Dexmedetomidine Sublingual Film: A New Treatment to Reduce Agitation in Schizophrenia and Bipolar Disorders.

OBJECTIVE: The objective of this study was to review the available literature for dexmedetomidine sublingual film use in the treatment of acute agitation associated with schizophrenia and bipolar disorders. DATA SOURCES: A literature search of PubMed (January 2017-March 2023) and EMBASE (January 2017-March 2023) was performed using the terms: Igalmi, dexmedetomidine, schizophrenia, bipolar disorder, and agitation. Additional information sources include ClinicalTrials.gov, scientific posters, and articles identified through review of references from clinical trials publications. STUDY SELECTION AND DATA EXTRACTION: Relevant English-language articles conducted in humans were considered, with a preference for phase 3 clinical trials. Trial analyses and articles discussing pharmacology, pharmacokinetics, efficacy, and safety were also evaluated. DATA SYNTHESIS: Dexmedetomidine sublingual film was evaluated for use in schizophrenia in the SERENITY 1 pivotal trial and for bipolar disorders in the SERENITY 2 pivotal trial. Both studies found treatment of mild to moderate agitation with dexmedetomidine sublingual film 180 and 120 µg to be superior to placebo in reducing the severity of agitation. Treatment effect was seen as early as 20 minutes. Somnolence was the most common adverse effect in both studies. Cardiovascular adverse effects were mild and transient in most cases. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Dexmedetomidine sublingual film is a new and novel treatment for agitation and gives clinicians an alternative to antipsychotic and benzodiazepine use. It has advantageous properties including its noninvasive route of administration, fast absorption, and rapid onset of effect. Cost may limit its use. CONCLUSION: Dexmedetomidine sublingual film provides an alternative approach to treatment of acute agitation in adults with schizophrenia and bipolar disorders based on both mechanism of action and route of administration.

Zuranolone: The First FDA-Approved Oral Treatment Option for Postpartum Depression.

OBJECTIVE: The objective of this study was to review the characteristics, efficacy, and safety of zuranolone in the management of postpartum depression (PPD). DATA SOURCES: Literature was identified using PubMed (1966-August 2023) and EMBASE (1973-August 2023) and clinicaltrials.gov. Search terms included zuranolone, SAGE-217, and PPD with further limitation of those published in English. STUDY SELECTION AND DATA EXTRACTION: Articles selected for inclusion included trials evaluating zuranolone for the treatment of PPD. DATA SYNTHESIS: Zuranolone was evaluated for the treatment of moderate to severe PPD in 2 phase III trials. Both studies resulted in statistically significant improvement in depressive symptoms at day 15 (P = 0.003 and P < 0.001). Sustained differences in remission rates favoring zuranolone were found in both studies at day 45 compared with placebo (P = 0.01 and P < 0.05). Zuranolone was well tolerated, with somnolence, dizziness, headache, and sedation reported as the most common side effects. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON TO EXISTING DRUGS: Zuranolone is only the second medication approved by the Food and Drug Administration (FDA) for PPD and offers an advantage over brexanolone in that it can administered orally in the outpatient setting. The rapid onset of effect of zuranolone is advantageous to traditional antidepressant therapy which can be weeks to months; however, limited information is available on safety during lactation. CONCLUSIONS: The recent FDA approval of oral zuranolone for PPD offers a second rapid-acting treatment for PPD, extending the opportunity for treatment to patients in the outpatient setting.

Factors associated with COVID-19 vaccination for patients in an inpatient forensic psychiatric hospital.

OBJECTIVE: The aim of this study was to assess factors associated with SARS-CoV-2 (COVID-19) vaccination in patients in 2 inpatient forensic psychiatric hospitals. METHODS: This was a retrospective chart review evaluating factors associated with COVID-19 vaccination for patients residing in two inpatient forensic psychiatric hospitals between January 1, 2021 and February 28, 2022. Data was collected through electronic medical records utilizing MetaCare Enterprise™ and secure facility computer drives, individual patient paper charts, and Missouri's vaccination records database, ShowMeVax. Several variables were collected to assess factors associated with COVID-19 vaccination. Additionally, COVID-19 vaccination rates were compared to the influenza vaccination rates at these hospitals. RESULTS: Overall, 229 patients (84.5%) were vaccinated against COVID-19 during or before the study period and 42 (15.5%) were unvaccinated. Patients who were deemed incompetent to stand trial were less likely to receive the COVID-19 vaccine. Those that had a higher body mass index (BMI), were diagnosed with multiple comorbid conditions, not prescribed involuntary medications, were offered incentives, and received the influenza vaccine were more likely to receive the COVID-19 vaccine. Education level, race, sex, age, and being prescribed psychiatric medications did not affect vaccination status. CONCLUSIONS: Patient specific factors should be used when educating and offering COVID-19 vaccines to patients in an inpatient forensic psychiatric unit. Awareness of these results can facilitate targeted interventions for optimal care in a psychiatric population.

Effectiveness evaluation of a pharmacist-driven monitoring database for tardive dyskinesia.

BACKGROUND: Tardive dyskinesia (TD) is a potentially irreversible, chronic syndrome related to antipsychotic medication use characterized by hyperkinetic abnormal involuntary movements. Various studies have shown that development of TD is possible with both first- and second-generation antipsychotics. Regular monitoring for emergence of TD symptoms is recommended in clinical practice for early recognition and intervention. METHODS: This is a retrospective, single-center, observational study of the effectiveness of a pharmacist-driven monitoring database for TD assessment. Subjects were adult inpatients at a state psychiatric hospital who received antipsychotic treatment for at least 3 or 6 months between January 2006 and December 2011. The primary objective was to assess compliance rates with TD monitoring based on facility policy before and after implementation of the database at 3 and 6 months following initiation of antipsychotic therapy. RESULTS: A significant improvement in compliance with TD monitoring policy was seen after implementation of the database (2.9% vs 66.7%; P < .001). Compliance with TD monitoring did not differ between classes of antipsychotic medication, hospital units, or age groups. CONCLUSION: The results of this study demonstrate that pharmacists can help improve compliance with TD assessment and that monitoring databases may be useful for similar extended or long-term care settings to ensure timely assessment of patients for the development or progression of TD.

Adverse drug reactions: a retrospective review of hospitalized patients at a state psychiatric hospital.

BACKGROUND: There is a paucity of information regarding adverse drug reactions (ADRs) in psychiatric patients. Information on common and preventable ADRs (pADRs) in psychiatric patients will allow for targeted improvement projects. OBJECTIVE: To characterize reported ADRs and pharmacist interventions to prevent ADRs in an extended-care state psychiatric hospital. METHODS: Four years of ADR reports were assessed for probability, reaction severity, pharmacological class of medication involved, preventability, change in therapy, and transfers to a medical facility. The pharmacist intervention database was queried for interventions classified as "prevention of ADR." The interventions were assessed for type of medication and recommendation acceptance. RESULTS: Medication classes responsible for ADRs included mood stabilizers (30%), typical antipsychotics (25%), atypical antipsychotics (25%), and antidepressants (8%). Nine percent resulted in transfer to a medical facility. Of all ADRs, 34.4% were pADRs; mood stabilizers (41%) and atypical antipsychotics (27%) were the most common pADRs. The most common causes of pADRs were supratherapeutic serum concentrations, drug-drug interactions, and history of reaction. There were 87 pharmacist interventions that were classified as "prevention of ADR," and the acceptance rate of pharmacists' recommendations was 96.5%. Mood stabilizers (20%), atypical antipsychotics (17%), and typical antipsychotics (11%) were commonly associated with prevented ADRs. Lithium accounted for 13.8% of prevented ADRs; these ADRs were most often due to a drug-drug interaction with a nonsteroidal anti-inflammatory drug. CONCLUSIONS: ADRs were most commonly associated with mood stabilizers and antipsychotics, and pADRs were common. There is an opportunity to provide education to medical staff on therapeutic drug monitoring and drug-drug interactions for these classes, particularly lithium.

Diltiazem for clozapine-induced generalized hyperhidrosis.

Background: Clozapine can be associated with significant side effects and tolerability issues. Hyperhidrosis occurs less commonly and is unanticipated by clinicians because of clozapine's significant anticholinergic activity. Case Report: A 34-year-old female developed clozapine-induced nocturnal, generalized hyperhidrosis following initial titration to 400 mg/day. Dose reduction did not decrease the side effect. Treatment with an anticholinergic medication could not be initiated because of constipation. Treatment with a beta blocker resulted in worsening of asthma. Treatment with a calcium channel blocker, diltiazem CD 180 mg/day, resulted in a significant reduction in hyperhidrosis. Conclusion: This case supports the use of calcium channel blockers to reduce clozapine-induced hyperhidrosis and offers an alternative to anticholinergic medications that may negatively impact clozapine tolerability.

Barriers to access to psychiatric medications in Missouri county jails.

Introduction: Objectives of this study were to characterize barriers to receiving psychiatric medications for people who are incarcerated, to compare barriers before competency restoration to those after competency restoration, and to characterize psychiatric medication formularies. Methods: A survey of county jails in Missouri was completed between October 2021 and February 2022. Survey questions were answered by medical department personnel, nurses, or a person responsible for medication oversight. Formularies were requested. Results: Of 97 jails contacted, 51 completed the survey (53%). Most jails allowed patients to supply their own medications and reported they were "often" or "always" able to continue home medications. Inability to provide home medications was frequently attributed to cost. Notably, only 57% of jails were able to provide long-acting injectable antipsychotics (LAIA), 22% charged a fee for administration of medications, and 31% would not adjust medication times based on food requirements. No major differences existed precompetency and postcompetency for any question. Discussion: Jail policies varied; thus, medication access for patients should be approached at the individual level. Potential areas to target to improve access are medication administration times, LAIA access, and removal of medication administration fees.

Olanzapine/Samidorphan: A New Combination Treatment for Schizophrenia and Bipolar I Disorder Intended to Reduce Weight Gain.

Olanzapine is a second-generation antipsychotic with established efficacy in several psychiatric disease states, but its use is limited because of weight gain and metabolic side effects. Samidorphan is a novel opioid antagonist that binds to mu-opioid, kappa-opioid, and delta-opioid receptors and is hypothesized to reduce cravings for high-calorie foods thus attenuating antipsychotic-induced weight gain. The combination product olanzapine/samidorphan was approved by the US Food and Drug Administration in June 2021 for the treatment of schizophrenia and bipolar I disorder; this article reviews the pharmacological properties of oral olanzapine/samidorphan and its clinical efficacy and tolerability with a focus on mitigation of olanzapine-induced weight gain in these patient populations. In clinical trials, the combination of olanzapine/samidorphan was associated with significantly less weight gain and smaller increases in waist circumference as compared with olanzapine monotherapy. Olanzapine/samidorphan demonstrated similar efficacy as olanzapine monotherapy and was well tolerated. Weight gain and metabolic side effects associated with olanzapine monotherapy can result in tolerability issues and potentially medication nonadherence. Olanzapine/samidorphan is an effective treatment for schizophrenia and bipolar I disorder with less weight gain than olanzapine monotherapy.

Enhancing Outcomes: Acceptability of Medication Formulations for the Treatment of Acute Agitation in a Psychiatric Population.

BACKGROUND: There is limited research evaluating patient acceptability of medication formulations in the treatment of acute agitation. This study assessed patient acceptability of medication formulations (tablet, orally-dissolving-tablet [ODT], liquid, intramuscular injection [IM], inhaled device [INH]) for the treatment of acute agitation and examined correlating factors. METHODS: Adults with psychotic illness or bipolar disorder receiving emergency or inpatient services at an inpatient psychiatric facility in Kansas City, Missouri were included. Participants viewed a presentation on medication formulations for acute agitation and were surveyed on acceptability (measured on a five-point Likert scale). The primary outcome variable was the attitudinal measurement of acceptability of each formulation in correlation with the severity of agitation for use in themselves and other patients. RESULTS: One hundred participants completed the survey. Participants rated the following: (1) This medication formulation would be acceptable to treat mild agitation in themselves and others (oral tablet 85% and 48%; ODT 82% and 55%; liquid 74% and 51%; IM 53% and 74%; INH 78% and 72%); and (2) This medication formulation would be acceptable to treat severe agitation in themselves and others (oral tablet 75% and 52%; ODT 74% and 53%; liquid 66% and 53%; IM 61% and 67%; INH 77% and 72%). For treating mild agitation, participants preferred tablets and ODTs to the IM (p < 0.05) and the INH to liquid or IM (p < 0.05), for themselves; and oral formulations were preferred to the IM (p < 0.05) for other patients. For severe agitation in themselves and others, preference for the INH and IM versus oral formulations (p < 0.05) was significant, with no difference between the INH and IM (p > 0.05). CONCLUSIONS: The proportion of responses preferring oral formulations was higher than IM and INH. Dosage formulation acceptability differed depending on the severity of agitation and intended recipient of the medication.

Antipsychotic factors related to time to competency for forensic inpatients in a state psychiatric facility.

Introduction: A defendant who is deemed incompetent to stand trial may go through competency restoration consisting of mental health treatment and legal education. Antipsychotics are often used in treatment; however, there is little data examining their role. Methods: This retrospective study included subjects opined competent to stand trial from July 2016 to February 2020 and prescribed an antipsychotic. The primary outcome was difference in time to competency between antipsychotics. Secondary outcomes included difference in time to competency between groups of antipsychotics, difference in length of stay after opined competent based on medication availability in jail, individual antipsychotics, and formulations. Results: There were 117 subjects included for analysis. There were no differences in time to competency between individual antipsychotics, first- and second-generation antipsychotics, or formulations. Length of stay after opined competent was significantly longer for subjects who were prescribed a long-acting injectable antipsychotic (103 days vs 56 days), who were not able to receive their antipsychotic in jail (104 days vs 54 days), or who were prescribed any formulation of paliperidone compared with olanzapine (88 days vs 35 days). Discussion: Since there were no differences in time to competency, patient-specific factors should be used to choose an agent for competency restoration. Length of stay differences are likely related to the antipsychotic access differences between jails and state psychiatric facilities. Therefore, policies related to antipsychotic access should better align between state psychiatric facilities and jails to improve the capacity of the system and provide better care.

Publication rates and characteristics of PGY2 psychiatric pharmacy resident research projects.

Introduction: To describe the publication rates and characteristics of PGY2 psychiatric pharmacy residency projects presented as a poster presentation at the annual meetings of the College of Psychiatric and Neurologic Pharmacists (CPNP) from 2002 to 2018. (As of 2022 the organization is under the name, American Association of Psychiatric Pharmacists.). Methods: CPNP abstracts from even years were strategically searched in PubMed, Ovid MEDLINE, and Google Scholar. If a publication was identified, additional data were collected for characterization, including study information, journal information, author information, institutional affiliation, publication year, and time to publication. Results: A total of 348 abstracts were evaluated. Publication in a journal was achieved for 60 projects (17.2%), with publication rates decreasing from 2012 to 2018. The mean time to publication was 17.3 months after completion of the residency, with most projects published at 8 months. More than half (51.7%) of these projects were published in a psychiatric pharmacy journal affiliated with CPNP. Study designs were predominantly retrospective, observational, cohort studies with a focus on evaluation of a drug therapy outcome. The PGY2 resident was the first author in 90% of the publications. Forty percent included other health care professionals outside of pharmacy as a coauthor. PGY2 residencies affiliated with academic institutions had overall higher publications rates. Discussion: Publication rates for PGY2 psychiatric pharmacy residency projects are low and are decreasing over time despite an increasing number of PGY2 psychiatric pharmacy residency programs. This publication rate is lower than that reported in the literature for PGY2 critical care residency programs. The downward trend of publication rates for PGY2 psychiatric pharmacy residency projects is concerning.

Assessing the understandability, actionability, and quality of online resources for the self-management of bipolar disorder.

INTRODUCTION: This study aims to assess the understandability, actionability, and quality of online resources for the self-management (SM) of bipolar spectrum disorders in adults. METHODS: An online search using Google, Bing, and Yahoo! search engines was conducted to identify resources for bipolar disorder. Those that were published in English, discussed at least 1 method directed at improving an SM task, and were within the first 25 nonadvertisement results for each search were included. Resources directed specifically at adolescents were excluded. Understandability and actionability of the online resources were evaluated using the Patient Education Materials Assessment Tool (PEMAT). Quality of the online resources was evaluated using the DISCERN instrument. The number of SM tasks each resource discussed was also evaluated. Overall mean appropriateness was calculated by averaging the percentage scores of understandability, actionability, and quality. RESULTS: Fifty-two resources were included. The mean sample scores were 8.4 (SD, 2.1; range, 2-13; maximum, 15) for understandability, 2.2 (SD, 1.2; range, 0-4; maximum, 5) for actionability, and 46.1 (SD, 8.9; range, 30-57; maximum, 75) for quality. The overall mean appropriateness percentage was 53.5% (SD, 11.7%; range, 18%-77%), with a goal of at least 70%. Included resources addressed a mean of 7.1 tasks (SD, 2.5; range, 1-14; maximum, 20). DISCUSSION: Most online resources for the SM of bipolar disorder scored poorly for understandability and actionability based on PEMAT scores and had low to moderate scores for quality using the DISCERN instrument. Future online resources should be designed with the goal of increasing appropriateness for patients.

Adherence to antihyperlipidemic medication and lipid control in diabetic Veterans Affairs patients with psychotic disorders.

BACKGROUND: Medication adherence for chronic medical illnesses has been studied extensively, but there is limited data evaluating medication adherence for comorbid medical illnesses in a psychiatric population. Furthermore, only one study has evaluated both medication adherence and clinical outcomes between the two populations. Examining medication adherence rates and clinical outcomes are important as chronic medical illnesses occur commonly in psychiatric patients, can be drug-induced, and have negative long-term consequences. OBJECTIVES: To compare antihyperlipidemic medication adherence and lipid control between individuals with psychotic disorders and those without a psychiatric illness. METHODS: This was a retrospective medical record review of 124 subjects with hyperlipidemia and diabetes (62 subjects with schizophrenia or a related psychotic disorder and 62 randomly selected, age-matched individuals without a psychiatric illness) receiving medical and psychiatric care through the Veterans Affairs Medical Center during 2008. Cumulative mean gap ratio (CMGR) was used to determine adherence. Lipid values were utilized to compare lipid control between groups. RESULTS: A significant difference in CMGR was detected. Subjects with psychotic disorders were without antihyperlipidemic therapy for 44 days compared with 62 days for the nonpsychiatric comparison group (P = 0.034). Antipsychotic adherent subjects (≥80% adherent) were more likely to adhere to their antihyperlipidemic medication (P = 0.0007). There were no significant differences between the groups for lipid control. CONCLUSION: Antihyperlipidemic medication adherence differed with the psychotic disorder group having fewer days without drug therapy. However, there was no significant difference in lipid control between subjects with a psychotic disorder and those without a psychiatric illness.

Psychotropic-Induced Priapism in a Treatment-Refractory Patient: A Case Report.

PURPOSE: A case report of multiple episodes of priapism associated with the use of 4 different psychotropic medications. SUMMARY: A 34-year-old African American male with treatment-refractory schizoaffective disorder suffered priapism on 6 separate occasions. His medical history is relatively unremarkable, with the exception of possible undiagnosed thalassemia. All incidences were potentially attributable to psychotropic medications, with chlorpromazine, risperidone, trazodone, and quetiapine being the most likely culprits. The onset of priapism ranged from hours after a single injection of chlorpromazine, to years after multiple injections of risperidone, with nothing to indicate a medication dose or duration relationship to priapism. While on clozapine, fluphenazine, haloperidol, lurasidone, and olanzapine at varying times, the patient did not appear to develop priapism. The commonality of high-affinity alpha-1 antagonism with these psychotropics may be to blame. No pharmacokinetic or pharmacodynamic interactions were noted, which would have produced elevations in the levels of these psychotropics, nor was the patient on any phosphodiesterase type 5 (PDE-5) inhibitors or antihypertensives known to cause priapism. Depending on the offending agent, the Naranjo et al's Adverse-Reaction Probability Scale scores ranged from 5 to 8 (probable). CONCLUSION: A man suffered from multiple episodes of priapism attributed to psychotropic medications. This is not the first case to describe this effect, but will give clinicians a timeline of events and medications that did and did not appear to elicit priapism in a patient with treatment-refractory schizoaffective disorder. Knowledge of which psychotropic medications may be more likely to induce priapism is crucial to preventing long-term penile damage.

Guidance on the treatment of antipsychotic-induced hyperprolactinemia when switching the antipsychotic is not an option.

PURPOSE: This article aims to evaluate management options for antipsychotic-induced hyperprolactinemia and associated treatment considerations such as efficacy, tolerability, drug interactions, contraindications, and dosing regimens. SUMMARY: Hyperprolactinemia is a common adverse effect of antipsychotics. First-line management includes reducing the dose of the offending antipsychotic, discontinuing the antipsychotic, or switching to another antipsychotic associated with a lower risk of hyperprolactinemia. However, these options are not always practical and are associated with a risk of relapse of the psychiatric illness. Other management options include adjunctive aripiprazole, dopamine agonists (cabergoline and bromocriptine), metformin, and herbal supplements. A search of Embase, PubMed, and Google Scholar using key terms such as hyperprolactinemia, prolactin, antipsychotic, treatment guidelines, aripiprazole, dopamine agonist, cabergoline, bromocriptine, metformin, herbals, supplements, and medications was conducted for literature retrieval. Upon evaluation of the available literature we found the following: (1) aripiprazole is safe and effective in lowering prolactin levels within normal limits; (2) adjunctive cabergoline and bromocriptine decrease elevated prolactin levels, while cabergoline may be more effective in reducing prolactin but can also be associated with a more serious adverse effect of cardiac valvular abnormalities; (3) metformin causes a mild reduction of prolactin levels; and (4) there are limited data to support use of herbal medications (chamomile, Peony-Glycyrrhiza decoction, and shakuyaku-kanzo-to) in antipsychotic-induced hyperprolactinemia. CONCLUSION: There are treatments available for antipsychotic-induced hyperprolactinemia in patients who are unable to alter their current antipsychotic regimen. However, there remains a need for additional short- and long-term studies to determine the efficacy and safety of these treatment strategies, given that patients taking antipsychotics typically require chronic, life-long treatment for their illnesses.

The effects of concurrent oral paliperidone or risperidone use with paliperidone long-acting injection.

INTRODUCTION: Dosing recommendations for paliperidone long-acting injectable antipsychotic (LAIA) do not include oral antipsychotic (OAP) overlap; however, OAPs are often given concurrently despite limited evidence describing both the risks and benefits of this practice. METHODS: A retrospective chart review was conducted in patients initiated on paliperidone palmitate (PP) during a psychiatric hospitalization to compare patients who received OAP overlap versus those who did not. The primary outcome is the proportion of patients who receive prescription claims for benztropine, a medication commonly prescribed for extrapyramidal symptoms, at the time of LAIA discontinuation and 6 months postdischarge. Secondary outcomes include prescription claims for beta blockers and diphenhydramine, number of psychiatric emergency visits and hospitalizations, length of stay of the index hospitalization, frequency of LAIA discontinuation and the time to LAIA discontinuation. RESULTS: There is a significant difference in the proportion of benztropine prescription claims in the OAP overlap group versus the no-overlap group at the time of LAIA discontinuation (30% vs 0%, P = .046) but not at 6 months postdischarge. There are also significant differences in the number of psychiatric emergency visits (0.7 vs 0.1, P = .02) and psychiatric hospitalizations (0.6 vs 0.1, P = .029) at the time of LAIA discontinuation. No other differences are observed in defined secondary outcomes. DISCUSSION: Patients who receive OAP overlap while receiving PP receive more benztropine and have more psychiatric emergency visits and hospitalizations than those treated without OAP. Larger studies with better control for confounding variables are needed to confirm these results.

Gabapentin-induced bilateral lower extremity edema in a patient with pervasive developmental disorder and schizoaffective disorder.

Gabapentin binds to the alpha-2-delta subunit of presynaptic voltage-gated calcium channels and is used for a wide variety of on- and off-label indications. Gabapentin is dosed at total daily doses ranging from 300 to 3600 mg/d, which is generally divided into 3 doses. Although gabapentin is generally well tolerated, 1 potential reported adverse effect is peripheral edema. However, due to the extensive number of etiologies of peripheral edema, medication causes may be overlooked on an inpatient psychiatric unit. This is a case of delayed identification of a probable adverse drug reaction to gabapentin (Naranjo score of 5) consisting of painful, 4+ pitting bilateral edema and a clear dose relationship in a patient with pervasive developmental disorder and schizoaffective disorder.

Assessment of pharmacy student attitudes and beliefs toward patients with mental illnesses on inpatient psychiatric units.

INTRODUCTION: People with mental illness continue to face stigma, despite these illnesses being common. Previous studies have demonstrated reduced stigma in pharmacy students after various exposures and education, although results have been mixed. The primary objective of this study was to evaluate the effects of an advanced pharmacy practice experience (APPE) in psychiatric pharmacy on students' stigma toward patients with mental illness using the Opening Minds Stigma Scale for Healthcare Providers (OMS-HC) at 2 psychiatric hospitals. METHODS: This was a prospective, multicenter survey study of pharmacy students on an APPE rotation at an inpatient psychiatric hospital conducted during 3 academic years. Prior to starting and upon completion of their rotation, participants completed the OMS-HC and provided demographic and rotation information. RESULTS: A total of 26 students participated in the prerotation survey, with 88.5% (n = 23) completing the postrotation survey. The primary outcome showed a significant decrease in total OMS-HC score (Z = -2.376, P = .017), indicating a decreased level of stigma at rotation completion. Analysis of the OMS-HC subscales for attitudes toward people with mental illness and attitudes toward self-disclosure of a mental illness also yielded significant decreases (Z = -2.425, P = .015; Z = -2.462, P = .014, respectively). DISCUSSION: This study showed that APPE rotations at inpatient psychiatric hospitals may help reduce stigma among pharmacy students. Pharmacy schools should consider increasing access to and encouraging completion of psychiatric pharmacy rotations to help reduce stigma prior to graduation.

Variability in Price of Generic Antipsychotic Medications at Community Pharmacies.

OBJECTIVE: This study aimed to examine variability in pricing of generic antipsychotic medications in a diverse metropolitan area and to determine whether prices varied by pharmacy type. METHODS: A cross-sectional survey was conducted of pharmacy-level variability in retail cash prices for a 30-day supply of one first-generation and five generically available second-generation antipsychotic medications at community pharmacies in the Kansas City metropolitan area. All community pharmacies in the area were identified (N=281), and 94% (N=265, with 147 in Missouri and 118 in Kansas) responded to phone queries between April 25 and May 25, 2017, requesting the cash price of a 30-day supply of each of the six antipsychotics. All included pharmacies were categorized as a nationwide chain (N=182), grocery store (N=53), or independent pharmacy (N=30). RESULTS: Retail cash prices varied for all antipsychotic medications, with significant differences in price by pharmacy type. Price variation across all pharmacy types was lowest for haloperidol ($20-$102.99) and highest for aripiprazole ($29.99-$1,345.00). Pairwise comparisons showed that chain pharmacies had higher prices, compared with independent pharmacies, for all medications except haloperidol. Overall, chain pharmacies had the highest prices, with prices at grocery store pharmacies averaging $180 lower than chain pharmacies, and independent pharmacies averaging $415 lower than chain pharmacies. CONCLUSIONS: This report is the first on pharmacy-level variability in the costs of generic antipsychotic treatment options for schizophrenia. Appreciable differences were found in the costs of generic antipsychotics. Understanding variability in antipsychotic pricing may be important for providers serving uninsured patients.