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Role of Clinical Pharmacist in Psychiatry
Alam Sher, PharmD, MBA
MHC Cl. Pharmacist, Togus VAMC, Augusta, MaineAdj. Assoc. Prof. Pharmacy Practice, MCPHS, Boston, Mass
Cl. Assoc. Prof. Family Med. (Psychiatry), UNE Col Of Osteopath Medicine
HEC Visiting Scholar, Islamia Uni of Bahawalpur, PakistanPresident, NA Sher Foundation for Health, Education & Humanitieswww.sherfoundation.org - Wikipedia Article: Nasreen & Alam Sher
Foundation
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Road Map• Definitions
• Psychiatry / Mental Health• Psychiatric Pharmacist• History of Psychiatric Pharmacy
• Is there a need for it?• What Does a Psychiatric Pharmacist Do?• Psychiatric Pharmacist Skills
• Assessment and Interview Skills• Comprehensive Medication History
• Literature Review• Other Notable References• Q/A
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Psychiatry or Mental Health
Psychiatry is devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioral, cognitive and perceptual abnormalities.
The term was first coined by the German physician Johann Christian Reil in 1808, and literally means the 'medical treatment of the mind' (psych-: mind; from Ancient Greek psykhē: soul; -iatry: medical treatment; from Gk. iātrikos: medical, iāsthai: to heal).
Wikipedia - 2011
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The Psychiatric Pharmacist
PharmD with relevant clinical experience in Psychiatry
Additional residency and fellowship in psychiatric medication use
Board certified in psychiatric pharmacyMost work in academics, MH facilities, VAIncreasing interest in the Patient-Centered
Medical Home (PCMH)
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
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Brief History of Psychiatric Pharmacy Practice
For over 40 years, some pharmacists have specialized in psychiatric pharmacy
In 1992, the Board of Pharmacy Specialty recognized psychiatric pharmacy as a specialty of pharmacy
As of 2011, there are 627 board-certified pharmacists (BCPP)
In 1998, the College of Psychiatric and Neurologic Pharmacists (CPNP) was founded
In 2011, CPNP membership grew to 1,130
Glen Stimmel, PharmD, Manifesto - Psychiatric Pharmacy, CPNP
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Is there a need?
Mental/behavioral health problems are under diagnosed and often untreated
Untreated MH = more health care costs Many of these conditions can be successfully
treated in primary care 80% of patients prefer to get their behavioral
health care from their family doctor Up to 70% of primary care visits have a
behavioral health basis
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
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Number of Physical Symptoms and Likelihood of Mental Illness
0-1 2-3 4-5 6-7 >810%
50%
30%
70%
Number of Physical Symptoms
Frank deGruy (2010). Kentucky Policy Summit
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Fit in the PCMHFits with NCQA, HEDIS, ACO, NQF measuresDepression screeningMedication reconciliation
Hospital follow-up, care transitionsDevelop care plansSelf-management goal settingCare coordination
High-risk populations and medicationsEvidence-based guidelines
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
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What Does a Psychiatric Clinical Pharmacist Do?
Teach pharmacy, nursing, medical students/residents/practitioners
Lead medication education groupsAssist with formulary decision processesWork collaboratively with teams to optimize
pharmacotherapyProvide direct patient care via assessment and
medication managementConduct research/publishPatient advocacy
The University of Texas Medical Branch at Galveston (UTMB) - CPNP - 2011
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Psychiatric Pharmacist Skills
Interview techniquesComfort with patients with mental illnesses and
their familiesMeasurement-based careEvidence-based treatment guidelinesAccess to affordable medicationsPatient medication educationTeam-based careReferral to therapy, support
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
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Assessment
Indication for useEfficacySafety – adverse effects, drug
interactionsAdherence Comprehensive Medication
Management
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Comprehensive Medication Management DefinedMeet with the patient and family or NOK, if
needed, to help them identify their medication-related goals
Review all medicationsRx, OTC, supplementsCaffeine, tobacco, alcohol, illicit drugsFrom all providersAs they actually take themObtain pertinent vital signs, labs especially UDS, TSH,
Vit. B12, Folate, and Vit. D3
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
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Comprehensive Medication Management
Focus on medication useGoal to prevent or identify and resolve
medication-related problemsReferred to as Medication Therapy
Management (MTM) by Medicare Part DSee Patient-Centered Primary Care
Collaborative (PCPCC )Document developed by the Medication Management task force
www.cms.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet_2010_06-2010_final.pdf
www.pcpcc.net/files/medmanagement.pdf - 2010
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Comprehensive Medication Management (cont’d)
Identify medication-related problemsUntreated indications
Glucose, lipids, hypertensionNot meeting goalsAdverse effects, drug interactionsAdherence, Cost
Complete medication list to patient, providerCare plan with recommendations to resolve
problems to provider(s)Follow-up with patient to assess outcomes
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
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Meds Non-Adherence - Quotes for the Day
“Drugs don’t work in patients who don’t take them.”
- C. Everett Koop, M.D.
The most expensive pill is that which is not taken or taken inappropriately.
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Model ProgramsFederally Qualified Health Center (FQHC) in Billings,
MTFamily Medicine ResidencyIntegrated behavioral health with PsyD and 2 mental
health/addiction counselorsIntegrated medication management with PharmD,
pharmacy residents and studentsAvailable for brief interventions in clinic dailyLonger appointments can be scheduled for
comprehensive medication assessments
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
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North Carolina Medicaid
Currently have “generalist” pharmacists imbedded in selected practices
Pharmacists involved in medication reconciliation for all Medicaid patients entering hospital
“Boot-camp” training on behavioral health medications ongoing
Assess impact of training on outcome metrics
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
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2010 Medicare Part D Medication Therapy Management (MTM) Programs
www.cms.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet_2010_06-2010_final.pdf Accessed 11/11
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ReimbursementVaries by statePharmacy schoolsMedicare Part DEmployersMedicaid in some statesNew payment structures???
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Medication Management Services: Resource-Based Relative Value Scale
Source: Minnesota Department of Human Services, MHCP Provider Manual, Medication Management Therapy Services, - HIPAA– Compliant MTMS CPT Codes, Revised 1/5/2010. Accessed 11/11
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Value
Return on investment varies, average 5:1Improves patient outcomesImproves access to careDecreases resource utilization, admissionsImproves patient satisfactionMay increase drug spend
Untreated indications, adherence improvesDecreases overall cost
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
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Bond et alIntervention: Drug monitoringPt population: SchizophreniaStudy design: Retrospective chart reviewStudy duration: 1 yearN = 25Results: ↓ in hospital readmissions (42 vs
3), ↓ in AEs reported (38 vs 4), 39% ↓ in fluphenazine dosage requirements, 42% ↓ in anticholinergic use
AE = Adverse EffectBond et al. J Clin Psychiatry 1979;40:501-3.
Brianne Fairchild – BECVAMC, Pa
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Gray et alIntervention: Treatment
recommendations b/f clinic visit & education to pts
Pt population: VariousStudy design: Retrospective chart reviewStudy duration: 3 monthsN = 19Results: ↓ in AEs reported (61 vs 20), ↓
of 1.32 meds/pt/month, improvement in pt’s drug knowledge score (53% vs 77%)
Gray et al. Contemp Pharm Pract 1979;2:108-16.Brianne Fairchild –
BECVAMC, Pa
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Lobeck et alIntervention: Drug monitoring & weekly
groupsPt population: UndisclosedStudy design: Retrospective chart review &
provider satisfaction surveyStudy duration: 3 monthsN = Unknown (total of 4734 visits b/f
intervention & 2662 visits after)Results: 66% of recommendations were
implemented, very favorable provider response to survey (4.41 on a 1-5 scale), saved $22,241
Lobeck et al. Hosp Commun Psychiatry 1989;40:643-4.Brianne Fairchild –
BECVAMC, Pa
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Lee et al600 VA pharmacist recommendations
reviewed
92% were accepted by providers
Improved clinical outcomes in >30%
Avoided harm in 90%
Total cost avoidance = $420,155
Lee et al. Am J Health-Syst Pharm 2002;59:2070-7. Brianne Fairchild – BECVAMC, Pa
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ACCP Task ForceEvidence of economic benefit of clinical
pharmacy services: 1996-2000
No. of studies = 59 (12 were VA)
100% demonstrated positive findings
Benefit:cost ratio range = 1.74:1 – 17.0:1 (median = 4.68:1)
Schumock et al. Pharmacotherapy 2003;23:113-32.Brianne Fairchild – BECVAMC,
Pa
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Other Notable Publications JH Colman, III, RL Evans and SA Rosenbluth. “Extended clinical roles for the
pharmacist in psychiatric care”; AJHP, 30:1143-1146 (Dec) 1973 KK Roe, JA Doheide, and MZ Wincor. “Developing a Partnership With NAMI
and Psychiatric Pharmacists”; Schizophrenia Bulletin, 28 (3), 2002 N Sanghera, PO chan, ZF Khaki, Claire Planner, KKC Lee, NE Cranswick, and
ICK Wong. “Interventions of hospital Pharmacists in Improving Drug Therapy in Children”; Drug Society 29(11): 1031-1047, 2006
P Tait, and D Hall. “Pharmacy Involvement on a Psychiatric Unit at St. Paul’s Hospital”; The Canadian Journal of Hospital Phramacy, Vol XXXI, Nov-Dec, 1978
GL Ellenor, and BR Dishman. “Pharmaceutical Care Role Model in Psychiatry-Pharmcist Prescribing”; Hosp Pharm, 30(5):371-373, 377-378, 1995
MH Jenkins, and CA Bond. “The Impact of Clinical Pharmacists on Psychiatric Patients”; Pharmacotherapy, 16(4): 708-714, 1996
WA Morton, AR Mendenhall, PG Windsor, B Lydiard. “Clinical Psychopharmacy Cosultations: Acceptance of Recommendations on an Adult Inpatient Psychiatric Unit”; Hosp Pharm, 30(9), 786-790, 1995
CA O’Reilly, JS Bell, and TF Chen. “Pharmacists’ beliefs about Treatment and Outcomes of Mental Disorders: “A Mental Health Literacy Survey”; Aust N Z J Psychiatry 44: 1089-1096, 2010
JE Duga, AA Cardoni, and PG Pierpaoll. “Pharmacists Should Serve on Psychiatric Patients’ Units”; Hospitals, J.A.H.A., 49, Sept 16, 1975
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SummaryPharmacist interventions improve:
Better Patient CarePrescribing patterns
↓ the dosage & absolute number of psychotropic drugs
↓ the potential AE burden of the psychotropic agents administered
Access to prescribersCost-EffectivePatient and medication safety
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For every $1 invested in clinical pharmacy services, more than $4 in benefit is
expected.
.
Schumock et al. Pharmacotherapy 2003;23:113-32.Brianne Fairchild – BECVAMC,
Pa
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Thank you !Questions & Comments?