Many health care institutions are working to improve depression screening and management with the use of the Patient Health Questionnaire 9 (PHQ-9). Clinical decision support (CDS) within the EHR is one strategy, but little is known about effective approaches to design or implement such CDS. The purpose of this study is to compare implementation outcomes of two versions of a CDS tool to improve PHQ-9 administration for patients with depression. This was a retrospective, observational study comparing two versions of a CDS. Version 1 interrupted clinician workflow, and version 2 did not interrupt workflow. Outcomes of interest included reach, adoption, and effectiveness. PHQ-9 administration was determined by chart review. Chi-square tests were used to evaluate associations between PHQ-9 administration with versions 1 and 2. Version 1 resulted in PHQ-9 administration 77 times (15.3% of 504 unique encounters) compared with 49 times (9.8% of 502 unique encounters) with version 2 (P = .011). An interruptive CDS tool may be more effective at increasing PHQ-9 administration, but a noninterruptive CDS tool may be preferred to minimize alert fatigue despite a decrease in effectiveness.Abstract
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The purpose of this study was to investigate the significant contributions of coping, resilience, personal characteristics, and health behaviors on the emotional well-being of pharmacy students during the COVID-19 pandemic. COVID-19 was identified in December 2019 and declared a pandemic by the World Health Organization in March 2020. Pharmacy students may experience greater stress during this outbreak because of interruptions in classes or rotations, concerns regarding personal or family health, and social isolation from peers. These changes may result in behavior shifts, difficulty concentrating, and increased use of negative coping strategies. The extent to which these factors affect overall student well-being during a pandemic is largely unknown. A cross-sectional study of 3 colleges of pharmacy was completed during May to July 2020 via an online, anonymous 64-item questionnaire using REDCap software. Linear regression and descriptive statistical analyses were conducted using SPSS version 26. Using the enter method, levels of coping strategies, personal resilience, and Hispanic ethnic identity explain 29% of the variance in emotional well-being scores in pharmacy students during the first months of the COVID-19 pandemic (F (2,76) = 11.785, P < .000, R2 = 0.317, R2adjusted = 0.291). For this sample (N = 104), higher levels of resilience, greater use of coping strategies, and identifying as Hispanic were significant predictors of emotional well-being. Student mental health continues to be important, especially during crises and pandemics. Therefore, pharmacy programs should cultivate an environment that supports the emotional well-being of their students. Campus-based initiatives may be needed to encourage healthy coping behaviors and bolster students' personal resilience to better prepare them for providing front-line patient care in the future.Abstract
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US employee absence benefits may include workers' compensation (WC) for work-related injuries/illnesses, short- and long-term disability (STD and LTD, respectively) for non–work-related injuries/illnesses, and discretionary sick leave (SL). Absences can significantly impact business performance, and employers are intensifying efforts to manage benefits and connections with employee health. This research compares all-cause STD/LTD/WC/SL use and variation from baseline (2002) for eligible employees (EMPs) with mental disorders (MDs) and SUDs to determine if use/payments varied over time. Employees incurring medical claims with Agency for Healthcare Research and Quality MD and SUD ICD-9/10 codes were identified in the WorkPartners database (January 1, 2002 to December 31, 2019). Retrospective analysis was performed on annual prevalence, benefit use, mean days of leave, and median payments as a percent of salary (including lump-sum distributions and potentially extending beyond initiation year). WC claims without work absences were excluded. For each benefit, annual outcomes were calculated as a percent of baseline to show variability. Use was 48.1% to 202.2% (median, 102.8%) of baseline rates for SL (SUD-EMPs), and 87.3% to 108.4% (median, 97.3%) for STD (MD-EMPs). Days of LTD leaves were 21.5% to 657.8% (median, 359.2%) of baseline days (MD-EMPs), and 122.7% to 1042.2% (median, 460.0%) of baseline days for (SUD-EMPs). Median payments for WC were 78.6% to 253.6% (median, 114.6%) of baseline (MD-EMPs) and 97.9% to 481.6% (median, 104.0%) for SUD-EMPs. Employees with MD/SUD used absence benefits at differing rates over time with varying days of leave and payments as a percent of salary. Using a constant cost or salary replacement factor over time for all benefits is not accurate or appropriate.Abstract
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Carbamazepine has demonstrated anticonvulsant properties and is used for a variety of indications in psychiatry and neurology. Total daily doses typically range from 200 to 1200 mg/d, generally divided into 2 doses. Carbamazepine has a broad side-effect profile but is not typically thought to produce high fevers in the absence of a hypersensitivity syndrome. This is a case of a probable adverse drug reaction to carbamazepine consisting of fever without severe major organ involvement. In this instance, a patient in a manic episode with psychotic features was briefly transferred to a COVID-19 unit to rule out coronavirus infection before the fever resolved.Abstract
There is an increasing number of case reports of COVID-19 reinfection. The mechanism of reinfection is poorly understood and evolving. Prevention of the transmission of severe acute respiratory syndrome coronavirus 2 for those with a serious mental illness (SMI) living in a congregate setting presents unique challenges. In this case report, we describe an individual with an SMI in a long-term inpatient psychiatric care hospital who was initially diagnosed in June 2020 with COVID-19 infection via a polymerase chain reaction test. Approximately 6 months later, the patient presented with a COVID-19 reinfection and more severe COVID-like symptoms.Abstract
Aripiprazole, an atypical antipsychotic, is a metabolic substrate for cytochrome P450 (CYP)3A4 and 2D6. Terbinafine, an antifungal agent used for onychomycosis, is a CYP2D6 inhibitor and could theoretically reduce the metabolism of aripiprazole. However, there are no published reports describing this interaction. We present 2 female patients hospitalized in a psychiatric unit who were both taking aripiprazole 15 mg daily and terbinafine 250 mg daily prior to admission. The first patient was a 58-year-old female who was prescribed aripiprazole and terbinafine concomitantly for approximately 5 months prior to admission. A commercial pharmacogenetic testing platform classified this patient as a normal metabolizer for CYP3A4 and 2D6. The first patient's serum trough aripiprazole concentration at steady-state concentration (Css) was 207.5 ng/mL. The second patient was a 43-year-old female who was taking aripiprazole and terbinafine concomitantly for approximately 2 weeks prior to admission who had a Css aripiprazole concentration of 278.9 ng/mL. Aripiprazole has a wide therapeutic range (100 to 350 ng/mL) and a reference dose-related drug concentration of 11.7 (mean) ± 5.6 (SD) ng/mL/mg/d. Our patients had Css aripiprazole concentrations 18% and 59% higher than guideline-supported dose-related drug concentrations. Through the use of therapeutic drug monitoring, pharmacogenetic data, electronic pharmaceutical claims data, and the Drug Interaction Probability Scale, we suggest terbinafine possibly increases aripiprazole concentrations 18% to 59%. Further reports are needed to confirm these findings prior to using this information in clinical practice.Abstract
We present a case in which a patient developed fever and leukocytosis subsequent to each monthly haloperidol decanoate injection, an adverse reaction that does not meet the diagnostic criteria of neuroleptic malignant syndrome (NMS) or any previously reported adverse reaction for this medication. A patient being treated with haloperidol decanoate for psychosis experienced a fever within 3 days of injection and leukocytosis along with swelling, pain, and a “knot” feeling at the injection site. This recurred after each injection for several months. Muscle rigidity or changes in vital signs other than temperature were not noted. Temperature and injection site reactions resolved with administration of acetaminophen and ibuprofen. The elevation in temperature was discovered as a result of universal twice daily temperature monitoring implemented due to the COVID-19 pandemic. Reports of fever with antipsychotics are typically associated with NMS or heat stroke; the details of this case do not meet the clinical criteria for either. Similar reactions are reported for other antipsychotics, such as clozapine and olanzapine, but not for haloperidol. The recommendation was to discontinue use of the medication due to an unclear mechanism of the reaction.Abstract
International schizophrenia guidelines endorse seeking the patient's preference for guiding antipsychotic therapy. There exists a small niche of patients who prefer, or are required to use, long-acting injectable antipsychotic medications due to the adherence benefit. However, they may not be able to achieve adequate symptom reduction prior to experiencing treatment-limiting adverse effects from a single agent. Here, we present a patient case prescribed concurrent long-acting injectable antipsychotic therapy with paliperidone palmitate and aripiprazole monohydrate due to patient preference in the setting of a history of nonadherence to oral medications, treatment-limiting adverse effects to long-acting injectable paliperidone, and failure to achieve adequate symptom reduction with long-acting injectable aripiprazole monotherapy.Abstract