There are currently no guidelines for switching patients from oral risperidone to paliperidone palmitate (Invega Sustenna®). Furthermore, the paliperidone long-acting injectable (LAI) package insert does not recommend bridging with oral antipsychotics, which may result in inadequate serum concentrations in patients on ≥4 mg/d risperidone. This study evaluated the effects of suboptimal dosing and bridging in patients switched from oral risperidone to paliperidone LAI on hospitalization days, emergency department (ED)/mental health urgent care visits, and no-shows/cancellations to mental health appointments. Patients were categorized into optimal or suboptimal dosing based on their loading and maintenance paliperidone doses. Patients on risperidone ≥4 mg/d were categorized as bridged if they received risperidone for ≥7 days after the first paliperidone injection. There were no significant differences in outcomes between optimally and suboptimally dosed patients. There were statistically significant reductions in hospitalization days in patients who were bridged compared with patients who were not bridged. There were statistically significant reductions in hospitalization days and ED/mental health urgent care visits after switching to paliperidone LAI. The results of this study indicate that bridging patients who are on ≥4 mg/d risperidone, when converting to paliperidone LAI, is associated with reductions in hospitalization days. However, more research is required to determine the optimal dose and duration of the bridge. The results also indicate that switching patients from oral risperidone to paliperidone LAI, even if the dose is suboptimal, is associated with reductions in hospitalization days and ED/mental health urgent care visits.Abstract
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Primary care mental health integration (PCMHI) teams function to improve access and quality of integrative physical and mental health (MH) care through a stepped care treatment approach. The project's primary objective was to evaluate the impact a PCMHI clinical pharmacist made on treatment outcomes and interventions. The secondary objective was to assess medication adherence rates. An electronic medical record was used to identify PCMHI patient referrals for medication management during an 8-month period. Patients were included if they were at least 18 years old and referred for medication management of depression, anxiety, posttraumatic stress disorder, or alcohol use disorder. The scores for the Patient Health Questionnaire (PHQ-9), the Generalized Anxiety Disorder Questionnaire (GAD-7), and the Posttraumatic Stress Disorder Checklist (PCL-C) were recorded at baseline and weeks 4, 8, and 12 during treatment. The analysis included 50 patients, which resulted in a total of 156 contacts between July 2014 and March 2015. The mean change in PHQ-9, GAD-7, and PCL-C scores at week 12 as compared to baseline were a decrease of 10 (95% confidence interval [CI], 6.2-13.8, P < .001), 8 (95% CI, 3.1-12.9, P = .006), and 14.5 (95% CI, –17.3-46.3, P = .109), respectively. A total of 336 treatment interventions were made, and the overall medication adherence rate was 82.9%. Medication management, provided by a clinical pharmacist, was associated with a statistically and clinically significant improvement on several MH disorder rating scale scores.Abstract
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Approximately 17 million Americans and 300 000 veterans have an alcohol use disorder (AUD). Both oral naltrexone (NTX) and long-acting, injectable naltrexone (LAI NTX) are FDA-approved to treat AUD. LAI NTX is often reserved for patients with adherence concerns due to considerable differences in drug cost and administration requirements. To date, there are no randomized trials comparing efficacy of LAI NTX to oral NTX. This retrospective cohort study compared clinical outcomes in veterans treated with LAI NTX or oral NTX. Health care utilization in veterans at 1 Veterans Affairs facility treated for AUD with oral NTX and LAI NTX was compared. The primary outcome was 90-day alcohol-related hospital admissions per patient (ARA90). Secondary outcomes included 90-day outpatient clinic and emergency department visits and 30-day alcohol-related admissions (ARA30). Inclusion criteria included first-time prescription of NTX for AUD from January 1, 2015, through December 1, 2015. Veterans receiving concurrent acamprosate or disulfiram were excluded. Seventy-nine patients were included with 65 in the oral NTX group and 14 in the LAI NTX group. The ARA90 was 0.17 for the oral NTX group and 0.64 for the LAI NTX group (P = .06). The oral NTX group had significantly fewer ARA30 than the LAI NTX group (P < .01). Oral NTX also had significantly lower health care utilization for all other parameters. Oral NTX was associated with lower health care utilization compared to LAI NTX in this veteran population. This indicates that LAI NTX may not provide additional benefit justifying the cost. This study had several limitations. Randomized trials comparing efficacy between oral NTX and LAI NTX are needed.Abstract
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Turnover leading to fluctuations in prescriber availability presents many challenges, most notably in access to and continuity of care. In 2015, the Veterans Affairs Eastern Colorado Healthcare System (VA ECHCS) experienced a period of significant mental health prescriber turnover leading to patient utilization of psychiatric emergency services (PES) for nonemergent medication management. The resulting increase in volume placed excessive stress on PES prescribers. Mental health pharmacists have opportunities to provide interim medication management while patients are between prescribers. This study was a retrospective, cohort study of patients unassigned to an outpatient mental health prescriber due to prescriber turnover, receiving care at VA ECHCS between October 1, 2015, and February 28, 2016. The primary outcome was the number of pharmacist interventions performed. Secondary outcomes characterize the interventions performed and describe the change in the mean monthly volume of patients presenting to PES. In this veteran population, 152 interventions were performed in 81 unique patients. The most common intervention was prescription renewals (80%). Interventions most commonly involved antidepressants (28%), antipsychotics (10%), and mood stabilizers (10%). Before initiation of the clinic, Denver VA PES experienced a mean of 300 monthly visits. After clinic implementation, PES visits decreased significantly to a mean of 237 visits per month (P = .041). The pharmacist interim prescriber clinic was associated with a significant decrease in mean number of patients seen per month in PES. The success of the clinic also contributed to interest by the mental health service to expand clinical pharmacy services.Abstract
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It is estimated that up to 50% of medications for long-term conditions are not taken as prescribed. In mental health conditions, poor adherence leads to increased relapse, suicide rates, and hospitalizations. It is recommended that health care professionals aim to elicit and address beliefs and attitudes about medication, and to understand the patient's experience of taking them, as these, among other factors, affect adherence rates. This study evaluated a pilot trial of a medicines group for adult inpatients on an acute mental health ward. This study comprises a pilot service evaluation of a medicines education group through the descriptive analysis of data obtained using a tailored outcome measure using validated experience and attitude measures. The medicines education group was designed by a multidisciplinary team and focused on eliciting perceptual and practical barriers to adherence, lived experience, psychoeducation, and shared problem solving. The group was run during a period of 3 months and was compared to a baseline data set. In total there were 35 medicine group attendees, there were 3 dropouts, and the outcome measure was fully completed in 68% of cases, with only 4 refusing, indicating this pilot evaluation was feasible and acceptable. Descriptive analysis found that on average, group attendees reported a better understanding of the purpose and side effects of their medication, and felt more involved in decisions about their medicines compared with the baseline data set. This pilot evaluation found that running a novel medicines education group, targeting perceptual and practical barriers to adherence, was acceptable to attendees and feasible to deliver on an adult psychiatric inpatient unit.Abstract
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This chart review utilizes readmission rates and mean time to readmission as markers of drug efficacy to compare different categories of long-acting injectable antipsychotics (LAIAs), antipsychotic polypharmacy, and clozapine to oral antipsychotic monotherapy (OM) at a state psychiatric hospital in Oregon (Oregon State Hospital). Charts were reviewed for patients discharged between October 20, 2011, and September 23, 2015, with a diagnosis of schizophrenia spectrum or mood disorder. Admission dates, discharge dates, and discharge antipsychotics were reviewed for each patient dating back to 1991. Discharge antipsychotics were categorized into groupings of LAIAs, antipsychotic polypharmacy, and clozapine and compared with OM to assess readmission data within 1, 3, and 5 years of discharge. The primary end point was readmission rate, measured as a percentage, and the secondary end point was mean time to readmission (MTR), measured in days. Of 1088 patients reviewed, there were 2031 patient discharges associated with antipsychotic agents and 1258 readmissions. Patients discharged on LAIA monotherapy or clozapine generally had a lower readmission rate, and patients discharged on antipsychotic polypharmacy generally had a higher readmission rate. Statistical significance for these findings varied over time frames and subgroup analyses. The most notable finding for the secondary end point was a significantly shorter MTR for patients discharged on clozapine for all diagnoses and the subgroup analysis of schizoaffective disorder. These results are only a reflection of the patient population at this hospital, and additional reviews at other facilities with different patient characteristics could clarify applicability to other patient populations.Abstract
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The demand for mental health services has increased as more veterans have been diagnosed with—and sought care for—one or more mental health conditions. Within the South Texas Veterans Health Care System (STVHCS), providers may submit electronic consults (e-consults) to mental health clinical pharmacy specialists for medication review and recommendations. These consults aim to manage veterans with uncomplicated mental health conditions in primary care, making specialty mental health providers more available for those who need such services. Pharmacists have improved outcomes and access to care for conditions such as diabetes and hypertension, but currently, there is limited evidence demonstrating the impact of pharmacists in mental health. This quality improvement project assessed the effectiveness of the e-consult service. Information was collected through a retrospective chart review of STVHCS veterans with the corresponding consult note placed in their chart from May 2014 through December 2015. Numbers of recommendations implemented and veterans maintained in primary care were analyzed as markers of effectiveness. Time and cost savings were secondarily explored. A total of 361 consults were submitted for 353 unique patients. Of the 322 patients included in analyses, a total of 301 unique patients (93.5%) were maintained in primary care for at least 3 months. Of the 21 not maintained in primary care, 15 recommendations were implemented; of those maintained in primary care, 271 recommendations were implemented. This service improves mental health care—and patient access—by promoting successful management and maintenance of less complicated patients in primary care.Abstract
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Neuroleptic malignant syndrome (NMS), which is considered a neurologic emergency, is believed to be caused by exposure to dopamine antagonist or withdrawal from a dopamine agonist. This article reports a case of suspected atypical NMS in a patient following rapid conversion of ziprasidone to risperidone without titration. While the initial presentation did not fully meet the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, diagnostic features, a sequential treatment strategy was initiated and the patient appropriately responded to antipsychotic cessation in addition to combination therapy with dantrolene and bromocriptine. Neuroleptic malignant syndrome diagnostic criteria, treatment, and prognosis are discussed.Abstract