Transcript SGAs - NAMI: National Alliance on Mental Illness

How to Utilize Your Pharmacist
In the Inpatient/Hospital Setting
Julie Dopheide, PharmD, BCPP
Associate Professor
USC School of Pharmacy
[email protected]
NAMI 2007
Annual Convention
June 22, 2007
My experience….
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Psychiatric Pharmacist specialist at LAC+USC
Inpatient Psychiatric service
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Pharmacist Specialist at Kaiser Mental Health
Center in Los Angeles, CA
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40 bed adult unit, 12 bed adolescent unit
12 years of clinic experience (1988-2000)
60 bed adult unit, partial hospitalization program
Consulting Clinical Pharmacist at BHC Alhambra
Hospital in Rosemead, CA
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25 children, 15 adolescents, 40 adults general psychiatry
Eating Disorders inpatient, partial hospitalization unit
Psychiatric Hospitalization
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Relief that treatment is underway in a safe
place, with trained medical staff
Fear regarding an unknown medical team,
medication changes, limited contact with
loved one(s)
Concern that symptoms are not fully
stabilized before discharge
Unaware that a pharmacist is actively
participating in care and can be a resource
Role of the Pharmacist
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Multidisciplinary treatment planning
Individual medication review, recommendations
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Fill prescriptions for routine and prn medications
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Appropriate medication, dose, duration of tx
Drug intx screening, monitoring, simplify dosing
Proper labeling, integrity, security of medications
Education of patients, treatment team, family
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Individual counseling, medication group, discharge
counseling, family meetings, new drug inservices
Medication Recommendations
“Another pair of eyes….”
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“Dose too low”, “Dose too high”
“Adequate trial has not been achieved yet,
allow more time before change”
“Give at bedtime to minimize daytime
sleepiness” or “Give in am to prevent insomnia”
“Check liver, kidney, thyroid, cholesterol,
glucose, to ensure safety of medication”
Interpret lithium or valproate blood level
Individual Medication Review
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JJ is a 22 year old hospitalized for running naked in the
street; paranoid, not sleeping, Dx: Schizoaffective
Current medications: risperidone 4mg/d, olanzapine 30
mg/d, lithium 600mg/d, clonazepam 2mg
Lithium level 0.6 mEq/L
Recommendation: optimize lithium dose for maximum
benefit, may not need 2 antipsychotics or clonazepam
when lithium level is 0.8-1.2mEq/L
Use tylenol for pain instead of ibuprofen to avoid
increase in lithium level and potential for toxicity
Individual Medication Review
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FA is a 42 year old hospitalized after stopping
olanzapine 30mg when told of Hep C, ↑ liver enzymes,
↑cholesterol, Dx: Schizophrenia, substance abuse
AH, VH, persecutory delusions, depression, isolation
Current meds: quetiapine 1200mg/d, citalopram 40mg/d,
trazodone 200mg, temazepam 30mg at bedtime x 4wk
Recommendation: taper off quetiapine and start loxapine
because it has > D2 blockade, evidence of liver safety
Psychosis greatly improved, trazodone, temazepam
tapered off with ↓ daytime sedation, more socialization
Individual Med Consultation - SE
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BB, a 36 yo engineer has + response to Abilify
and Depakote but is concerned that coworkers
will notice hand tremor or tremor will interfere
with functioning at work. Discharge in 2 days
Recommend propranolol for tremor if related to
Depakote, benztropine if tremor from Abilify
Discuss recommendations with physician, BB
Medication Education
Group
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45 to 60 minutes, 6 – 12 patients
Interactive Discussion – structured format
Overview of psychotropics: thought organizers,
mood stabilizers, antidepressants, sleep meds
Goals: de-stigmatize illness and medications,
discuss med benefits, side effects/management
Answer questions and address concerns
Discuss consequences of alcohol & drugs
Medication Education Group
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22 yo newly diagnosed bipolar, resistant to
meds hears from a 52 yo w/ bipolar x 30yrs,
“Medication keeps you out of the hospital”.
48 yo, obese person w/ diabetes learns there
are meds w/ low to no weight gain and receives
support from others struggling w/ weight issues
36 yo, tells group “Taking medication helps
keep me off drugs and alcohol”
Discharge Medication
Counseling
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PR is a 27 yo mother of 2 hospitalized after a
suicide attempt, in hospital x 7 days
Diagnosis: Major depression w/ psychosis
Discharge medications:
fluoxetine 20mg qam, olanzapine 15mg qhs
Question: “how come I don’t feel much better?”
Concern: “I don’t want to be addicted to drugs”
Family planning issues
Family Meetings
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Family and friends provide encouragement and
support to facilitate recovery, prevent relapse
How can refills be obtained? how often do blood
tests need to be done?
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What can risperidone liquid be mixed with?
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Is it safe to take an antidepressant with blood
pressure or pain medication?
Clinical Pharmacists Improve Care in
Hospitals
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36 studies analyzed
General Medicine, Geriatrics, Psychiatry
Activities: interacting with health-care team, pt
interviews, monitoring, discharge counseling
Improved med appropriateness
Improved med adherence
Decreased med errors
Decreased adverse drug events
Kaboli P. Archives of Internal Medicine 2006;166:955-964
Outcomes of Clinical Pharmacist
Interventions in Psychiatric Hospital
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93 participants
Compared usual care to regular pharmacist
assessments, recommendations, education
Improved clinical response (↓ psychosis ↑ mood
measured on objective rating scales
Decreased abnormal involuntary movements
Decreased restlessness (akathisia)
No sig. difference in med costs or length of stay
Canales PL Am J Health-System Pharmacy 2001;58:1309-1316
Recommendations
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Ask if hospital has a clinical pharmacist
participating in treatment and med education
Ask for medication consultation with a
pharmacist prior to discharge from hospital
Ask about clinic follow-up appointments
Verify discharge prescriptions include enough
medication to last until clinic appointment
Utilize medication fact sheets and “Ask the
Psychiatric Pharmacist” on NAMI.org