Practice Pearls for Stimulant Treatment of Attention-Deficit/Hyperactivity Disorder in Youth.

Over half of youth with attention-deficit/hyperactivity disorder (ADHD) have co-occurring psychiatric or medical conditions that present treatment challenges. Stimulants are the most effective pharmacologic treatment of ADHD for preschoolers to adults but questions about safety with co-occurring conditions frequently arise. In addition, stigma surrounding diagnosis and treatment can negatively impact care. This manuscript presents evidence-based practice pearls to guide treatment decisions for youth with ADHD and common coexisting psychiatric and medical conditions. Recommendations address specific stimulant adverse effects (i.e., anxiety, cardiac, growth, mania, psychosis) along with management strategies. Pearls were developed for the most common clinical questions, controversial topics, or therapeutic issues that may not be widely known. The goals of this manuscript are to: 1) provide a detailed resource for interprofessional teams regarding stimulant use in youth with ADHD, 2) improve therapeutic outcomes for youth with ADHD and co-occurring psychiatric and/or medical conditions through evidence-based recommendations, and 3) decrease stigma associated with stimulant use through education.

Best practices for documentation of psychotropic drug-drug interactions in an adult psychiatric clinic.

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."

Antipsychotic Safety in Liver Disease: A Narrative Review and Practical Guide for the Clinician.

BACKGROUND: Clinicians treating psychiatric disorders in medically ill patients need a comprehensive resource for comparing the risk and types of liver injury associated with antipsychotic therapy. OBJECTIVE: We conducted a narrative review aimed at developing a comprehensive resource comparing antipsychotics with regard to risk of inducing or worsening liver injuries, types of liver injury, associated pharmacokinetic changes, dosing, monitoring, and patient counseling recommendations. METHODS: We conducted database searches of LiverTox.nih.gov, DailyMed.nlm.nih.gov, and PubMed through June of 2022. Sources describing premarketing data, observational studies, case reports and case series of antipsychotic-induced liver injuries, types of hepatic dysfunction, interventions, recovery, and treatment for 15 antipsychotics were included. Duplicate reports were excluded. Antipsychotics were graded as low, low to moderate, moderate, moderate to high, or high risk for causing or worsening a liver disease. RESULTS: Of the 1861 publications, 21 papers met criteria and were included. Evidence shows antipsychotic-induced liver dysfunction is uncommon to rare. Chlorpromazine, clozapine, and olanzapine pose the greatest risk of hepatoxicity; quetiapine and risperidone pose a moderate risk with haloperidol considered to pose low to moderate risk. Paliperidone, aripiprazole, lurasidone, and loxapine are lower-risk agents with no reports of liver failure. Transaminitis that is mild and self-limiting is the most common antipsychotic-induced liver injury followed by hepatocellular disease, steatosis, and mixed liver injury. A careful risk-benefit analysis should guide the decision to discontinue the antipsychotic in cases of severe liver disease. Dose adjustments and careful monitoring are recommended for a mild to moderate disease when the benefits of treating psychosis outweigh the risks. Patients without an existing liver disease initiating a treatment with a higher-risk antipsychotic should be counseled to report symptoms of liver injuries along with regular lab monitoring. CONCLUSIONS: Antipsychotic selection, dosing, monitoring, and counseling should be individualized based on whether a patient has an existing liver disease and if they are receiving an agent that poses a higher risk of liver injury. The consultation-liaison psychiatry provider can guide the primary team in management through thoughtful integration of the known pathophysiologic changes in hepatic disease and risk-benefit analysis of antipsychotic safety profiles.

Positioning psychiatric pharmacists to improve mental health care.

Psychiatric pharmacy continues to grow and look to the future with a focus on helping individuals recover from mental health and substance use disorders. The American Association of Psychiatric Pharmacists (AAPP) considers Board Certified Psychiatric Pharmacist (BCPP) the gold standard credential that all psychiatric pharmacists should attain to demonstrate specialized knowledge and expertise in psychiatry. BCPPs are part of collaborative interprofessional teams and practice in hospitals, clinics, and diverse health systems. Two out of 3 BCPPs practicing in clinics have prescriptive authority. BCPPs improve access, safety, medication adherence, and therapeutic outcomes. Every person with a mental health and substance use disorder should have access to a BCPP providing comprehensive medication management (CMM) and psychotropic stewardship aimed at improving population health. BCPPs are in demand owing to their expertise. AAPP envisions growth and expansion of the BCPP role in many areas including coordinating psychiatric transitions of care and telehealth services, managing long-acting injectable medication clinics, providing pharmacogenomic consultation, conducting clozapine and lithium monitoring, managing medications for substance use disorders, leading medication groups, CNS drug development, research, and provider education. To prepare the workforce, colleges and schools of pharmacy should hire BCPPs for optimal curriculum development, and each student pharmacist should have an opportunity to develop a therapeutic alliance with a person recovering from psychiatric illness. Postgraduate year (PGY) 1 residencies should offer learning experiences in psychiatric pharmacy to prepare residents to enter an expanded number of PGY2 psychiatric pharmacy residencies, ultimately earning their BCPP and being well positioned to improve mental health care.

Changing manufacturer to address neutropenia induced by non-clozapine second-generation antipsychotics: Changing antipsychotic manufacturer to address neutropenia.

BACKGROUND: Clozapine is the antipsychotic most associated with causing neutropenia, a reduction of absolute neutrophil count (ANC) to less than 1500 cells/µL, but neutropenia can also occur with other second-generation antipsychotics (SGAs). Studies suggest that patients who develop clozapine-induced neutropenia may be rechallenged with clozapine after their ANC recovers. However, evidence for rechallenging patients who develop neutropenia with other SGAs is scarce and limited to case reports typically involving switching antipsychotics. CASE SUMMARIES: Reported are 2 cases in which patients who developed neutropenia with a generic formulation of a non-clozapine SGA were successfully rechallenged with the same antipsychotic from a different manufacturer: one brand name and one alternative generic. PRACTICE IMPLICATIONS: These cases show how switching to an alternative manufacturer may help resolve neutropenia without changing antipsychotic. Inactive ingredients used by different manufacturers are presented as a potential contribution to the development of neutropenia.

Collaboration Between Child and Adolescent Psychiatrists and Mental Health Pharmacists to Improve Treatment Outcomes.

Access to mental health care is a long-standing challenge. The high, rising prevalence of mental health disorders and a shortage of mental health professionals has further strained an already fragile system. The clinical pharmacy is underutilized within the mental health space. Interdisciplinary collaboration between child psychiatrists and mental health pharmacists gives the psychiatrist more time for patient evaluation and treatment, while the psychiatric pharmacist provides drug monitoring, medication coordination, and education for providers. This collaborative approach improves outcomes, prevents adverse drug events, reduces hospital stays, lessens emergency department visits, and improves engagement and adherence.

Insomnia overview: epidemiology, pathophysiology, diagnosis and monitoring, and nonpharmacologic therapy.

Insomnia, whether short-term or chronic, is a common condition. It has a negative impact on vulnerable patient groups, including active military personnel and veterans, patients with coexisting psychiatric and medical disorders, those in life transitions such as menopause, and elderly persons. Although cognitive behavioral therapy for insomnia (CBTI) is first-line treatment for insomnia, its high cost and a lack of trained providers has prevented widespread uptake. Now, digital CBTI (dCBTI) is emerging as a scalable option with the potential to overcome these barriers in managed care. The first part of this article reviews the epidemiology and pathophysiology of insomnia with a focus on vulnerable patient groups. The second part explores the rapidly evolving landscape of nondrug therapy for insomnia. The underlying concepts and supporting evidence for CBTI and dCBTI are presented, including their utility in vulnerable patient groups.

Pharmacy resident teaching in psychiatry and neurology for pharmacy programs in the United States.

INTRODUCTION: The American Society of Health-System Pharmacists' Postgraduate Year 1 and Year 2 Residency Accreditation Standards require that residents demonstrate effective teaching skills. The College of Psychiatric and Neurologic Pharmacists' survey of pharmacy program curricula assessed resident teaching in psychiatry and neurology, however, results were not published. The objective of this article is to describe resident teaching in psychiatry and neurology curricula as reported by responses to the college's survey. METHODS: An electronic survey was sent to a curricular representative from each of 133 US pharmacy programs accredited as of July 2015. Programs were asked to report on psychiatry and neurology curricular content, faculty credentials, and types of teaching activities, including resident teaching. RESULTS: Fifty-six percent (75/133) of programs responded to the survey. Fifty out of 75 (67%) distinct pharmacy programs reported utilizing residents for teaching topics in psychiatry and neurology. Residents were twice as likely to teach didactic topics in psychiatry (n = 44) compared to neurology (n = 22). Three times as many residents were involved in precepting psychiatric Advanced Pharmacy Practice Experiences (n = 37) compared to neurology Advanced Pharmacy Practice Experiences (n = 12). DISCUSSION: Residents are involved in both didactic and experiential teaching with more residents teaching psychiatry content compared to neurology content. Authors recommend utilizing the American Society of Health-System Pharmacists' electronic resident assessment tool, PharmAcademic®, to capture the quantity and quality of resident teaching across accredited programs.

Curriculum in Psychiatry and Neurology for Pharmacy Programs.

Objective. To describe pharmacy curricula in psychiatry and neurology and to report on neuropsychiatric pharmacy specialists' views on optimal curriculum. Methods. Design and administer one electronic survey to accredited pharmacy programs asking them to report information on curricula in psychiatry and neurology for the 2014-2015 academic year. Design and administer a separate electronic survey to board certified pharmacists with an academic affiliation who are members of the College of Psychiatric and Neurologic Pharmacists (CPNP) asking about their teaching activities and their opinion on optimal curricula. Results. Fifty-six percent of pharmacy programs and 65% of CPNP members responded to the surveys. The program survey revealed greater than 80% of topics were taught by full-time faculty. Didactic lecturing, team-based learning, and case studies were the most common teaching methods. Programs dedicated the most didactics (3 to 5+ hours) to epilepsy, depression, schizophrenia, substance use disorders, and pain. Autism, traumatic brain injury, personality, and eating disorders were either not taught or given ≤ 1 hour of didactics in most programs. Inpatient psychiatry had the most APPE placements with a mean of 19.6, range 0-83. APPE electives in psychiatry outnumbered those in neurology 5 to 1. CPNP member survey results showed 2 out of 3 members agreed that curriculum could be improved with additional APPEs in psychiatry and neurology. Conclusion. Didactic hour distribution in psychiatry and neurology could be improved to better align with board certification in psychiatric pharmacy (BCPP) recommendations and disorder prevalence and complexity. Specialists recommend an experiential component in neurology and psychiatry to combat stigma and improve pharmacist knowledge and skills.

Nonpsychiatric medication interventions initiated by a postgraduate year 2 psychiatric pharmacy resident in a patient-centered medical home.

OBJECTIVE: Studies have demonstrated the benefits of incorporating comprehensive medication management into primary care, but no study describes the types of nonpsychiatric medication-related interventions provided by a psychiatric pharmacist while providing comprehensive medication management. METHOD: A chart review of Center for Community Health patients enrolled in the University of Southern California Psychiatric Pharmacy Clinic, Los Angeles, between July 1, 2013, and January 10, 2014, was conducted. Progress notes were reviewed to collect medication recommendations and interventions. The number and types of interventions were compared between groups based on substance abuse history, comorbid medical conditions, number of psychiatric diagnoses, and number of medications. An anonymous survey was distributed to primary care providers (PCPs) regarding perceptions and attitudes toward a postgraduate year 2 psychiatric pharmacy resident's interventions pertaining to nonpsychiatric medications. RESULTS: 177 nonpsychiatric medication interventions were documented. Fifty interventions required PCP approval, and 45% of those were accepted. Having a diagnosis of diabetes (P < .0001), hypertension (P < .0001), gastroesophageal reflux disease (P < .0001), ≥ 9 medications (P < .0001), or ≥ 5 medical diagnoses (P < .0001) were all associated with an increased mean number of interventions. Of the PCPs, 66% viewed the psychiatric pharmacist as a resource for addressing medical interventions by providing drug information. The PCPs were agreeable to having a psychiatric pharmacist provide drug information and monitor the patient but reported mixed opinions on whether a psychiatric pharmacist should comanage nonpsychiatric conditions. CONCLUSIONS: Psychiatric pharmacists can successfully collaborate with PCPs in primary care clinics to provide comprehensive medication management that optimizes pharmacotherapy for patients with medical and psychiatric conditions. Continued efforts are needed to promote interdisciplinary approaches to provide comprehensive medication management services for patients with both psychiatric and medical disorders.

Psychiatric pharmacist and primary care collaboration at a skid-row safety-net clinic.

PURPOSE: There is limited access to psychiatric medication follow-up services at safety-net clinics serving the largely homeless minority population of Los Angeles' skid-row district. This paper describes the process of establishing a pharmacist-run psychiatric medication management service, the types of interventions provided by the psychiatric pharmacist, and patient and provider satisfaction with the service. METHODS: The establishment of a collaborative practice agreement between primary care physicians and psychiatric pharmacists is described along with the patient demographics and types of pharmacist interventions. Primary care physicians were surveyed regarding their comfort level with managing psychiatric illness and prescribing psychotropic medications. They were also asked about their opinion of psychiatric pharmacist medication management services. An anonymous patient satisfaction survey was also administered. RESULTS: The development of psychiatric pharmacy services is described. The types of interventions included initiating drug therapy, adjusting dosages, discontinuing drug therapy, and providing medication education. Primary care providers were not comfortable in providing psychiatric medication follow-up for patients beyond uncomplicated depression and anxiety disorders. They expressed an overall positive view of psychiatric pharmacist services for their patients with established psychiatric diagnoses. Patient satisfaction ratings were high. CONCLUSIONS: A psychiatric pharmacist-run medication management service in collaboration with primary care providers can improve access to mental health services in safety-net clinics with good provider and patient satisfaction.

The role of pharmacotherapy and managed care pharmacy interventions in the treatment of ADHD.

Pharmacotherapy plays a primary role in the management of attention-deficit/hyperactivity disorder (ADHD), despite the availability of effective behavioral interventions. Psychostimulants are the most commonly prescribed form of pharmacotherapy for patients with ADHD and their benefits in managed care are severalfold, leading not only to symptom resolution and improved quality of life for patients, but also reduced costs for payers and purchasers. The use of these agents requires careful consideration and management by health plan stakeholders for optimal effectiveness. Concerns regarding medication adherence, in addition to the potential for diversion and abuse of psychostimulants, highlight the importance of effective pharmacotherapy management in patients with ADHD. Initiatives promoting medication adherence, such as patient/parent education, provider follow-up, and adverse effect management, are crucial for ensuring treatment success. Once-daily, extended-release formulations of stimulants may also contribute to improving medication adherence, as may managed care pharmacy interventions such as pharmacy database monitoring.

Attention-deficit-hyperactivity disorder: an update.

Attention-deficit-hyperactivity disorder (ADHD) is a common neuropsychiatric disorder that impairs social, academic, and occupational functioning in children, adolescents, and adults. In patients with ADHD, neurobiologic research has shown a lack of connectivity in key brain regions, inhibitory control deficits, delayed brain maturation, and noradrenergic and dopaminergic dysfunction in multiple brain regions. The prevalence of this disorder in the United States is 6-9% in youth (i.e., children and adolescents) and 3-5% in adults. Prevalence rates for youth are similar worldwide. Children with ADHD are at greater risk than children without ADHD for substance abuse and delinquency whether or not they receive drug therapy; however, early treatment with psychoeducation as well as drug therapy and/or behavioral intervention may decrease negative outcomes of ADHD, including the rate of conduct disorder and adult antisocial personality disorder. Drug therapy is effective for all age groups, even preschoolers, and for late-onset ADHD in adults. Stimulants, such as methylphenidate and amphetamine, are the most effective therapy and have a good safety profile; although recent concerns of sudden unexplained death, psychiatric adverse effects, and growth effects have prompted the introduction of other therapies. Atomoxetine, a nonstimulant, has no abuse potential, causes less insomnia than stimulants, and poses minimal risk of growth effects. Other drug options include clonidine and guanfacine, but both can cause bradycardia and sedation. Polyunsaturated fatty acids (fish oil), acetyl-L-carnitine, and iron supplements (for youth with low ferritin levels) show promise in improving ADHD symptoms. As long-term studies show that at least 50% of youth are nonadherent with their drug therapy as prescribed over a 1-year period, long-acting formulations (administered once/day) may improve adherence. Comorbid conditions are common in patients with ADHD, but this patient population can be treated effectively with individualized treatment regimens of stimulants, atomoxetine, or bupropion, along with close monitoring.

Depression screening in a university campus pharmacy: a pilot project.

OBJECTIVE: To evaluate the usefulness of a depression screening tool in a university campus pharmacy. DESIGN: Uncontrolled study. SETTING: University campus pharmacy. PARTICIPANTS: 25 individuals were screened while waiting for a prescription to be dispensed or while browsing in the pharmacy. INTERVENTIONS: Completion of a depression screening tool and a follow-up participant satisfaction survey to rate the usefulness of the depression screening tool. MAIN OUTCOME MEASURES: Scores on the depression screening tool and descriptive analysis of participant satisfaction survey. RESULTS: One participant was rated as depressed and one participant as "borderline" depression on the screening tool. Overall, 64% (16/25) of participants rated the screening tool as very useful, 92% (23/25) felt very comfortable while completing the screening tool, 40% (10/25) were very likely to read the provided written information, and 60% (15/25) learned about depression or themselves by participating in the survey. CONCLUSION: Depression screening is feasible in a university campus pharmacy. Participants reported feeling comfortable discussing depression with a pharmacist in a university campus pharmacy. In addition, they considered the information provided by the pharmacist on depression to be useful.