By: Amanda Winslow, PharmD, BCPS
Over the past decade, there has been an increased focus on mental health throughout both the healthcare landscape and society in general. When thinking about the care of mental health patients, specific providers come to mind, like psychiatrists, psychologists and counselors. Most people would not immediately add pharmacists to that list. However, with an increase in mental health medications with overlapping indications and drug interactions, the pharmacist should be a central part of the team. Pharmacists are able to provide a long list of services within this practice area, including cost savings, drug interaction checking, drug monitoring, and direct patient counseling.
Regardless of the area of pharmacy worked, there are specific roles pharmacists always fill, including reviewing drug interactions and duplications of therapy. This can be especially important with mental health medications as many have overlapping indications and are in similar drug classes. A medication review for interactions and duplications should be completed in every setting including retail pharmacies, inpatient pharmacies and ambulatory care pharmacies to name a few. The review would include matching medications with disease state and checking for appropriateness by reviewing labeled and off-labeled indications for each medication. A drug-interaction report should also be processed to assess for any contraindications and to help form a monitoring plan. For example, if several medications are acting to increase serotonin, there would need to be education provided to the patient about signs and symptoms of serotonin syndrome.
Cost savings is another large role for pharmacists. The number one way to accomplish this would be to work in conjunction with the treating physician to remove any unnecessary or overlapping medications. This may not only reduce drug expenditure each month, but also reduce adverse events and costs associated. Pharmacists, especially those specialized in the area, are also likely to be familiar with any coupon cards that can be applied to brand name medications. These are usually given by drug reps to help increase usage of new and expensive medications. Many can also be found on manufacturers’ websites. Pharmacists can help the patients navigate the process of finding and utilizing these coupon cards when appropriate.
Drug monitoring is another major role of pharmacists within mental health care. Several medications, such as clozapine, require special monitoring of patients to be dispensed. These programs are called Risk Evaluation and Mitigation Strategies (REMS) and typically involve the patient, prescribing practitioner and pharmacist. Clozapine’s program specifically requires that pharmacies and pharmacists be registered with the program and must review the patient’s labs prior to dispensing the medication in order to reduce the risk of neutropenia, which can be very severe. Therapeutic drug monitoring (TDM) is another type of intervention pharmacists can make. Certain medications have very narrow therapeutic windows and require monitoring of levels to assure they are therapeutic. Lithium is a great example of this because it can be affected by so many outside factors including fluid or electrolyte intake or drug-drug interactions.
Lastly, as the most accessible part of the healthcare team, direct patient counseling is of paramount importance. In order to receive medications, the patients will at some point interact with a pharmacist. This interaction should be utilized to counsel on side effects, directions, importance of continuing medications and monitoring parameters. Mental health patients sometimes stop taking their medications when they are feeling better, so using this interaction to remind them to continue taking the medications could make a huge impact. Also, adherence is improved if patients are taking medications at the correct time of day. For example, suggesting the patient take a sedating medication at bedtime or an activating medication in the morning, rather than just defaulting to take once a day.
Recognizing the emerging roles and increased importance of having pharmacists involved in mental health, the Board of Pharmacy Specialties has created a Board Certification in Psychiatric Pharmacy (BCPP). This board certification can only be obtained after several years of qualified training and practice in the area of psychiatry. After said training, the applicants then take a test focusing mostly on patient-centered care, but the material also includes regulatory issues and literature evaluation. The addition of this specialty demonstrates that pharmacists have a well-defined role and should be considered integral to any complete mental healthcare team.