Antipsychotic factors related to time to competency for forensic inpatients in a state psychiatric facility.

Introduction: A defendant who is deemed incompetent to stand trial may go through competency restoration consisting of mental health treatment and legal education. Antipsychotics are often used in treatment; however, there is little data examining their role. Methods: This retrospective study included subjects opined competent to stand trial from July 2016 to February 2020 and prescribed an antipsychotic. The primary outcome was difference in time to competency between antipsychotics. Secondary outcomes included difference in time to competency between groups of antipsychotics, difference in length of stay after opined competent based on medication availability in jail, individual antipsychotics, and formulations. Results: There were 117 subjects included for analysis. There were no differences in time to competency between individual antipsychotics, first- and second-generation antipsychotics, or formulations. Length of stay after opined competent was significantly longer for subjects who were prescribed a long-acting injectable antipsychotic (103 days vs 56 days), who were not able to receive their antipsychotic in jail (104 days vs 54 days), or who were prescribed any formulation of paliperidone compared with olanzapine (88 days vs 35 days). Discussion: Since there were no differences in time to competency, patient-specific factors should be used to choose an agent for competency restoration. Length of stay differences are likely related to the antipsychotic access differences between jails and state psychiatric facilities. Therefore, policies related to antipsychotic access should better align between state psychiatric facilities and jails to improve the capacity of the system and provide better care.

Enhancing Outcomes: Acceptability of Medication Formulations for the Treatment of Acute Agitation in a Psychiatric Population.

BACKGROUND: There is limited research evaluating patient acceptability of medication formulations in the treatment of acute agitation. This study assessed patient acceptability of medication formulations (tablet, orally-dissolving-tablet [ODT], liquid, intramuscular injection [IM], inhaled device [INH]) for the treatment of acute agitation and examined correlating factors. METHODS: Adults with psychotic illness or bipolar disorder receiving emergency or inpatient services at an inpatient psychiatric facility in Kansas City, Missouri were included. Participants viewed a presentation on medication formulations for acute agitation and were surveyed on acceptability (measured on a five-point Likert scale). The primary outcome variable was the attitudinal measurement of acceptability of each formulation in correlation with the severity of agitation for use in themselves and other patients. RESULTS: One hundred participants completed the survey. Participants rated the following: (1) This medication formulation would be acceptable to treat mild agitation in themselves and others (oral tablet 85% and 48%; ODT 82% and 55%; liquid 74% and 51%; IM 53% and 74%; INH 78% and 72%); and (2) This medication formulation would be acceptable to treat severe agitation in themselves and others (oral tablet 75% and 52%; ODT 74% and 53%; liquid 66% and 53%; IM 61% and 67%; INH 77% and 72%). For treating mild agitation, participants preferred tablets and ODTs to the IM (p < 0.05) and the INH to liquid or IM (p < 0.05), for themselves; and oral formulations were preferred to the IM (p < 0.05) for other patients. For severe agitation in themselves and others, preference for the INH and IM versus oral formulations (p < 0.05) was significant, with no difference between the INH and IM (p > 0.05). CONCLUSIONS: The proportion of responses preferring oral formulations was higher than IM and INH. Dosage formulation acceptability differed depending on the severity of agitation and intended recipient of the medication.

The effects of concurrent oral paliperidone or risperidone use with paliperidone long-acting injection.

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.

Assessment of pharmacy student attitudes and beliefs toward patients with mental illnesses on inpatient psychiatric units.

INTRODUCTION: People with mental illness continue to face stigma, despite these illnesses being common. Previous studies have demonstrated reduced stigma in pharmacy students after various exposures and education, although results have been mixed. The primary objective of this study was to evaluate the effects of an advanced pharmacy practice experience (APPE) in psychiatric pharmacy on students' stigma toward patients with mental illness using the Opening Minds Stigma Scale for Healthcare Providers (OMS-HC) at 2 psychiatric hospitals. METHODS: This was a prospective, multicenter survey study of pharmacy students on an APPE rotation at an inpatient psychiatric hospital conducted during 3 academic years. Prior to starting and upon completion of their rotation, participants completed the OMS-HC and provided demographic and rotation information. RESULTS: A total of 26 students participated in the prerotation survey, with 88.5% (n = 23) completing the postrotation survey. The primary outcome showed a significant decrease in total OMS-HC score (Z = -2.376, P = .017), indicating a decreased level of stigma at rotation completion. Analysis of the OMS-HC subscales for attitudes toward people with mental illness and attitudes toward self-disclosure of a mental illness also yielded significant decreases (Z = -2.425, P = .015; Z = -2.462, P = .014, respectively). DISCUSSION: This study showed that APPE rotations at inpatient psychiatric hospitals may help reduce stigma among pharmacy students. Pharmacy schools should consider increasing access to and encouraging completion of psychiatric pharmacy rotations to help reduce stigma prior to graduation.

Identifying Predictors of Primary Adherence to Second Generation Long-Acting Injectable Antipsychotics Following Discharge from an Acute Inpatient Psychiatry Unit.

Objectives: Describe primary adherence and medication persistence to second generation long-acting injectable (LAI) antipsychotics following an inpatient psychiatry hospitalization, compare rates of psychiatric-related hospital readmissions and emergency visits within 6 months of discharge between patients who were adherent versus nonadherent, and explore predictors of primary adherence to second generation LAI antipsychotics following hospitalization. Experimental Design: This retrospective chart review included patients who received at least 1 dose of a second-generation LAI antipsychotic while hospitalized in an acute care psychiatry unit between April 1, 2016 and July 31, 2017, had active Missouri Medicaid, and continued on the second-generation LAI antipsychotic upon discharge. Patients were excluded if they were discharged to a care setting where medication was administered. Principal Observations: Seventy-five charts were included. Primary adherence rate was 37% and only 46% of those persisted with LAI antipsychotic treatment over a 6-month time period following discharge. Rates of psychiatric-related readmission or emergency visit within 6 months post-discharge did not differ between groups. No statistically significant correlations between primary adherence and demographic or socioeconomic variables were found. Conclusions: Primary adherence and medication persistence to second generation LAI antipsychotics following hospital discharge is low with approximately 60% of patients not receiving another injection. Clinicians should consider outpatient medication adherence before initiating a second-generation LAI antipsychotic during hospitalization. Efforts should be made to facilitate adherence to LAI antipsychotics during transition of care from inpatient to outpatient settings.

Plasma Insulin Level Correlation to Metabolic Parameter Shifts in Hospitalized Psychiatric Patients.

OBJECTIVE: To identify potential correlations between baseline plasma insulin level and shifts in metabolic status in psychiatric inpatients. METHODS: A population of 75 patients was identified for this single-center, retrospective study conducted at a state psychiatric hospital in Kansas City, Missouri. Patients were selected on the basis of presence of a baseline fasting plasma insulin level drawn at admission; duration of stay ≥ 12 weeks between August 1, 2013, and December 31, 2015; and presence of metabolic laboratory and weight measurements at baseline and 3 months. Total initial plasma insulin level (≥ 19 µIU/mL or < 19 µIU/mL) was compared to shifts in metabolic laboratory measurements and weight. A secondary analysis was performed to detect association between the numerical values of assessed parameters and the numerical values for plasma insulin measurements. RESULTS: The primary analysis found no correlation between plasma insulin level and changes in any metabolic parameter category at 3 (n = 75) or 6 months (n = 30) after admission. Secondary analysis found significant correlations between the numerical values of baseline total plasma insulin level and fasting plasma glucose level at baseline (r = 0.492, P < .001), 3 months (r = 0.247, P = .035), and 6 months (r = 0.723, P < .001). Secondary analysis demonstrated a significant correlation between baseline total plasma insulin level and hemoglobin A1c values at baseline (r = 0.329, P = .004), 3 months (r = 0.455, P < .001), and 6 months (r = 0.517, P = .003). CONCLUSIONS: Baseline total plasma insulin levels were strongly correlated with parameters affected directly by alterations in glucose up to 6 months after admission but were weakly correlated or not correlated with other metabolic parameters. The results do not support routine use of plasma insulin as a predictor for shifts in metabolic parameters in patients receiving antipsychotic medications.

Brexpiprazole: A review of a new treatment option for schizophrenia and major depressive disorder.

Brexpiprazole is an atypical antipsychotic that works as a partial agonist at serotonin 5-hydroxytryptamine1A and dopamine D2 receptors and an antagonist at serotonin 5-hydroxytryptamine2A. It has US Food and Drug Administration approval for monotherapy treatment of schizophrenia and adjunctive treatment to antidepressants for major depressive disorder. Two phase-3 clinical trials demonstrated efficacy and relatively fair tolerability with regard to adverse effects for each indication. Akathisia was frequently reported in the major depressive disorder trials but less so in the schizophrenia trials. Significant increases in body weight and triglycerides were seen across all studies. Brexpiprazole appears to be a viable option for treating an acute exacerbation of schizophrenia requiring hospitalization or adjunctive treatment of major depressive disorder in patients who showed an inadequate response to 1 to 3 antidepressants. Further clinical trials are warranted to determine the long-term efficacy of brexpiprazole, and comparison trials would be beneficial to establish its place in therapy.

Cost-avoidance and qualitative analysis of clinical pharmacy interventions by psychiatric pharmacy residents at state psychiatric facilities.

PURPOSE: The cost avoidance and quality of clinical interventions made by postgraduate year 2 (PGY2) psychiatric pharmacy residents are analyzed. METHODS: A retrospective database review of clinical interventions made by PGY2 psychiatric pharmacy residents in two state psychiatric facilities from July 1, 2007 through June 30, 2014, was conducted using a clinical intervention documentation software system. Cost avoidance was calculated by multiplying the mean cost of an adverse drug reaction (ADR) by the probability of an ADR occurring had the intervention not occurred. Sensitivity analyses were performed to identify a conservative estimate of cost avoidance and an upper limit estimate of cost avoidance. The significance of an intervention was determined based on the potential of the intervention type to impact patient care. RESULTS: A total of 2,329 clinical interventions were documented by 10 residents during the seven-year study period, with a mean of 233 interventions made per resident. Interventions were largely accepted (70.1%), were of moderate significance (61.9%), were associated with management of psychiatric conditions (48.7%), and primarily involved medication adjustments (13.7%), particularly for antipsychotics (24.6%). The estimated overall cost avoidance associated with PGY2 psychiatric pharmacy resident interventions was $406,944 over the study period, with a mean cost avoidance of $40,694 per resident. CONCLUSION: A detailed qualitative analysis revealed that PGY2 psychiatric pharmacy residents' interventions were largely accepted, focused on medication adjustments for psychiatric conditions, and were of moderate significance at two state psychiatric facilities. Antipsychotics were associated with the greatest cost avoidance and total number of interventions.

Effectiveness evaluation of a pharmacist-driven monitoring database for tardive dyskinesia.

BACKGROUND: Tardive dyskinesia (TD) is a potentially irreversible, chronic syndrome related to antipsychotic medication use characterized by hyperkinetic abnormal involuntary movements. Various studies have shown that development of TD is possible with both first- and second-generation antipsychotics. Regular monitoring for emergence of TD symptoms is recommended in clinical practice for early recognition and intervention. METHODS: This is a retrospective, single-center, observational study of the effectiveness of a pharmacist-driven monitoring database for TD assessment. Subjects were adult inpatients at a state psychiatric hospital who received antipsychotic treatment for at least 3 or 6 months between January 2006 and December 2011. The primary objective was to assess compliance rates with TD monitoring based on facility policy before and after implementation of the database at 3 and 6 months following initiation of antipsychotic therapy. RESULTS: A significant improvement in compliance with TD monitoring policy was seen after implementation of the database (2.9% vs 66.7%; P < .001). Compliance with TD monitoring did not differ between classes of antipsychotic medication, hospital units, or age groups. CONCLUSION: The results of this study demonstrate that pharmacists can help improve compliance with TD assessment and that monitoring databases may be useful for similar extended or long-term care settings to ensure timely assessment of patients for the development or progression of TD.

Risperidone-induced Pisa syndrome in MS: resolution with lurasidone and recurrence with Chlorpromazine.

OBJECTIVE: To report a case of risperidone-induced Pisa syndrome in a patient with multiple sclerosis (MS) that resolved with lurasidone, recurred with chlorpromazine, and was complicated by possible drug-drug interactions. CASE SUMMARY: A 31-year-old white male with MS developed Pisa syndrome after years of treatment with risperidone at varying doses for behavioral symptoms associated with pervasive developmental disorder. The patient experienced improvement in symptoms after treatment was switched to lurasidone; however, due to psychiatric decompensation, a switch to chlorpromazine was made and Pisa syndrome recurred. To maintain control of the patient's behavioral symptoms, chlorpromazine was not discontinued. DISCUSSION: Pisa syndrome is a rare adverse drug reaction induced most often by neuroleptic medications. The reaction is characterized by dystonia affecting cervical and lumbar musculature, resulting in flexion of the head and body to one side with axial rotation of the trunk. The etiology is believed to involve a dopaminergic-cholinergic imbalance. Most practitioners are not familiar with this syndrome, and it has not been reported previously in a patient with MS. Definitive diagnostic criteria and treatment have not been established. We identified 15 case reports involving risperidone, paliperidone, chlorpromazine, clomipramine, or valproic acid. The time to development of Pisa syndrome, patient demographics, dosing and titration of causative medications, approach to treatment, and resolution of Pisa syndrome varied widely in these reports. Dystonia in MS often presents differently than Pisa syndrome. The Naranjo probability scale indicated a probable relationship between either risperidone or chlorpromazine in each instance of Pisa syndrome in our patient. CONCLUSIONS: Pisa syndrome is a rare adverse drug reaction associated with neuroleptic medications. Our report highlights the importance of identifying this uncommon type of dystonia in order to consider modification of the medication regimen when appropriate.