The effect of a computerized best practice alert system in an outpatient setting on metabolic monitoring in patients on second-generation antipsychotics.

WHAT IS KNOWN AND OBJECTIVE: Metabolic syndrome is a well-documented adverse effect of second-generation antipsychotics (SGAs). Patients with metabolic syndrome are at an increased risk of potentially fatal cardiovascular events, including myocardial infarction and stroke. This elevated risk prompted the creation of a national guideline on metabolic monitoring for patients on SGAs in 2004. However, monitoring practices remained low at our clinic. To address this concern, a clinical decision support system was developed to alert providers of monitoring requirements. The purpose of this study is to determine the effect of the best practice alert (BPA), and to assess the impact of provider and patient characteristics on metabolic laboratory (lab) order rates. METHODS: A retrospective chart review was conducted at a large outpatient psychiatric clinic. Data were collected from all adult patients who were prescribed an SGA and triggered the BPA (indicating lab monitoring is needed for the patient). Data collection included a variety of patient, provider and alert variables. The primary outcome was a composite of fasting blood glucose (FBG), haemoglobin A1c (HbA1c) and/or fasting lipid panel order rates. Secondary outcomes included the rate of valid response, which considered appropriate reasons for not ordering labs (ie monitoring already completed during recent primary care visit), as well as order rates of individual labs. RESULTS AND DISCUSSION: Data from 1112 patients were collected and analysed. Patients with a thought disorder diagnosis had significantly more labs ordered than those without. No other patient factors affected order rates. Resident psychiatrists and nurse practitioners ordered significantly more labs and had significantly more valid responses than attending psychiatrists. An active alert, which fired during medication order entry, was associated with a higher rate of lab ordering and valid response compared to a passive alert, which fired whenever a prescribing healthcare provider opened the chart. WHAT IS NEW AND CONCLUSION: Prescribers may associate metabolic syndrome with schizophrenia or with use of SGAs specifically in thought disorders, even though these medications pose a risk for all indications. Higher rates of monitoring by resident physicians may have been due to spending more time with patients during the encounter and in documentation. Lastly, the active BPA was an effective tool to increase metabolic monitoring in patients taking SGAs. Continued education on the importance of regular metabolic monitoring should be implemented for all providers.

Development and evaluation of an interprofessional seminar pilot course to enhance collaboration between health professions at a student-run clinic for underserved populations.

This report describes the development and evaluation of an interprofessional pilot course aimed at health science students. The course was developed through collaboration of three health professions: Dentistry, Kinesiology, and Pharmacy. The coursework comprised of traditional lecture-based learning, interprofessional experiential education through four on-site visits at two area clinics that participate in team-based care, four student self-reflections following each site visit, and demonstration of interprofessional education and collaboration (IPEC) competencies through student evaluation of current interprofessional care at those existing clinics with a component for key improvement intervention. The study aims include evaluating both the course's effectiveness and quality in increasing student preparedness for interprofessional practice and its ability to enhance collaboration between health professions at two area clinics. Methods of evaluation include the Interprofessional Collaborative Competency Attainment Survey (ICCAS) instrument, pre- and post- course surveys, and course evaluation survey. The results show that students felt their knowledge and skills increased across the four IPEC core competency domains: interprofessional communication, values and ethics, roles and responsibilities, and team and teamwork. We suggest that using an integrated course framework is an effective measure in enhancing interprofessional education (IPE) outcomes.

Clinical Management of Bleeding Risk With Antidepressants.

OBJECTIVE: This nonsystematic review describes risk of bleeding in treatment with serotonin reuptake inhibitors (SRIs) and provide recommendations for the management of patients at risk of bleeding. DATA SOURCES: Articles were identified by English-language MEDLINE search published prior to June 2018 using the terms SRI, serotonin and noradrenaline reuptake inhibitors, OR antidepressive agents, AND hemorrhage OR stroke. STUDY SELECTION AND DATA EXTRACTION: Meta-analyses were utilized to identify information regarding risk of bleeding with antidepressants. Individual studies were included if they had information regarding bleeding risk with specific SRIs, timing of risk, or risk with medications of interest. DATA SYNTHESIS: SRIs increase risk of bleeding by 1.16- to 2.36-fold. The risk is synergistic between SRIs and nonsteroidal anti-inflammatory drugs (NSAIDs; odds ratio [OR] range between studies 3.17-10.9). Acid-reducing medications may mitigate risk of gastrointestinal bleeds in chronic NSAIDs and SRI users (OR range between studies 0.98-1.1). Antidepressants with low or no affinity for the serotonin transporter, such as bupropion or mirtazapine, may be appropriate alternatives for patients at risk of bleeding. Relevance to Patient Care and Clinical Practice: This review includes data regarding bleeding risk for specific antidepressants, concomitant medications, and risk related to duration of SRI use. Considerations and evidence-based recommendations are provided for management of SRI users at high bleeding risk. CONCLUSIONS: Clinicians must be aware of the risk of bleeding with SRI use, especially for patients taking NSAIDs. Patient education is prudent for those prescribed NSAIDs and SRIs concurrently.

Provider perceptions of pharmacists providing mental health medication support in patient-centered medical homes.

OBJECTIVES: To identify primary care providers' (PCPs') comfort level, potential barriers to management of patients with mental health disorders, and attitudes around clinical pharmacist-provided mental health medication-related support. METHODS: A 16-item cross-sectional survey was completed by PCPs in 14 patient-centered medical homes (PCMHs) at 1 academic medical center. Items assessed include PCPs' perceptions of the proportion of patients with a mental health condition, access to psychiatry services, confidence in mental health condition management, clinical pharmacist-provided mental health medication support, and demographics. Checklist, Likert-type-scale agreement statements, and an open-ended question to assess barriers to managing mental health medications were included. Descriptive statistics and qualitative content analysis were used. RESULTS: Respondents (n = 85) included attending physicians (67.1%), resident physicians (24.7%), and advanced practice providers (8.2%). The average number of years in practice was 11 (SD 8.6). The majority perceived that 26% to 50% of their patients had a psychiatric illness (57.7%), referred < 10% of their patients (67.1%) to psychiatry services, and disagreed that access to psychiatric services was acceptably timely (87.0%). Participants felt confident diagnosing a patient with depression (97.6%) and starting antidepressants (94.1%) compared with antipsychotics (11.7%) or mood stabilizers (7.1%). Participants agreed that having the clinical pharmacist in clinic to provide support regarding psychiatric medications would increase their comfort level; increase in comfort level by provider type was not different (P = 0.20). Emerging barriers were lack of knowledge or training, low comfort in diagnosing severe psychiatric conditions, and access to psychiatry services. CONCLUSION: Outside of the diagnosis and treatment of depression, PCPs indicate a lack of comfort in treating PCMH patients with mental health disorders. Pharmacists can play a key role by providing mental health medication management support to improve access and address PCMH patients' mental health needs.

Videoconferencing Technology to Facilitate a Pilot Training Course in Advanced Psychopharmacology for Psychiatrists.

OBJECTIVE: Psychopharmacology requires practitioners to continually upgrade knowledge and skills, but attendance at live continuing medical education events presents many barriers. In addition, technology has generated new learning approaches. In response, a videoconference-based course on psychopharmacology was developed and evaluated for feasibility and acceptability. Specific goals included whether learners would engage and whether the technology would work well for both learners and instructors. Additional aims included providing guideline-concordant psychopharmacology training, enhancing patient safety, and fostering case discussion. METHODS: The course used BlueJeans® videoconferencing technology. Each of the six weekly sessions was taught by a facilitator and a speaker. Every class incorporated a 1-h interactive didactic presentation, followed by 1 h for case reviews. Topics included six major psychiatric disorders, managing key drug interactions, and pharmacogenomics. Three types of online self-report evaluations were conducted-individual session evaluation, overall evaluation, and faculty speaker evaluation. RESULTS: Nineteen participants enrolled, with 85% of respondents reporting course objectives were met as "very good" or "excellent." Moreover, 92% of respondents rated the course as "very good" or "excellent." Sixty percent of the faculty were "somewhat satisfied" and 40% were "extremely satisfied" with the videoconferencing tool. Qualitative responses from both participants and faculty were positive overall. CONCLUSIONS: This course provides preliminary evidence that an online, live longitudinal course in psychopharmacology is both acceptable and effective, both for CME learners and teachers. The authors plan to disseminate this model of CME to other institutions while extending the reach of the present course to more diverse practitioners.

The Effects of Cannabis on Inpatient Agitation, Aggression, and Length of Stay.

OBJECTIVE: This study examines the association between cannabis use and the hospital course of patients admitted to the psychiatric inpatient unit with a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder. Many confounding variables potentially contribute to the clinical presentation of hospitalized patients in the psychiatric unit. Illicit drug use, in particular, has been associated with acute agitation, and questions can be raised as to what lasting effects drug use prior to admission may have throughout a patient's hospital stay. METHODS: Subjects with a discharge diagnosis of bipolar disorder, schizophrenia, schizoaffective disorder, or psychosis not otherwise specified (N = 201) were retrospectively identified, and those with positive results of urine drug screen for cannabis on admission were compared to negative counterparts. Agitation and aggression were measured using an adaptation of the Excited Component of the Positive and Negative Syndrome Scale (PANSS-EC). These markers were also quantified by comparing charted episodes of restraint and seclusion and administration of as needed medications, such as benzodiazepines and antipsychotics. RESULTS: Positive urine drug screen results for cannabis was correlated with young (p = .001) males (p = .003) with bipolar disorder (p = .009) exhibiting active manic symptoms (p = .003) at the time of admission. Cannabis use was further associated with a shorter length of stay (p = .008), agitation triggering adapted PANSS-EC nursing assessments (p = .029), and oral medications as needed (p = .002) for agitation. CONCLUSIONS: Cannabis use, as defined by positive urine drug screen results, was more common in patients with bipolar disorder and was accompanied by a higher incidence of inpatient agitation. Although these patients also had short hospital lengths of stay, there was no clear relationship between level of agitation and length of stay across all patient groups. One possible explanation for patients with bipolar disorder experiencing short lengths of stay is that their source of agitation may be more closely related to a complex effect of cannabis use rather than a sole etiology of mental illness. Inpatient clinicians should be aware of patient cannabis use proximate to admission.

Alternate Routes of Administration of Antidepressant and Antipsychotic Medications.

OBJECTIVE: To review the administration of antidepressant and antipsychotic medications via inhaled, intranasal, buccal, sublingual, transdermal, and rectal routes. DATA SOURCES: A PubMed search was conducted for all data through March 31, 2015 to identify pertinent literature. Search terms included the generic name of each antidepressant and antipsychotic medication in combination with the following terms: alternate routes of administration, inhaled, intranasal, buccal, sublingual, transdermal, and rectal. STUDY SELECTION AND DATA EXTRACTION: English-language case reports, studies, and reviews describing medication administration in human subjects were included. DATA SYNTHESIS: Commercially available products that use an alternative route of administration include loxapine for inhalation, asenapine for sublingual administration, and selegiline for transdermal administration. Case reports and studies describe intranasal, sublingual, and transdermal routes of administration of antipsychotic medications as well as buccal, sublingual, transdermal, and rectal administration of antidepressant medications. The concordance between the physicochemical properties possessed by some antipsychotic and antidepressant agents and the physicochemical properties required for nontraditional routes of administration suggest that administration via alternative routes may be feasible for some of these drugs. Further exploration of drug absorption via alternative routes in addition to consideration of patient and formulation factors may yield improvements in medication therapy for patients with psychiatric illnesses. CONCLUSIONS: For patients unable to tolerate oral or injectable therapy, administration of psychotropic medications via nontraditional routes may be feasible. The development of alternative routes of drug delivery could prevent discontinuation of needed medication therapy.

Procarbazine and antidepressants: a retrospective review of the risk of serotonin toxicity.

BACKGROUND: Procarbazine is an anticancer agent that also inhibits monoamine oxidase, an enzyme responsible for the metabolism of various catecholamines, including serotonin. METHODS: A retrospective chart review of lymphoma patients who were treated with both procarbazine and an antidepressant, as well as procarbazine alone, was performed to determine if signs and symptoms of serotonin toxicity were present. RESULTS: A total of 65 patients received procarbazine between 2004 and 2010 and were eligible to be included in the study. Twenty-six of these patients received an antidepressant in combination with procarbazine, with selective serotonin reuptake inhibitors being the most common type of antidepressant. No patients in the study were diagnosed with serotonin toxicity, nor did any meet Hunter's diagnostic criteria for serotonin toxicity. Diarrhea, tremor, and shivering were the symptoms from Sternbach's criteria that were further analyzed, with diarrhea occurring 8.54% of the time, tremor occurring 5.53% of the time, and shivering occurring 2.51% of the time in patients who received an antidepressant with their procarbazine. Despite these symptoms, the diagnosis of serotonin toxicity according to Sternbach's criteria was determined to be unlikely. CONCLUSIONS: In this small sample of patients treated with procarbazine plus an antidepressant (most typically SSRIs), there were no reports of serotonin toxicity, nor did any patients demonstrate symptoms consistent with serotonin toxicity. The authors urge clinicians to ensure depression is adequately managed in cancer patients who are undergoing procarbazine therapy, starting with typical first-line antidepressant agents.

Risk of QT/QTc prolongation among newer non-SSRI antidepressants.

OBJECTIVE: To review QT prolongation potential with newer nonselective serotonin reuptake inhibitor (non-SSRI) antidepressants. DATA SOURCES: A PubMed literature search was performed from 1982 through June 16, 2014. Search terms included bupropion, desvenlafaxine, duloxetine, levomilnacipran, mirtazapine, venlafaxine, and vilazodone in combination with each of the following terms: cardiac toxicity, QTc prolongation, QT prolongation, torsades de pointes, and TdP. STUDY SELECTION AND DATA EXTRACTION: English-language human studies, case reports, package inserts, manufacturer electronic communications, and ArizonaCert database were utilized. DATA SYNTHESIS: Rare QT prolongation has been reported with venlafaxine at therapeutic doses and in overdose. Bupropion has also been linked to QT prolongation in overdose situations. In elderly patients with a variety of high-risk comorbidities, mirtazapine did demonstrate higher odds of sudden cardiac death and ventricular arrhythmias when compared with paroxetine. Largely because of a lack of available data, existing studies fail to demonstrate QT prolongation with desvenlafaxine, duloxetine, levomilnacipran, and vilazodone. CONCLUSION: Based on the current literature, risk of QT/QTc prolongation with the majority of newer non-SSRI antidepressants at therapeutic doses is low. The highest risk for QT prolongation appears to exist in overdose situations with venlafaxine and bupropion. Given the few to nonexistent controlled studies and confounding variables present in case reports, it is difficult to draw conclusions on QT prolongation risk with many of the newer non-SSRI antidepressants.

Transitioning From Points-Based Grading to a Modified Pass/Fail Grading Approach in a Simulated Patient Program.

OBJECTIVE: To determine the impact of transitioning from points-based grading to a modified pass/fail grading approach in a simulated patient (SP) program on first year pharmacy (P1) student performance in a PharmD curriculum. METHODS: Course-level data from the 2021-2022 and 2022-2023 academic years were collected to assess the impact of transitioning to a modified pass/fail grading approach on P1 student performance. During the 2021-2022 academic year, points-based grading was used. In 2022-2023, a modified pass/fail grading approach was implemented: communication assessment used pass/fail grading and clinical assessment used points-based grading; each assessment was worth 50% of the total SP activity grade. Chi-square tests were used to compare the percentage of students who passed each assessment (≥70%) with those who failed. RESULTS: Across both academic years, students completed 9 formative (18 rubrics) and 6 summative (12 rubrics) SP activities. Each activity included separate communication and clinical assessment rubrics. There were no significant differences in performance on 27 of 30 rubrics. There were two formative SP activities where the percentage of students who passed the communication assessment using pass/fail grading (2022-2023 academic year) was different than points-based grading (2021-2022 academic year). In one fall semester activity, the cohort with the modified pass/fail grading approach had lower pass rates, but the opposite trend was observed in the winter semester. CONCLUSION: Our program was able to successfully move to a pass/fail approach for communication assessments of SP activities while maintaining points-based grading for clinical assessments in our P1 curriculum with minimal impact on student performance.

A comparison of the risk of QT prolongation among SSRIs.

OBJECTIVE: To report QT prolongation potential in selective serotonin reuptake inhibitors (SSRIs) in order to advise clinicians on safe use of SSRIs other than citalopram in light of citalopram warnings. DATA SOURCES: Primary literature and case reports were identified through a systematic search. Data from drug manufacturers, package inserts, and the ArizonaCERT database were also utilized. STUDY SELECTION AND DATA EXTRACTION: English-language studies and case reports were included. DATA SYNTHESIS: Studies demonstrate possible dose-related clinically significant QT prolongation with escitalopram. Fluoxetine, fluvoxamine, and sertraline at traditional doses demonstrate a lack of clinically significant increases in QTc in the majority of studies. Further, paroxetine monotherapy shows a lack of clinically significant QTc prolongation in all studies. However, case reports or reporting tools still link these SSRIs with QTc prolongation. Fluoxetine, escitalopram, and sertraline used in post-acute coronary syndrome patients did not demonstrate risk of QTc prolongation. CONCLUSION: For clinicians who choose not to use citalopram due to recent Food and Drug Administration (FDA) recommendations, other antidepressants within this class may be considered. When citalopram is not utilized based on risk factors for TdP, use of escitalopram is not likely the safest alternative. Based on current literature, fluoxetine, fluvoxamine, and sertraline appear to have similar, low risk for QT prolongation, and paroxetine appears to have the lowest risk. However, there are significant limitations in interpreting the studies, including varying definitions of significant QT prolongation. Therefore, choice of an alternative SSRI should be based on individual risk factors for arrhythmias and other patient-specific factors.

Psychotropic stewardship: Advancing patient care.

Board Certified Psychiatric Pharmacists (BCPPs) practice in a variety of inpatient and outpatient health care settings as part of collaborative, multidisciplinary teams. The American Association of Psychiatric Pharmacists (AAPP) has promoted the expansion of psychiatric pharmacy through the development of psychotropic stewardship programs (PSPs). Based on the standards developed during the creation and expansion of antimicrobial stewardship programs, psychotropic stewardship promotes the safe and appropriate use of psychotropic medications. AAPP envisions every patient with a psychiatric diagnosis will have their medication treatment plan reviewed, optimized, and managed by a psychotropic stewardship team with a psychiatric pharmacist as a co-leader. Because of variations in practice site resources, patient populations, and provider collaboration, the creation and implementation of PSPs should be based on site-specific needs and opportunities. Initial patient identification could prioritize those prescribed multiple medications, high-risk psychotropics, or comorbid medical diagnoses. However, every patient prescribed a psychotropic medication should have the opportunity to work with a PSP. Incremental implementation may be required during the planning stages of stewardship teams. Use of clinical practice-related core outcomes will allow for the optimization of program resources, increased recognition, and improved patient outcomes. PSPs should be patient-focused and integrate patients' preferences and access to recommended treatment options. The eventual goal of PSP implementation is official recognition by key regulatory agencies as a standard of care for patients who receive a diagnosis of a psychiatric or substance use disorder.

Needs assessment and impact of mental health training among doctor of pharmacy students.

INTRODUCTION: Mental illness is extremely prevalent, yet many pharmacy students get little exposure to mental health training. The majority of studies assessing mental health training and Mental Health First Aid (MHFA) are focused on undergraduate programs. This study critically evaluated the impact of MHFA on pharmacy students' knowledge, confidence, and perceptions as they pertain to mental health, as well as the appropriateness of MHFA as a training course for pharmacy students. METHODS: There were two parts to this study: (1) a pre-/post-survey that assessed the impact of MHFA on pharmacy students as well as the appropriateness of MHFA for students at this level of education and training and (2) a college-wide survey that assessed the impact of mental health training of any type on confidence in mental health-related skills and the perceived usefulness of mental health training for pharmacy students. RESULTS: Participants of the MHFA portion of the study demonstrated a statistically significant improvement in knowledge of mental health-related topics and confidence to interact with someone experiencing mental illness (P < .05) after completing the MHFA course. Perceptions of mental illness did not improve significantly following a single training. The college-wide survey (N = 275) revealed a significantly higher confidence level among students who had previously completed any mental health training program compared to those who had not (P < .05). CONCLUSIONS: MHFA training significantly increased students' knowledge and confidence in approaching and interacting with persons experiencing mental illness.

Using the Higher Learning Commission's Assessment Culture Matrix to Support Continuous Quality Improvement of a Simulated Patient Program.

The purpose of this commentary is to advocate for the use of the Higher Learning Commission's Assessment Culture Matrix to support continuous quality improvement (CQI) of simulated patient (SP) programs. We will share examples from our program demonstrating our maturation as it relates to leadership, shared mission and vision, faculty, and resources. While we are at the beginning stages of engaging students, we continue to make progress accessing and systematically using assessment data. We anticipate that sharing our process for utilizing this matrix may help other institutions as they conduct CQI with their SP programs and in other areas of their assessment portfolio.

Impact of a pilot elective course to address student pharmacist well-being.

INTRODUCTION: Survey results from 2016 and 2018 at the University of Michigan College of Pharmacy highlighted mental health concerns for the student population, including struggles with depression, anxiety, and academic distress. This led to creation of a pilot well-being elective course for first year doctor of pharmacy students. This article describes how this course was assessed and adapted for the future. METHODS: The well-being elective course used a course-specific survey and the Brief Inventory of Thriving to assess student outcomes. The course-specific survey was based upon the course objectives and the University of Michigan Common Agenda for Well-Being. Both surveys were given pre- and post-course to identify change. RESULTS: Course survey results illustrated an improvement in student well-being over a single semester. Compared with pre-course responses, students who completed the course were significantly more likely to agree with statements indicating they had strong time management skills, resilience to manage the fluctuations of life, were able to make thoughtful choices to reduce harm and promote well-being, and overall rated their well-being as excellent. Additionally, nearly all students felt a sense of strengthened community with peers and faculty within the course, better able to recognize or refer a peer for help, and felt the course contributed to their overall well-being. CONCLUSIONS: Implementation of this well-being elective pilot course provided students the tools and resources to improve upon their overall well-being in an effort to address anxiety, depression, and academic distress.

Addressing the Conflict Between Promoting Wellness, Perpetuating Mental Illness Stigma and Making Psychiatric Pharmacy Education Less Intense.

One in five Americans has a diagnosable mental illness, and pharmacists encounter these patients daily. This commentary addresses the conflict between the profession's wellness movement and its ongoing contribution to mental illness stigma. The need for improved pharmacist wellness is based on the profession's risk for burnout and development of related mental illness. The presence of stigma towards patients with mental illness among pharmacists is multi-factorial and complex. Risk of those within the profession perpetuating mental illness stigma could be diminished by developing pharmacy curricula that provide greater opportunities for students to learn more completely about mental illness, how to effectively engage persons with mental illness, and how to take care of themselves, express vulnerability, and talk about mental illness. While reducing mental illness stigma through curricular revision is best achieved through in-person learning experiences, elective coursework and cocurricular activities may also help achieve this goal. Examples of evidence-based best practices are provided.

Practical Considerations for Community-Based Health Promotion Events during the COVID- 19 Pandemic.

Community-based health promotion events provide student pharmacists the opportunity to give back to the local community while simultaneously applying the knowledge and skills they are learning in the classroom (Accreditation Council for Pharmacy Education Standards 3, 4, and 12). In turn, community members receive benefits, such as receiving a vaccination and learning their blood pressure, as well as strategies to manage their health conditions. Traditionally, both individual community members and student pharmacists receive benefit. As a result of the coronavirus disease 2019 (COVID-19) pandemic, it is critical to consider the impact of public health via the local community when choosing to hold or suspend these activities. It is necessary to consider whether the benefits to individual community members who choose to participate (e.g., older adult with type 2 diabetes or underserved adults with limited access to the influenza vaccine) outweigh the risks to the public due to the pandemic. If there is sufficient benefit, there are practical considerations related to regulations, recruitment of community members, involvement of students and preceptors, location, supplies, delivery of patient care services, and activities after the event.

Role of hyperparathyroidism in the management of depression and anxiety.

A thorough workup of patients who present with depression and anxiety is imperative to treat underlying conditions in order to potentially decrease psychiatric symptoms. This case describes the hospital course of a patient previously diagnosed with depression and anxiety who experienced an exacerbation of symptoms that may have been related to hyperparathyroidism.

Evaluating pharmacy student use of ExamSoft strength and opportunity reports.

INTRODUCTION: This paper assesses use of ExamSoft strength and opportunity (S&O) reports amongst doctor of pharmacy students, student perceptions of the reports, and the effect of instructing students on how best to use the reports. METHODS: Second-year pharmacy students enrolled in the medicinal chemistry and pharmacology course sequence completed a baseline survey regarding use of S&O reports in the fall semester. Educational interventions describing best practices on how to use the S&O report were provided to students. A follow-up survey was conducted in the winter semester. RESULTS: Eighty-four percent (69/82) of students returned a valid baseline survey, and 89% (71/80) returned a valid follow-up survey. At baseline, 55% (38/69) always/sometimes downloaded the report; this increased to 68% (48/71) after educational interventions (P = .06). Students who downloaded the report were asked to provide their perceived usefulness of the S&O report. At baseline, 76% (29/38) of students downloading the report rated it as either somewhat/very useful; this increased to 94% (45/48) following educational interventions (P = .002). Fewer students reported not being able to interpret the report post-intervention vs. baseline, although the decrease was not significant (9% vs. 21%, respectively; P = .07). CONCLUSIONS: Our findings indicate that providing students with a downloadable S&O report after exams is beneficial. There was a trend towards increased student use and a significant increase in perceived usefulness of the report following brief educational interventions. Our pilot data suggest that educational interventions on use of S&O reports should be included in student ExamSoft training.

Akathisia and Newer Second-Generation Antipsychotic Drugs: A Review of Current Evidence.

Akathisia continues to present a significant challenge in clinical practice. As a class, so-called atypical, or second-generation, antipsychotics (SGAs) are the mainstay of treatment for schizophrenia and are commonly used to treat mood disorders. These medications have traditionally been distinguished from first-generation antipsychotics by their lowered risk of extrapyramidal side effects (EPS) such as dystonia, dyskinesia, akathisia, and pseudoparkinsonism. However, the occurrence of EPS, particularly akathisia, has been demonstrated to some degree in all commercially available SGAs. This review examines the incidence of akathisia in nine newer SGAs in patients with schizophrenia, bipolar disorder, and major depressive disorder (MDD). We performed a search of PubMed, ClinicalTrials.gov, Cochrane Central Register, and Google Scholar, as well as manufacturer websites and product labeling for published and unpublished clinical trials, meta-analyses, and systematic reviews. Studies evaluating adult patients with schizophrenia, bipolar disorder, or MDD were eligible for inclusion. Data on treatment-emergent akathisia rates were gathered from each study, and potential dose-response relationships were explored. A total of 177 studies were included in this review, comprising 58,069 patients across 414 treatment arms. Compared with placebo with a composite 3.7% incidence of akathisia, individual SGAs produced akathisia at total composite rates ranging from 2.9-13.0% across the included studies. High doses of an SGA were generally associated with an increased risk of akathisia. Clinicians should consider the risk of akathisia when choosing a treatment option and monitor for akathisia in patients beginning therapy with an SGA or following a dose increase of the SGA.