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

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

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

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

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

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

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

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

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

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

Assessment

Indication for useEfficacySafety – adverse effects, drug

interactionsAdherence Comprehensive Medication

Management

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

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

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

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.

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

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

2010 Medicare Part D Medication Therapy Management (MTM) Programs

www.cms.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet_2010_06-2010_final.pdf Accessed 11/11

ReimbursementVaries by statePharmacy schoolsMedicare Part DEmployersMedicaid in some statesNew payment structures???

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

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

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

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

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

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

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

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

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?