The Mental Health Clinician最新文献

Introduction: Patients with mental illness are particularly at risk for OUD, and due to this higher risk, providers may be more inclined to withhold their home opioids when they are admitted to a psychiatric hospital. Patients whose home opioids are continued or withheld during admission may be treated differently with respect to pain control, orders for nonopioid adjunctive pain agents, orders for intramuscular as-needed medications, orders for seclusion and/or restraints, and outpatient referrals for OUD treatment. The objective of this retrospective pilot study was to characterize inpatient care for these 2 patient populations.

Methods: Thirty-one inpatient encounters were reviewed for patients who had opioid prescriptions before admission and were discharged from the medical center's psychiatric service from June 1 through August 31, 2019.

Results: Orders for nonopioid adjunctive pain agents and intramuscular as-needed medications trended higher for the opioid-withheld group, suggesting greater polypharmacy and patient dissatisfaction compared with the opioid-continued group. Additionally, what became evident was the lack of consistent and clear documentation regarding the discharge plans for the patients' home opioid and OUD treatment.

Discussion: These findings may prompt inpatient interdisciplinary teams to develop a better process of documentation to facilitate continuity of care.

Introduction: This quality improvement initiative aimed to implement a strategy to increase access to care with clinical pharmacy specialists (CPSs), optimize CPS direct patient care activities, and promote clinical pharmacy services. The primary objective was to assess the impact of patient marketing on expanding access to care and clinic utilization in a CPS clinic.

Methods: A marketing technique was applied by a mental health (MH) CPS to expand clinical pharmacy services. Direct-to-patient brochures advertising MH CPS comprehensive medication management services were placed at the check-in window of an interdisciplinary outpatient MH clinic. Brochure content included a description of an MH team, the role of MH CPSs, and benefits of being managed by MH CPSs. Patients could contact the MH CPS or speak to their primary provider for referral. The preintervention and postintervention evaluation periods were 4-month time frames. Clinic utilization for the MH CPS clinic was compared before and after dissemination of marketing brochures. Additional outcomes evaluated were number of encounters, number of patients seen, and number of clinical interventions completed by the MH CPS.

Results: There was a significant increase in clinic utilization postintervention. The total number of encounters, patients, and clinical interventions were numerically increased postintervention.

Discussion: The observed improvements in clinic utilization suggest the benefit of marketing in optimization of access to care in CPS clinics and justification of clinical pharmacy services.

Introduction: Knowledge about fundamental sleep disorders and dysregulation that occurs in children with PTSD is limited. Prazosin is an alpha-1 receptor antagonist often used off label for the treatment of PTSD-associated nightmares in adults; however, evaluation of its use in pediatrics and adolescents is limited. The primary objective of this study was to assess the impact of prazosin on nightmares associated with PTSD in this population. Secondary objectives included assessing side effects, changes in blood pressure, and 30-day readmission rates.

Methods: This was a retrospective, single-center chart review of inpatients diagnosed with PTSD nightmares from January 1, 2017, to July 31, 2019. Patients 4 to 18 years old with a PTSD diagnosis, experiencing nightmares, and initiating any dose of prazosin were assessed to determine efficacy and tolerance.

Results: Forty-two patients were evaluated to determine symptom improvement after initiation of prazosin for PTSD nightmares in children and adolescents. Of the 42 patients, 24 (57.1%) reported improvement in nightmares (average dose 1.05 mg). For secondary results, 38 (90.5%) patients continued prazosin at discharge, and 2 (5%) were readmitted within 30 days for reasons other than PTSD-associated nightmares. Thirty-four (81%) reported having no adverse effects to prazosin. There was no significant difference in systolic (P = .1883) or diastolic (P = .2777) blood pressure preinitiation and postinitiation of prazosin.

Discussion: Despite the limitations of this retrospective study, the data suggests that prazosin may be associated with an improvement in nightmares in children and adolescents with PTSD. Adverse events were rarely reported, and there was no significant change in blood pressure with initiation of prazosin.

Introduction: Despite the high prevalence of those with mental illnesses, there is a critical shortage of psychiatric providers in the United States. Psychiatric pharmacists are valuable members of the health care team who meet patient care needs, especially those practicing with prescriptive authority (PA).

Methods: A cross-sectional electronic survey was administered to Board Certified Psychiatric Pharmacists (BCPPs) and non-BCPP members of the College of Psychiatric and Neurologic Pharmacists. The objective of this study was to compare demographic and practice characteristics between respondents with and without PA.

Results: Of the 334 respondents, 155 (46.4%) reported having PA. Those with PA, including those with Veterans Affairs (VA) affiliated PA, had fewer mean number of years of licensure than those without PA (P = .008 and P = .007, respectively). The majority with PA practiced in outpatient settings (53.5%). Respondents with PA (including those with VA-affiliated PA) were more likely to have their positions funded by practice sites (P < .001). The most common referral source for medication management for those with PA were physicians although pharmacists also provided referrals in both VA and non-VA settings. Pharmacists with PA were more likely to track practice outcomes versus those without PA (P < .001).

Discussion: The current study confirms the variability in PA among psychiatric pharmacists. Demographics of the respondents reflect changes in residency accreditation and increased numbers of psychiatric residencies within VA facilities. Psychiatric pharmacists with PA reported treating psychiatric and medical conditions, creating added value. Psychiatric pharmacists should be empowered to track outcomes and help meet the critical shortage of psychiatric providers.

Objective: To describe a case of a patient who developed psychosis after ingestion of Vertigoheel for treatment of dizziness.

Case summary: A 28-year-old male with no psychiatric history presented with 5 days of worsening depression and psychosis. He denied current use of prescription medications, alcohol, or illicit substances. Approximately 2 weeks prior, while visiting family in Germany, he developed dizziness. A provider in Germany prescribed Vertigoheel, 1 tablet to be taken every hour until symptom improvement. This did not improve his dizziness but did cause him to feel as if he were "in a dream." He stopped taking the medication after 2 days but continued to feel amotivated with decreased appetite and insomnia. Several days later, he developed ego-dystonic auditory hallucinations. He returned to the United States; was admitted to an inpatient psychiatric unit for 4 days; and given olanzapine 5 mg at bedtime, lorazepam 1 mg every evening, and melatonin 6 mg every evening. He experienced gradual improvement in symptoms and was discharged with olanzapine 5 mg daily and outpatient follow-up.

Discussion: Vertigoheel is a homeopathic preparation containing ambra grisea, Cocculus indicus, Conium maculatum, and petroleum. Psychosis was not reported in any of the randomized controlled trials evaluating the use of Vertigoheel for treatment of vertigo. A literature search revealed no published reports of psychosis as a result of administration of any components of Vertigoheel.

Conclusion: A possible causal relationship was observed between the homeopathic supplement Vertigoheel and an acute episode of psychosis in a young male patient with no comorbidities.

Introduction: Patients who are transgender have unique population-specific needs and risk factors. Nationwide surveys of health profession school administrators indicate a gap in coverage of lesbian, gay, bisexual, and transgender health content in their curricula. To address this gap, a pharmacist-developed transgender-health care focused seminar was presented to medical professionals, trainees, and students accompanied by a novel education assessment scale.

Methods: The seminar was presented by a psychiatric pharmacy resident to health care professionals and trainees in various settings. Subjects covered during the seminar included terminology, diagnostic criteria and prevalence of gender dysphoria, nonhormonal treatment, gender-affirming hormone therapy, and other considerations. The Trans* Health Education Evaluation Scale (THEES) was developed to assess participants' self-perceived proficiency regarding care of patients who are transgender immediately before and after attending a seminar. Total scale scores were compared preseminar and postseminar using a repeated-measures t-test, and sign tests with Bonferroni correction were used for individual scale items. Psychometric properties of this scale were examined.

Results: Five seminars were given, and a total of 100 scales were completed by health care-associated workers and students. The majority of participants were in the pharmacy or medical professions. Attending 1 seminar significantly improved THEES total and individual item scores (P < .001). Additionally, 90% of participants felt the seminar was directly applicable to their practice, and 84% felt more confident in providing care to patients who are transgender.

Discussion: A single, pharmacist-led, trans health-focused education session significantly improved the confidence level and self-perceived proficiency of health care-associated personnel as measured by THEES.

Introduction: Despite the paucity of studies evaluating short-acting parenteral second-generation antipsychotics in the medically ill, their use in this population has increased. The purpose of this study was to characterize the use of IM olanzapine and ziprasidone in the medically ill at an academic medical center.

Methods: This is a retrospective medical record review of all patients who received IM olanzapine or ziprasidone on nonpsychiatric inpatient units at a large academic medical center from August 1, 2015 to July 31, 2017. The primary endpoint characterized the indication for use. Secondary endpoints included safety, effectiveness, and prescribing patterns.

Results: After exclusion criteria, a total of 100 patients were included in this study, predominantly white males with a mean age of 56 years. Seventy-four percent of patients received IM ziprasidone and 26% received IM olanzapine. The most common indications for use were agitation of nonpsychotic origin (40%) and delirium (33%). Patients received IM olanzapine and ziprasidone when their use was contraindicated (26.9% vs 9.5%, respectively).

Discussion: Intramuscular second-generation antipsychotics are increasingly being used in the medically ill for delirium and agitation. Our study confirms these were the most common indications for IM second-generation antipsychotic use in this population. Additionally, their use appeared to be well-tolerated, and no patient developed Torsades de Pointes even when combined with other agents that putatively increase QTc. Given the retrospective, single-center, nonrandomized design of this study, the safety and effectiveness of these parenteral second-generation antipsychotics in common causes of acute agitation should continue to be further evaluated.

The divalproex (DVP) package insert states that rifampin may increase the oral clearance of valproate by 40% and that valproic acid derivative dose adjustments may be required when starting or stopping rifampin. However, the overall clinical significance of this drug-drug interaction remains unclear given that limited clinical outcome data has been published. This case describes a 52-year-old female with bipolar disorder, borderline personality disorder, and PTSD who was previously stable on a medication regimen consisting of DVP delayed-release 500 mg every morning and 1500 mg every evening (baseline steady-state trough 99.8 mcg/mL). Throughout rifampin therapy for latent tuberculosis treatment, she required an increase in both the frequency of DVP administration, from 2 to 3 times daily, and DVP dose by 75% to maintain clinical stability. Valproic acid trough concentrations ranged from 56.4 to 75.9 mcg/mL during the 4-month course of rifampin. This report supports that the DVP-rifampin interaction may be clinically significant and of a greater magnitude than suggested by the package insert.

Electroconvulsive therapy (ECT) may be considered for treatment of severe, treatment-resistant, and emergent depression associated with MDD or bipolar disorder. Patients with epilepsy usually take medications that raise the seizure threshold, which poses challenges during ECT. We report a 66-year-old male with epilepsy taking levetiracetam extended-release (XR), lorazepam, and zonisamide requiring ECT for severe MDD. After literature review, the XR form of levetiracetam was changed to higher doses of the immediate-release (IR) formulation, and zonisamide was discontinued 2 days prior to ECT in the hospital and was resumed when the patient underwent outpatient continuation ECT. The patient was treated to remission after receiving 8 acute bilateral ECT treatments before being transitioned to continuation ECT. We provide a brief review of medication management of antiepileptic drugs and other medications that increase the seizure threshold during ECT. To our knowledge, this is the first reported case describing the management of levetiracetam, lorazepam, and zonisamide concomitantly during ECT. Our case suggests that utilizing the IR formulation of levetiracetam, administering the evening dose early the day prior to the procedure, and temporarily discontinuing zonisamide prior to bilateral ECT is effective for the treatment of severe MDD while maintaining seizure prophylaxis.

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.