This study aims to assess the understandability, actionability, and quality of online resources for the self-management (SM) of bipolar spectrum disorders in adults. An online search using Google, Bing, and Yahoo! search engines was conducted to identify resources for bipolar disorder. Those that were published in English, discussed at least 1 method directed at improving an SM task, and were within the first 25 nonadvertisement results for each search were included. Resources directed specifically at adolescents were excluded. Understandability and actionability of the online resources were evaluated using the Patient Education Materials Assessment Tool (PEMAT). Quality of the online resources was evaluated using the DISCERN instrument. The number of SM tasks each resource discussed was also evaluated. Overall mean appropriateness was calculated by averaging the percentage scores of understandability, actionability, and quality. Fifty-two resources were included. The mean sample scores were 8.4 (SD, 2.1; range, 2-13; maximum, 15) for understandability, 2.2 (SD, 1.2; range, 0-4; maximum, 5) for actionability, and 46.1 (SD, 8.9; range, 30-57; maximum, 75) for quality. The overall mean appropriateness percentage was 53.5% (SD, 11.7%; range, 18%-77%), with a goal of at least 70%. Included resources addressed a mean of 7.1 tasks (SD, 2.5; range, 1-14; maximum, 20). Most online resources for the SM of bipolar disorder scored poorly for understandability and actionability based on PEMAT scores and had low to moderate scores for quality using the DISCERN instrument. Future online resources should be designed with the goal of increasing appropriateness for patients.Abstract
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Methamphetamine is an addictive stimulant that may induce symptoms of agitation and psychosis. The estimated rate of methamphetamine use is 6.6 per 1000 people. Currently, no treatment guidelines exist to support the optimal management of patients presenting with methamphetamine-induced agitation. Emergency department (ED) providers may prescribe various benzodiazepines (BZDs) and antipsychotics (APs) as first-line agents to stabilize these agitated patients. This study aims to determine the effectiveness of a protocol to guide management of this condition. This was a retrospective, pre- and poststudy conducted from July 2020 to March 2021 at a large academic medical center. A multidisciplinary protocol was designed to help manage methamphetamine-induced agitation in the ED. The primary outcome of the study was a reduction in the number of BZDs and APs used for the treatment of methamphetamine-induced agitation. This was measured by the incidence of overprescribing, defined as 3 or more APs or BZDs administered within 30 minutes. Secondary outcomes included the use of physical restraints, ED length of stay, and adverse events. We did not observe a significantly lower incidence of overprescribing, adverse events, or ED length of stay when comparing pre- and postprotocol groups. A subgroup analysis demonstrated that when protocol was followed, there was a statistically significant reduction in overprescribing (P = .001). We did not find any differences among our primary and secondary outcomes, which may be attributed to protocol nonadherence. Full compliance to the protocol may reduce the rate of overprescribing APs or BZDs in patients with methamphetamine-induced agitation.Abstract
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Mental health (MH) clinical pharmacy specialists (CPS) are increasingly functioning as integral providers in MH care teams. MH providers may delegate many medication management tasks to the CPS. As there is a shortage of primary care and specialist MH providers, CPS are increasingly being utilized in MH care clinics. We assess provider and CPS perceptions of the contributions of CPS to MH clinical teams in the Veterans Health Administration. We examined the roles and functions of CPS in MH clinics through surveys (n = 374) and semistructured interviews (n = 16) with MH CPS and other members of MH clinical teams (psychiatrists, nurse practitioners, registered nurses, social workers) to gain insight into how CPS were integrated in these settings. We assessed perceptions of CPS contributions to MH teams, interactions between CPS and other providers, and challenges of integrating CPS into MH clinical teams. Contributions of CPS in MH were received positively by clinical team members. Clinical pharmacy specialists providing comprehensive medication management were especially valuable in the management of clozapine. The knowledge and training of CPS reassured providers who frequently referred to them with questions about medication and medication therapy management. MH CPS were also perceived to be received well by patients. The integration of MH CPS into MH teams was well received by team members and patients alike. The MH CPS have become important members of the MH team and are widely viewed as being able to improve access, quality, and workflow.Abstract
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Stigma and negative attitudes toward people with mental health disorders can impair the provision of pharmaceutical care. The purpose of the study was to assess the effect of classroom lectures on mental health disorders and a movie recommendation on pharmacy students' attitudes and stigma toward persons with schizophrenia (PwS). The study consisted of a presurvey and postsurvey carried out among final-year pharmacy students of the University of Nigeria Nsukka. A survey comprising 3 sections on sociodemographic details, attitudes toward PwS, and a social distance scale was given to conveniently sampled students before and after lectures on schizophrenia. Students were encouraged to watch a movie about the experiences of a PwS after the first lecture. One hundred seventy-nine students (of the 200 sampled, response rate 91.1%) agreed to participate and completed the survey instrument before the clinical lecture, whereas 108 students who took part in the presurvey participated in the postsurvey (response rate of 76.0%). The overall mean negative attitude score reduced from 2.79 ± 0.412 to 2.72 ± 0.357. The overall mean social distance score increased from 2.48 ± 0.415 to 2.49 ± 0.467, indicating increased stigma. In both presurveys and postsurveys, people with a friend or relative with schizophrenia had a lower mean negative attitude score compared with those who did not. People who had watched the movie recommendation (n = 85) had a higher mean negative attitude (2.74 vs 2.67, P = .433) and a lower social distance toward PwS (2.57 vs 2.48, P = .415). Classroom lectures on mental health among pharmacy students might not significantly improve the overall attitudes and social distance toward PwS. Schools of pharmacy should consider alternative formats of teaching mental health–related topics, such as contact with real patients and simulation.Abstract
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The current gold standard for treatment of Parkinson disease (PD) is levodopa/carbidopa (L/C), but long-term treatment frequently results in motor complications, such as wearing-off and motor fluctuations (eg, dyskinesia, “on-off” phenomenon). Istradefylline is a new drug with a unique pharmacologic profile that was approved by the FDA for use as adjunctive treatment to L/C in adult patients with PD experiencing “off” episodes. The drug was shown to reduce “off” time in 4 randomized, double-blind, placebo-controlled studies. The most common adverse effects are dyskinesia, dizziness, constipation, nausea, hallucinations, and insomnia. Unlike many drugs that treat PD, istradefylline is a nondopaminergic drug that exerts its effects via adenosine A2A receptor antagonism. The major drug interactions involve inhibitors or inducers of CYP3A4 as well as tobacco smoking via induction of CYP1A1. Istradefylline is taken once daily as a 20- or 40-mg dose, except in cases involving drug interactions or hepatic impairment. The cost of the drug is relatively expensive, which has implications for Medicare and private insurance coverage. Istradefylline is an alternative option to dopaminergic drugs such as dopamine agonists, monoamine oxidase B inhibitors, and catechol-O-methyltransferase inhibitors as an adjunct to L/C in patients with motor fluctuations, but clinical use will further define its role in treatment of PD.Abstract
Olanzapine (Zyprexa) package labeling includes a warning for hyperglycemia, stating physicians should consider the risks and benefits when prescribing olanzapine to patients with an established diagnosis of diabetes mellitus or having borderline increased blood glucose levels. A case report of olanzapine-associated hyperglycemia in a patient with a history of gestational diabetes mellitus (GDM) is presented and literature review is discussed. A 33-year-old female with a past medical history of bipolar disorder, cocaine and amphetamine use disorder, hypertension, and GDM was initiated on olanzapine 5 mg PO daily which was subsequently titrated to 25 mg daily. On day 15 of admission, she developed signs and symptoms of hyperglycemia, with blood glucose readings >500 mg/dL. Insulin was initiated, olanzapine was discontinued, and her blood glucose began improving. She was later discharged on ziprasidone 20 mg PO twice daily. There have been several case reports published on olanzapine-induced hyperglycemia. This is the first case report to specifically recognize a history of GDM as a potential risk factor for developing olanzapine-associated hyperglycemia. Adverse effect profiles and patient-specific risk factors should be considered when selecting appropriate antipsychotic treatment. Olanzapine may not be an ideal medication choice for a person with a history of GDM; however, if olanzapine is indicated, then close blood glucose monitoring is recommended.Abstract
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Clozapine levels can be influenced by many factors, including pharmacogenomic variability, pharmacokinetic drug interactions, and infection/inflammation. The concentration-to-dose ratio (C/D), a measure of a medication's rate of metabolism and clearance, may increase during an acute infection due to decreased medication metabolism and clearance. A 56-year-old White man was restarted on clozapine and titrated up to 350 mg/d with therapeutic steady-state levels (C/D 1.11) on hospital day (HD) 69. At this time, he was also being treated for COPD exacerbation. For the next month, he continued to complain of cough, but vital signs and chest x-ray remained normal. Labs were unremarkable except for occasional leukocytosis that would resolve on repeat evaluation. A routine clozapine level drawn on HD 104, resulted on day 108 and showed clozapine toxicity with C/D 4.05, although the patient was asymptomatic. After receipt of labs on day 109, showing elevated WBC count, he was immediately sent to the emergency room where he was admitted for treatment of pneumonia. On return to the state hospital, the patient was continued on 100 mg clozapine and titrated to 200 mg/d based on low drug levels. He continued to do well on 200 mg/d clozapine with C/D averaging 1.13 (range, 0.75-1.52). Acute infection and illness can lead to significantly increased clozapine levels and toxicity, even if symptoms of toxicity are minimal or absent. This appears to be the first report of a toxic level being the first indication of severe medical illness.Abstract
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Peer comparison is a behavioral strategy that provides feedback to individuals on how they compare with others. It is used to improve health care quality, reduce inappropriate prescribing, and improve physician performance. There is very little data on peer comparison and the impact on system-wide prescribing practices, particularly with antipsychotics. To that end, the Maryland statewide pharmacy and therapeutics committee reviews hospital-level antipsychotic data for 5 facilities on a quarterly basis, including high doses and polypharmacy. One facility, Springfield Hospital Center, consistently stood out in 2016 as having higher rates of high doses of haloperidol, olanzapine, and quetiapine as well as patients receiving 3 or more antipsychotics. The pharmacist began to send out individual letters to the psychiatrists detailing their prescribing habits in these areas compared with other psychiatrists and the other state facilities. Over the course of 4 years, the percentage of patients on high doses of 3 antipsychotics substantially decreased. The percentage of patients on polypharmacy in the facility decreased, but not at the same rate as the other hospitals, leaving the facility even higher than the state average at the end of the 4-year period. Pharmacist-initiated physician peer comparison letters were associated with a considerable decrease in the prevalence of high-dose olanzapine, haloperidol, and quetiapine but did not appear to impact antipsychotic polypharmacy. This type of communication may be beneficial for stimulating system-wide changes in prescribing practices for high doses of antipsychotics; however, more individualized interventions are likely needed to reduce antipsychotic polypharmacy.Abstract