medication-related problem-related interventions addressed in clinical pharmacy at a tertiary care setting. The high rate of physician acceptance emphasizes the integral patient safety role of clinical pharmacy services.

Systematic literature review of the impact of psychiatric pharmacists

Introduction

Pharmacists focusing on psychotropic medication management and practicing across a wide variety of healthcare settings have significantly improved patient-level outcomes. The Systematic Literature Review Committee of the American Association of Psychiatric Pharmacists was tasked with compiling a comprehensive database of primary literature highlighting the impact of psychiatric pharmacists on patient-level outcomes.

Methods

A systematic search of literature published from January 1, 1961, to December 31, 2022, was conducted using PubMed and search terms based on a prior American Association of Psychiatric Pharmacists literature review. Publications describing patient-level outcome results associated with pharmacist provision of care in psychiatric/neurologic settings and/or in relation to psychotropic medications were included. The search excluded articles for which there was no pharmacist intervention, no psychiatric disorder treatment, no clinical outcomes, no original research, no access to full text, and/or no English-language version.

Results

A total of 4270 articles were reviewed via PubMed, with 4072 articles excluded based on title, abstract, and/or full text in the initial pass and 208 articles selected for inclusion. A secondary full-text review excluded 11 additional articles, and 5 excluded articles were ultimately included based on a secondary review, for a final total of 202 articles meeting the inclusion criteria. A comprehensive database of these articles was compiled, including details on their study designs and outcomes.

Discussion

The articles included in the final database had a wide range of heterogeneity. While the overall impact of psychiatric pharmacists was positive, the study variability highlights the need for future publications to have more consistent, standardized outcomes with stronger study designs.

Clinical pharmacist interventions in the transition of care in a mental health hospital: case reports focused on the medication reconciliation process

The transition of care represents a key point in the hospital admission and discharge process. A comprehensive transition could lead to fewer medication-related problems. The hospital clinical pharmacist could help in the transition of care process with a comprehensive medication reconciliation process, which has been poorly described in mental health hospitals. This study presents two clinical cases in which hospital clinical pharmacists identified omitted medications and other medication-related issues, including medication errors, during the transition of care in a mental health hospital. These positive experiences may encourage other countries to establish similar collaborations with hospital clinical pharmacists in mental health hospitals.

Mental health symptoms and their associated factors among pharmacists in psychiatric hospitals during the early stage of the COVID-19 pandemic

As frontline workers, pharmacists often face significant work stress, especially in psychiatric settings. A multicenter cross-sectional design was conducted in 41 psychiatric hospitals. The Depression, Anxiety and Stress Scale-21 (DASS-21) was used to measure the mental health of 636 pharmacists. We also collected demographic data and work-related variables. The prevalence of depression, anxiety and stress was 20.60%, 22.96% and 8.96%, respectively. Multivariate logistic regression showed that several common factors were associated with depression, anxiety and stress, including professional identity (odds ratio [OR] = 0.132, 0.381 and 0.352) and verbal violence (OR = 2.068, 2.615 and 2.490). Those who were satisfied with their job were less likely to develop depression (OR = 0.234) or anxiety (OR = 0.328). We found specific factors associated with mental health. Older age (OR = 1.038) and perceived negative impact (OR = 2.398) of COVID-19 on medical work were associated with anxiety, and those with frontline experience with COVID-19 patients (OR = 2.306) were more likely to experience stress. More than one-fifth of pharmacists in psychiatric hospitals experienced symptoms of depression or anxiety during the pandemic, highlighting the need for policy change to improve workplace conditions and psychological well-being for this professional group.

Clozapine-Associated Agranulocytosis: A Systematic Review. Is It Really So Frighteningly Common?

BACKGROUND

Clozapine is a very effective therapeutic option for schizophrenic disorders that have been refractory to most other therapies. This extremely positive aspect clashes easily with an adverse effect of the drug that is deemed to be a very dangerous one: agranulocytosis. We asked whether the mandatory strict hematological follow-up prescribed in the black box warning of clozapine's label is proportioned to the actual incidence of agranulocytosis, considering that is the main reason that such a drug is often used only late in the treatment course.

METHODS

We carried out a systematic review of reports examining clozapine administration and agranulocytosis incidence. We specifically selected those where mild and moderate neutropenia was not used as a trigger to stop administration of clozapine, to better estimate the sheer incidence of agranulocytosis when clozapine was continued even with mild hematological effect, where detected. We used PubMed, MEDLINE, EMBASE, Cochrane, and ScienceDirect databases to identify clinical studies conducted between January 1975 and April 2023.

RESULTS

We included 14 studies, mostly retrospective ones, that examined the incidence of hematological adverse effects in patients using clozapine. A total of 2354 subjects were included. The mean age of the subjects was 33.5 years. The mean duration of observation of subjects who took clozapine was 800 days, with a mean daily dose of 319.5 mg per day. Of the 2354 subjects examined, we found that 11 of them experienced agranulocytosis (0.47%).

CONCLUSIONS

These results suggest the evidence of a lower incidence of agranulocytosis than previously estimated and are in line with more recent meta-analyses. We may therefore think that clinical practice may demand a revision of the approach that both psychiatrists and supervising organizations often take when talking about clozapine.

Drug Therapy Safety in Palliative Care-Pharmaceutical Analysis of Medication Processes in Palliative Care

Pharmacotherapy plays a crucial role in symptom management in palliative care and is associated with risks potentially leading to drug-related problems (DRP). Pharmacists can identify DRPs and advise prescribers on optimizing drug therapy. The aim of this study was to identify DRP in a palliative care unit (PCU) and evaluate corresponding pharmaceutical interventions. A non-randomized before-and-after study in a PCU starts with a control phase, an interphase, and an intervention phase. Primary endpoint: DRP, including pharmaceutical interventions and their acceptance. The medication of all inpatients was recorded at set time points, assessed for potential and manifest DRP, and categorized. In the control phase, the ward pharmacist did not interfere with the clinical team. In the intervention phase, the pharmacist could intervene when a DRP was identified and give recommendations. During the 12-month period, 284 patients were included (control phase n = 138; intervention phase n = 146) and 1079 DRPs were identified (control phase n = 634; intervention phase n = 445). The number of DRPs/patient was significantly reduced by the pharmacist's interventions between the control and intervention phases (4 vs. 3 DRPs, p = 0.001). Overall acceptance of pharmaceutical interventions by prescribers was very high (227/256; 88%). DRPs are hardly preventable. With a clinical pharmacist as a member of the palliative care team, it is possible to reduce the number of DRPs and identify potential problems earlier.

Clinical pharmacy services in mental health in Europe: a commentary paper of the European Society of Clinical Pharmacy Special Interest Group on Mental Health

A large proportion of the world's disease burden is attributable to mental illnesses. Although effective interventions are available, many patients still have limited access to evidence-based treatments. Aside from access, treatment gaps, including inappropriate medication selection and monitoring, are also routinely recognised. Mental health clinical pharmacists can help address these gaps and enable patients to receive optimised pharmaceutical care, particularly appropriate medication selection and monitoring. The European Society of Clinical Pharmacy (ESCP) Special Interest Group on Mental Health was established to improve standardised service provision in mental health settings across Europe. The Special Interest Group identified significant barriers (predominantly associated with reimbursement and position within the multidisciplinary team) to effective pharmaceutical care amongst those with mental illnesses. This commentary presents recommendations to address these gaps through improved mental health clinical pharmacy service provision.

Building a novel self-iterative clinical pharmacist intervention model in psychiatric hospital: Application and evaluation

Clinical pharmacist intervention (CPI) in psychiatric hospital has not been widely developed in China. This study aimed to establish a real-time dynamic self-iterative CPI model in The Affiliated Mental Health Center of Jiangnan University and evaluated its effect. We focused on the running data in 2021 and 2022. The number of interventions, intervention types and intervention strategies were evaluated. In 2021 and 2022, a total of 443 interventions were reported. Among them, 271 (61.17 %) were identified during ward rounds by physicians, pharmacists and nurses. The proportion of CPI through ward rounds and information system gradually decreased while intervention through other ways increased. Meanwhile, there are various of CPI types including adverse drug reactions (26.86 %), therapeutic drug monitoring recommendations (13.32 %), drug usage and dose adjustment (10.61 %) and among them, adverse reactions are the focus of pharmacists' attention. Besides, the intervention strategies of pharmacists mainly concentrated in medication change (18.74 %), medication discontinuation (15.58 %) and dose reduction (12.19 %). In addition, the self-iterative function can continuously optimize the intervention level of clinical pharmacists. Overall, the CPI model established in this study effectively promote pharmacist intervention and accelerate pharmaceutical transformation.

Clinical pharmacy interventions in an Austrian hospital: a report highlights the need for the implementation of clinical pharmacy services

BACKGROUND

Clinical pharmacy services face challenges in Austria due to limited implementation and acceptance, outdated legislation and a lack of guidelines and training, despite the evidence from global studies of the positive impact of clinical pharmacists on patient care.

OBJECTIVES

First, to identify the necessary types of clinical pharmacy interventions required at a 360-bed hospital located in Austria. Second, to evaluate the extent to which physicians accept the suggestions made by clinical pharmacists.

METHODS

Over a period of 27 months, a clinical pharmacist made a series of interventions, which were evaluated using a six-point clinical significance scale. To determine the inter-rater reliability, a subset of 25 interventions was assessed for their clinical significance by four independent internal medicine physicians.

RESULTS

A total of 1064 interventions were made by the pharmacist. Clinical pharmacy input was deemed necessary for 986 out of 1364 (72.3%) patients, with an average of 1.08 interventions per patient. The prompt acceptance rate of these interventions by physicians was 83.5% (888/1064), while 12.9% (137/1064) were considered by physicians but not immediately acted upon. The average clinical significance intervention rating was 2.15. The inter-rater reliability agreement between the four MDs and between the four MDs and the pharmacist was classified as 'good' to 'moderate'.

CONCLUSION

This study in a secondary care Austrian hospital demonstrates the requirement for clinical pharmacy services, which are highly valued by other healthcare professionals. The clinical pharmacist is a key member of the multidisciplinary ward team, playing a vital role in reducing drug-related problems and enhancing patient safety. This work should now be scaled and tested in other Austrian hospitals.

Pharmaceutical care model in precision medicine in China

Pharmacy service is to provide individualized pharmaceutical care for patients, which should follow the current evidence-based pharmacy, and constantly verify the evidence and then produce new evidence. In pharmaceutical care, differences are often found in the efficacy and adverse reactions of drugs among individuals, even within individuals, which are closely related to patients' genetics, liver and kidney functions, disease states, and drug interactions. Back in the 1980s, therapeutic drug monitoring (TDM) has been applied to routinely monitor the blood drug concentration of patients taking antiepileptic drugs or immunosuppressants after transplantation to provide individualized dosage recommendations and accumulate a large amount of pharmacokinetic (PK)/pharmacodynamic (PD) data. As individualized pharmaceutical care proceeds, the concept of precision medicine was introduced into pharmacy services in combination with evidence-based pharmacy, PK/PD theories, and big data to further promote the TDM technology and drugs, and carry out pharmacogenomics analysis. The TDM and pharmacogenomics have been applied gradually to the fields of antimicrobial, antitumor, and antipsychotic drugs and immunosuppressants. Based on the concept of precision pharmacy, we adopted approaches including PK/PD, quantitative pharmacology, population pharmacokinetics, and big data machine learning to provide more personalized pharmacy services, which is mainly for special patients, such as critical patients, patients with interaction risk of multiple drugs, patients with liver and renal insufficiency, pregnant women, children, and elderly patients. As the service pattern of precision pharmacy has been constructed and constantly improved, better evidence in clinical practice will be produced to provide patients with better precision pharmacy service.

Pharmaceutical care model in precision medicine in China

Pharmacy service is to provide individualized pharmaceutical care for patients, which should follow the current evidence-based pharmacy, and constantly verify the evidence and then produce new evidence. In pharmaceutical care, differences are often found in the efficacy and adverse reactions of drugs among individuals, even within individuals, which are closely related to patient's genetics, liver and kidney functions, disease states, and drug interactions. Back in the 1980s, therapeutic drug monitoring (TDM) has been applied to routinely monitor the blood drug concentration of patients taking antiepileptic drugs or immunosuppressants after transplantation to provide individualized dosage recommendations and accumulate a large amount of pharmacokinetic (PK)/pharmacodynamic (PD) data. As individualized pharmaceutical care proceeds, the concept of precision medicine was introduced into pharmacy services in combination with evidence-based pharmacy, PK/PD theories and big data to further promote the TDM technology and drugs, and carry out pharmacogenomics analysis. The TDM and pharmacogenomics have been applied gradually to the fields of antimicrobial, antitumor and antipsychotic drugs and immunosuppressants. Based on the concept of precision pharmacy, we adpoted approaches including PK/PD, quantitative pharmacology, population pharmacokinetics, and big data machine learning to provide more personalized pharmacy services, which is mainly for special patients, such as critical patients, patients with interaction risk of multiple drugs, patients with liver and renal insufficiency, pregnant women, children and elderly patients. As the service pattern of precision pharmacy has been constructed and constantly improved, better evidence in clinical practice will be produced to provide patients with better precision pharmacy service.

Recommendations for wider adoption of clinical pharmacy in Central and Eastern Europe in order to optimise pharmacotherapy and improve patient outcomes

Clinical pharmacy as an area of practice, education and research started developing around the 1960s when pharmacists across the globe gradually identified the need to focus more on ensuring the appropriate use of medicines to improve patient outcomes rather than being engaged in manufacturing and supply. Since that time numerous studies have shown the positive impact of clinical pharmacy services (CPS). The need for wider adoption of CPS worldwide becomes urgent, as the global population ages, and the prevalence of polypharmacy as well as shortage of healthcare professionals is rising. At the same time, there is great pressure to provide both high-quality and cost-effective health services. All these challenges urgently require the adoption of a new paradigm of healthcare system architecture. One of the most appropriate answers to these challenges is to increase the utilization of the potential of highly educated and skilled professionals widely available in these countries, i.e., pharmacists, who are well positioned to prevent and manage drug-related problems together with ensuring safe and effective use of medications with further care relating to medication adherence. Unfortunately, CPS are still underdeveloped and underutilized in some parts of Europe, namely, in most of the Central and Eastern European (CEE) countries. This paper reviews current situation of CPS development in CEE countries and the prospects for the future of CPS in that region.

A case report-"When less is more": controlled inpatient reduction of anticholinergic burden in a patient with clozapine-resistant schizophrenia

The functional status of an individual with schizophrenia is the defining factor in their quality of life and is closely associated with cognitive abilities, which are impaired in individuals with schizophrenia and considered to be the core symptom of the disorder. The use of psychopharmacotherapy can also have a significant impact on cognitive functioning. The relationship between clozapine treatment and cognitive impairment in individuals with schizophrenia is an intricate one. While some studies have reported a positive effect of clozapine on learning and memory, other studies have found that patients treated with clozapine experienced a decline in cognitive functioning in particular areas. In particular, attention and memory have been shown to deteriorate with rising plasma levels of clozapine. This effect may be attributed to its anticholinergic effect. A reduction in the medication related to anticholinergic burden has been previously found to improve cognitive abilities. In the presented case, we describe a psychotic relapse with delirium symptoms in a patient on clozapine treatment with potentially toxic clozapine blood level. The symptoms of delirium subsided after a clozapine dose adjustment. Gradually lowering the initially very high anticholinergic burden improved the patient's cognitive functioning.

Symptoms associated with ADHD/treatment-related adverse side effects and their impact on quality of life and work productivity in adults with ADHD

OBJECTIVE

Describe symptoms associated with ADHD/treatment-related adverse side effects among adults with ADHD in the US and assess their impact on quality of life (QoL) and work productivity.

METHODS

An online survey among adults receiving ADHD medications in the US was conducted to collect information relating to symptoms associated with ADHD/treatment-related adverse side effects. Participants were recruited from the panel of a well-established market research firm, Dynata, from 26 July to 30 July 2021 and were included in the study if they met the eligibility criteria and were willing to participate in the survey. Correlations between symptoms and key outcomes (QoL/employment/work impairment) were estimated using linear regression analyses.

RESULTS

Of 585 participants, 95.2% experienced ≥1 symptom associated with ADHD/treatment-related adverse side effects in the past month (average = 5.8 symptoms). The number of symptoms was significantly correlated with reduced QoL, reduced probability of being employed, and increased work/activity impairment. Among subgroups with insomnia/other sleep disturbances and emotional impulsivity/mood lability, 50.4% and 44.7% reported their symptoms had "a lot" or "extremely" negative impact on their overall well-being, respectively.

CONCLUSIONS

Symptoms associated with ADHD/treatment-related adverse side effects are common and have a substantial negative impact on QoL and reduces patients' probability of employment. Improved management of ADHD/treatment-related adverse side effects and more tolerable treatment options have the potential to improve QoL and work productivity among adults with ADHD.

Improving the Physical Health of Psychiatric Hospital Residents: An Evaluation of an Obesity Education Program for Mental Health Professionals

Background: People living with mental health disorders are at increased risk for developing obesity due to poor diet, physical inactivity, and antipsychotic medications. In the United States, the obesity rate is 36% in the general population and more than 50% for people living with mental health disorders. Although mental health clinicians concentrate on managing psychiatric disorders, they seldom recognize the gradual increase in body mass index of their patients. The result is a disconnection between the clinical management of psychiatric disorders and the medical management of obesity. Purpose: This study assessed the effectiveness of an evidence-based education program for improving the obesity management practices of mental health clinicians caring for residents at a state psychiatric hospital. Methods: This was a quasi-experimental study design with a pretest and posttest evaluation. Convenience sampling was used to recruit mental health professionals, or clinicians, at a large psychiatric hospital in the Southern region of the United States. Data was collected with the Advising and Treating Overweight and Obese Patient questionnaire (17 items). Data analysis included descriptive and inferential statistics. The findings were reported in accordance with the TREND and GREET guidelines. Results: The education program was completed by 50 MHCs. The pretest indicated that 76% of MHCs were not involved in helping obese residents manage their weight, but the posttest indicated 90% were involved. There was a significant increase in MHC knowledge about obesity management and reported actions 90-days after the program. MHCs were unable to arrange follow-up visits for residents, a task not directly within their control. Conclusions: Mental health clinicians reported increased knowledge and improved clinical practice after an education program. Because the outcomes were reported at 90-days after the program, further research needs to evaluate the longitudinal impact of this type of program, where the reported behaviors are correlated to process and clinical outcome measures for obesity.

Optimal Injectable Haloperidol Dose Assessment in the Older Hospitalized Inpatient

Background:

Haloperidol can be used off-label for agitation and/or delirium in older individuals. The recommended initial intramuscular or intravenous dose is 0.5 to 1 mg. However, the evidence to support these doses is nominal.

Objectives:

The primary outcome was to determine whether low-dose injectable haloperidol (≤0.5 mg) was similar in effect to higher doses by assessing the need for repeat doses within 4 hours as a surrogate marker. Secondary outcomes include comparison of length of stay, utilization of restraints, and discharge outcomes between dosage groups.

Methods:

This was a retrospective, single-center, cohort study. Patients aged ≥65 years who received haloperidol injectable who were not on antipsychotics prior to admission were reviewed.

Results:

In the low-dose group (n = 15), no patients required additional haloperidol doses within 4 hours compared with 1 patient each in the medium-dose (n = 23) and high-dose (n = 19) groups ( P = 0.94). There was a difference regarding length of stay, utilization of restraints, and discharge to facility when admitted from home favoring low-dose haloperidol.

Conclusions and Relevance:

While limited by sample size and retrospective design, patients who received low-dose haloperidol demonstrated similar efficacy to those who received higher doses of haloperidol. In addition, secondary outcomes mentioned above favored the use of low-dose haloperidol as well. Based on these findings, low-dose haloperidol is a reasonable initial dose for the agitated older patient.

Impact of a clinical pharmacist on medication safety in mental health Hospital-in-the-Home: a retrospective analysis

BACKGROUND

Integration of clinical pharmacists into multidisciplinary Mental Health Hospital-in-the-Home teams is increasing but little is known about the medication safety contribution these pharmacists make.

AIM

To evaluate whether clinical pharmacist involvement in a Mental Health Hospital-in-the-Home service improved medication safety key performance indicators.

METHOD

Medical records were retrospectively reviewed of all patients admitted to 2 Western Australian Mental Health Hospital-in-the-Home services from September to November 2015. SITE 1: was a 16-bed service incorporating a clinical pharmacist as part of its multidisciplinary team. SITE 2: was a similarly structured 18-bed service but without clinical pharmacist involvement. The primary outcome measure was completion of medication safety key performance indicators obtained from the Western Australian Government Pharmaceutical Review Policy and mental health-specific best practice guidelines.

RESULTS

Key performance indicators from Site 1 (n = 75 records), which incorporated a clinical pharmacist, demonstrated significantly (p < 0.001) higher rates of completion of medication reconciliation [65 (87%) versus 17 (29%)], accurate adverse drug reaction list [73 (97%) versus 34 (58%)], accurate discharge medication list [51 (74%) versus 18 (45%)], accurate medication profile [74 (99%) versus 40 (68%)] and medication chart review [74 (99%) versus 0 (0%)] than Site 2 (n = 59).

CONCLUSION

Integrating a clinical pharmacist into a Mental Health Hospital-in-the-Home program significantly improved achievement of medication safety key performance indicators.

Exploring the Views of Healthcare Professionals Working in a Mental Health Trust on Pharmacists as Future Approved Clinicians

This qualitative research explored the views and attitudes of healthcare professionals towards the role of the mental health pharmacist, and whether this group should be enabled to become approved clinicians (ACs) in England and Wales under the Mental Health Act in future. Following ethical approval, recruitment based on systematic purposive sampling principles took place at one mental health trust in England. Six pharmacists, five medical ACs and two mental health nurses participated in one-to-one digitally audio-recorded semi-structured interviews between June and November 2020. The recordings were transcribed verbatim before being inductively coded and thematically analysed. Notwithstanding the wide recognition among participants of several key skills possessed by mental health pharmacists, various obstacles were identified to them becoming ACs in future, including prevalent conventional models of pharmacy services delivery restricting adequate patient access, as well as insufficient training opportunities to acquire advanced clinical skills, particularly in diagnosis and assessment. In addition to the inherent legislative hurdles, fundamental changes to the skill mix within multidisciplinary mental health teams and improvements to the training of pharmacists were reported by participants to be required to equip them with essential skills to facilitate their transition towards the AC role in future. Further research is needed to gain a better understanding of the challenges facing the clinical development and enhanced utilisation of mental health pharmacists and non-medical ACs across services.

Pharmacist Intention to Provide Medication Therapy Management Services in Saudi Arabia: A Study Using the Theory of Planned Behaviour

Medication therapy management (MTM) is provided by pharmacists and other healthcare providers, improves patient health status, and increases the collaboration of MTM providers with others. However, little is known about pharmacists’ intention to provide MTM services in Saudi Arabia. This study aimed to predict the pharmacists’ willingness in this nation to commit to providing MTM services there. This study used a cross-sectional questionnaire based on the theory of planned behaviour (TPB). The survey was distributed to 149 pharmacists working in hospital and community pharmacies. It included items measuring pharmacist attitudes, intentions, subjective norms, perceived behavioural control, knowledge about the provision of MTM services, and other sociodemographic and pharmacy practice-related items. The pharmacists had a positive attitude towards MTM services (mean = 6.15 ± 1.12) and strong intention (mean = 6.09 ± 1.15), highly perceived social pressure to provide those services (mean = 5.42 ± 1.03), strongly perceived control over providing those services (mean = 4.98 ± 1.05), and had good MTM knowledge (mean = 5.03 ± 1.00). Pharmacists who completed a pharmacy residency programme and had good knowledge of MTM services and a positive attitude towards them usually strongly intended to provide MTM services. Thus, encouraging pharmacists to complete pharmacy residency programmes and educating them about the importance and provision of MTM services will enhance their motivation to provide them.