The mental health clinician最新文献

Introduction: MDD is often managed with antidepressants that may carry a fall risk. Limited data exist comparing fall risk across individual SNRIs. Therefore, this study aimed to determine the fall rates associated with SNRIs.

Methods: Data were drawn from Merative MarketScan Medicare Supplemental claims (January 1, 2015 to November 30, 2021), including adults 65 years and older prescribed an SNRI (ie, duloxetine, venlafaxine, desvenlafaxine, milnacipran, levomilnacipran). The index date was the first prescription claim. Patients were followed up to 1 month after their last prescription to identify falls, using International Classification of Diseases (ICD) 9^th Revision and ICD-10 codes. Fall-related injuries were identified using trauma codes. Descriptive statistics and odds ratios (95% CI) were calculated to compare fall rates between agents. Propensity score weighting adjusted for potential selection bias.

Results: A total of 79 256 patients met eligibility (68% female; mean age: 75 years). Duloxetine (66%) and venlafaxine (30%) were the most prescribed. The overall fall rate was approximately 1% with duloxetine having the highest (1.1%), and venlafaxine having the lowest rate (0.68%). Injuries occurred in 79% of fall cases. After adjusting for age, sex, and comorbidities, the odds ratio for falling with venlafaxine versus duloxetine was 0.69 (95% CI = 0.56, 0.83), indicating a 31% odds reduction with venlafaxine compared with duloxetine.

Discussion: Venlafaxine appears to have a lower fall risk than duloxetine. Further studies are needed to determine clinical significance and assess fall-related costs to support safer SNRI use in older adults.

Introduction: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are increasingly prescribed for weight management. Although generally well-tolerated, these agents may alter the pharmacokinetics of concurrently administered medications.

Case presentation: A 23-year-old male with schizoaffective disorder, bipolar type, developed lithium toxicity shortly after switching from semaglutide to tirzepatide. While taking semaglutide, the patient was started on lithium and titrated to 1800 mg nightly, corresponding to a level of 0.9 mEq/L. Four days after his first dose of tirzepatide, he reported early symptoms of potential lithium toxicity, which progressed significantly after the second dose. Symptoms corresponded to a 15-hour post-dose level of 1.7 mEq/L, despite no changes in renal function, hydration status, or other concurrent medications. Management with intravenous fluids was sufficient, and lithium dose reduction prevented future toxicity.

Discussion: Application of the Drug Interaction Probability Scale suggests a probable interaction between tirzepatide and lithium. The interaction might be mediated through delayed gastric emptying or other pharmacokinetic changes. Limited reports of GLP-1-modulating agents associated with lithium toxicity have been published and may be an underrecognized phenomenon. To date, no pharmacokinetic studies have been published evaluating this potential drug-drug interaction. Although many other medications seem to be at risk for decreased absorption, tirzepatide may enhance the absorption of lithium.

Conclusion: Clinicians should be vigilant when initiating or switching GLP-1-modulating agents in patients receiving lithium. Pharmacokinetic studies are needed to clarify the mechanism of this interaction. Until more is known, increased monitoring of lithium levels is warranted, with initiation of a GLP-1-modulating agent, a dose change, or switching to another agent.

Serotonin-related adverse drug reactions (ADRs) of selective serotonin reuptake inhibitors, including serotonin toxicity (ST) and antidepressant discontinuation syndrome (ADS), may significantly affect adherence to antidepressant therapy. ST is a rare but potentially serious adverse drug reaction resulting from excessive serotonergic activity, while ADS may occur after the abrupt discontinuation or dose reduction of an antidepressant. Both complications may be influenced by pharmacokinetic and pharmacogenetic (PGx) factors, although research on these relationships is limited. This case report describes a 40-year-old, medically healthy patient identified to be a CYP2C19 *2/*2 poor metabolizer (PM) who potentially experienced ST and prolonged ADS following treatment with escitalopram. After starting escitalopram while on buspirone and stimulant medications, she developed symptoms consistent with ST, including agitation, confusion, diarrhea, and muscle rigidity, leading to discontinuation. A retrial of escitalopram after 3 weeks resulted in similar symptoms. Despite ongoing ST-like symptoms, the patient chooses to continue escitalopram for 2 years, given her perceived benefits with treatment. Upon discontinuation after being on escitalopram for more than 2 years, the patient experienced prolonged withdrawal symptoms consistent with ADS. This case highlights the utility of pre-emptive PGx testing in antidepressant therapy and the importance of interprofessional care in enhancing the patient's self-efficacy.

Introduction: Contingency management (CM) is a behavioral intervention that offers incentives to individuals who meet their goals in a substance use disorder (SUD) treatment program. This review highlights CM for abstinence, which is related to abstaining from using a target substance, and CM for adherence, which is related to adherence to receiving injectable medications for SUD. Clinical pharmacist practitioners (CPPs) are well-suited to serve as resources for the growth of CM.

Practice description: Standardized protocols for CM are used across the Department of Veterans Affairs (VA) healthcare facilities involving various interprofessional team members. All patients receiving CM for abstinence or CM for adherence to injectable medications for SUD involving a CPP at 3 VA facilities from November 13, 2017, to December 31, 2023, were retrospectively reviewed to describe patient characteristics and key outcomes. Patients receiving CM for adherence to injectable medications (n = 98) completed 88.3% of appointments on time, with a total of 574 injections of either naltrexone extended-release injection (XR) or buprenorphine XR given. Patients enrolled in CM for abstinence (n = 51) provided 566 total urine samples within the study period, 80% of which were negative for the targeted substance.

Conclusion: CPPs are expanding access to CM for abstinence and adherence to injectable medications for SUD, with similar rates of abstinence and adherence seen in the current literature. Continued expansion of the CPP provision of CM in various outpatient settings would further expand access to these evidence-based treatments for patients with SUD.

MDD can affect anyone regardless of age, and it often starts during late teens or early adulthood. Although some patients with MDD have an adequate response to medications, only approximately 50% respond to the first treatment, and approximately 30% do not achieve remission despite multiple interventions. Several strategies exist for treating patients who have failed multiple first-line agents, including switching to first-generation antidepressants or to antidepressants unavailable in generic. Other options include augmenting the current antidepressant with other medications such as antipsychotics. Alternatively, augmentation with electroconvulsive therapy, transcranial magnetic stimulation, or esketamine nasal spray can be considered. Prescribing antidepressants unavailable in generic limits accessibility to patients due to cost and prior authorization process. Dextromethorphan/bupropion, a new combination therapy, has shown promise in the treatment of MDD with efficacy seen as early as week 1. Although commercially available, cost and insurance limitations may necessitate consideration of separate administration of its components. This case report describes a 31-year-old male with a history of treatment-resistant depression and alcohol use disorder who experienced symptom improvement on bupropion and dextromethorphan. This case shares observations and clinical considerations of using such combinations in the management of treatment-resistant depression in the context of substance use disorder.

Introduction: Literature comparing differences in efficacy of inpatient initiation of long-acting paliperidone palmitate once monthly (PP1M) and subcutaneous risperidone long acting-injectable (SC-RLAI) is currently limited and inconclusive. Differences in drug costs may guide choice of the preferred medication for inpatient formularies. In this study, we evaluated potential drug acquisition cost savings if PP1M initiations in the inpatient setting were replaced by SC-RLAI once monthly (SC-RLAI1M) at a single center where manufacturer programs and rebates are not used.

Methods: This was a single-center, retrospective, exploratory analysis examining dosages of oral risperidone prior to PP1M conversion and whether SC-RLAI1M could have been used based on dose equivalency. Single-center data from September 1, 2020, to February 29, 2024, were analyzed. The primary outcome was the predicted savings on drug costs based solely on U.S. dollars if each PP1M initiation was replaced with an equivalent SC-RLAI1M during the data period averaged on a yearly basis.

Results: Based on 45 total eligible initiations over the 3.5-year data-collection period and drug compendia available average wholesale prices, the use of SC-RLAI1M instead of PP1M would have translated to an average yearly hospital drug acquisition cost reduction of $49 257.37. Depending on the dose of SC-RLAI1M utilized in each instance, a reduction between $3111.63 and $5420.03 would have been observed per patient.

Discussion: Inpatient institutions may have an opportunity to decrease drug costs by switching from PP1M to SC-RLAI1M as a formulary-preferred medication when appropriate. However, administrators should consider institution-specific costs as well as product availability for patients after discharge.

Introduction: To describe the perceived barriers to and values of postgraduate year 2 (PGY2) psychiatric pharmacy resident research project publication, characterized by PGY2 Psychiatric Residency Program Director (RPDs) responses to an electronic email survey.

Methods: This is a prospective, cross-sectional, anonymous survey distributed to PGY2 psychiatric pharmacy RPDs. The contact information for RPDs was obtained from the American Society of Health System Pharmacists (ASHP) directory. An email for a 1-time survey was provided for all RPDs listed in the directory.

Results: Surveys were sent to 75 PGY2 psychiatric pharmacy RPDs listed in the ASHP directory, and 36 were completed for a response rate of 48%. The most common barrier to publication identified by RPDs was lack of resident motivation (47.2%). It was unanimously agreed upon that all psychiatrically trained PGY2 pharmacists should have strong written communication skills; however, the most significant disagreement is that all residents should be required to submit their residency projects for publication.

Discussion: The most common barriers identified were a lack of resident motivation, a lack of statistical knowledge, and difficulty completing the project in 1 year. RPDs emphasized the importance of strong written communication skills for residents, but did not believe that residency research projects should be required to be submitted for publication.

Introduction: Considering the expected decrease in psychiatrists due to retirements and fewer individuals entering the field, it is important to examine the pharmacist's role in improving mental health outcomes. This study evaluated pharmacist treatment of depression in a behavioral health-integrated virtual (BHIV) clinic where patients were generally followed twice monthly compared with the standard of care, twice-yearly primary care management.

Methods: A descriptive report from January 1, 2020, to May 31, 2023, identified patients diagnosed with depression managed in the pharmacist-run BHIV clinic and the internal medicine (IM) clinics. Patients were excluded if they were established with a psychiatric specialist, diagnosed with a severe psychiatric disorder or postpartum depression, pregnant, or only prescribed trazodone at doses less than 100 mg. One hundred forty-two patients were included, with 71 in each group. The primary outcome was the final Patient Health Questionnaire-9 (PHQ-9) score.

Results: The average initial PHQ-9 score was equal in both groups (13 ± 4.5; 13 ± 5.5; P = 0.8). The average final PHQ-9 score was similar between groups (7 ± 5.6; 6 ± 6.6; P = 0.7). The average time to remission and response in weeks was shorter in the BHIV group (9 ± 6.4; 27 ± 20.5; P ≤ 0.001; 7 ± 5.9; 29 ± 26.0; P ≤ 0.001).

Discussion: Remission and response were identified more rapidly in the BHIV group than in the IM group. Clinical outcomes were comparable between cohorts at the final assessment. Overall, this shows that pharmacists can provide close follow-up and improve patients' quality of life by providing rapid symptom resolution.

Cannabis is the most used federally illicit substance in the United States, yet there is limited knowledge about its pharmacology; efficacy for various medical conditions; or, more importantly, its safety profile. There is significant interest in exploring the full extent of the pharmacologic effects of cannabinoids. Psychoactive effects of cannabis are well-established, but the other effects of cannabinoids, including their effect on mood symptoms; suicidal ideation; and activity outside of the central nervous system, including actions on the cardiovascular system, are still being uncovered. With an increasing number of states in the United States independently authorizing medicinal and, in some cases, recreational use of cannabis, it is essential that our health care professionals are aware of these potential risks when caring for patients who are using cannabis. The objective of this manuscript is to describe how mood symptoms, suicidality, cardiovascular effects, and drug interactions may be associated with cannabis use.