The Mental Health Clinician最新文献

Introduction: Long-acting injectable (LAI) antipsychotics are a promising solution to combating issues related to nonadherence to oral antipsychotics. Oral overlap is utilized when an LAI is initiated to achieve therapeutic concentrations. The place in therapy in which additional overlap is warranted is often mistaken, and providers may prescribe additional overlap based on the presentation of the patient or misunderstanding of appropriate overlap.

Methods: This retrospective chart review assesses patients who were initiated on an LAI while admitted to the acute inpatient psychiatric unit from January 1, 2016, to December 31, 2019. The primary outcome assesses the appropriateness of oral overlap with LAIs. Secondary outcomes include adherence to oral overlap, discontinuation of an LAI within 4 months, and reason for discontinuation of LAI.

Results: A total of 62 patients were included: 40 (65%) had appropriate overlap, and 22 (35%) had inappropriate overlap. The most common LAI was paliperidone (n = 50, 81%). Patients were adherent to oral overlap in 67% (n = 6) of the appropriate overlap group and 85% (n = 17) of the inappropriate overlap group. Discontinuation of an LAI in 4 months occurred in 62.5% (n = 25) of the appropriate group and 40.9% (n = 9) of the inappropriate group. There were no significant differences in secondary outcomes when comparing adherence to oral overlap (p = .26), discontinuation of LAI within 4 months (p = .62), and reason for discontinuation (p = .69).

Discussion: This study identified that a majority of patients had appropriate prescribing of oral antipsychotic overlap.

Introduction: Second-generation antipsychotics (SGA) are associated with misuse potential; however, there are limited data describing the prevalence and characteristics of this misuse. This study was conducted to identify and describe quetiapine and olanzapine misuse among US adults.

Methods: This cross-sectional survey questionnaire was conducted online using Qualtrics research panel aggregator service to identify a quota-based sample of respondents constructed to mimic the general US population aged 18 to 59 years, with regards to gender, geographic region, ethnicity, income, and education level. Misuse was defined as using quetiapine or olanzapine for treatment outside of medical recommendations, for reasons other than a diagnosed medical condition, or obtaining without a prescription. A logistic regression was used to identify factors associated with SGA misuse, incorporating relevant covariates.

Results: Among 1843 total respondents, 229 had a history of quetiapine or olanzapine use. Misuse prevalence was estimated to be 6.3% (95% CI: 5.2, 7.5%). Although most respondents (∼70%) using quetiapine or olanzapine reported doing so to treat a diagnosed medical condition, those misusing them most commonly did so because prescribed medications failed to relieve their symptoms. Misuse was commonly reported (∼50%) concomitantly with opioids, benzodiazepines, or alcohol. Factors significantly associated with quetiapine or olanzapine misuse included employment (OR = 4.64), previous substance use disorder treatment (OR = 2.48), and having riskier attitudes toward medication misuse (OR = 1.23).

Discussion: Misuse of quetiapine and olanzapine, while fairly limited in prevalence, appears to be primarily associated with under-treatment of existing medical conditions.

Board Certified Psychiatric Pharmacists (BCPPs) practice in a variety of inpatient and outpatient health care settings as part of collaborative, multidisciplinary teams. The American Association of Psychiatric Pharmacists (AAPP) has promoted the expansion of psychiatric pharmacy through the development of psychotropic stewardship programs (PSPs). Based on the standards developed during the creation and expansion of antimicrobial stewardship programs, psychotropic stewardship promotes the safe and appropriate use of psychotropic medications. AAPP envisions every patient with a psychiatric diagnosis will have their medication treatment plan reviewed, optimized, and managed by a psychotropic stewardship team with a psychiatric pharmacist as a co-leader. Because of variations in practice site resources, patient populations, and provider collaboration, the creation and implementation of PSPs should be based on site-specific needs and opportunities. Initial patient identification could prioritize those prescribed multiple medications, high-risk psychotropics, or comorbid medical diagnoses. However, every patient prescribed a psychotropic medication should have the opportunity to work with a PSP. Incremental implementation may be required during the planning stages of stewardship teams. Use of clinical practice-related core outcomes will allow for the optimization of program resources, increased recognition, and improved patient outcomes. PSPs should be patient-focused and integrate patients' preferences and access to recommended treatment options. The eventual goal of PSP implementation is official recognition by key regulatory agencies as a standard of care for patients who receive a diagnosis of a psychiatric or substance use disorder.

Introduction: Cocaine use disorder (CUD) is a disabling disease associated with high rates of relapse and intense cravings. Patients with CUD struggle to adhere to treatment, which contributes to relapse and frequent readmissions to residential rehab (RR) facilities. Preliminary studies suggest that N-acetylcysteine (NAC) attenuates cocaine-induced neuroplasticity and, therefore, may assist with cocaine abstinence and adherence to treatment.

Methods: This retrospective cohort study obtained data from 20 RR facilities across Western New York. Eligible subjects were 18 or older, diagnosed with CUD, and were divided based on their exposure to 1200 mg NAC twice daily during RR. The primary outcome was treatment adherence measured by outpatient treatment attendance rates (OTA). Secondary outcomes included length of stay (LOS) in RR and craving severity on a 1 to 100 visual analog scale.

Results: One hundred eighty-eight (N = 188) patients were included in this investigation: NAC, n = 90; control, n = 98. NAC did not significantly impact OTA (% appointments attended), NAC 68%; control 69%, (P = .89) or craving severity NAC 34 ± 26; control 30 ± 27, (P = .38). Subjects treated with NAC had a significantly longer average LOS in RR compared with controls, NAC 86 ± 30; control 78 ± 26, (P = .04).

Discussion: In this study, NAC did not impact treatment adherence but was associated with a significantly longer LOS in RR for patients with CUD. Owing to limitations, these results may not be applicable to the general population. More rigorous studies examining NAC's impact on treatment adherence in CUD are warranted.

Introduction: Psychotropic drug-drug interactions (DDIs) contribute to adverse drug events, but many go undetected or unmanaged. Thorough documentation of potential DDIs can improve patient safety. The primary objective of this study is to determine the quality of and factors associated with documentation of DDIs in an adult psychiatric clinic run by postgraduate year 3 psychiatry residents (PGY3s).

Methods: A list of high-alert psychotropic medications was identified by consulting primary literature on DDIs and clinic records. Charts of patients prescribed these medications by PGY3 residents from July 2021 to March 2022 were reviewed to detect potential DDIs and assess documentation. Chart documentation of DDIs was noted as none, partial, or complete.

Results: Chart review identified 146 DDIs among 129 patients. Among the 146 DDIs, 65% were not documented, 24% were partially documented, and 11% had complete documentation. The percentage of pharmacodynamic interactions documented was 68.6% with 35.3% of pharmacokinetic interactions documented. Factors associated with partial or complete documentation included diagnosis of psychotic disorder (p = .003), treatment with clozapine (p = .02), treatment with benzodiazepine-receptor agonist (p < .01), and assumption of care during July (p = .04). Factors associated with no documentation include diagnosis of "other (primarily impulse control disorder)" (p < .01) and taking an enzyme-inhibiting antidepressant (p < .01).

Discussion: Investigators propose best practices for psychotropic DDI documentation: (1) description and potential outcome of DDI, (2) monitoring and management, (3) Patient education on DDI, and (4) patient response to DDI education. Strategies to improve DDI documentation quality include targeted provider education, incentives, and electronic medical record "DDI smart phrases."

Introduction: Diabetes and depression may present concurrently, and clinical pharmacists are well equipped to manage these conditions. Clinical pharmacists were grant funded to implement a diabetes-focused randomized controlled trial in a Federally Qualified Health Center. The objective of this analysis is to evaluate if glycemic control and depressive symptoms improve for patients with diabetes and depression with additional management from clinical pharmacists compared with those receiving the standard of care.

Methods: This is a post hoc subgroup analysis of a diabetes-focused randomized controlled trial. Pharmacists enrolled patients with type 2 diabetes mellitus (T2DM) and a glycated hemoglobin (A1C) greater than 8% and randomly assigned them to 1 of 2 cohorts, one managed by the primary care provider alone and one with additional care from the pharmacist. Pharmacists completed encounters with patients who have T2DM with or without depression to comprehensively optimize pharmacotherapy while tracking glycemic and depressive outcomes throughout the study.

Results: A1C improved from baseline to 6 months in patients with depressive symptoms who received additional care from pharmacists by -2.4 percentage points (SD, 2.41) compared with a -0.1 percentage point (SD, 1.78) reduction in the control arm (P  .0081), and there was no change in depressive symptoms.

Discussion: Patients with T2DM and depressive symptoms experienced better diabetes outcomes with additional pharmacist management compared with a similar cohort of patients with depressive symptoms, managed independently by primary care providers. These patients with diabetes and comorbid depression received a higher level of engagement and care from the pharmacists, which led to more therapeutic interventions.

Introduction: Numerous strategies exist following antipsychotic monotherapy failure including transition to another antipsychotic, dosing above FDA recommendations, or dual antipsychotic therapy. This study described antipsychotic prescribing practices on an acute psychiatry unit following antipsychotic monotherapy failure and compared outcomes to determine if any strategy resulted in superior short-term outcomes.

Methods: This retrospective chart review assessed postintervention time to discharge for patients with schizophrenia or schizoaffective disorder requiring therapy change following treatment failure. Secondary outcomes included 30-day readmission rate, length of stay, and discharge chlorpromazine equivalents.

Results: There were no differences in number of past antipsychotic trials between groups (4.8 vs 4.5; P = .73). Of all the patients, 73% (n = 30) discharged on alternative antipsychotic monotherapy while 27% (n = 11) discharged on dual antipsychotic therapy. No patients had doses increased above FDA recommendations. The alternative antipsychotic group had shorter mean postintervention time to discharge (8.8 vs 20.6 days; P = .003) and shorter mean length of stay (16.7 vs 32.1 days; P = .03). Median time to discharge was not statistically significant (6.4 vs 14.0 days; P = .17). The dual antipsychotic group had higher mean chlorpromazine equivalents (723 mg vs 356 mg; P = .002). There was no difference in 30-day readmission rates (16.7% vs 27.3%; χ² = 0.5765; P = .45).

Discussion: This study found that following failure of antipsychotic monotherapy, transition to an alternative antipsychotic was associated with decreased mean time to discharge as compared to dual antipsychotic therapy. Further studies are needed to assess long-term clinical implications of these findings.