Adverse Childhood Experiences and Trust in the Medical Profession among Young Adults.

Attachment theory suggests that adverse childhood experiences (ACEs) should predict lower trust in the medical profession. To test this theory, a cross-sectional survey was administered to young adults self-identifying as homeless. The purpose of the survey was to examine the relationship of ACEs, attachment style, and trust in the medical profession. Hierarchical linear regression was used to determine if ACEs predict variance in trust in the medical profession after controlling for participants' attachment style and demographics. Results indicated ACEs were a robust predictor of lower trust in the medical profession over the controls. Since lower trust in the medical profession is associated with less willingness to seek care and follow provider recommendations, the established link between poorer health and ACEs may partially result from lower trust in the medical profession. The paper concludes with a discussion of the results' implications for future research and practice with ACE survivors.

Evaluating antidepressant treatment prior to adding second-line therapies among patients with treatment-resistant depression.

BACKGROUND: Patients with depression can be mistakenly labeled as treatment-resistant if they fail to receive an adequate first-line antidepressant trial. Adding second-line agents to the treatment regimens can create an additional burden on both the patients and the healthcare system. OBJECTIVES: To determine if depressed patients receive an adequate antidepressant trial prior to starting second-line therapy and to investigate the association between the type of second-line treatment and severity of illness or depression among unipolar versus bipolar patients. SETTING: Oklahoma Medicaid claims data between 2006 and 2011. METHODS: Subjects were depression-diagnosed adult patients with at least two prescriptions of antidepressants followed by a second-line agent. Patients were categorized into one of three groups: an atypical antipsychotic, other augmentation agents (lithium, buspirone, and triiodothyronine), or adding antidepressants, based on the type of second-line therapy. An adequate trial was defined per the American Psychiatric Association guidelines. Factors associated with the type of treatment were tested using multinomial logistic regression models stratified by type of depression (unipolar vs. bipolar patients). MAIN OUTCOME MEASURE: Variables used to measure receiving an adequate antidepressant trial included: trial duration, adherence, dose adequacy, and number of distinct antidepressant trials. RESULTS: A total of 3910 patients were included in the analysis. Most subjects reached the recommended antidepressant dose. However, 28 % of patients had an antidepressant trial duration <4 weeks and only 60 % tried at least two antidepressant regimens prior to adding second-line therapy. Approximately 50 % of the subjects were non-adherent across all groups. Severity of illness and receipt of an adequate antidepressant trial were not predictors of the type of second-line treatment. CONCLUSION: Many patients do not receive an adequate antidepressant trial before starting a second-line agent. The type of second-line treatment was independent of severity of depression. These findings support policies that require reviewing the recommended dose and duration of the first-line antidepressant before adding second-line agents. Healthcare providers need to review the patient's history and reconsider the evidence for prescribing second-line agents.

Does the use of atypical antipsychotics as adjunctive therapy in depression result in cost savings? Comparing healthcare costs and utilization between second-line treatment options.

BACKGROUND: Several atypical antipsychotics (AAPs) are used as second-line agents for treatment resistant depression. AAPs can be expensive compared to other treatment options and can cause several side effects. OBJECTIVES: To estimate healthcare costs and utilization of AAPs compared to other second-line agents. METHODS: Observational study using Medicaid claims data (2006-2011). Subjects were depression-diagnosed adult members with at least two prescriptions of antidepressant medications followed by a second-line agent. Gamma generalized linear models (GLM) produced estimates of the difference in mean expenditures among treatment groups after adjusting for individual baseline characteristics using propensity scores. Negative binomial models produced estimates of the difference in number of hospitalizations and emergency department (ED) visits. RESULTS: A total of 3910 members received second-line treatment. Treatment groups were AAPs (n = 2211), augmentation agents other than AAPs (n = 1008), and antidepressant switching (n = 691). AAPs resulted in higher mean adjusted pharmacy costs and higher mean adjusted total mental health-related costs. Mean adjusted total healthcare costs and number of inpatient and ED visits were not different among treatments. CONCLUSION: The results show no evidence that AAPs used as second-line treatment for depression results in overall cost savings or lower inpatient and ED visits compared to other treatment strategies.

Use of visual cueing for blood glucose documentation in a person with schizophrenia and diabetes.

Persons diagnosed with schizophrenia are also at-risk for medical comorbidities. We present the case of one such patient with the comorbidity of diabetes. By applying the research on visual cueing for this population, we developed a glucose monitoring form that increased documentation. We encourage other healthcare practitioners to develop visually appealing or interesting documentation forms for their patients to help empower them for self-care.

National antidepressant prescribing in children and adolescents with mental health disorders after an FDA boxed warning.

BACKGROUND: In October 2004, the U.S. Food and Drug Administration (FDA) issued a boxed warning about an increased risk of suicidality (i.e., suicidal ideation, behavior, or attempts) related to all antidepressants in children and adolescents. OBJECTIVE: To describe national antidepressant prescribing patterns in children and adolescents before, during, and after the introduction of the FDA boxed warning. METHODS: Cross-sectional data from the 2002-2009 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to describe antidepressant prescribing patterns within a nationally-representative sample of 4035 physician visits for children and adolescents diagnosed with depression or other psychiatric disorder(s) [i.e., anxiety disorders or attention deficit/hyperactivity disorder (ADHD)]. RESULTS: In 2002-2003, antidepressants were prescribed in 4.1 million (36.1%) visits, followed by 3.2 million (28.8%) visits in 2004-2005 and 2.8 million (26.8%) visits in 2006-2007. However, antidepressant prescribing patterns reversed during 2008-2009, with an increase to 3.6 million (32.5%) visits. Compared to the period preceding the FDA boxed warning (2002-2003), a significant decline in visits related to antidepressant prescribing detected in the immediate post-FDA boxed warning period (2006-2007) (AOR = 0.67, 95% CI: 0.47-0.96). No association between the FDA boxed warning and antidepressant prescribing visits was detected during the FDA boxed warning period (2004-2005) (AOR = 0.80, 95% CI: 0.53-1.21) and in the late post-FDA boxed warning period (2008-2009) (AOR = 1.01, 95% CI: 0.63-1.60). CONCLUSIONS: After a 2-year lag period, antidepressant prescribing for visits of children and adolescents diagnosed with depression or other psychiatric disorder(s) in community-based and outpatient clinic settings declined when compared to the period preceding the FDA boxed warning. This decline was not sustained in the period of five years after implementation of the FDA boxed warning.

Evaluation of serum prolactin levels in intellectually disabled patients using antipsychotic medications.

BACKGROUND: Patients with intellectual disabilities may be treated with antipsychotic medications for a variety of diagnoses. Use of this category of medication can increase prolactin levels and place the patient at risk for sexual dysfunction and lower bone mineral density. The proposed mechanism of action is affinity for the dopamine receptor. Use of bromocriptine, a dopamine receptor antagonist, was proposed to attenuate hyperprolactinemia. OBJECTIVES: The objectives of this study were to (1) review serum prolactin (PRL) elevations associated with the use of antipsychotic (AP) medications in an intellectually disabled adult population and (2) determine if any association existed between the level of elevation and AP used. PATIENTS AND METHODS: Medical records for adult patients at two Oklahoma facilities for the intellectually disabled were reviewed to evaluate prolactin levels for individuals prescribed antipsychotics. A linear regression model was used to evaluate the relationship between prolactin levels with intellectual disability level, bromocriptine use, demographics, and antipsychotic. RESULTS: 73 (n = 53 males, n = 20 females) patients met criteria. The average age was 41.2 years. Nearly 70% of the patients had severe to profound levels of disability. 77% were prescribed second generation antipsychotics; 19% received first generation agents. Two variables, gender and bromocriptine use, were found to be significant predictors of prolactin levels. Mean prolactin level for females was 44 ng/mL (normal range: 4-30 ng/mL, males = 4-23 ng/mL). Patients who did not receive bromocriptine had mean levels of 23 ng/mL. No significant difference in prolactin levels was found for type of AP. CONCLUSIONS: Mean prolactin levels for females were significantly higher than for males. Both sexes were found to have higher-than-normal levels. Use of bromocriptine was associated with higher prolactin levels. In this population of patients, the type of AP used had no significance on prolactin levels.

Mental health treatment associated with community-based depression screening: considerations for planning multidisciplinary collaborative care.

BACKGROUND: Depression places a large economic burden on the US health care system. Routine screening has been recognized as a fundamental step in the effective treatment of depression, but should be undertaken only when support systems are available to ensure proper diagnosis, treatment, and follow-up. OBJECTIVE: To estimate differences in prescribing new antidepressants and referral to stress management, psychotherapy, and other mental health (OMH) counseling at physician visits when documented depression screening was and was not performed. METHODS: Cross-sectional physician visit data for adults from the 2005-2007 National Ambulatory Medical Care Survey were used. The final analytical sample included 55,143 visits, representing a national population estimate of 1,741,080,686 physician visits. Four dependent variables were considered: (1) order for new antidepressant(s), and referral to (2) stress management, (3) psycho therapy, or (4) OMH counseling. Bivariable and multivariable associations between depression screening and each measure of depression follow-up care were evaluated using the design-based F statistic and multivariable logistic regression models. RESULTS: New antidepressant prescribing increased significantly (2.12% of visits without depression screening vs 10.61% with depression screening resulted in a new prescription of an antidepressant). Referral to stress management was the behavioral treatment with the greatest absolute change (3.31% of visits without depression screening vs 33.10% of visits with depression screening resulted in a referral to stress management). After controlling for background sociodemographic characteristics, the adjusted odds ratio of a new antidepressant order remained significantly higher at visits involving depression screening (AOR 5.36; 99.9% CI 2.92-9.82), as did referrals for all behavioral health care services (ie, stress management, psychotherapy, and OMH counseling). CONCLUSIONS: At the national level, depression screening was associated with increased new antidepressant prescribing and referral for behavioral health care. It is critical for policy planners to recognize changes in follow-up depression care when implementing screening programs to ensure adequate capacity. Pharmacists are poised to assume a role in collaborative depression care, particularly with antidepressant medication therapy management.

Evaluation of monitoring for metabolic effects in children treated with second generation antipsychotics in a pediatric clinic.

OBJECTIVES: The aim of this retrospective study was to identify the frequency of recommended metabolic monitoring and follow-up in pediatric patients on second-generation antipsychotic (SGA) medications from a pediatric clinic. METHODS: A retrospective review of electronic medical records of all patients on antipsychotics from an academic medical center pediatric clinic was conducted. Inclusion criteria required patients to be established members of the pediatric clinic, < 19 years of age, and on ≥ 1 SGA for at least 1 year, regardless of medical diagnosis. Data collection consisted of patient demographic information and frequency of family history, vital signs, and recommended laboratory monitoring. RESULTS: A total of 67 patients on antipsychotics were identified. After the application of inclusion criteria, 32 patients qualified for review. The average age was 13.5 ± 4 years and gender distribution included 72% males. Only 4 (13%) patients had documented baseline monitoring that included weight, blood pressure, and fasting lipid panel. No patient had a fasting plasma glucose recorded at any point during antipsychotic therapy. Follow-up monitoring decreased over time, with the exception of quarterly weight and annual blood pressure. CONCLUSIONS: The results of this study highlight the lack of baseline and periodic monitoring that occur when pediatric patients are prescribed antipsychotic medications, putting the patient at risk for adverse events. The marked increase in antipsychotic prescribing and concerns related to their safety emphasize the need for improvement in monitoring of antipsychotic medications. This gap in patient care and safety opens an excellent opportunity for a clinical pharmacy team to provide education and assistance with SGA monitoring for the purpose of providing optimal patient care.

Schizophrenia and the immune system: pathophysiology, prevention, and treatment.

PURPOSE: Published evidence on established and theoretical connections between immune system dysfunction and schizophrenia is reviewed, with a discussion of developments in the search for immunologically-targeted treatments. SUMMARY: A growing body of evidence indicates that immunologic influences may play an important role in the etiology and course of schizophrenia. A literature search identified more than 100 articles pertaining to suspected immunologic influences on schizophrenia published over the past 15 years. Schizophrenia researchers have explored a wide range of potential immune system-related causal or contributory factors, including neurobiological and neuroanatomical disorders, genetic abnormalities, and environmental influences such as maternal perinatal infection. Efforts to establish an immunologic basis for schizophrenia and identify reliable immune markers continue to be hindered by sampling challenges and methodological problems. In aggregate, the available evidence indicates that at least some cases of schizophrenia have an immunologic component, suggesting that immune-focused prevention strategies (e.g., counseling of pregnant women to avoid immune stressors) and close monitoring of at-risk children are appropriate. While antipsychotics remain the standard treatments for schizophrenia, a variety of drugs with immunologic effects have been investigated as adjunctive therapies, with variable and sometimes conflicting results; these include the cyclooxygenase-2 inhibitor celecoxib, immune-modulating agents (e.g., azathioprine and various anticytokine agents such as atlizumab, anakinra, and tumor necrosis factor-α blockers), and an investigational anti-interferon-γ agent. CONCLUSION: The published evidence indicates that immune system dysfunction related to genetic, environmental, and neurobiological influences may play a role in the etiology of schizophrenia in a subset of patients.

Case report: increased patient response to intramuscular haloperidol decanoate following a change in needle length.

INTRODUCTION: Intramuscular (IM) injection is a commonly used administration route for a variety of medications. Determining the optimum needle length for administration of IM formulations based on individual patient variables has not been extensively reported in patients receiving antipsychotic medication via IM administration. CASE REPORT: The patient, a 23-year-old African American female diagnosed with schizophrenia, was referred to a community-based treatment program following multiple inpatient admissions. At age 19, she began experiencing psychiatric symptoms that resulted in assault and incarceration. Treatment included separate trials of haloperidol and fluphenazine decanoate formulations with minimal success reported. At the time of evaluation, she was experiencing constant positive psychiatric symptomatology. Oral haloperidol was started. Haloperidol decanoate 150 mg by IM injection using a 1.5-inch needle was added and titrated to 350 mg IM over 11 months. Auditory hallucinations continued. Following refusal of a haloperidol level, the physician changed to a 2-inch needle for decanoate injections. Noticeable and continued slow improvement of her psychotic symptoms resulted. CONCLUSION: Needle length may be of new importance to practitioners. If anticipated results of IM antipsychotic medication administration are not realized, practitioners are urged to consider patient variables, notably the amount of adipose tissue in the administration area.

Treatments for methamphetamine abuse: a literature review for the clinician.

Methamphetamine (METH) use and dependence is a serious public health concern with implications across multiple areas from societal impact to burden on psychiatric and medical resources. An estimated 8% of admissions to substance abuse treatment programs are related to stimulants with METH/amphetamine abuse. To date, effective pharmacotherapy options to enhance abstinence have not been identified. The objective of this article is to critically review the literature of METH treatment options. Preclinical research and human research with compounds not yet available commercially in the United States will not be included. A literature review was conducted for research on pharmacological treatments for METH use and addiction. Trial information on the use of sertraline, bupropion, mirtazapine, modafinil, dextroamphetamine, ondansetron, risperidone, aripiprazole, baclofen, and gabapentin was reviewed. Aripiprazole trials appeared in the reviewed literature more frequently than the other medications. Based on the findings of this review, no single medication demonstrated consistent efficacy and each trial contained a variety of methodological limitations.

Probable quetiapine-mediated prolongation of the QT interval.

PURPOSE: QT prolongation can occur with both first- (FGA) and second-generation antipsychotics (SGA). QT prolongation was identified in an adult patient who presented to the emergency room with schizophrenia, fluid and electrolyte imbalances, and pneumonia. Quetiapine, an SGA, was a component of the pharmacotherapy regimen. Based on the Naranjo adverse drug reaction probability scale rating criteria, a probable causal association was made. METHODS: PubMed and Ovid were searched using the terms antipsychotic, psychotropic, QT interval, corrected QT interval (QTc) prolongation, and quetiapine. References were examined for additional articles related to antipsychotic drugs and the QT interval. DISCUSSION: In this patient, the use of quetiapine was identified as a contributing factor in QT prolongation. Prior QT prolongation was experienced with ziprasidone, another SGA. The antidepressant and dose remained consistent throughout the inpatient course of treatment. Other risk factors in this patient included hypokalemia, dehydration, pneumonia, age, gender, and concurrent usage of an antidepressant. Dual psychiatric diagnoses, preexisting cardiovascular disease, and electrolyte disturbances may increase this risk potential. CONCLUSION: Psychiatric patients may be more at risk of cardiovascular complications, such as QT interval prolongation. The pharmacist can help evaluate risk factors and provide input into the care of all patients, particularly those identified as at risk.

Antidepressant-mediated gastroesophageal reflux disease.

Anticholinergic effects of medications are factors in autonomic control of the lower esophageal sphincter function. Changes in sphincter control often lead to gastroesophageal reflux disease (GERD), a chronic disease with a prevalence of up to 25% for adults. This effect is a consideration in the treatment of depression, the fourth-leading disease burden. Lower esophageal-sphincter changes are well documented in association with tricyclic antidepressants. The newer medications, selective serotonin-reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors, are often used as first-line agents. This case report reviews the emergence of GERD in association with the use of newer agents. The patient, a 55-year-old woman, presented to her primary care physician with complaints of low energy, dysphoric mood, and anhedonia of several months' duration. Trials of citalopram and escitalopram were associated with reports of persistent nausea and gastric reflux unresolved by changes in dosing schedule or positioning. Over-the-counter omeprazole on an as-needed basis was added. Ultimately, the patient was successfully managed with desvenlafaxine for dysphoric mood and low energy and scheduled administration of omeprazole for GERD. The adverse drug reaction was evaluated using the Naranjo Adverse Drug Reaction Probability Scale. This methodology indicated a probable relationship (score of 7 out of 12) between initiation of antidepressant therapy and the presentation of GERD symptoms. When evaluating patient response to medication, inquiring about new-onset symptoms may help assess pharmacotherapy, identify potential medication-related effects such as the anticholinergic profile, evaluate the need to add an antisecretory/antispasmodic agent, or consider an alternative treatment strategy.

Violence among persons diagnosed with schizophrenia: how pharmacists can help.

Violence among those diagnosed with schizophrenia has been reported but is not a diagnostic component of the disorder. The position of the courts regarding fulfillment of the requisite intent to commit violent acts has not been extensively reported. This article discusses the impact of a diagnosis of schizophrenia in an individual and how the pharmacist can help integrate information into the health care system. The recent Supreme Court case of Clark versus Arizona and the older case of Patterson versus Cockrell are discussed with respect to the concept of intent (to commit the act) and the implications this has on an individual in the midst of a psychotic episode. Quality of life, the perception of the stigma associated with a diagnosis of schizophrenia, and pharmacotherapy are briefly discussed. The origin of schizophrenia is multifactorial. Persons with schizophrenia are not innately violent, but alteration in perception may precipitate aggressive acts. Given the complex and diverse nature of schizophrenia and the fact that even with successful pharmacological treatment residual symptoms may still be present, there is a need to provide information to health care practitioners and the court.

Antipsychotic treatment of adolescent dual diagnosis patients.

BACKGROUND: A diagnosis of schizophrenia requires development of a pharmacotherapy regimen that balances many factors in the therapeutic decision-making process. Patient age and the presence or absence of comorbid chemical dependency represent two factors. Comorbid chemical dependency can have a profound impact on the successful treatment of schizophrenia, making patients with dual diagnoses of schizophrenia and chemical dependence a uniquely challenging population. There is little information regarding treatment of schizophrenia and chemical dependence in the pediatric population. Existing data from pediatric and adult populations may facilitate a well-guided and knowledgeable approach to treating pediatric dual diagnosis patients. METHODS: A review of the literature for medication trials evaluating antipsychotic medication used to treat schizophrenia in childhood and adolescence as well as antipsychotic use in the treatment of the dual diagnoses of schizophrenia and chemical dependence was done. Databases for Ovid MEDLINE, PubMed, and PsycInfo were searched using the terms "addiction," "adolescence," "childhood," "dual diagnosis," "schizophrenia," and "substance abuse." Results were limited to English-language articles. RESULTS: Seven articles were identified related to psychotic disorders and substance abuse in pediatric populations. Psychosis measurement instruments included the Brief Psychiatric Rating Scale, Positive and Negative Syndrome Scale, and Clinical Global Impression. Mean improvements were insignificant in most cases. Medication trials included clozapine, olanzapine, risperidone, and molindone. Trial safety concerns included metabolic effects, increased prolactin levels, and akathisia. One study with random assignment to olanzapine was discontinued early because of substantial weight gain without evidence of superior efficacy. Clozapine treatment was associated with more adverse drug events. CONCLUSION: There is a great need for more research and use of available data to develop safe and effective treatment guidelines for childhood and adolescent dual diagnosis patients. When appropriate decisions are made regarding treatment of patients with comorbid schizophrenia and chemical dependence, both conditions may benefit with increased remission.

Commonly prescribed medications and potential false-positive urine drug screens.

PURPOSE: The implications of potential false-positive urine drug screen (UDS) results for patients receiving commonly prescribed medications were evaluated. SUMMARY: A comprehensive literature review was conducted to identify false-positive UDSs associated with all clinic formulary medications, as well as common nonprescription medications. The references of each report describing a medication whose use was associated with false-positive UDS results were also reviewed. If a class effect was suspected, additional agents in the category were searched. A total of 25 reports of false-positive UDS results were identified. Categories of medications included antihistamines, antidepressants, antibiotics, analgesics, antipsychotics, and nonprescription agents. Reports of false-positive results were found for the following formulary and nonprescription medications: brompheniramine, bupropion, chlorpromazine, clomipramine, dextromethorphan, diphenhydramine, doxylamine, ibuprofen, naproxen, promethazine, quetiapine, quinolones (ofloxacin and gatifloxacin), ranitidine, sertraline, thioridazine, trazodone, venlafaxine, verapamil, and a nonprescription nasal inhaler. False-positive results for amphetamine and methamphetamine were the most commonly reported. False-positive results for methadone, opioids, phencyclidine, barbiturates, cannabinoids, and benzodiazepines were also reported in patients taking commonly used medications. The most commonly used tests to screen urine for drugs of abuse are immunoassays, even though false-positive results for drugs of abuse have been reported with a number of these rapid-screening products. Results from such tests should be confirmed using additional analytical methods, including gas chromatography-mass spectrometry. CONCLUSION: A number of routinely prescribed medications have been associated with triggering false-positive UDS results. Verification of the test results with a different screening test or additional analytical tests should be performed to avoid adverse consequences for the patients.

Recurrent episodes of serotonin-reuptake inhibitor-mediated hyponatremia in an elderly patient.

OBJECTIVE: To report a case of recurrent episodes of serotonin-reuptake inhibitor-mediated hyponatremia in an elderly patient and compare it with other reports of similar occurrences. CASE SUMMARY: A 66-year-old white woman was diagnosed with drug-induced syndrome of inappropriate antidiuretic hormone (SIADH) attributed to selective serotonin-norepinephrine-reuptake inhibitor (SNRI) therapy. Duloxetine was initiated following failure of several other antidepressants. The patient was admitted with sudden onset altered mental status, memory loss, personality changes, and a serum-sodium level of 128 mEq/L (range 135-145 mEq/L), despite receiving sodium supplementation. The duloxetine dose was 60 mg daily. Three months later she presented to the emergency department with complaints of lethargy, muscle weakness, nausea, altered mental status, and a serum sodium level of 129 mEq/L. SIADH was diagnosed and attributed to duloxetine therapy. Duloxetine was titrated to 30 mg every other evening. She remained stable on the lower dose, fluid restriction, and sodium supplementation. Diuretic reinitiation and sodium supplementation discontinuation resulted in serum sodium of 123 mEq/L. This increased to low/normal (136 mEq/L) with duloxetine discontinuation. A rechallenge with escitalopram resulted in low serum-sodium levels. DISCUSSION: A PubMed search was done utilizing the terms duloxetine, elderly, hyponatremia, selective serotonin-reuptake inhibitor, SSRI, SNRI, syndrome of inappropriate antidiuretic hormone, SIADH, and selective serotonin-norepinephrine reuptake inhibitor to find similar reports. CONCLUSION: Clinicians evaluating older patients taking serotonin-reuptake inhibitors are encouraged to monitor serum sodium if the patient presents with vague, nonspecific symptoms commonly associated with older age or depression to rule-out SIADH.