Abstract
Introduction
Antipsychotics improve symptoms associated with schizophrenia and bipolar disorder. To improve medication adherence and decrease the need for hospitalization, many antipsychotics have been developed into long-acting injectable (LAI) formulations. Though mirror-image studies have demonstrated significantly decreased hospitalization rates with LAI use, there is limited data when suboptimal use parameters are present.
Methods
A retrospective chart review was conducted on patients who were administered aripiprazole monohydrate long-acting injectable (AM-LAI) in an adult mental health unit. Demographics and AM-LAI use parameters were analyzed descriptively. Endpoints compared the days between encounters pre and post AM-LAI administration and number of inpatient encounters between the 180 days pre and post AM-LAI administration. Effects of AM-LAI on inpatient encounters were analyzed using a Wilcoxon signed rank test with an alpha set to <0.05 for significance.
Results
Fifty-eight patients met inclusion criteria. Mean (± SD) age was 39.4 (11.4) years with 55.2% of the sample male. Most patients were diagnosed with schizophrenia or unspecified psychotic disorder and admitted involuntarily. The mean number of days from last admission to the date of initial AM-LAI administration was 109.3 (75.2), compared with 131.3 (69.8) days to next encounter (P = .044) post AM-LAI. Total inpatient encounters were also reduced (P = .004), although no differences in encounters for psychiatric reasons were detected.
Discussion
Use of AM-LAI was associated with a prolonged time to next inpatient encounter and reduced total inpatient encounters, however its use failed to demonstrate reductions in psychiatric encounters.
Abstract
Introduction
Intensive care unit (ICU) delirium is a major contributing factor to increased mortality, length of stay, and cost of care. Psychotropic medications may often require extensive tapering to prevent withdrawal symptoms; during ICU admission, home psychotropics are frequently held which may precipitate acute drug withdrawal and subsequent delirium.
Methods
This is a single-center, observational, retrospective chart review. The primary endpoint was the total number of new-start antipsychotics used to treat ICU delirium. Secondary endpoints included use of restraints, ICU length of stay, and hospital length of stay.
Results
A total of 2334 charts were reviewed for inclusion; 55 patients were categorized into each group. There was no statistically significant difference in the requirement for new-start antipsychotics (P = 1.0), restraint use (P = .057), or ICU length of stay (P = .71). There was a statistically significant decrease in hospital length of stay (P = .048).
Discussion
Early reinitiation was associated with a decrease in hospital length of stay but was not associated with a decrease in the number of new-start antipsychotics, use of restraints, or ICU length of stay.
Abstract
Introduction
Traditionally, clinical pharmacists have been employed in the primary care setting to help manage chronic disease states, such as diabetes and hypertension. Although the benefits of pharmacists managing chronic conditions have been extensively published, published data for clinical pharmacist mental health services in primary care is limited to Veterans Affairs populations. This article describes a practice model in which pharmacists are providing psychiatric medication management and consultation in a federally qualified health center.
Methods
A period of 1 year from the psychiatric pharmacy service was analyzed from April 1, 2017, to March 31, 2018. Reports were generated that included information about psychiatric pharmacy consults, 1-on-1 psychiatric pharmacy visits, and psychotropic medication prescribing/dispensing trends. Each consult was further reviewed for additional details, including patient characteristics, medications prescribed, psychiatric diagnoses involved, and actions taken.
Results
A review of this pharmacy service showed significant pharmacist involvement in psychiatric medication consults and 1-on-1 visits. Common disease states consulted on were depressive disorders, anxiety disorders, and neurologic disorders, which reflects psychiatric disease states commonly seen in primary care practice. Provider satisfaction survey results showed that the service was valued and that providers felt their comfort in prescribing psychotropic medications improved due to the service.
Discussion
The service described here exemplifies the potential for pharmacists in the ambulatory care setting to expand beyond the traditional chronic disease state management. It also speaks to a potential role for psychiatric pharmacists in the primary care setting.
Abstract
Introduction
Naloxone has become an important component of preventing deaths from opioid overdose. Although studies have confirmed its cost-effectiveness, naloxone is rarely prescribed proactively in case of accidental overdose. The perception still exists that a reversal agent may enable patients with opioid use disorder to continue abusing opioids without fear of death from overdose. This study was designed to determine the general public's knowledge of naloxone and their perceptions about receiving a naloxone prescription with opioid use.
Methods
Participants were recruited through Amazon Mechanical Turk (MTurk), where a link directed participants to an electronic survey. Participants were included if they were 18 years of age or greater and currently living in the United States. Participants were paid $0.10 USD via Amazon MTurk upon completing the survey.
Results
Four hundred five participants successfully completed the survey, and 61% were aware that there is a medication available to treat opioid overdose. The majority of participants responded positively to the idea of acquiring naloxone. Responses were evenly split for agreeing and disagreeing with the statement “naloxone is only necessary for people who abuse opioids.” Although 51% of respondents believed that having naloxone available enables people who abuse opioids, 88% agreed that naloxone is beneficial for people who accidentally overdose on opioids. A majority believed that naloxone should be made available upon request to anyone concerned about opioid overdose.
Discussion
Participants were generally aware of the availability of an opioid reversal agent and responded positively to 3 different methods of acquiring naloxone through their prescriber or pharmacist.
Abstract
Introduction
Neuropsychiatric disorders affect millions of older adults. Despite this, there are relatively few older adults included in clinical trials evaluating treatments for psychiatric disorders. Citalopram has been evaluated in older adults with neuropsychiatric disorders and has largely been found beneficial, making the 2011 US Food and Drug Administration (FDA) safety advisory on citalopram extremely impactful.
Methods
A literature search was completed using the PubMed database. Results were limited to clinical trials conducted in older adults that were published in English.
Results
Review of the literature confirms the efficacy of citalopram in depression, anxiety, depression associated with Parkinson disease, and behavioral and psychological symptoms of dementia. Additionally, no adverse cardiac outcomes have been described related to citalopram.
Discussion
The FDA's evidence for applying this safety advisory to citalopram is minimal and largely based on surrogate markers, such as the QTc interval rather than clinical and safety outcomes. Citalopram is known to increase the QTc, but this increase has not been linked to adverse cardiac outcomes. The evidence for efficacy and against adverse outcomes suggests that a reevaluation of the dosing restrictions in older adults with neuropsychiatric disorders is needed.
Abstract
Introduction
In addition to clozapine, there is a growing body of evidence that supports therapeutic drug monitoring (TDM) for additional antipsychotics commonly used in the United States.
Methods
The Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) published TDM guidelines for several psychiatric medications. Sources were identified that the authors used to establish therapeutic reference ranges for haloperidol, fluphenazine, perphenazine, and olanzapine—4 antipsychotics commonly used in the United States with a “strong recommendation” for TDM. The sources were then reviewed for content and appropriateness for utilization in establishing the reference ranges.
Results
Olanzapine had 15 citations, haloperidol had 9, perphenazine had 4, and fluphenazine had 2. The studies' methods were reviewed along with the proposed therapeutic reference ranges.
Discussion
Several limitations of the guidelines were identified. Reference ranges were suggested based on studies of patients with various diagnoses; some patients had an acute exacerbation, and others were in a maintenance phase. An additional publication was identified that reviewed similar (and additional) TDM studies; those conclusions were in slight contrast with those of the AGNP guidelines. In the future, guidance should be given to those looking to conduct TDM studies to standardize methods and make meta-analysis of this data more feasible.
Abstract
To achieve the nationwide goal of reducing opioid-related deaths, a clinical pharmacy specialist–led clinical video telehealth (CVT) clinic was created at a Veterans Affairs medical center (VAMC) to deliver opioid overdose prevention and naloxone education to at-risk patients. The purpose of this innovative practice was to improve access to this potentially life-saving intervention to patients across urban and rural areas. This study is a single-center, descriptive analysis of adult patients across 2 VAMC campuses and 4 community-based outpatient clinics from July 11, 2016, through December 31, 2016. The purpose of this innovative practice was to increase access to overdose education and naloxone distribution (OEND) to at-risk patients across urban and rural areas. Patient-specific factors were also examined among those receiving naloxone through the CVT clinic compared to other prescribers. During the first 6 months from the initiation of the clinic, 1 pharmacist prescribed 21% of the health care system's naloxone. These patients identified by the pharmacist-led CVT clinic were more likely to be considered high-risk due to concomitant use of opioids and benzodiazepines. In conclusion, the pharmacist-led CVT group clinic has been an efficient strategy to extend OEND services to high-risk patients beyond central, urban areas.