Practice Points:

Treatment-emergent hypo/mania (TEM) or “manic switch” is a transition from a depressive episode to a hypomanic, manic, or mixed episode within 12 weeks of medication initiation or dose escalation.
Risk factors for TEM include a history of hypo/manic switch or rapid cycling, bipolar disorder (BD) I, earlier-onset BD, severe manic symptoms, suicide attempts, comorbid panic attacks, and amphetamine use.
Bupropion has been found to be the lowest-risk antidepressant in causing TEM compared with tricyclic antidepressants, monoamine oxidase inhibitors, venlafaxine, and sertraline in adjunct to a mood stabilizer.
A randomized, double-blind, placebo-controlled trial published in 2020 studied guanfacine XR

Abstract

Introduction

Clozapine is the most effective antipsychotic in the management of treatment-resistant schizophrenia; however, its use is challenging due to the risk of severe adverse effects. Despite the risks associated with clozapine, there is no mandatory monitoring in Canada beyond hematologic testing for agranulocytosis surveillance. This study focuses on the development, implementation, and evaluation of a clozapine clinical toolkit (CTK) targeted at optimizing inpatient clozapine use.

Methods

A comprehensive literature review was conducted to identify clozapine best practices, experts were consulted, and a comprehensive clozapine CTK was developed and implemented at a large Canadian tertiary hospital in December 2018. To evaluate the CTK, a retrospective chart review was conducted to assess for change in guideline-concordant monitoring pre- and post- CTK implementation. Patients were included if they were > 18 years of age and received clozapine during inpatient admission. Results were analyzed using descriptive and inferential statistics.

Results

Among the charts reviewed, 185 and 113 admissions met the pre- and post-CTK inclusion criteria, respectively. Staff used the CTK in the care of 96% of clozapine patients post implementation, and its use resulted in improvements in guideline-concordant monitoring for agranulocytosis and myocarditis.

Discussion

Implementation of the clozapine CTK increased the concordance of clozapine monitoring with best practice recommendations. Future research is necessary to assess the impact of the CTK on clinical outcomes and patient satisfaction.

Abstract

Introduction

Studies indicate that long-acting injectable antipsychotics (LAIAs) reduce the risk of relapse and hospitalization compared with oral antipsychotics (APs) in adults. Oral formulations of APs are well-studied in the pediatric population, but little is known regarding the off-label use of LAIAs in this population.

Methods

This retrospective chart review evaluated readmission rates for pediatric patients admitted to a psychiatric ward in a large academic hospital between January 1, 2015, and December 1, 2022, requiring AP therapy. The experimental group included patients initiated on LAIA therapy, and the control group included patients initiated on a new oral AP. Patients were matched by several clinical factors.

Results

Each group consisted of 38 patients. For the primary outcome, hospital readmission rates at 3 months, the LAIA group had a 13.2% readmission rate compared with 26.3% in the comparator group (p = .153). In months 4 through 6, there was a 5.3% versus 15.8% readmission rate, respectively (p = .139). In months 7 through 12, it was 7.9% versus 18.4% (p = .179). There were significantly fewer cumulative readmissions at the 1-year mark in the LAIA group (N = 9, 23.7%) compared with the oral AP group (N = 18, 47.4%) (p = .031). No statistically significant differences were seen in hospital length of stay although results numerically favored LAIA.

Discussion

In a pediatric population, the administration of an LAIA when compared with the oral equivalent resulted in numerically fewer hospital readmissions, decreased length of stay, and fewer adverse effects, but these effects were not statistically significant except for cumulative readmissions at 1 year.

Abstract

Introduction

The role of pharmacists during medication reconciliation (MR) is well established, with a number of reports describing this in the context of psychiatric hospitalizations. However, medication errors (MEs) are common during transitions of care, with no exception during psychiatric hospitalizations. Our institution uses pharmacy-performed MR processes using patient interviews and reviewing objective sources, such as electronic pharmaceutical claims data (EPCD), which includes Medicaid Web portals. The inpatient psychiatric pharmacist reviews EPCD sources against previously pharmacy-completed MRs for new admissions, where if discrepancies are found, the patient is reinterviewed to identify and correct MEs.

Methods

We performed a prospective quality improvement project during 28 days to evaluate the quantity and classification of MEs upon admission to a 22-bed inpatient psychiatry unit.

Results

Of 52 included patients, where a cumulative 426 medications were reviewed, a total of 29 MEs in 16 patients were identified. Eight patients had discrepancies on their home medication lists when compared to EPCD, where 7 of these had at least 1 ME due to inaccurate MR.

Discussion

Of all the MEs identified, the greatest quantity was found secondary to the EPCD “double-check” method. The most common MEs in all patients were the omission of home medications (34%), wrong frequency (28%), and ordering medication the patient is not taking (10%). All patients admitted on long-acting injection antipsychotics had errors in last dose received. No MEs resulted in patient harm, and they were identified and corrected by the psychiatric pharmacist 97% of the time.

Research Trainee Award Finalists

Characterization of Flumazenil Utilization in Electroconvulsive Therapy

Michelle Yang, PharmD; Daniel McGraw, PharmD, BCPP; Clint Ross, PharmD, BCPP

Medical University of South Carolina Health, Charleston, South Carolina

Type: Original research. Background: Flumazenil is a benzodiazepine reversal agent that is suggested to have a periprocedural role in electroconvulsive therapy (ECT) for patients on concomitant benzodiazepines. However, there is limited information available regarding its efficacy and appropriate use in this patient population. The primary objective of this study was to evaluate the efficacy of flumazenil administered postbenzodiazepine prior to a patient receiving ECT. The secondary

Clozapine rechallenge after clozapine-induced myocarditis: A case report to validate a previously published protocol

Sara J. RussellBScKin,

Matthew JosdalMD,

Annabelle WansonMD, FRCPC, and

Katelyn HalpapeBSP, ACPR, PharmD, BCPP