The Role of Board-Certified Psychiatric Pharmacists in Expanding Access to Care and Improving Patient Outcomes

Evaluation of major adverse events of clozapine based on accordance to an international titration guideline

Introduction

Clozapine is the only antipsychotic approved for treatment-resistant schizophrenia, but without appropriate monitoring, it can be associated with potentially fatal outcomes. An International Adult Clozapine Titration Guideline categorizes patients into normal or slow metabolizers. Categorization provides clozapine titration schedules and recommends regular c-reactive protein (CRP) and clozapine concentration monitoring to reduce the risk of adverse drug reactions (ADRs). The impact of the guideline on clozapine ADRs has not been evaluated.

Methods

A retrospective chart review assessed clozapine titrations, laboratory monitoring, ADRs, and discontinuations for clozapine-naive adult inpatients at a single center from January 1, 2013, to June 1, 2022. Each patient's cumulative weekly clozapine dosage was compared with their guideline recommended dosage to create a percent accordance. Linear logistic regression evaluated the relationship between titration speed and the presence of an ADR, while descriptive statistics analyzed laboratory monitoring.

Results

Forty-three patients were included, with the majority being White males with schizophrenia. An inverse relationship existed between the last inpatient week clozapine dose percent accordance and the probability of an ADR. Nonobese patients were less likely than obese patients to experience an ADR (odds ratio = 0.17; 95% CI, 0.03-0.99). CRP and clozapine concentration monitoring was suboptimal.

Discussion

Based on our small retrospective review of primarily White males, more aggressive clozapine titrations did not increase ADRs. Future studies with more diverse samples are needed and should focus on specific ADRs, which may have increased occurrence with rapid titrations. Obese patients were at higher risk of ADRs, correlating with the guideline-recommended slower titrations for these patients.

Integrating Board-Certified Psychiatric Pharmacists in a Certified Community Behavioral Health Clinic

Demand for mental health services has dramatically increased in recent years, raising concerns about the availability of service providers to meet these increased needs. One approach to expanding access to care is the use of highly qualified board-certified psychiatric pharmacists (BCPPs). However, the implementation of programs for integrating BCPPs has not been well characterized in community mental health settings. This column describes the development and implementation of a comprehensive practice model to incorporate BCPPs in a certified community behavioral health clinic. The authors report the results from the first 14 months of BCPP integration (based on 3,221 direct patient care interventions), offer recommendations, and highlight lessons learned.

Impact of Psychiatric Pharmacist-Led Psychopharmacology Didactics for Psychiatry Residents

OBJECTIVE

The purpose of this study is to explore the impact of board-certified psychiatric pharmacist (BCPP)-led psychopharmacology lectures to psychiatry residents and fellows.

METHODS

Surveys were administered to psychiatry residents and geriatric psychiatry fellows at two teaching institutions between Fall 2021 and Spring 2023, including two distinct residency programs and one fellowship program. The survey consisted of three quantitative questions and one qualitative question soliciting open-ended constructive feedback.

RESULTS

Of 39 participants (response rate: 80%), 100% strongly agreed that learning from a BCPP enhanced their learning of psychopharmacology concepts. Additionally, 100% strongly agreed they would recommend psychopharmacology lectures from a BCPP to other psychiatry residents and that concepts taught by the BCPP were applicable to their clinical practice. Qualitative feedback indicated valuing pharmacist input and stated preference to learn from medication-experts on psychopharmacology topics.

CONCLUSIONS

Integrating BCPPs into psychiatry resident/fellow didactic training is well received by psychiatry residents and may simultaneously enhance education of psychopharmacologic concepts in addition to enrichment of interprofessional experiences by increased routine exposure to working directly with a clinical pharmacist. Program directors are encouraged to meet with BCPPs at their respective institutions to discuss opportunities for collaboration.

Board-Certified Psychiatric Pharmacists and Their Potential Role in Addressing Behavioral Health Workforce Shortages

Board-certified psychiatric pharmacists (BCPPs) are doctorate-level, board-certified experts in managing medications for people living with psychiatric disorders, including substance use disorders. BCPPs work as part of an integrated health care team that provides comprehensive medication management focused on optimizing medication-related outcomes and ensuring the safety of the prescribed medications. The authors describe BCPP education and training, settings in which BCPPs practice, and in what roles. Current policies that limit BCPP involvement in behavioral health care and proposed solutions to support the role of BCPPs in addressing behavioral health workforce shortages are discussed.

Between what is and what could be: a survey of pharmacists' practices, attitudes, and beliefs in the provision of mental health care

BACKGROUND

Pharmacists can have an essential role in providing care for patients with mental illness. There are gaps in the understanding of the current extent of pharmacists' involvement in caring for patients with mental illness and their readiness to effectively provide this care.

AIM

To describe the current practices, attitudes, and beliefs of pharmacists in providing care to individuals with mental illness, and to assess factors that may impact these practices.

METHOD

An electronic questionnaire was emailed to pharmacists in Saskatchewan, Canada. Likert scale questions were utilized, and data were analyzed using descriptive statistics and content analysis for free-text responses.

RESULTS

The response rate was 9.1% (n = 146/1596). Fewer than 20% of respondents reported they were providing the clinical services listed to most or all patients with mental illness, except for providing basic medication education (61%). Almost all agreed it is a pharmacist's role to provide all the services (61-98% for different services) and many were motivated to provide them (47-91%). The factors most frequently selected as having the greatest impact on service provision were insufficient knowledge (27%, n = 34) and competing priorities (19%, n = 24).

CONCLUSION

Consistent with international trends, Saskatchewan pharmacists reported low provision of clinical services for individuals with mental illness, despite a readiness to provide these services. There is an opportunity and a need to better utilize pharmacists internationally in the provision of mental health care.

Pharmacist interventions in medication adherence in patients with mental health disorders: a scoping review

OBJECTIVE

Mental health patients struggle with medication adherence, providing opportunities for pharmacists to have a critical role in implementing key interventions for this patient cohort. This scoping review aimed to identify and evaluate evidence of pharmacists' involvement in medication adherence interventions in mental health patients.

METHODS

Three databases were searched from January 2013 to August 2022: PubMed, Embase and CINAHL. The first author independently performed screening and data extraction. Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) was utilized to report this review. Themes related to the pharmacist's role in improving medication adherence for mental health patients were identified and the strengths and weaknesses of these studies were evaluated.

KEY FINDINGS

A total of 3476 studies were identified and 11 studies met the selection criteria. Study types included retrospective cohort studies, quality improvement projects, observational studies, impact studies, service evaluations and longitudinal studies. Pharmacists worked primarily in community pharmacies, hospitals, or interdisciplinary mental health clinics, and improved medication adherence within these settings, at transitions of care, and by utilizing digital health. The patient perspective was valuable in identifying barriers and enablers to medication adherence. Pharmacists had varying levels of education and training, with studies highlighting the importance of completing extended training programs and partaking in expanded roles such as pharmacist prescribing.

CONCLUSIONS

This review highlighted the need for expanded pharmacist roles within multidisciplinary mental health clinics and further training in psychiatric pharmacotherapy, to aid pharmacists in confidently improving medication adherence for mental health patients.

Increasing access to psychiatric care during the COVID-19 pandemic through mental health clinical pharmacy specialist services

Introduction

Higher rates of mental health conditions, increased incidence of psychiatric diagnoses, and symptom relapse with minimal access to psychotherapeutic services are reported during the COVID-19 pandemic. A local area clinic in the United States that exists to serve underprivileged patients helps to combat poor psychiatric outcomes by offering psychiatric clinics, pharmacotherapy management, and medications at reduced or no cost.

Methods

Recruitment and data collection were conducted from May 3, 2021, to March 3, 2022. Patients were seen by psychiatrists or the mental health clinical pharmacy specialist (MHCPS), and consent was obtained for the completion of satisfaction surveys. Five-point Likert scale comparisons were utilized to assess patient-perceived differences in clinician care. The primary study objective was to determine if access to care could be increased with the addition of an MHCPS, and secondary objectives included evaluating patient perceptions of clinician care as well as reporting MHCPS interventions.

Results

Participant baseline demographics and common psychiatric diagnoses are reported. An MHCPS was incorporated into the clinic during the study allowing for 1 additional patient care period per month. The most frequent score among all surveys was 4.8 (P > .05) on a 5-point scale, indicating no statistically significant differences between clinician care. MHCPS interventions are reported.

Discussion

The addition of an MHCPS allowed for additional patient care appointments for the clinic each month. MHCPS care offered no significant differences from psychiatrist care based on patient satisfaction surveys, highlighting the utility of pharmacist involvement for managing psychiatric disease states and increasing access to mental health services.

Outcomes of Pharmacist-Led Pharmaceutical Care Interventions Within Community Pharmacies: Narrative Review

Pharmaceutical care (PhC) services interventions led by pharmacists within community pharmacies (CPs) are essential in achieving optimal medication use outcomes. PhC is a concept related to medication use goals optimization through the reduction and prevention of drug-related problems (DRPs). This review paper summarized the literature on pharmacist-led PhC interventions within CPs. PubMed and Google Scholar publications were searched, identified, and summarized. Results showed that some studies handled community pharmacists' roles, and some talked about PhC interventions. However, some studies reviewed the use of medicines, adherence, and follow-up, while other groups were on counseling, patient education, and health promotion. Pharmacists integrated some studies concerning diagnosis and disease screening into community pharmacy services. Besides these studies, there were studies on system design and installation of PhC service models. Most of the identified research results showed pharmacist-led intervention benefits for patients. These benefits include reduced DRPs, clinical, economical, humane, education and knowledge, disease prevention and immunization, identification of practice process problems, and the need for current practice redesigning. In conclusion, pharmacists can help patients achieve optimal outcomes through pharmacist-led interventions. Despite mentioned results, We recommend researching comprehensively applied PhC services provision models within CPs for more pharmacists-led interventions and role activation.

Social Determinants of Health in People Living with Psychiatric Disorders: The Role of Pharmacists

Introduction

Social determinants of health (SDOH) affect outcomes of people living with psychiatric disorders, including substance use disorders. As experts in medication optimization, pharmacists play a vital role in identifying and addressing medication-related problems associated with SDOH. However, there is a paucity of literature on how pharmacists can be part of the solution.

Objective

The purpose of this article is to provide a narrative review and commentary on the intersection between SDOH, medication-related outcomes in people living with psychiatric disorders, and the role of pharmacists in addressing them.

Method

The American Association of Psychiatric Pharmacists appointed an expert panel to research the issue, identify barriers, and develop a framework for including pharmacists in addressing medication therapy problems associated with SDOH in people with psychiatric disorders. The panel used Healthy People 2030 as the framework and sought input from public health officials to propose solutions for their commentary.

Results

We identified potential connections between SDOH and their impact on medication use in people with psychiatric disorders. We provide examples of how comprehensive medication management can afford opportunities for pharmacists to mitigate medication-related problems associated with SDOH.

Conclusion

Public health officials should be aware of the vital role that pharmacists play in addressing medication therapy problems associated with SDOH to improve health outcomes and to incorporate them in health promotion programs.

Systematic review of community pharmacist administration of long-acting injectable antipsychotic medications

BACKGROUND

Long-acting injectable antipsychotic (LAIA) medications offer an effective treatment option for patients with serious mental illness. Despite demonstrated clinical safety and efficacy as well as increased adherence and less frequent administration compared with daily oral regimens, LAIAs remain underutilized in clinical practice. With legislation allowing pharmacists to administer injectable medications in 48 U.S. states, community pharmacies are uniquely positioned to serve as an access point for patients with serious mental illnesses to receive LAIA injections.

OBJECTIVE

This study aimed to conduct a systematic review of the health and economic benefits and costs of community pharmacist administration of LAIA medications.

METHODS

A systematic search of the literature published from January 1996 to April 2022 was conducted across 3 databases (Embase, PubMed, and Scopus Plus). Publications describing pharmacist administration of LAIA medications in outpatient settings were included. Publications that examined the use of LAIAs but did not involve a pharmacist administering the medication were excluded.

RESULTS

Of 2261 publications reviewed, we identified 8 publications (4 articles and 4 abstracts) that met our inclusion criteria, of which only 7 included results. Four studies reported high medication adherence achieved by patients receiving pharmacist-administered LAIAs. Two publications surveyed patient satisfaction with pharmacist administration of LAIAs in community pharmacy settings. One study found pharmacists' mixed attitudes regarding LAIA administration and time and safety barriers to offering the service.

CONCLUSION

We found very little evidence on the impact of pharmacist administration of LAIAs on patient outcomes. This review highlights the need to generate greater evidence on the health and economic benefits as well as financial models for pharmacists to administer LAIA medications in outpatient and community pharmacy settings. Such evidence could support more community pharmacists to offer LAIA medications and contribute to the shift toward value-based care.

Attitudes and perceptions about the use of long-acting injectable antipsychotics among behavioral health practitioners

Introduction

Long-acting injectable antipsychotics (LAI-As) are important tools for the treatment of schizophrenia, yet they appear to be underutilized. This study will assess practitioner perceptions of LAI-As to elucidate reasons for underuse and uncover new avenues to increase appropriate use.

Methods

An anonymous electronic survey was developed and actively distributed to behavioral health care practitioners (MD, DO, PA, NP, PharmD, RN, LCSW). Independent t testing and linear regression analysis was used to assess for interactions between survey responses and individual factors.

Results

A total of 146 survey responses were collected from September 3, 2020 to March 17, 2021. On average, participants thought that LAI-As were slightly underutilized in practice. The mean estimated patient acceptance rate for LAI-A therapy was 38.6% ± 29.5% (range = 0%-100%). Participants who were <40 years of age and those with a psychiatric pharmacist at their practice site had significantly higher estimated acceptance rates. The highest-rated barriers to LAI-A use were related to negative patient attitudes, lack of patient education, and access issues (eg, transportation, cost). Respondent characteristics including age, gender identity, geographic location, practice setting, and the presence of a psychiatric pharmacist significantly influenced the perceived impact of these barriers.

Discussion

Behavioral health practitioners generally believed that LAI-As were underused, and only one-third of their patients would be accepting of the therapy. Several barriers were perceived as frequently impacting LAI-A use, but these were reduced by the presence of a psychiatric pharmacist. Understanding practitioner perceptions can assist with increasing the use of LAI-As.

An innovative approach to teaching depression and anxiety medication management: Virtual choose your own adventure, psychiatry edition

Introduction

Rates of depression and anxiety continue to increase in the United States. It's important for pharmacy students to graduate knowledgeable and confident in treating these disorders. The purpose of this study was to evaluate whether a virtual active-learning exercise (choose your own adventure) is helpful in teaching students how to manage medications for depression and anxiety.

Methods

Third-year pharmacy students responded to preactivity questions and then worked on a single patient case in which the presenting problem is worsening depression and anxiety. Students worked in virtual groups of 4 to 5 to select 1 treatment among 5 multiple-choice options and documented the rationale for their choice. Each multiple-choice option led to a different follow-up case. After writing their assessment and plan, the instructor debriefed on therapeutic concepts from each follow-up case. Students then answered postactivity questions and participated in a voluntary survey consisting of 10 retrospective questions.

Results

Of 106 participants, 85 completed the survey (80.2% response rate). Most agreed that their understanding of treatment of depression and anxiety disorders increased following participation (92.9% strongly/somewhat agreed). This was supported by an increase in the percentage of correct responses on the knowledge questions (preactivity: 67.2%, n = 91; postactivity: 83.5%, n = 97; P = .01). Additionally, students reported their confidence in their understanding of depression and anxiety management increased following activity participation (93.0% strongly/somewhat agreed).

Discussion

The virtual active-learning exercise improved student knowledge and confidence in managing depression and anxiety treatments. Educators teaching depression and anxiety pharmacotherapy may consider implementing such activity into their lecture(s).

Closing the Care Gap for People with Severe and Persistent Mental Illness: Collaborative Care, Telehealth, and Clinical Pharmacy

People with severe and persistent mental illness (SPMI) frequently struggle to maintain their recovery from recurring suicidality, psychosis, and debilitating mood episodes. They also face a high risk of chronic health conditions. Traditional - often short-term - psychiatric care is ill-equipped to meet the health needs of people with SPMI. Patients often require regular and sustained follow-up to support medication effectiveness and adherence and to screen for and treat cardiovascular disease and other common health risks. Kaiser Permanente Northern California has implemented a novel telehealth-based collaborative care program, SPMI Population Care, led by advanced practice clinical pharmacists, to improve the mental and physical health of its patients with SPMI. Although the individual program components of telehealth, collaborative care, and clinical pharmacy service have been employed successfully in the past for mental health care, the SPMI Population Care model combines the components and extends this approach to individuals at the most severe end of the psychiatric illness spectrum.

Positioning psychiatric pharmacists to improve mental health care

Psychiatric pharmacy continues to grow and look to the future with a focus on helping individuals recover from mental health and substance use disorders. The American Association of Psychiatric Pharmacists (AAPP) considers Board Certified Psychiatric Pharmacist (BCPP) the gold standard credential that all psychiatric pharmacists should attain to demonstrate specialized knowledge and expertise in psychiatry. BCPPs are part of collaborative interprofessional teams and practice in hospitals, clinics, and diverse health systems. Two out of 3 BCPPs practicing in clinics have prescriptive authority. BCPPs improve access, safety, medication adherence, and therapeutic outcomes. Every person with a mental health and substance use disorder should have access to a BCPP providing comprehensive medication management (CMM) and psychotropic stewardship aimed at improving population health. BCPPs are in demand owing to their expertise. AAPP envisions growth and expansion of the BCPP role in many areas including coordinating psychiatric transitions of care and telehealth services, managing long-acting injectable medication clinics, providing pharmacogenomic consultation, conducting clozapine and lithium monitoring, managing medications for substance use disorders, leading medication groups, CNS drug development, research, and provider education. To prepare the workforce, colleges and schools of pharmacy should hire BCPPs for optimal curriculum development, and each student pharmacist should have an opportunity to develop a therapeutic alliance with a person recovering from psychiatric illness. Postgraduate year (PGY) 1 residencies should offer learning experiences in psychiatric pharmacy to prepare residents to enter an expanded number of PGY2 psychiatric pharmacy residencies, ultimately earning their BCPP and being well positioned to improve mental health care.

Best practice model for outpatient psychiatric pharmacy practice, part 2: Confirmation of the attribute statements

Introduction

The American Association of Psychiatric Pharmacists (AAPP) used multiple modalities to develop and refine 28 attribute statements to describe a best practice model for outpatient psychiatric pharmacists. Before addressing implementation, assessment, and field testing, it was necessary to finalize and confirm the statements and their supporting narratives among stakeholders. The objective of this project was to confirm the attribute statements and supporting justifications for a best practice model for outpatient psychiatric pharmacists providing direct patient care.

Methods

The 4 phases that resulted in the 28 attribute statements and supporting narratives have been described and published elsewhere. As part of phase 5, the confirmation survey was distributed to pharmacists and resident members of AAPP in November 2021 for 3 weeks.

Results

The survey respondents (n = 74; 6.1%) were licensed pharmacists for an average of 15.6 years (SD = 12.0) and had been practicing as psychiatric pharmacists for an average of 11.3 years (SD = 10.4). Slightly more than half (54.2%) of the respondents reported practicing in the outpatient setting and three-fourths (74.3%) were Board Certified Psychiatric Pharmacists. For each of the 28 statements, more than 90% of respondents either agreed or agreed with minimal reservations.

Discussion

Given the high degree of agreement on the proposed practice model statements, they will be used as the basis for the outpatient psychiatric pharmacist best practice model. Next steps in developing this model include establishing implementation guidance, determining appropriate metrics for evaluation of these statements in practice, and establishing appropriate field-testing methods.