The Impact of High-density Lipoprotein Cholesterol (HDL-C) Levels and Risk of Movement Disorders in Patients Taking Antipsychotics.

Introduction: Well-known adverse events of antipsychotics are movement disorders, or extrapyramidal symptoms, such as drug-induced parkinsonism and tardive dyskinesia. Objective: With new evidence suggesting a link between low high-density lipoprotein cholesterol (HDL-C) and risk of Parkinson's disease, this study sought to investigate if that link also translated to patients taking antipsychotics with low HDL-C and an increased risk for developing a movement disorder. Design: Adult patients (n=89) at an inpatient state psychiatric facility taking at least one antipsychotic with at least one HDL-C level were assessed for signs of a movement disorder through their history and physical, progress notes, and Abnormal Involuntary Movement Scale (AIMS) score. Results: There was no statistical significance when comparing a patient's movement disorder, AIMS scores, and HDL-C levels to suggest that the HDL-C level influenced a patient's movement disorder. Conclusion: This study did not show a correlation between HDL-C levels and a patient's risk of developing a movement disorder while taking an antipsychotic.

Navigating the pharmacologic complexities of QTc prolongation: assessing the cumulative burden in individuals with serious mental illness.

The scientific progress made in the pharmacologic management of serious mental illness (SMI) has been significant. However, the benefits of medication management must continually be weighed against the risks of adverse effects of the agents prescribed. While many medications pose increased danger of QTc prolongation, which may result in malignant arrhythmia and sudden cardiac death, the combination of medications contributing QTc risk can result in an impact of unpredictable pharmacodynamic magnitude. Pharmacists play a key role in communicating QTc risks to prescribers, however little if any clinical guidance informs clinicians of specific actions to take when initiating or continuing a clinically necessary combination that poses risk. This study is a cross-sectional view of Med Safety Scan (MSS) QT prolongation risk scores, generated from the ranking tool available from the CredibleMeds website, intended to provide greater understanding of overall risk of QT burden to assist in the prescribing of medications to patients with SMI in a psychiatric hospital.

Exploring the Impact of COVID-19 Vaccination on Patients Taking Clozapine.

Objective: Individuals with serious mental illness (SMI) are recognized to be among the highest risk patients to experience more severe symptoms of COVID-19, not only due to poor baseline health and associated disparity, but also due to medications prescribed to manage their illness that are known to compromise immunity even further. Clozapine, a gold standard antipsychotic used in the treatment for refractory schizophrenia, is considered to be the antipsychotic with the greatest risk of compromising immunity due to its potential to cause blood dyscrasia, including leukopenia and rarely, but potentially, agranulocytosis. The objective of this study is to determine if there is any potential hematological consequence for the use of COVID-19 messenger ribonucleic acid (mRNA) vaccines or the impact of active severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients receiving clozapine therapy. Since there is controversy over the rate of vaccine hesitancy in patients with SMI, we also examined the rate of vaccine acceptance in our subject population. Design: This study was a retrospective chart review conducted at a 160-bed state psychiatric inpatient hospital in upstate New York evaluating the impact of COVID-19 vaccination, SARS-CoV-2 infection, and vaccine acceptance in patients prescribed clozapine. Results: Both the administration of COVID-19 mRNA vaccines and SARS-CoV-2 infection did not appear to significantly influence the hematologic values that are monitored by the United States (US) Food and Drug Administration (FDA) to ensure safe use of clozapine. When offered vaccination, most patients hospitalized for SMI were willing to accept it. Conclusion: With the likelihood of COVID-19 mRNA vaccinations becoming a recommended routine vaccination, requiring periodic boosters, patients receiving clozapine therapy have been observed to not be at higher risk of adverse hematological consequences when the mRNA vaccine is administered. Furthermore, inpatient psychiatry settings should be considered an optimal site of vaccination to improve vaccination efforts in our communities.

Impact of the Medication Shortages on Psychiatric Patients: Exploring the Consequences of Lorazepam Injection Scarcity.

Objective: This study reviewed the cases of 13 patients in a psychiatric hospital during the 2022 lorazepam injection shortage in the United States (US). The objective was to determine if there were any patterns to the management of the medication shortage of an essential psychiatric medication at a psychiatric hospital. Methods: A retrospective review of eligible patients who had an order for lorazepam injection prescribed as needed (PRN) between July and October 2022 were divided into, and compared between, two groups: those who had orders permitting continued PRN administration of the medication and those who were discontinued. Results: No negative behavioral issues were seen in the patients who had their doses discontinued. Conclusion: The absence of negative psychiatric consequences suggests that either nonpharmacotherapeutic interventions were alternatively stabilizing or that the standing PRN orders for lorazepam injection were not needed for these patients. A proactive emergency management plan to address critical medication shortages has become an increasingly necessary contingency and would have been appropriate for use during this national shortage.

Impact of COVID-19 on the Mental Health of Psychiatric Inpatients.

Purpose: The perceptions and responses to acute states of emergency may vary for people experiencing serious mental illness (SMI). Therefore, studying the mental health toll of the COVID-19 pandemic on psychiatric inpatients can inform psychiatric care in the event of future global crises. The objective of this study was to determine if there was a difference in the incidence of mental health manifestations in an adult inpatient state psychiatric facility during the COVID-19 pandemic, compared to the immediately preceding year. Methods: Medication administration history for patients who utilized an as needed (PRN) medication for anxiety, agitation, or psychosis between March 1, 2020, and February 28, 2021, were analyzed. Secondary data on the incidence of restraints and seclusions were also examined. Results: The total number of PRN medications was higher during the pre-COVID-19 time frame than during the pandemic (8,139 vs. 7,630), but this was not statistically significant. The following assessments were statistically significant: predominance of psychosis as a psychiatric symptom during the COVID-19 time frame (557 vs. 389), and the difference in PRN medication administration times between time frames as categorized by day (3,741 vs. 2,623), evening (3,844 vs. 4,239), and night (554 vs. 768). Conclusion: During the height of the COVID-19 pandemic, the use of PRN medications for psychosis increased and the use of PRN medications for anxiety and agitation decreased among inpatients at a state psychiatric hospital. These results suggest that experiencing a worldwide pandemic in a psychiatric inpatient facility may be protective in some respects but may exacerbate symptoms of psychosis.

Perceptions and barriers of adverse drug reaction reporting within inpatient state psychiatric facilities.

Introduction: Adverse drug reactions (ADRs) are a leading cause of morbidity and mortality for hospitalized patients. Health care organizations track ADRs to reduce patient mortality, reduce hospital readmissions, decrease costs, and improve patient care. Differing definitions of ADRs cause confusion among providers, leading to hesitation with ADR reporting. The objective of this study was to understand health care professionals' perspectives of ADR reporting within inpatient state psychiatric facilities. Methods: A survey was sent to 143 health care professionals throughout 25 inpatient state psychiatric facilities within 1 state. The survey assessed the definition of an ADR, confidence in reporting, barriers to reporting, the role of reporting, who should report and review ADRs, and strategies for process improvement. Results: The survey had a 75.5% response rate with 108 respondents. Most respondents could identify the definition of an ADR, were moderately confident in reporting ADRs, and understood the importance of ADR reporting. Barriers to ADR reporting included the reaction not being serious, a lack of information about the ADR, or not enough clarity on how to report an ADR. Fear of retaliation was an additional barrier to ADR reporting. Training and direction on ADR reporting, education on real versus perceived consequences, a designated point person to aid in reporting, and better access to reporting technology were suggested improvements for ADR reporting. Discussion: From this survey, it is evident that respondents believe improved education and training, improved communication regarding reporting consequences, and consensus on the definition of an ADR would encourage reporting.

Selective Serotonin Reuptake Inhibitors (SSRIs) and Their Effect on Patient Aggression in Adult Patients in a State Psychiatric Facility: A Retrospective Analysis.

Objective: The utility of selective serotonin reuptake inhibitors (SSRIs) has been overshadowed by the box warning they received when the United States (US) Food and Drug Administration (FDA) identified an increased risk of suicidality in patients 24 years of age or younger. Newer studies have identified suicidality as self-aggression and hypothesized whether this might also apply to aggression toward others. The controversy surrounding SSRIs has led to a decrease in prescriptions from healthcare clinicians and number of patients seeking the necessary treatment. The objective of this study was to determine if there is a relationship between SSRI use and aggressive behavior in an inpatient state psychiatric facility. Design: Using a retrospective analysis, patients (N=64) admitted to an inpatient state psychiatric facility between January 1, 2013, and December 31, 2020, who were taking SSRIs were assessed to determine if they had an increased risk of aggression, whether toward themselves or others. Patients served as their own comparators and were required to have a period without an SSRI and an equivalent period taking an SSRI. Patients were assessed through markers of aggression, including psychiatric emergencies; restraints; seclusions; as needed (PRN) medication use or STAT medication use for agitation, aggression, violence, poor impulse control, or psychosis; and PRN nicotine use. Results: There was no statistical significance in any of the analyses demonstrating that SSRI use led to an increased risk of aggression in this sample of inpatients. Conclusion: The FDA warning of increased risk of suicidality and case reports of aggression potentially associated with the use of certain antidepressants should not prevent prescribers from treating adult patients with SSRI medications.

Pharmacological and philosophical considerations for the around-the-clock use of scheduled melatonin to promote sedation and reduce aggression in individuals with serious mental illness: a case report.

Melatonin, the endogenous hormone that helps maintain circadian rhythm, has been used exogenously for both primary and secondary sleep disorders. While the effects of melatonin given prior to planned sleep and to restore normal circadian sleep phases have been well studied, there is little information on the use of melatonin as a pharmacotherapeutic intervention for around-the-clock sedation to prevent agitation and aggressive patient behaviors. This is the first case report to our knowledge of melatonin used throughout the day, as a scheduled dose for prolonged treatment duration, to reduce aggression in a patient with severe mental illness.

Trends of Adverse Drug Reaction Reports in a Hospitalized Psychiatric Population: Exploring Prescriber Discontinuations as Potential Unreported Adverse Drug Events.

The review of adverse drug reactions (ADRs) is a safety mandate required by numerous organizations in the medication safety community. For adverse reactions to be properly reviewed, they must first be reported as potential events. There are notable challenges to ensure adequate and accurate reporting of ADRs that could be overcome if obstacles were better understood and addressed in a manner that is not punitive or threatening. Even reports of seemingly benign side effects might be valuable when considering the deleterious impact on medication adherence, notably in a psychiatric population. Our study examines the potential underreporting of adverse drug reactions that have been likely dismissed as expected side effects of medications. We underscore that there is a significant difference in what has been reported formally as an ADR and what should be reported based on the ability to identify prescribing changes that might be initiated in response to an ADR.

Challenges associated with treating and preventing antipsychotic-induced constipation: considerations and cautions when prescribing novel interventions.

Antipsychotic-induced constipation is a treatment-limiting side effect for patients with serious mental illness (SMI). In addition to increased risk of constipation, due to adverse medication effects, individuals diagnosed with SMI are also prone to lifestyle factors that contribute to this medical complication. The USA Food and Drug Administration (FDA) recently released enhanced warnings about the risk of serious, sometimes fatal, complications associated with constipation caused by the antipsychotic, clozapine. It is likely this heightened warning will prompt providers to seek additional means to prevent and treat antipsychotic-induced constipation, despite having no agent with FDA approval for this specific indication. Off-label prescribing of newer medications for the treatment of antipsychotic-induced constipation is associated with risks, many of which are still unknown, considering the exclusion of patients with SMI in studies measuring nonpsychiatric outcomes.

The Role of Serum Lithium Concentration on Pill Burden in Psychiatric Populations.

Objective: Current research validates the use of lithium as a first-line agent in bipolar disorder, yet it remains underutilized. This might, in part, be the result of lithium's risk of toxicity. A lower serum lithium concentration would decrease the risk of toxicity. This study examined whether lithium serum concentrations are associated with an additional medication burden resulting from psychiatric polypharmacy. Methods: The retrospective data of adult inpatients receiving lithium who had at least one serum lithium concentration recorded were extracted from the computerized patient record system, bar code medication administration, and mental health automated health record system. Results: 38 patient charts were reviewed and a total of 192 individual serum lithium concentrations were analyzed. There was no statistically significant difference (increase or decrease) in the number of psychiatric medications prescribed or the number of scheduled psychiatric medication doses administered. There was a statistically significant increase in the number of psychiatric medications prescribed over the Food and Drug Administration (FDA) recommended maximum daily dose (MDD) following a serum lithium concentration record. Individuals with a serum lithium concentration below 0.6mEq/L were more likely to be prescribed medications over the MDD. Conclusion: Serum lithium concentrations did not increase or decrease the overall psychiatric pill burden. The number of psychiatric medications an individual is prescribed remained the same regardless of their serum lithium concentration. Overall pill burden did not change with the serum lithium concentration; however, lower serum lithium concentrations might necessitate prescribing of psychiatric medications in doses exceeding the MDD.

High-dose Clozapine Withdrawal: A Case Report and Timeline of a Single Potential Withdrawal Seizure.

Clozapine, a second-generation antipsychotic (SGA), is known for its superior efficacy in the treatment of refractory schizophrenia. Clozapine's hallmark side effects are well-known, including, but not limited to, drug-induced seizures associated with daily goal doses greater than 600mg and rapid dose escalation, which can also contribute to significant risk of orthostatic hypotension, bradycardia, and syncope. However, less well-known is the potential withdrawal that can occur from its rapid discontinuation. Here, we describe a case of seizure-like activity that occurred 72 hours after an abrupt high-dose clozapine discontinuation in a patient with schizoaffective disorder, bipolar type. Seizures, although known to be a high-serum-concentration-dependent side effect of clozapine, could not be excluded as a possible withdrawal syndrome in this patient.

Exploring the Effectiveness of Team-based Enablement Interventions to Improve Antibiotic Prescribing within a Psychiatric Hospital.

Background: Antimicrobial resistance threatens the effective prevention and treatment of many types of infections. Infection occurs more frequently in patients diagnosed with psychiatric illness due to a number of risk factors. Urinary tract infections (UTI) are among the most common infections in this patient population. Currently, there is little information available offering guidance on how to treat infections commonly reported in patients with psychiatric illnesses, nor are there specific recommendations on how to provide efficient and effective educational interventions to prescribers who typically are not infectious disease specialists yet are responsible for treating infections within a psychiatric hospital. This study aims to determine 1) whether psychiatric inpatients were appropriately treated for a urinary tract infection (UTI) prior to educational interventions, and 2) whether there is a relationship between different modes of educational interventions and increased knowledge attainment and retention among healthcare clinicians regarding UTI treatment. This study also sought to determine if 3) health-team teaching used as an enablement method improves antibiotic prescribing and if 4) the number of appropriate UTI treatment regimens increased following educational intervention compared to baseline (prior to educational intervention). Methods: A 10-question pre-test survey focusing on UTIs was administered to clinicians in various healthcare disciplines who were later randomly assigned to receive UTI educational interventions either as a live lecture or independent study with identical content. The same 10-question survey was administered as a post-test, 6 to 7 weeks following the educational intervention. Antibiotic prescribing prior to and following educational interventions was assessed to note prescribing trends. Results: Analysis showed that healthcare providers who received live education scored higher on the post-test survey versus those who received directions for self-directed review of educational material presented at the live educational intervention (p<0.001). Following educational interventions, the number of urine samples collected for suspected UTI decreased, resulting in a decrease of unnecessary antibiotic treatment. The number of appropriately prescribed antibiotic treatment regimens increased following educational efforts. Conclusion: These enablement educational intervention strategies resulted in significantly improved antibiotic prescribing, indicating that andragogical teaching methods, reinforced through printed material and verbal communication of prescribing deficits, promotes knowledge retention and improved care for patients hospitalized with psychiatric illness.

Impact of Ramadan fasting on medical and psychiatric health.

Ramadan is a religious month dedicated to prayer, fasting and feasting. Recently, there has been an increased interest among healthcare providers regarding possible health-related complications as a consequence of religious fasting such as that seen during Ramadan. In , a 34-year-old female patient with a diagnosis of schizoaffective disorder, depressive type, was admitted for inpatient hospitalization to an inpatient psychiatric hospital in Buffalo, New York. The earliest date of initial diagnosis is unclear; however, the patient reports an increase in symptoms during her early twenties. Upon admission, the patient was continued on haloperidol, lithium and fluphenazine decanoate which had been initiated prior to this admission. Medication administration and meal times were adjusted to accommodate her observance of Ramadan. Despite efforts to mitigate the potential impact, the patient complained of dizziness and weakness following initiation and titration of clozapine. Due to psychiatric exacerbation, inpatient hospitalization and continuous monitoring, clozapine titration occurred quickly. Upon admission, the patient's blood pressure was 137/85 mmHg, which decreased to a low of 87/58 mmHg as her clozapine dose was increased, leaving the patient requesting bedrest due to significant dizziness and weakness. On the 21st day of Ramadan, the patient broke her fast due to substantial adverse effects. Five days after breaking her fast, the patient's blood pressure increased and returned to baseline. Individuals participating in Ramadan tend to have disrupted sleep cycles, including nocturnal sleep reduction and broken sleep patterns, which can impact overall health. Additional health-related complications that have been reported include dehydration and changes in blood glucose, blood pressure, lipid panel, body weight and exacerbation of psychiatric symptoms. These adverse effects can result in serious complications in fasting individuals with acute medical and psychiatric illness. Clozapine was initiated and rapidly titrated during the patient's observance of Ramadan. She exhibited signs and symptoms of hypotension, which were also subjectively reported by the patient. The significant drop in blood pressure while fasting, and rapid increase once the fast was broken, confirm that medication changes implemented during religious fasting, such as that seen during Ramadan, can increase a patient's risk of serious adverse effects.

Exploring the Potential Psychiatric Implications of Astronomical Phenomena.

Objective: Our study evaluates the potential psychiatric impact of the full phase of the moon on patients in a state psychiatric hospital in Buffalo, New York, between September 2013 and July 2018. Methods: This relationship is presented as the average number of restraints or seclusions (R&S) and code green psychiatric emergencies (CG) recorded 14 days before and 14 days after a full moon. Since the timeframe of the analysis included the August 21, 2017, solar eclipse, we also highlight the correlation between a partial solar eclipse and the number of CG events. We also compared full moon phase effects in 2017 to other years to benchmark whether the solar eclipse appeared to influence behavioral effects from baseline. Results: While there was a slight decrease in mean R&S on days where there was a full moon or in the month of a partial solar eclipse, the results were not considered to be significant or associated with human behavior. Conclusion: There was no real association between lunar and solar behavior and the actions of patients with psychiatric disorders.

A review and study of aspirin utilization for the primary prevention of cardiovascular events in a psychiatric population.

In April 2016, the US Preventive Service Task Force (USPSTF) updated the aspirin guidelines for the primary prevention of cardiovascular disease (CVD) and colorectal cancer. This review assesses the importance of appropriate use of aspirin for the primary prevention of CVD and, specifically, how individuals with psychiatric disorders may benefit from such use. This study examined how current prescribing practices of aspirin in a state psychiatric hospital align with these new guidelines and how inappropriate prescribing may jeopardize patient safety. A retrospective chart review of 93 patients was performed to evaluate whether aspirin therapy would be recommended for primary prevention of CVD based on the new USPSTF guidelines. A secondary analysis of these data was performed using the 2009 USPSTF recommendations to strengthen the assumption that practitioners were no longer using the old guidelines. Drug interactions between aspirin and concurrently prescribed pharmacotherapy were classified based on of severity, and the past events of bleeding were quantified. Based on the 2016 guidelines, 25 of the 93 patients included in this study were identified as potential candidates who would benefit from aspirin use for the primary prevention of CVD; of whom 22 (88%) were not prescribed aspirin. The remaining 68 patients did not meet the criteria for aspirin use for primary prevention, although 11 (16.2%) of these patients were taking low-dose aspirin. Based on the 2009 guidelines, 49 of the 93 patients included in our study would have been identified as potential candidates who would benefit from the use of aspirin for the primary prevention of CVD; 41 (83.7%) of whom were not prescribed aspirin. The remaining 44 patients did not meet the previous criteria for aspirin use for primary prevention, although six (13.6%) of these individuals were taking low-dose aspirin daily. The results above indicate a difference between prescribing practices of aspirin use for the primary prevention of CVD. We identified a similar rate of underuse; however, there was a slight increase in the appropriate prescribing according to the 2016 guidelines compared with the 2009 guidelines (88 vs. 83.7%, respectively). Also, there was a higher incidence of unnecessary prescribing (overutilization) of aspirin for the primary prevention of CVD in 2016 compared with 2009 despite the more restrictive criteria (and smaller candidate pool) published in these newer guidelines. There were 47 drug interactions identified when patients' aspirin and concurrent medication regimens were reviewed for our entire sample population. These interactions could potentially lead to an adverse drug reaction in the future. Our safety analysis revealed that none of the patients who were prescribed aspirin had any bleeding events while on therapy within the period of this study. Inappropriate omission of aspirin (underutilization) was more prevalent in our psychiatric institution than overutilization; however, the overall percentage of both underuse and overuse were greater when patients were evaluated according to the 2016 guidelines and then compared with the 2009 statistics. Overutilization did not pose a serious risk for those on aspirin therapy in this sample, as there were no major episodes of bleeding. However, future harm from aspirin still exists based on the significant number of major and moderate potential drug interactions with aspirin and the increased risk of decreased adherence to critical psychiatric medications due to increased pill burden and regimen complexity. Our findings demonstrate that there is an opportunity to educate prescribers on the updated 2016 USPSTF guidelines to improve preventive care and patient safety, which include harm reduction by initiating aspirin in those who are at a risk of cardiovascular events, continuing aspirin in those who are currently receiving aspirin appropriately, and discontinuing aspirin in those who are not considered to be at a high risk of CVD and who may also be at a risk of experiencing an increased risk of bleeding.

Effects of Statins and Cholesterol on Patient Aggression: Is There a Connection?

Overview: Psychiatric adverse effects, including aggression, have been reported with the use of statin medications; however, there is little data to support or refute the theory that statins or low serum cholesterol do in fact increase a patient's risk of aggression. Objective: This study examined 1) statin use and increased aggression, measured by the requirement of either emergent psychiatric intervention referred to as "Code Green" (CG) or "Restraint and Seclusion" (RS) and 2) cholesterol level and increased aggression in psychiatric inpatients. Materials and Methods: Patient charts from January 1, 2011, to December 31, 2015 were reviewed. Statin therapy, lipid panel, and requirement of a psychiatric emergency code CG or RS were noted. Inpatients who did not receive cholesterol-lowering therapy were used as controls. Analyses of variance (ANOVAs) were used to examine the relationship between statin use and increased aggression. Results: Eleven (9.6%) patients receiving statins required a total of 57 CGs, and five (4.4%) required 27 RSs. Conversely, 33 (28.9%) patients not receiving statins required a total of 64 CGs, and 14 (12.3%) required 27 RSs. No statistically significant relationship between statin therapy and agitation was found as evidenced by a CG (F=0.068; p=0.795) or RS (F=0.001; p=1.000). A statistically significant relationship was found between total cholesterol level and requirement of a CG (F=1.435; p=0.029) or RS (F=2.89; p=0.000). Conclusion: It is evident that psychiatric inpatients with lower total cholesterol levels are at an increased risk for loss of behavioral control.

Examining prescriber perceptions of statin therapy and the potential implications these perceptions may have on guideline adherence.

Not all psychiatric inpatients who are candidates for statin therapy are prescribed statin medication. It is unclear whether this is because of prescriber guideline uncertainty or purposeful avoidance because of other reasons. This study aims to determine prescribers' perceptions of recent cholesterol treatment guidelines, and whether their prescribing may be influenced by recent, potentially oversimplified headlines in the media.

Implications of infection and trends of antibiotic prescribing in hospitalized patients diagnosed with serious mental illness.

Hospital-acquired infections have been recognized as a significant factor in increased morbidity and mortality across our health system. Unique to infections associated with inpatient psychiatric hospitalization is the additional hypothesized association of the role that antipsychotic agents and/or underlying disease may play in an increased risk for infection. In this paper, we explore the types of infections diagnosed in an inpatient psychiatric hospital, the demographics of the patients infected, and whether or not the patient was on antipsychotic agents at the time of infection.