Ambulatory detoxification in alcohol use disorder and opioid use disorder is an important component in the management of patients experiencing withdrawal symptoms from alcohol or opioids. The goal of withdrawal management is ultimately to provide each patient with comfort and safety. Having the knowledge of the possible signs and symptoms of intoxication and withdrawal assists providers to institute the most appropriate treatment protocol and setting for the patient. Pharmacists play a vital role in choosing appropriate therapeutic management options for common or complex clinical situations involving ambulatory detoxification from alcohol and opioids. Ambulatory detoxification serves as an appealing option to many patients and helps save the limited inpatient resources that many institutions have for those patients with more severe withdrawal presentations.Abstract
Epilepsy, although common, remains difficult to treat with as much as 30% of patients having treatment-resistant conditions. Lennox-Gastaut syndrome and Dravet syndrome are childhood-onset epilepsies and among the most difficult to treat. Cannabidiol has been approved by the Food and Drug Administration to treat these conditions in individuals over 2 years of age; however, there is a great deal of interest in off-label use. This article examines 3 cases: 1 of a patient with Lennox-Gastaut syndrome, 1 of off-label use of cannabidiol to treat epilepsy, and 1 of nonprescription forms of cannabidiol to treat epilepsy.Abstract
Generalized anxiety disorder (GAD) is characterized by persistent and excessive worry. Around half of the patients treated for GAD will fail to respond to initial treatment. Treatment-resistant (or refractory) GAD is defined as failure to respond to at least 1 trial of antidepressant therapy at adequate dose and duration. Review of the literature indicates several potential medication classes and individual agents that can be used as augmentation strategies to treat residual symptoms when recommended therapy per clinical practice guidelines fails. A thorough literature search revealed 2 medication classes with the largest amount of data to support their use in treatment-resistant GAD treatment: gamma-aminobutyric acid–related agents and atypical antipsychotics. This article focuses on evidence-based recommendations for the use of these agents as adjunctive therapies for patients with treatment-resistant GAD. Different pharmacologic approaches to use these agents are demonstrated through 2 patient cases in which patients have failed first-line treatment options.Abstract
Traumatic brain injury is an increasing cause of morbidity worldwide. Neuropsychiatric impairments, such as behavioral dysregulation and depression, have significant impacts on recovery, functional outcomes, and quality of life of patients with traumatic brain injuries. Three patient cases, existing literature, and expert opinion are used to select pharmacotherapy for the treatment of target symptoms while balancing safety and tolerability.Abstract
A comprehensive review of psychiatric pharmacy practice has never been performed in the United States. As psychiatric pharmacists become more involved in mental illness treatment, determining the current state of practice is important to help advance the specialty. The Professional Affairs Committee of the College of Psychiatric and Neurologic Pharmacists (CPNP) was charged with performing this review to define current psychiatric pharmacy practice. An electronic survey was sent to all pharmacist members of CPNP and all nonmember Board Certified Psychiatric Pharmacists (BCPPs) in the United States in late summer 2019. The survey consisted of 36 questions across multiple domains to obtain information about respondents' education and training background, practice setting and type, and information about prescriptive authority and other areas. An initial e-mail invitation was sent along with 2 reminder e-mails over the subsequent 2 weeks. A total of 334 of 1015 pharmacists completed the survey (32.9%). Responders completed a postgraduate residency 77.8% of the time, and 88.3% were BCPP. Practice settings were split evenly between inpatient and outpatient practices or a combination of the 2. Among respondents, 46.5% reported having prescriptive authority as part of their practice, and 41.3% reported treating nonpsychiatric as well as psychiatric illnesses. Prescriptive authority was more likely in outpatient practices and in those treating nonpsychiatric illnesses. The current practice of psychiatric pharmacy is incredibly varied in terms of practice setting, activities performed, and services provided. Further exploration is needed to help determine the optimal role of psychiatric pharmacists.Abstract
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Atypical antipsychotics (AAPs) are associated with serious cardiometabolic disturbances, including hyperlipidemia, hyperglycemia, and weight gain. The American Academy of Child and Adolescent Psychiatry Practice parameter for the use of AAPs in children and adolescents encourages that the same monitoring schedule as recommended by the American Diabetes Association be applied to the pediatric population. This study assessed adherence to these monitoring recommendations for AAPs in children and adolescents admitted to a community teaching hospital's inpatient child and adolescent psychiatry unit. Patients age <18 years were included if therapy was initiated with an AAP during an inpatient admission to the child and adolescent psychiatry unit. Patients were excluded if prescribed an AAP prior to admission or if the AAP was ordered as needed. The presence of the following was collected upon initiation: body mass index (BMI), fasting blood glucose (FBG), blood pressure (BP), fasting lipids, heart rate (HR), waist circumference, electrocardiogram when indicated, and assessment of efficacy and extrapyramidal symptoms (EPS). Any adverse effects and means of mitigation of those adverse effects were also collected. In the 45 patients included, the following monitoring parameters were collected: 91.1% had BMI, 84.4% had FBG, 46.6% had fasting lipids, and 0% had waist circumference recorded. Additionally, 100% of patients had an assessment of efficacy and EPS and BP and HR documented. Although this study included a small number of patients, there is area for improvement in obtaining baseline monitoring parameters in children and adolescents initiated on AAPs during an inpatient admission.Abstract
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Psychiatric and neurologic illnesses are highly prevalent and are often suboptimally treated. A 2015 review highlighted the value of psychiatric pharmacists in improving medication-related outcomes. There is a need to describe areas of expansion and strengthened evidence regarding pharmacist practice and patient care impact in psychiatric and neurologic settings since 2015. A systematic search of literature published from January 2014 to June 2019 was conducted. Publications describing patient-level outcome results associated with pharmacist provision of care in a psychiatric/neurologic setting and/or in relation to central nervous system (CNS) medications were included. A total of 64 publications were included. There was significant heterogeneity of published study methods and data, prohibiting meta-analysis. Pharmacists practicing across a wide variety of health care settings with focus on CNS medication management significantly improved patient-level outcomes, such as medication adherence, disease control, and avoidance of hospitalization. The most common practice approach associated with significant improvement in patient-level outcomes was incorporation of psychiatric pharmacist input into the interprofessional health care team. Pharmacists who focus on psychiatric and neurologic disease improve outcomes for patients with these conditions. This is important in the current health care environment as most patients with psychiatric or neurologic conditions continue to have unmet needs. Additional studies designed to measure pharmacists' impact on patient-level outcomes are encouraged to strengthen these findings.Abstract
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A pharmacist-led telemental health transitions of care clinic was created at a Veterans Affairs Medical Center to improve continuity of psychiatric medication therapy following discharge from an acute psychiatric hospitalization. This was a single-center, multi-site, retrospective cohort study (historical cohort). The primary study objective was to determine the impact of a post-discharge pharmacist-led telemental health transitions of care clinic on improving antidepressant adherence rates after an acute psychiatric hospitalization. Secondary objectives included evaluation of rates of readmission to psychiatric hospitals, time to first mental health provider follow-up, and characterization of various pharmacist interventions made during the clinic visit. Pilot study results support that a pharmacist-led telemental health transitions of care clinic can improve antidepressant adherence after psychiatric hospital discharge and reduce time to postdischarge follow-up with a mental health provider. Patients enrolled in the clinic were more likely to maintain a medication possession ratio >0.8 within 90 days of discharge when compared to a historical control (100% vs 43%, P = .035). The clinic also improved time to first mental health provider follow-up as seen by a statistically significant improvement in the number of patients seen within 14 days of discharge by a mental health provider (100% vs 43%, P = .035). Results highlight the valuable role of psychiatric pharmacists in delivery of transitions of care services and support the expansion of current roles to improve outcomes after psychiatric hospitalizations.Abstract