The Role of Board-Certified Psychiatric Pharmacists in Expanding Access to Care and Improving Patient Outcomes.

Although approximately 20% of adults in the United States experience a mental health condition annually, there continues to be a gap in the provision of care because of a shortage of behavioral health providers. The National Council for Behavioral Health Medical Director Institute has recommended that the number of board-certified psychiatric pharmacists (BCPPs), who are clinical pharmacists with advanced specialized training and experience in the treatment of patients with psychiatric and substance use disorders, be expanded to help meet this need. Although BCPPs currently assist in expanding care access, improving medication-related outcomes, and reducing health care costs by working collaboratively with physicians and other health care providers, BCPPs are often underutilized. This lack of utilization results in lost opportunity to better address the needs of persons with psychiatric or substance use disorders and to meet these needs in a timely manner. Here, the authors bring attention to five key areas-opioid use disorder, antipsychotic use among children, long-acting injectable antipsychotics, clozapine use, and transitions of care and care coordination-in which BCPPs, along with other pharmacists, provide evidence-based care and could be more extensively used as a collaborative solution to the mental health and substance use disorder crisis in the United States.

Twice-daily versus once-daily lisinopril and losartan for hypertension: Real-world effectiveness and safety.

BACKGROUND: Lisinopril and losartan manufacturer labels recommend twice-daily dosing (BID) if once-daily (QDay) is insufficient to lower blood pressure (BP). METHODS AND RESULTS: Retrospective cohort study of patients taking QDay lisinopril and losartan who experienced a dose-doubling (index date). A text-processing tool categorized BID and QDay groups at the index date based on administration instructions. We excluded: pregnant/hospice, regimens other than BID/QDay, and without BP measurements -6 months/+12 months of the index date. The most proximal BP measurements -6 months and +2 weeks to 12 months of the index date were used to evaluate BP differences. Propensity scores were generated, and differences in BP and adverse events (angioedema, acute kidney injury, hyperkalemia) between BID/QDay groups were analyzed within dosing cohorts using inverse propensity of treatment-weighted regression models. Of 11,210 and 6,051 patients who met all criteria for lisinopril and losartan, 784 (7.0%) and 453 (7.5%) were taking BID, respectively. BID patients were older and had higher comorbidity and medication burdens. There were no differences in systolic/diastolic BP between BID and QDay, with absolute differences in mean systolic BP ranging from -1.8 to 0.7 mmHg and diastolic BP ranging from -1.1 to 0.1 mmHg (all 95% confidence intervals [CI] cross 0). Lisinopril 10mg BID was associated with an increased odds of angioedema compared to lisinopril 20mg QDay (odds ratio 2.27, 95%CI 1.13-4.58). CONCLUSIONS: Adjusted models do not support improved effectiveness or safety of BID lisinopril and losartan.

Tobacco smoking behaviors in bipolar disorder: a comparison of the general population, schizophrenia, and major depression.

OBJECTIVES: This study compared the prevalence of tobacco smoking behaviors in patients with bipolar disorder with normal and psychiatric (schizophrenia and major depression) controls. The main goal was to establish that bipolar patients smoke more than normal controls. Differences with psychiatric controls were explored. METHODS: Samples of 424 patients (99 bipolar, 258 schizophrenia and 67 major depression) and 402 volunteer controls were collected in Central Kentucky. Smoking data for Kentucky's general population were available. Odds ratios (ORs) and their 95% confidence intervals (CIs) were used to establish the strength of associations. Logistic regression was used to adjust ORs for confounding variables. RESULTS: Using epidemiological definitions of smoking behaviors and the general population as controls provided bipolar disorder unadjusted ORs of 5.0 (95% CI: 3.3-7.8) for current cigarette smoking, 2.6 (95% CI: 1.7-4.4) for ever cigarette smoking, and 0.13 (95% CI: 0.03-0.24) for smoking cessation. Using a clinical definition and volunteers as controls provided respective bipolar disorder adjusted ORs of 7.3 (95% CI: 4.3-12.4), 4.0 (95% CI: 2.4-6.7), and 0.15 (95% CI: 0.06-0.36). Prevalences of current daily smoking for patients with major depression, bipolar disorder, and schizophrenia were 57%, 66%, and 74%, respectively. CONCLUSIONS: Bipolar disorder was associated with significantly higher prevalences of tobacco smoking behaviors compared with the general population or volunteer controls, independently of the definition used. It is possible that smoking behaviors in bipolar disorder may have intermediate prevalences between major depression and schizophrenia, but larger samples or a combination of multiple studies (meta-analysis) will be needed to establish whether this hypothesis is correct.

Medication adherence and its effect on relapse among patients discharged from a Veterans Affairs posttraumatic stress disorder treatment program.

BACKGROUND: Clinical outcomes in patients with posttraumatic stress disorder (PTSD) can be affected by several factors, including medication adherence. PTSD is associated with an increased likelihood of missed appointments, medication underuse or abuse, and treatment nonadherence. OBJECTIVE: To evaluate medication adherence and its effect on relapse following discharge of veterans from a PTSD residential rehabilitation program (PRRP). METHODS: A retrospective evaluation of drug adherence and relapse in the 12 months following discharge of patients from a PRRP was performed. All veterans who were discharged from January 1, 2005, to December 31, 2006, and were receiving antidepressant therapy were included. Adherence to antidepressant therapy was assessed by electronic prescription claims and defined as a medication possession ratio of at least 0.8 in the year following discharge. Relapse was defined as a hospitalization for psychiatric symptomatology. Predictive factors of adherence were also explored. RESULTS: Twenty-eight of the 82 (34%) veterans included in our study were adherent to medication during the 12 months following discharge. Seventeen (20.7%) veterans were rehospitalized for psychiatric symptoms, but nonadherence was not significantly associated with relapse (p = 0.91). The total number of drugs that a veteran received was related to adherence; patients who had a higher median number of medications were more adherent (p = 0.014). Age, comorbid substance abuse, combat service, and service connection were not associated with drug adherence. CONCLUSIONS: The majority of patients who were discharged from a residential PTSD treatment program were nonadherent to antidepressant drug therapy. One in 5 veterans with PTSD was rehospitalized within 1 year; however, medication adherence did not affect this outcome.

Estimating the effects of co-medications on plasma olanzapine concentrations by using a mixed model.

The purpose of this study was to estimate the effect sizes of drug interactions on plasma olanzapine concentrations while adjusting for potentially confounding factors such as smoking. The estimation was performed by using a mixed model, data from a series of previously published studies of lamotrigine, oxcarbazepine, topiramate, and mirtazapine, and unpublished data from patients under clinical therapeutic drug monitoring (TDM). The total sample included 163 adult patients (age>or=18 years) who provided both steady-state plasma olanzapine concentrations and smoking information. They provided a total of 360 olanzapine concentrations (1 to 11 measures per patient). Smoking and concomitant carbamazepine or lamotrigine use were found to have significant effects on median plasma olanzapine concentrations. The effects of lamotrigine on plasma olanzapine concentrations were modified by smoking. After adjusting for olanzapine dose and carbamazepine intake, plasma olanzapine concentrations were 10% lower in non-smokers who were taking lamotrigine than in non-smokers who were not taking lamotrigine; olanzapine concentrations were 35% higher in smokers who were taking lamotrigine than in smokers who were not taking lamotrigine; olanzapine concentrations were 41% lower in smokers who were not taking lamotrigine than in non-smokers who were not taking lamotrigine; and olanzapine concentrations were 11% lower in smokers who were taking lamotrigine than in non-smokers who were taking lamotrigine. After adjusting for olanzapine dose and taking carbamazepine, the correction factor comparing smokers taking lamotrigine versus non-smokers who were not taking lamotrigine was 1.3. Gender, age, and concomitant use of mirtazapine, valproic acid, lamotrigine, topiramate, lorazepam, citalopram or oxcarbazepine did not have significant effects on olanzapine concentrations. The main limitation of this clinical design is the unavoidable substantial "noise" that characterizes (uncontrolled) clinical environments, which may make it difficult to detect the effects of some variables. Other limitations were the small sample size of some drug sub-samples and the lack of testing for plasma olanzapine metabolites.

Risk Factors for Utilization of Acute Care Services for Lithium Toxicity.

OBJECTIVE: This study evaluated risk factors for utilization of acute care services (ACS) (hospitalization or emergency department or urgent care visit) for lithium toxicity and the prevalence of lithium toxicity in a large, ambulatory population. METHODS: A nested case-control study compared lithium users with ACS utilization for lithium toxicity (case group) to lithium users without toxicity (control group) by using data from Kaiser Permanente Colorado for patients with at least one lithium prescription purchase. Patients in the case group were matched 1:5 with patients in the control group who had purchased lithium within 39 days of the ACS encounter. Possible lithium toxicity, identified by lithium level or diagnosis, was confirmed by chart review. Multivariable, conditional logistic regression analysis was used to identify patient and prescription characteristics associated with ACS utilization for lithium toxicity. The prevalence of lithium toxicity was determined. RESULTS: Of 3,115 individuals who took lithium, 70 experienced lithium toxicity, with or without ACS utilization, for a prevalence of 2.2%. Identified risk factors for ACS utilization for lithium toxicity included a newly initiated potentially interacting medication (odds ratio [OR]=30.30, 95% confidence interval [CI]=2.32-394.95), a higher number of treated chronic diseases (OR=1.28, CI=1.12-1.45), older age (OR=1.05, CI=1.02-1.09), and higher total daily lithium dose (OR=1.00, CI=1.00-1.00). CONCLUSIONS: Newly initiated, potentially interacting medications are a major preventable driver of ACS use for lithium toxicity, whereas age, chronic disease, and total daily lithium dose are small but significant factors. Clinicians should use extra caution when initiating a potentially interacting medication.

Metabolic monitoring in children 5 years of age and younger prescribed second-generation antipsychotic medications.

INTRODUCTION: The objective of this article was to identify the rates of patients ≤5 years of age who received recommended monitoring before and after second-generation antipsychotic (SGA) initiation and had an SGA metabolic adverse effect (MAE). METHODS: This was a retrospective cohort analysis conducted at Kaiser Permanente Colorado, an integrated health care delivery system, between January 1, 2002, and June 30, 2011. Commercially insured patients ≤5 years of age newly initiated on an SGA were included. Patients were followed for up to 3 years. Metabolic monitoring included lipid profile, blood glucose, blood pressure, and weight measurements. Patient characteristics and outcomes were described using descriptive statistics. RESULTS: A total of 40 patients were included. Overall, 2 (5.0%) patients received all recommended baseline monitoring, and no (0.0%) patients received all recommended follow-up monitoring. Weight monitoring was completed most frequently with rates of completion of 57.5%, 95.0%, 85.0%, and 76.5% at baseline and years 1, 2, and 3, respectively. At least 1 MAE was identified in 14/40 (35.0%), 5/28 (17.9%), and 2/17 (11.8%) patients during years 1, 2, and 3, respectively. The most frequent MAE identified was weight gain. Among patients identified with at least 1 MAE, 4/14 (28.6%), 2/5 (40.0%), and 2/2 (100%) received a behavioral intervention during years 1, 2, and 3, respectively. DISCUSSION: Overall, baseline and follow-up metabolic monitoring were poor. Future studies should focus on examining barriers to monitoring in order to improve health care quality.

Design and implementation of population-based specialty care programs.

PURPOSE: The development, implementation, and scaling of 3 population-based specialty care programs in a large integrated healthcare system are reviewed, and the role of clinical pharmacy services in ensuring safe, effective, and affordable care is highlighted. SUMMARY: The Kaiser Permanente (KP) integrated healthcare delivery model allows for rapid development and expansion of innovative population management programs involving pharmacy services. Clinical pharmacists have assumed integral roles in improving the safety and effectiveness of high-complexity, high-cost care for specialty populations. These roles require an appropriate practice scope and are supported by an advanced electronic health record with disease registries and electronic surveillance tools for care-gap identification. The 3 specialty population programs described were implemented to address variation or unrecognized gaps in care for at-risk specialty populations. The Home Phototherapy Program has leveraged internal partnerships with clinical pharmacists to improve access to cost-effective nonpharmacologic interventions for psoriasis and other skin disorders. The Multiple Sclerosis Care Program has incorporated clinical pharmacists into neurology care in order to apply clinical guidelines in a systematic manner. The KP SureNet program has used clinical pharmacists and data analytics to identify opportunities to prevent drug-related adverse outcomes and ensure timely follow-up. CONCLUSION: Specialty care programs improve quality, cost outcomes, and the patient experience by appropriating resources to provide systematic and targeted care to high-risk patients. KP leverages an integration of people, processes, and technology to develop and scale population-based specialty care.

Curriculum renewal: Alignment of introductory pharmacy practice experiences with didactic course content.

BACKGROUND AND PURPOSE: The University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences (SSPPS) used the opportunity of curriculum renewal to integrate knowledge and skills learned from didactic courses into the introductory pharmacy practice experiences (IPPEs) occurring simultaneously. This paper describes and evaluates the meaningful application of course content into IPPEs, and evaluates the success using qualitative feedback. EDUCATIONAL ACTIVITY AND SETTING: Students entering the renewed curriculum starting in fall 2012 were provided a list of pharmacy skills and activities from didactic course directors that reinforced course content for that semester. The skills and activities were to be completed during the students' IPPE visits in the community or health systems settings, depending on the program year and semester. FINDINGS: Students successfully completed course assignments during their IPPE course program. Not all activities could be completed as designed, and many required modification, including simulated experiences. Feedback from faculty and preceptor members of the school's experiential education committee demonstrated that these activities were valuable and improved learning of course material, but were challenging to implement. DISCUSSION AND SUMMARY: A renewed curriculum that mapped course assignments for completion in experiential settings was successfully established, after some modifications. The program was modified at regular intervals to improve the ability of preceptors to complete these activities in their individual practice environment. A balance between the school providing guidance on what activities students should perform and allowing unstructured independent learning with the preceptor is needed for an optimal experience.

High vulnerability to acute dystonic reactions: a case of antipsychotic exposure and uncontrolled seizure activity.

Antipsychotic-induced extrapyramidal side effects have a negative impact on treatment for mental illness. Acute dystonic reactions are uncomfortable and frightening to the patient, and often lead to early discontinuation of drug therapy and worsened long-term outcome. The lower propensity of the atypical antipsychotic agents to cause extrapyramidal symptoms (EPS) has been associated with multiple benefits, including improved adherence. The authors describe a 57-year-old male patient who was in the treatment refractory unit. This patient exhibited extreme sensitivity to antipsychotic agents, experiencing acute dystonic reactions with quetiapine and olanzapine, in addition to older typical antipsychotic agents. The patient has not experienced acute EPS since therapy with aripiprazole was initiated. Further complicating this patient's course is his unusual sensitivity to experiencing dystonic reactions. We have observed acute dystonias in the absence of antipsychotic treatment and in the context of seizure activity (or paroxysmal dyskinetic activity). The true etiology of the latter dystonic activity has not been completely determined due to the patient's unwillingness to cooperate with invasive testing. None of the gene variations tested (CYP2D6 phenotype, two dopamine D2 receptor variants and one D3 receptor variant) appeared to explain the patient's vulnerability to acute dystonic reactions.

Variables associated with high olanzapine dosing in a state hospital.

BACKGROUND: Olanzapine has a U.S. Food and Drug Administration-approved dosing range of 10 to 20 mg/day but is often used at doses exceeding this range. Olanzapine is largely metabolized by cytochrome P450 (CYP) 1A2. Smoking, which induces CYP1A2, is expected to increase clearance of olanzapine by 40%; however, dosage adjustment in smokers is not currently recommended. Additionally, female gender is expected to reduce clearance by 30%. Many institutions target high-dose olanzapine prescribers in an effort to reduce unnecessary drug costs. However, factors such as smoking or gender may necessitate increased doses. METHOD: A retrospective review of all patients receiving olanzapine during an inpatient stay at a state psychiatric hospital in Kentucky during 2001 was conducted. Demographic information and smoking status were collected for all patients. Olanzapine doses of > 20 mg/day were considered high doses. RESULTS: Nine percent (48/522) of olanzapine patients were prescribed high doses. The percentages were similar in women and men (10% vs. 9%, p =.69) and in smokers and nonsmokers (9% vs. 9%, p =.82). Moreover, the mean maximum olanzapine dose was also similar in men and women (15.4 +/- 7.2 vs. 14.9 +/- 7.3 mg/day, p =.51). The odds of receiving a high dose of olanzapine were increased 2.1 for patients with a schizophrenia spectrum diagnosis (DSM-IV schizophrenia or other psychotic disorder). The odds of receiving a high dose of olanzapine were increased with each incremental increase in length of stay (intermediate length of stay [8-60 days], OR = 5.6; long-term length of stay [> 60 days], OR = 12.0, relative to acute length of stay [< 8 days]). CONCLUSIONS: Neither gender nor smoking status was associated with receiving a high dose of olanzapine. The association of increased length of stay with high dose suggests that treatment resistance may be an important factor in receiving high daily doses of olanzapine.

Pharmacotherapy regimens among patients with posttraumatic stress disorder and mild traumatic brain injury.

OBJECTIVE: The purpose of this study was to determine if veterans with posttraumatic stress disorder (PTSD) and mild traumatic brain injury (TBI) are treated differently pharmacologically than patients with PTSD alone. METHODS: A retrospective evaluation of PTSD pharmacotherapy of Operation Enduring Freedom/Operation Iraqi Freedom veterans with PTSD (N=707) was conducted between April 1, 2007, and March 31, 2009. A total of 45 veterans had suffered a mild TBI. RESULTS: Compared with the patients with PTSD alone, the patients with PTSD and TBI were more likely to be prescribed an antidepressant (p<.001), a sedative-hypnotic (p<.001), or an antipsychotic (p=.024). The patients with TBI were also significantly more likely to receive psychotropic polypharmacy (p=.001) and to receive higher doses of psychiatric medications (p=.03). CONCLUSIONS: The differences in drug therapy found in this study may indicate that patients with TBI and PTSD respond differently to treatment than patients with PTSD alone.