Mental Health Clinician Volume 3: Issue 4

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The importance of pharmacoeconomics and outcomes in modern healthcare

PharmD, BCPS, BCPP

Disclaimer: This editorial contains opinions of the author and does not reflect any opinion or support of the United States Federal Government nor the Department of Veterans Affairs.

This month's issue is dedicated to pharmacoeconomics, outcomes, formulary management and the psychiatric pharmacist. Pharmacoeconomics is the branch of pharmacy practice which deals with the financial implications of medication use. Outcomes research is a broader term, which studies drug use in terms of economic, clinical and humanistic outcomes (often referred to as the ECHO model).¹ Formulary management, on the other hand, is a common strategy used to apply pharmacoeconomic considerations

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A retrospective chart review of a symptom-triggered alcohol withdrawal protocol versus previous standard of care at a veterans hospital

Pharm.D.,

Pharm.D., BCPS,

D.O., FAPA,

Pharm.D., BCPS, and

Pharm.D., BCPS, BCPP, CGP

DOI: 10.9740/mhc.n172309

Alcohol is a commonly abused substance, and it is important that healthcare facilities properly manage alcohol withdrawal. Studies have found that the most efficient way to manage alcohol withdrawal is to use a symptom-triggered approach and only administer medications if symptoms surpass a specific threshold determined by a clinician administered rating scale. Alternatively, a standard fixed-dose medication regimen can be utilized. This study assessed if a new symptom-triggered protocol, utilizing the Clinical Institute Withdrawal for Alcohol, Revised (CIWA-Ar) scale for the assessment of symptoms, resulted in the anticipated patient outcomes of decreased length of hospital stay, less benzodiazepine administered per patient, and a shorter administration time from first dose of benzodiazepine given to last dose, when compared to the previous standard of care. A retrospective chart review was performed for 70 patients who had been treated for alcohol withdrawal. Patients who were treated with the symptom-triggered protocol had a decreased length of hospital stay when compared to the previous standard of care (−2.62 days, p = 0.0054). Both secondary efficacy outcomes were also statistically significant in favor of the symptom-triggered group. This retrospective chart review adds to the body of evidence supporting the use of symptom-triggered protocols as opposed to fixed-dose protocols in the management of alcohol withdrawal.

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Automatic therapeutic substitution in a psychiatric hospital

PharmD, BCPP

DOI: 10.9740/mhc.n172343

Automatic therapeutic substitution protocols have become common practice in health care systems in the last ten to fifteen years. These protocols can help formulary management, simplify pharmacy inventory, and reduce costs. To date, psychotropics continue to be absent from the most common automatic substitution policies. This article will describe the rationale for select psychotropic substitutions.

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Dynamics of drug evaluation: Formulary placement of antipsychotics

Pharm.D., MS, BCPP and

Pharm.D.

DOI: 10.9740/mhc.n172348

Formulary management for psychotropic medications can be more difficult compared to other medication classes, as the same medications can produce significantly different results in individual patients. This article reviews various factors which should be examined when deciding which antipsychotics to include on a formulary.

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Implementation of antipsychotic selection recommendations at a veterans affairs facility

PharmD,

PharmD, BCPP, and

BS Pharm, BCPS

DOI: 10.9740/mhc.n172352

Introduction: In 2012, the Veterans Affairs (VA) Pharmacy Benefits Management Services created recommendations for antipsychotic selection in schizophrenia and schizoaffective disorders. The recommendations stated that patients must fail two first line agents (haloperidol, loxapine, quetiapine, risperidone or perphenazine) and clozapine (if appropriate) before being allowed to trial second line agents olanzapine, ziprasidone or aripiprazole. The aim of this project was to determine the amount of cost savings that could have been provided had the above recommendations been implemented last year.

Use of second generation antipsychotics has been associated with weight gain, diabetes, and worsening lipid profiles. The American Diabetes Association (ADA) has created guidelines regarding cardiometabolic monitoring of second generation antipsychotic agents. A secondary aim of this project was to determine the rate of provider adherence to the ADA recommendations.

Methods: A retrospective chart review was performed for patients >18 years of age who were initiated on aripiprazole, ziprasidone, or olanzapine for all indications between July 1, 2011 and July 1, 2012. The costs of the mean doses of these agents were compared to an equivalent mean dose of the first line agent risperidone (4mg) using VA drug acquisition costs.

Cardiometabolic monitoring data were collected to include weight, blood pressure, fasting glucose and fasting lipid profiles at baseline and at 12 weeks.

Results: Of the 542 patients started on second line agents, only 68 met criteria for their use. A potential cost savings of over $850,000 may have been realized had these criteria been enacted within the one year time period studied.

None of the 542 patients had both baseline and follow-up values for weight, blood pressure, fasting glucose and fasting lipid profiles. While roughly 60% of patients had blood pressure and weight values at baseline and 27% had glucose and cholesterol values, less than 14% received follow-up testing with approximately 2% receiving neither baseline nor follow-up testing.

Discussion: Significant cost savings can be realized via the use of selection criteria without sacrificing efficacy as most studies do not demonstrate the superiority of one agent and the rates of adverse events between first and second generation agents are more similar than previously thought. This study also highlighted the lack of adequate cardiometabolic monitoring which could lead to cardiovascular disease.

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Vilazodone: A landmark antidepressant approval or another “me-too” drug?

Pharm.D., MS

DOI: 10.9740/mhc.n172355

Vilazodone is a novel antidepressant which is indicated for the treatment of major depressive disorder (MDD) in adult patients. This article reviews the pharmacodynamics and pharmacokinetics of vilazodone, and discusses published and ongoing research on the medication.

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Depression screening in uninsured patients in a primary care setting

PharmD, BCPS,

MD, and

BSN

DOI: 10.9740/mhc.n172523

There is a strong correlation between chronic disease and depression; however, screening patients for depression is not typical in the primary care setting due to factors such as time constraints and the provider's ability to diagnose and manage depression. This study sought to: (1) determine the prevalence of depression in uninsured or underinsured patients with chronic diseases using a screening instrument validated for use in the primary care setting, (2) provide a referral to the patient's primary care provider (PCP) for depression management prior to disease management as needed, and (3) enroll patients for chronic disease management services. The study utilized a cross-sectional design consisting of a self-administered survey and medical record review after physician and nursing appointments. Patients completed the Beck Depression Inventory for Primary Care (BDI-PC) upon program enrollment. Patients that screened positively for depression were referred to the PCP for follow-up services prior to entry into one of the disease management programs. After PCP appointments took place, medical records were reviewed to obtain medical and depression diagnoses, along with mediation recommendations. Forty-one patients were enrolled in the clinic program and completed the depression screening. Eight patients were found to have mild depression and two patients had moderate depression as determined by the BDI-PC, which accounted for 24% of the clinic patients. Four of the patients with mild depression and both patients with moderate depression initiated antidepressant therapy. Additionally, three patients with minimal scores on the screening began medication therapy based on symptoms reported to the PCP. The results of this study suggest that it is feasible to incorporate a depression-screening tool in a primary care setting with further evaluation and follow-up by primary care providers.

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Comprehensive medication management for patients with mental illnesses

PharmD, BCPP

DOI: 10.9740/mhc.n169519

Comprehensive medication management (CMM) is a patient-care practice that aims to ensure that a patient's medication therapy is effective and safe. This article reviews pharmacist-provided CMM services, including services for psychiatric patients.

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STEPS for cost-effective prescribing of serotonin-norepinephrine reuptake inhibitors (SNRIs) in major depressive disorder: Focus on venlafaxine (Effexor®) versus duloxetine (Cymbalta®)

PharmD, BCPP, CGP

DOI: 10.9740/mhc.n172840

Selection of an antidepressant medication is based on various factors, such as safety, tolerability, and cost. This article reviews the cost-effectiveness of the different serotonin-norepinephrine reuptake inhibitors (SNRIs).

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Book Review: Condensed psychopharmacology 2013: A pocket reference for psychiatry and psychotropic medications

PharmD, BCPS

DOI: 10.9740/mhc.n170545

CPNP members maintain a suggested reading list to provide information on peer recommended resources and convenient access to the highest quality neuropsychopharmacology publications. A reminder that if you shop with CPNP, by following the links below to Amazon, a small commission will be paid to CPNP which helps to financially support our mission to improve the minds and lives of individuals with psychiatric and/or neurologic disorders.

You can help grow this list of resources by suggesting a book.

Book: Condensed Psychopharmacology 2013: A Pocket Reference for Psychiatry and Psychotropic Medications

FROM THE PUBLISHER

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Movie Review: Awakenings

, and

PharmD, BCPP

DOI: 10.9740/mhc.n170548

Awakenings, a film directed by Penny Marshall and released in 1990, follows the story of Dr. Malcolm Sayer (Robin Williams) as he interacts with catatonic patients infected by an epidemic of viral encephalitis earlier in life. This film is based on true events and takes place in a behavioral institution in the late 1960s. Sayer begins his career at this hospital, where he integrates his passion for neurological research into an investigative approach to the treatment of his patients. However, he is met by initial resistance and apathy from his colleagues, who view the patients as essentially hopeless. One

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Growing gains!

PharmD, BCPP

DOI: 10.9740/mhc.n172683

CPNP is in a period of growth which can only benefit our membership and the patients we serve. Membership has increased to approximately 1300 strong with students and residents representing a fourth of the membership. There are now student CPNP chapters at 11 different pharmacy schools and this will be the 2^nd year where a segment of the annual meeting programming is designed just for them. These student chapters increase awareness of careers in psychiatric pharmacy and provide valuable networking opportunities. In addition, they have the opportunity to liaison with NAMI through such programs as NAMI on campus,

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CPNP Announcements

DOI: 10.9740/mhc.n173478

PHOENIX RISES AT 2014 ANNUAL MEETING

The CPNP Program Committee is pleased to announce the 2014 Annual Meeting which is titled Phoenix Rising: Taking Neuropsychiatric Pharmacy Above & Beyond. The meeting will return to Phoenix, Arizona from April 27–30, 2014.

A stellar line-up of speakers and topics is taking shape and a sneak peak is provided on the Annual Meeting speaker page with more details to come by the end of October. In the meantime, details regarding the scheduled keynote addresses are provided below. We will keep you posted as more details emerge and as registration

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The importance of pharmacoeconomics and outcomes in modern healthcare

A retrospective chart review of a symptom-triggered alcohol withdrawal protocol versus previous standard of care at a veterans hospital

Automatic therapeutic substitution in a psychiatric hospital

Dynamics of drug evaluation: Formulary placement of antipsychotics

Implementation of antipsychotic selection recommendations at a veterans affairs facility

Vilazodone: A landmark antidepressant approval or another “me-too” drug?

Depression screening in uninsured patients in a primary care setting

Comprehensive medication management for patients with mental illnesses

STEPS for cost-effective prescribing of serotonin-norepinephrine reuptake inhibitors (SNRIs) in major depressive disorder: Focus on venlafaxine (Effexor®) versus duloxetine (Cymbalta®)

Book Review: Condensed psychopharmacology 2013: A pocket reference for psychiatry and psychotropic medications

FROM THE PUBLISHER

Movie Review: Awakenings

Growing gains!

CPNP Announcements

PHOENIX RISES AT 2014 ANNUAL MEETING

Pharmacist administration of long-acting injectable medications for substance use disorders: A scoping review

Transitions of care: Assessment of adherence to long-acting injectable antipsychotic treatment following discharge from inpatient psychiatry

Use of atypical antipsychotics in individuals with anorexia nervosa

Potential changes impacting psychiatric pharmacy by 2030

A model for timely dissemination of critical information: Clozapine toxicity during the COVID pandemic