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.

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.

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.

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.

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.

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.

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.

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.

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.

Identifying Predictors of Primary Adherence to Second Generation Long-Acting Injectable Antipsychotics Following Discharge from an Acute Inpatient Psychiatry Unit.

Objectives: Describe primary adherence and medication persistence to second generation long-acting injectable (LAI) antipsychotics following an inpatient psychiatry hospitalization, compare rates of psychiatric-related hospital readmissions and emergency visits within 6 months of discharge between patients who were adherent versus nonadherent, and explore predictors of primary adherence to second generation LAI antipsychotics following hospitalization. Experimental Design: This retrospective chart review included patients who received at least 1 dose of a second-generation LAI antipsychotic while hospitalized in an acute care psychiatry unit between April 1, 2016 and July 31, 2017, had active Missouri Medicaid, and continued on the second-generation LAI antipsychotic upon discharge. Patients were excluded if they were discharged to a care setting where medication was administered. Principal Observations: Seventy-five charts were included. Primary adherence rate was 37% and only 46% of those persisted with LAI antipsychotic treatment over a 6-month time period following discharge. Rates of psychiatric-related readmission or emergency visit within 6 months post-discharge did not differ between groups. No statistically significant correlations between primary adherence and demographic or socioeconomic variables were found. Conclusions: Primary adherence and medication persistence to second generation LAI antipsychotics following hospital discharge is low with approximately 60% of patients not receiving another injection. Clinicians should consider outpatient medication adherence before initiating a second-generation LAI antipsychotic during hospitalization. Efforts should be made to facilitate adherence to LAI antipsychotics during transition of care from inpatient to outpatient settings.