Ambulatory detoxification in alcohol use disorder and opioid use disorder.

Ambulatory detoxification in alcohol use disorder and opioid use disorder is an important component in the management of patients experiencing withdrawal symptoms from alcohol or opioids. The goal of withdrawal management is ultimately to provide each patient with comfort and safety. Having the knowledge of the possible signs and symptoms of intoxication and withdrawal assists providers to institute the most appropriate treatment protocol and setting for the patient. Pharmacists play a vital role in choosing appropriate therapeutic management options for common or complex clinical situations involving ambulatory detoxification from alcohol and opioids. Ambulatory detoxification serves as an appealing option to many patients and helps save the limited inpatient resources that many institutions have for those patients with more severe withdrawal presentations.

Clozapine-induced myocarditis: Two case reports and review of clinical presentation and recognition.

Myocarditis is a potentially fatal cardiac disease marked by inflammation of the heart muscle. With a noted black-box warning, rates of clozapine-induced myocarditis are reportedly as high as 3%. Since the first case of clozapine-induced myocarditis was documented in 1994, more than 250 cases have been described in literature with an approximate 33% case-fatality rate. We report 2 cases of patients with primary psychotic disorders treated with clozapine, who developed signs and symptoms of myocarditis. The first was a 35-year-old white male patient with a primary diagnosis of schizoaffective disorder (bipolar type) who was initiated on clozapine after nonresponse to several therapies. On day 26, the patient was admitted to the emergency department for chest pain presenting with eosinophilia and notable elevations in several biomarkers, including troponin and C-reactive protein. The second patient was a 45-year-old black male who was initiated on clozapine for treatment-resistant schizophrenia. On day 13, the patient reported cardiac-related concerns (tachycardia) and flu-like symptoms resulting in hospitalization. Similarly, this patient demonstrated elevated biomarkers (troponin and creatine kinase). Both patients experienced resolution of symptoms after discontinuation of clozapine. Clozapine was not rechallenged for either patient. Review of literature further elucidates the relationship between clozapine and myocarditis, including potential risk factors, pathophysiology, and symptom presentation. Due to the potentially fatal nature of this condition, clinical vigilance and awareness is warranted upon initiation of clozapine through monitoring of symptoms along with cardiac and inflammatory biomarkers as indicated.

Integrating a mental health clinical pharmacy specialist into the Homeless Patient Aligned Care Teams.

INTRODUCTION: To address the complex needs of the homeless veteran population, the US Department of Veterans Affairs created the Homeless Patient Aligned Care Team (H-PACT) model. The South Texas Veterans Health Care System has an established H-PACT model, however it does not include a clinical pharmacy specialist in mental health (MH). METHODS: An H-PACT MH pharmacy resident clinic was created and managed by a postgraduate year-2 psychiatric pharmacy resident. Improvements in access to MH care, Veterans Health Administration performance metrics, and estimated cost savings associated with resident interventions were reviewed to evaluate clinic utility. RESULTS: Over the 6-month clinic time frame, there were a total of 40 patient encounters in which 21 veterans had MH medication evaluation on at least 1 occasion. The average wait time for Veterans previously followed by the H-PACT psychiatrist was approximately 8 weeks. The H-PACT MH pharmacy resident clinic enabled veterans to be evaluated every 4 to 6 weeks. Interventions made by the resident included identification of medication administration errors, medication adjustments, adherence education, reduction in polypharmacy, and referral to other services. Estimated cost savings from clinic interventions totaled $33 613.67. DISCUSSION: The H-PACT MH pharmacy resident clinic allowed for an improvement in wait time for psychiatric pharmacotherapy follow-up for homeless veterans, with interventions that were associated with significant estimated cost savings.

A review of medical marijuana for the treatment of posttraumatic stress disorder: Real symptom re-leaf or just high hopes?

INTRODUCTION: The incidence of posttraumatic stress disorder (PTSD) is common within the population and even more so among veterans. Current medication treatment is limited primarily to antidepressants. Such medicines have shown to produce low remission rates and may require 9 patients to be treated for 1 to have a response. Aside from the Veterans Affairs/Department of Defense guidelines, other guidelines do not recommend pharmacotherapy as a first-line option, particularly in the veteran population. Marijuana has been evaluated as an alternative and novel treatment option with 16 states legalizing its use for PTSD. METHODS: A systematic search was conducted to evaluate the evidence for the use of marijuana for PTSD. Studies for the review were included based on a literature search from Ovid MEDLINE and Google Scholar. RESULTS: Five studies were identified that evaluated the use of marijuana for PTSD. One trial was conducted in Israel and actively used marijuana. Three studies did not use marijuana in the treatment arm but instead evaluated the effects postuse. A retrospective chart review from New Mexico relied on patients to recall their change in PTSD symptoms when using marijuana. Three studies concluded there might be a benefit, but two discouraged its use. Although the two negative studies show a statistical difference in worse PTSD outcomes, clinical significance is unclear. DISCUSSION: Conflicting data exist for the use of marijuana for PTSD; however, current evidence is limited to anecdotal experiences, case reports, and observational studies, making it difficult to make clinical recommendations.

Evaluating psychiatric outcomes associated with direct-acting antiviral treatment in veterans with hepatitis C infection.

INTRODUCTION: Approximately 70% of veterans with hepatitis C virus infection have at least one psychiatric illness. The advent of direct-acting antiviral (DAA) therapy provided an alternative to interferon-alpha regimens and revolutionized treatment, however, the extent of psychiatric effects attributed to these agents are unclear. The primary objective of this pilot study was to prospectively analyze psychiatric outcomes, specifically depression, in veterans with hepatitis C virus infection who are initiated on DAA therapy. METHODS: In this single center, prospective cohort study, psychiatric outcomes were analyzed using Patient Health Questionnaire assessments at baseline and weeks 4, 8, and 12 of complete DAA treatment. Outcome analysis were stratified based on specific DAA therapy and preexisting mental illness (mental health [MH] subjects and non-MH subjects), with a sub-analysis of major depressive disorder patients. RESULTS: Analysis included 48 patients, majority males (96%), with a mean age of 59.4 years (±8.0). Twenty-four (50%) patients had a preexisting MH diagnosis, with major depressive disorder being the most common MH diagnosis (50%, n = 12). Despite a trend toward improvement, no significant changes in questionnaire scores after 12 weeks of DAA therapy were observed for all patient groups (P > .05). Neither MH subjects nor non-MH subjects displayed a significant change in questionnaire scores from baseline to end of treatment (P > .05). No patients required acute psychiatric interventions during DAA treatment. DISCUSSION: Treatment with DAA therapy was not associated with psychiatric decompensation. Data from this pilot study supports the safe utilization of DAA therapy in hepatitis C virus patients with preexisting MH illness as it appears to be devoid of depressive and psychiatric side effects.

Levocarnitine for valproate-induced hyperammonemia in the psychiatric setting: A case series and literature review.

INTRODUCTION: Hyperammonemia is a potential adverse effect of valproic acid (VPA) therapy, which is often asymptomatic but can lead to severe, life-threatening encephalopathy. Carnitine deficiency due to VPA is the proposed mechanism for hyperammonemia and the development of VPA-induced hyperammonemic encephalopathy (VHE). Levocarnitine, the active form of carnitine, has been suggested for treatment and prevention of VHE. METHODS: Data was collected by chart review of 3 patients who received oral levocarnitine supplementation in the psychiatric setting for VPA-induced hyperammonemia. Review of the literature was performed through June 2017 using the following PubMed search terms: valproate, valproic acid, hyperammonemia, altered mental status, encephalopathy, and levocarnitine. Articles were included if they described use of levocarnitine in VPA-treated patients with psychiatric disorders. RESULTS: One patient developed encephalopathy with resolution of symptoms after VPA discontinuation. Valproic acid was restarted with the addition of levocarnitine to prevent VHE reoccurrence. In the other 2 cases, levocarnitine was started prophylactically in patients who developed hyperammonemia without emergence of any clinical symptoms. Ammonia levels were reduced to normal in all cases, and no symptoms consistent with encephalopathy were reported. The literature search identified 6 additional cases with 5 of 6 reports supporting use of levocarnitine for decreased ammonia levels as well as an observational trial. DISCUSSION: This literature review and case series illustrates successful use of levocarnitine supplementation for reduction of ammonia levels in the setting of VPA-induced hyperammonemia among patients with psychiatric disorders. However, clinical significance of ammonia reduction in asymptomatic patients is difficult to determine.

Consumer satisfaction with National Alliance on Mental Illness written medicine information.

INTRODUCTION: Written medicine information (WMI) is a collection of facts for a specific medication, and it helps facilitate patient understanding of medication therapy. The primary objective of this study was to assess consumer satisfaction with National Alliance on Mental Illness (NAMI) WMI. A secondary objective was to assess health care professional satisfaction. METHODS: National Alliance on Mental Illness WMI and surveys were offered to consumers, health care professionals, and trainees at 3 treatment centers with psychiatric services. All adults who received medication counseling were eligible for inclusion. Survey responses were evaluated using descriptive statistics. RESULTS: Most consumers (82.4%) and providers (74.5%) reported overall satisfaction with NAMI WMI. Consumers were least satisfied with information on how to manage unwanted effects, drug-drug interactions, and readability (9.5%, 14.9%, 41.9% dissatisfaction). DISCUSSION: Evaluation and feedback from consumers and health care professionals may influence decisions to refine NAMI WMI to meet consumer needs.

Outcomes of mental health pharmacist-managed electronic consults at a Veterans Affairs health care system.

INTRODUCTION: The demand for mental health services has increased as more veterans have been diagnosed with-and sought care for-one or more mental health conditions. Within the South Texas Veterans Health Care System (STVHCS), providers may submit electronic consults (e-consults) to mental health clinical pharmacy specialists for medication review and recommendations. These consults aim to manage veterans with uncomplicated mental health conditions in primary care, making specialty mental health providers more available for those who need such services. Pharmacists have improved outcomes and access to care for conditions such as diabetes and hypertension, but currently, there is limited evidence demonstrating the impact of pharmacists in mental health. METHODS: This quality improvement project assessed the effectiveness of the e-consult service. Information was collected through a retrospective chart review of STVHCS veterans with the corresponding consult note placed in their chart from May 2014 through December 2015. Numbers of recommendations implemented and veterans maintained in primary care were analyzed as markers of effectiveness. Time and cost savings were secondarily explored. RESULTS: A total of 361 consults were submitted for 353 unique patients. Of the 322 patients included in analyses, a total of 301 unique patients (93.5%) were maintained in primary care for at least 3 months. Of the 21 not maintained in primary care, 15 recommendations were implemented; of those maintained in primary care, 271 recommendations were implemented. DISCUSSION: This service improves mental health care-and patient access-by promoting successful management and maintenance of less complicated patients in primary care.

Hospitalizations and emergency room visits after initiation of long-acting injectable antipsychotics.

INTRODUCTION: Long-acting injectable antipsychotics (LAIs) serve as a means to ensure medication adherence with the intention of improving outcomes for psychiatric patients. Evidence remains inconclusive regarding the impact of LAIs on relapses and psychiatric hospitalizations rates. METHODS: The primary objective of this retrospective pre/post study was to determine whether initiating an LAI in a veteran population with schizophrenia, schizoaffective disorder, or bipolar disorder is associated with a decrease in the 1-year rate of psychiatric hospitalizations and emergency room (ER) visits. RESULTS: For the combined primary endpoint, the 1-year rate of psychiatric hospitalizations and ER visits for patients with schizophrenia, schizoaffective disorder, or bipolar disorder was not significantly reduced after initiation of LAIs (n = 50, median [interquartile range]: 1.5 [1, 3] to 1 [0, 3], P = .055). However, the secondary endpoint of the 1-year rate of psychiatric hospitalizations was reduced (1 [0, 3] to 0 [0, 2], P = .026). Additionally, for those who received injections on a regular basis, the 1-year rate of hospitalizations and ER visits was significantly reduced (2 [1, 3] to 0 [0, 1.5], P = .009). DISCUSSION: This retrospective study suggests that the initiation of LAIs is associated with a reduced rate of psychiatric hospitalizations as well as a reduced rate of psychiatric hospitalizations and ER visits for those patients who receive injections on a regular basis.

Assisting Social Security Disability Insurance beneficiaries with schizophrenia, bipolar disorder, or major depression in returning to work.

OBJECTIVE: People with psychiatric impairments (primarily schizophrenia or a mood disorder) are the largest and fastest-growing group of Social Security Disability Insurance (SSDI) beneficiaries. The authors investigated whether evidence-based supported employment and mental health treatments can improve vocational and mental health recovery for this population. METHOD: Using a randomized controlled trial design, the authors tested a multifaceted intervention: team-based supported employment, systematic medication management, and other behavioral health services, along with elimination of barriers by providing complete health insurance coverage (with no out-of-pocket expenses) and suspending disability reviews. The control group received usual services. Paid employment was the primary outcome measure, and overall mental health and quality of life were secondary outcome measures. RESULTS: Overall, 2,059 SSDI beneficiaries with schizophrenia, bipolar disorder, or depression in 23 cities participated in the 2-year intervention. The teams implemented the intervention package with acceptable fidelity. The intervention group experienced more paid employment (60.3% compared with 40.2%) and reported better mental health and quality of life than the control group. CONCLUSIONS: Implementation of the complex intervention in routine mental health treatment settings was feasible, and the intervention was effective in assisting individuals disabled by schizophrenia or depression to return to work and improve their mental health and quality of life.

Can medication management coordinators help improve continuity of care after psychiatric hospitalization?

OBJECTIVE: This demonstration project examined whether medication management coordinators enhanced continuity of care from inpatient facilities to an outpatient public mental health clinic. METHODS: From 2004 to 2008, patients (N=325) hospitalized with schizophrenia or schizoaffective or bipolar disorder enrolled in a medication management program before discharge or at their first clinic appointment. Medication management coordinators supplemented existing clinic practices by identifying recently hospitalized patients, providing inpatient and outpatient prescribing clinicians with patients' complete medication history, meeting with patients for six months postdischarge to assess clinical status and provide medication education, and advocating guideline-concordant prescribing. Recently discharged patients (N=345) assigned to a different outpatient clinic within the same agency served as the comparison group. Intent-to-treat, repeated-measures analyses for mixed models compared the groups' number of hospital admissions, hospital days, and medication appointments kept and use of nurse or case manager contact hours and emergency or crisis services during the 12 months before enrollment, the six-month intervention, and the six-month follow-up period. RESULTS: After discharge, individuals enrolled in medication management were more likely than comparison patients to attend outpatient appointments, and they had more medication visits and nurse or case manager treatment hours than the comparison group. Use of hospital and crisis or emergency services by all patients decreased. Almost one-third of patients never attended an outpatient appointment after hospital discharge. CONCLUSIONS: Although this program succeeded in improving continuity of care, additional interventions may be required to reduce rehospitalization and crisis care.

Review of the safety, efficacy, and side effect profile of asenapine in the treatment of bipolar 1 disorder.

OBJECTIVE: Asenapine is approved for acute manic and mixed states in bipolar disorder. The objective is to review the efficacy of asenapine in bipolar disorder, with a particular focus on acceptability and adherence to treatment. METHODS: FIVE CLINICAL TRIALS WERE CONDUCTED IN BIPOLAR DISORDER MANIC OR MIXED STATES: two 3-week trials (n = 976) comparing asenapine to placebo, a 9-week extension (n = 504), and a 40-week extension (n = 107). One trial was conducted comparing asenapine to placebo (n = 326) as adjunctive therapy for subjects with an incomplete response to lithium or valproate. All trials were conducted in the USA and internationally. RESULTS: Asenapine was found to be efficacious for manic and mixed states in bipolar disorder compared with placebo control, and compares equally well to olanzapine on efficacy measures after 3 weeks of treatment. Asenapine was not found to be efficacious for depression symptoms. Common asenapine side effects in the 40-week extension trial were sedation, insomnia, and dizziness, and 31% reported clinically significant weight gain, compared with 55% reporting clinically significant weight gain with olanzapine. Additionally, 18% had clinically significant changes in fasting blood glucose levels compared to 22% of those on olanzapine. In terms of patient acceptability, one concern may be sublingual administration requiring no liquids or food for 10 minutes after dosing and a twice-daily regimen. Suggestions about addressing barriers to adherence and acceptability are provided. CONCLUSION: Asenapine is a promising new medication in bipolar disorder. Asenapine in the long-term has a more favorable weight gain profile compared to olanzapine. No benefit was seen for depression symptoms, a major patient-reported concern. Some side effects do not remit after the short-term trials in at least 10% of patients.

Schizophrenia treatment guidelines in the United States.

BACKGROUND: The development of algorithms and guidelines in medicine is widespread. There are six major guidelines used and/or influencing the treatment of schizophrenia in the United States. The impact of these guidelines on clinical practice is difficult to evaluate. Many studies to date show poor adherence to schizophrenia guideline recommendations. OBJECTIVE: The purpose of this article is to discuss the rationale for use of guidelines/algorithms in medicine, the importance of schizophrenia guidelines, barriers to using guidelines, and to review key aspects of schizophrenia guidelines most commonly used in the United States. RESULTS: Schizophrenia guidelines/algorithms differ somewhat in scope, focus, goals, and recommendations. Each guideline/algorithm has its utility in clinical practice.

Barriers to, and strategies for, starting a long acting injection clinic in a community mental health center.

As many as 50% of patients with schizophrenia do not take oral antipsychotic medications as prescribed, yet long acting injections are rarely utilized. Community agencies that serve this population are often over-burdened and poorly funded. There are negative attitudes on the part of both physicians and consumers about injections. Transportation and logistics are often problematic. We describe the unique opportunity provided by the need for bi-weekly or monthly injections to establish a recovery-oriented group around injection visits. Our approach discusses methods and resources to help overcome some of the common barriers by establishing advocates within the agency, establishing necessary infrastructure, providing education for consumers, providers, and staff, sharing information about successful outcomes with clinic staff and working through billing issues. We also recommend public advocacy on the part of the clinic and consumers to work with state funding sources to change regulations that may limit appropriate clinical care.

The Texas Medication Algorithm Project antipsychotic algorithm for schizophrenia: 2006 update.

BACKGROUND: A panel of academic psychiatrists and pharmacists, clinicians from the Texas public mental health system, advocates, and consumers met in June 2006 in Dallas, Tex., to review recent evidence in the pharmacologic treatment of schizophrenia. The goal of the consensus conference was to update and revise the Texas Medication Algorithm Project (TMAP) algorithm for schizophrenia used in the Texas Implementation of Medication Algorithms, a statewide quality assurance program for treatment of major psychiatric illness. METHOD: Four questions were identified via premeeting teleconferences. (1) Should antipsychotic treatment of first-episode schizophrenia be different from that of multiepisode schizophrenia? (2) In which algorithm stages should first-generation antipsychotics (FGAs) be an option? (3) How many antipsychotic trials should precede a clozapine trial? (4) What is the status of augmentation strategies for clozapine? Subgroups reviewed the evidence in each area and presented their findings at the conference. RESULTS: The algorithm was updated to incorporate the following recommendations. (1) Persons with first-episode schizophrenia typically require lower antipsychotic doses and are more sensitive to side effects such as weight gain and extrapyramidal symptoms (group consensus). Second-generation antipsychotics (SGAs) are preferred for treatment of first-episode schizophrenia (majority opinion). (2) FGAs should be included in algorithm stages after first episode that include SGAs other than clozapine as options (group consensus). (3) The recommended number of trials of other antipsychotics that should precede a clozapine trial is 2, but earlier use of clozapine should be considered in the presence of persistent problems such as suicidality, comorbid violence, and substance abuse (group consensus). (4) Augmentation is reasonable for persons with inadequate response to clozapine, but published results on augmenting agents have not identified replicable positive results (group consensus). CONCLUSIONS: These recommendations are meant to provide a framework for clinical decision making, not to replace clinical judgment. As with any algorithm, treatment practices will evolve beyond the recommendations of this consensus conference as new evidence and additional medications become available.

Real-world antipsychotic treatment practices.

This article examines real-world antipsychotic use in the treatment of schizophrenia by comparing real-world prescribing with medication algorithms and guidelines, by evaluating the evidence underlying recommendations and guidelines, and by examining the roles of side effects and medication adherence in real-world prescribing decisions.