A Pilot Study to Explore the Effect of Long Acting Injectable Antipsychotics on Aggression.

Objectives: To explore the effect of switching from an oral antipsychotic to a long-acting injectable (LAI) antipsychotic on aggression, in terms of the changes of verbal and physical aggression, interventions required, self-injurious behavior, use of seclusion or restraint, antipsychotic medication refusal, and use of antipsychotics as needed (PRN). Methods: This was a retrospective chart review at a long-term state forensic psychiatric facility. Patients treated with an oral antipsychotic for at least 6 months and then switched to a LAI antipsychotic for an additional 6 months during an 80-month period were included. Results: Out of 70 patients evaluated, 18 were the study subjects. The median age of the cohort was 38 years with a majority being male. Of the seven patients who had an incident of aggression, two had an increase in aggressive incidents following the switch, three had a decrease, and two had no change. Thirty-six interventions occurred while patients were on an oral antipsychotic, which decreased by 30.6% to 25 interventions after the switch. Three patients had an incident of self-injurious behavior, and 6 patients required restraints/seclusions. Of the eight patients who had retrievable medication refusal and antipsychotic PRN use information, five had a decrease in antipsychotic medication refusals and five had an increase in PRN antipsychotic use after the switch. Conclusion: The switch from an oral antipsychotic to a LAI antipsychotic did not appear to significantly increase or decrease incidents of aggression or self-injurious behavior, but seemed to decrease the number of restraints/seclusions required.

Impact of COVID-19 quarantines on clozapine-induced constipation: Experience of utilizing a clozapine-induced constipation protocol at a state forensic psychiatric facility.

Objective: Since 2017, Fulton State Hospital (FSH) has implemented a clozapine-induced constipation protocol. In March 2020, FSH initiated unit quarantines to minimize the spread of coronavirus disease (COVID-19). The objective of this study was to evaluate the impact of these quarantines on medical referrals for constipation, the Bristol Stool Chart ratings, utilization of as-needed (PRN) laxatives, and adherence rates with scheduled constipation medication regimens. Methods: Patients on the clozapine-induced constipation protocol from May 1, 2019 to December 31, 2020, were included, with 10-month pre- and mid-quarantine implementation. Data collected included patient demographics, primary psychiatric diagnosis, and outcome variables. Descriptive statistics and paired t-tests were performed. Results: A total of 31 patients were included. Most were male (93.5%), with a median age of 40 years. The most common primary diagnosis was schizophrenia. Compared with the pre-quarantine implementation period, there were fewer medical referral contacts per person, less use of PRN laxatives, and slightly lower adherence rates to scheduled constipation medication regimens during the mid-quarantine implementation period. Conclusion: Compared with the pre-quarantine implementation period, there were fewer medical referrals per person during the mid-quarantine implementation period.

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.

Drug Development for New Psychiatric Drug Therapies.

Drug development is an expensive, high risk, and highly regulated process. Only about 6.2% of new molecules tested for mental disorders eventually achieve Food and Drug Administration (FDA) approval. New molecular entities are produced, and extensive in vitro animal testing is performed before they are evaluated in humans. The compound is used in animals to predict clinical effects in humans, and studies addressing pharmacodynamics, pharmacokinetics, toxicology, and mutagenicity are conducted. Human research proceeds in three stages with the ultimate goal of proving that a new agent is efficacious and safe for a treatment of a specific disease in humans. If efficacy and safety are demonstrated in two Phase III studies, then the sponsor can submit a new drug application (NDA) to the FDA. The FDA oversees each step of the process to assure that good research practices are followed, data integrity is assured, and human research subjects are protected.

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.

Aripiprazole Lauroxil Dosing Regimens: Understanding Dosage Strengths and Injection Intervals.

Aripiprazole lauroxil (AL) is a long-acting atypical antipsychotic approved for the treatment of schizophrenia in adults. AL has five regimen options that offer three different injection intervals using four different dosage strengths. The relationship between dosage strength (milligram injected), injection interval (time between injection visits), and expected steady-state plasma aripiprazole concentrations may not be readily apparent. This article illustrates the relationship by providing visual scenarios of steady-state plasma aripiprazole concentrations for the five AL regimens. The efficacy of AL was originally demonstrated in a pivotal study of two AL regimens (approved as 441 mg monthly and 882 mg monthly). The three additional regimens (662 mg monthly, 882 mg every 6 weeks, and 1064 mg every 2 months) were approved based on pharmacokinetic bridging studies and population pharmacokinetic models. For this paper, expected steady-state concentrations for each AL regimen were derived from the published population pharmacokinetic models and compared using median values and ranges. The five labeled AL regimens differ in dosage strength and injection interval; however, model-simulated concentrations illustrate that each regimen produces steady-state plasma aripiprazole concentrations within the upper and lower bounds associated with known efficacy for AL 441 mg and 882 mg administered monthly. This visual presentation of the relationship between dosage strength of the AL injection, the interval between successive injections, and steady-state aripiprazole plasma concentrations may demonstrate for clinicians how dosage strength and injection interval can be considered in selecting the AL regimen option that best fits the clinical circumstances of the individual patient.

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.

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.

Plasma Insulin Level Correlation to Metabolic Parameter Shifts in Hospitalized Psychiatric Patients.

OBJECTIVE: To identify potential correlations between baseline plasma insulin level and shifts in metabolic status in psychiatric inpatients. METHODS: A population of 75 patients was identified for this single-center, retrospective study conducted at a state psychiatric hospital in Kansas City, Missouri. Patients were selected on the basis of presence of a baseline fasting plasma insulin level drawn at admission; duration of stay ≥ 12 weeks between August 1, 2013, and December 31, 2015; and presence of metabolic laboratory and weight measurements at baseline and 3 months. Total initial plasma insulin level (≥ 19 µIU/mL or < 19 µIU/mL) was compared to shifts in metabolic laboratory measurements and weight. A secondary analysis was performed to detect association between the numerical values of assessed parameters and the numerical values for plasma insulin measurements. RESULTS: The primary analysis found no correlation between plasma insulin level and changes in any metabolic parameter category at 3 (n = 75) or 6 months (n = 30) after admission. Secondary analysis found significant correlations between the numerical values of baseline total plasma insulin level and fasting plasma glucose level at baseline (r = 0.492, P < .001), 3 months (r = 0.247, P = .035), and 6 months (r = 0.723, P < .001). Secondary analysis demonstrated a significant correlation between baseline total plasma insulin level and hemoglobin A1c values at baseline (r = 0.329, P = .004), 3 months (r = 0.455, P < .001), and 6 months (r = 0.517, P = .003). CONCLUSIONS: Baseline total plasma insulin levels were strongly correlated with parameters affected directly by alterations in glucose up to 6 months after admission but were weakly correlated or not correlated with other metabolic parameters. The results do not support routine use of plasma insulin as a predictor for shifts in metabolic parameters in patients receiving antipsychotic medications.

Cost-avoidance and qualitative analysis of clinical pharmacy interventions by psychiatric pharmacy residents at state psychiatric facilities.

PURPOSE: The cost avoidance and quality of clinical interventions made by postgraduate year 2 (PGY2) psychiatric pharmacy residents are analyzed. METHODS: A retrospective database review of clinical interventions made by PGY2 psychiatric pharmacy residents in two state psychiatric facilities from July 1, 2007 through June 30, 2014, was conducted using a clinical intervention documentation software system. Cost avoidance was calculated by multiplying the mean cost of an adverse drug reaction (ADR) by the probability of an ADR occurring had the intervention not occurred. Sensitivity analyses were performed to identify a conservative estimate of cost avoidance and an upper limit estimate of cost avoidance. The significance of an intervention was determined based on the potential of the intervention type to impact patient care. RESULTS: A total of 2,329 clinical interventions were documented by 10 residents during the seven-year study period, with a mean of 233 interventions made per resident. Interventions were largely accepted (70.1%), were of moderate significance (61.9%), were associated with management of psychiatric conditions (48.7%), and primarily involved medication adjustments (13.7%), particularly for antipsychotics (24.6%). The estimated overall cost avoidance associated with PGY2 psychiatric pharmacy resident interventions was $406,944 over the study period, with a mean cost avoidance of $40,694 per resident. CONCLUSION: A detailed qualitative analysis revealed that PGY2 psychiatric pharmacy residents' interventions were largely accepted, focused on medication adjustments for psychiatric conditions, and were of moderate significance at two state psychiatric facilities. Antipsychotics were associated with the greatest cost avoidance and total number of interventions.

Utilization of antipsychotic therapeutic drug monitoring at a state psychiatric hospital.

INTRODUCTION: This study assesses the utilization of antipsychotic therapeutic drug monitoring (TDM) and describes characteristics of appropriate and inappropriate TDM at a state psychiatric hospital. METHODS: A retrospective, descriptive review was conducted for antipsychotic TDM completed between December 1, 2009, and June 30, 2011, at a 65-bed adult inpatient extended-care and forensic state psychiatric hospital. RESULTS: One hundred thirty-three (n = 133) antipsychotic serum levels were collected from 44 patients during the study period. Sixty-nine percent (69%) of the TDM were deemed inappropriate, 28% were appropriate, and 3% could not be designated appropriate or inappropriate owing to the lack of information regarding steady-state conditions. The primary reason for inappropriate TDM was lack of documentation with regard to the indication for TDM (n = 79, 59.3%), the intervention following laboratory analysis (n = 88, 66%), or both. Appropriate TDM was associated with a lower laboratory cost for antipsychotic serum level ($48.98 ± $53.49 versus $72.06 ± $51.02, P < .05), lower daily cost of scheduled psychiatric medications ($17.72 ± $23.03 versus $32.26 ± $31.05, P < .05), lower daily cost of total medications ($19.28 ± $24.91 versus $33.82 ± $31.03, P < .05), fewer scheduled psychiatric medications (2.95 ± 1.90 versus 4.04 ± 2.19, P < .01), and fewer total scheduled medications (5.95 ± 3.60 versus 7.60 ± 3.29, P < .05). Inappropriate TDM led to approximately $6,753 in avoidable laboratory costs over a 20-month period. DISCUSSION: Therapeutic drug monitoring is a complex process with many points at which errors may occur. The majority of antipsychotic levels at this state psychiatric hospital were not documented in a way that was clinically useful. Inappropriate TDM was associated with increased laboratory and medication costs.

Long-acting injectable vs oral risperidone for schizophrenia and co-occurring alcohol use disorder: a randomized trial.

OBJECTIVE: Alcohol use disorders worsen the course of schizophrenia. Although the atypical antipsychotic clozapine appears to decrease alcohol use in schizophrenia, risperidone does not. We have proposed that risperidone's relatively potent dopamine D2 receptor blockade may partly underlie its lack of effect on alcohol use. Since long-acting injectable (LAI) risperidone both results in lower average steady-state plasma concentrations than oral risperidone (with lower D2 receptor occupancy) and encourages adherence, it may be more likely to decrease heavy alcohol use (days per week of drinking 5 or more drinks per day) than oral risperidone. METHOD: Ninety-five patients with DSM-IV-TR diagnoses of schizophrenia and alcohol use disorder were randomized to 6 months of oral or LAI risperidone between 2005 and 2008. Explanatory (efficacy) analyses were carried out to evaluate the potential benefits of LAI under suitably controlled conditions (in contrast to real-world settings), with intent-to-treat analyses being secondary. RESULTS: Explanatory analyses showed that heavy drinking in the oral group worsened over time (P = .024) and that there was a statistical trend toward significance in the difference between the changes in heavy drinking days in the oral and LAI groups (P = .054). Furthermore, the 2 groups differed in the mean number of drinking days per week (P = .035). The intent-to-treat analyses showed no difference in heavy drinking but did show a difference in average drinking days per week similar to that obtained from the explanatory analyses (P = .018). Neither explanatory nor intent-to-treat analyses showed any between-group differences in alcohol use as measured by intensity or the Alcohol Use Scale. The plasma concentrations of the active metabolite 9-hydroxyrisperidone were significantly lower in patients taking LAI (P < .05), despite their significantly (overall) better treatment adherence (P < .005). CONCLUSION: For the population considered here, schizophrenia patients with alcohol use disorder appear to continue drinking some alcohol while taking either form of risperidone. Nonetheless, our data suggest that injectable risperidone may be a better choice than the oral form for these dual diagnosis patients. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00130923.

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.

Analysis of cost avoidance from pharmacy students' clinical interventions at a psychiatric hospital.

OBJECTIVE: To analyze the cost avoidance resulting from clinical interventions made by pharmacy students completing an advanced pharmacy practice experience (APPE) at a psychiatric hospital. METHODS: A retrospective database review of documented clinical interventions by pharmacy students was conducted to classify interventions by type and significance. Interventions were assigned a cost avoidance value determined by an evaluation of the literature. RESULTS: Three hundred-twenty interventions were documented by 15 pharmacy students during the 1-year study period. The majority of interventions were related to psychiatric medication classes and most (n = 197; 61.6%) were classified as being of moderate significance. The most common interventions included patient education (13.1%), order clarification (11.6%), therapeutic dosing adjustments (10.9%), and laboratory order monitoring (8.8%). The estimated cost avoidance from all interventions made by pharmacy students was approximately $23,000. CONCLUSIONS: Pharmacy students completing APPEs at a psychiatric hospital contributed to a variety of significant clinical interventions and provided considerable cost avoidance value to the institution.