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Marquita Winder, Pharm.D., BCACP, CDE
Assistant Professor of Pharmacy Practice
South University School of Pharmacy
Columbia, SC

Clinical Pharmacy Specialist-Endocrinology
WJB Dorn VA Medical Center

 

 

“She puzzled over this for some time, but at last a bright thought struck her.”1

For at least 6-12 months prior to Midyear, I vascillated between ambulatory care and psychiatry in regards to which specialization I wished to pursue. Which way would the pendulum swing? After much consideration with regards to personal family experiences, self-awareness and emotional intelligence, one specialty had outweighed the other. I chose Ambulatory Care. With the assurance of many insightful mentors, it was determined that it was possible to explore both options. Although ambulatory care came out on top, in order to provide optimal patient care, mental illnesses must be managed as well. The pendulum rested in the middle.

Literature suggests that mental health disorders are associated with an increase in chronic disease development.2,3 On the contrary, patients diagnosed with a chronic disease are more likely to suffer from depression as well.3 Depression occurs concomitantly in 17% of cardiovascular cases, in 23% of cerebrovascular cases, and in 27% of patients with diabetes. 5,6 Thus, the relationship between mental health and chronic disease is significant. Mental illnesses such as depression often lead to poorer self-care behaviors.7

The economic burden of mental illnesses in the United States is substantial.9 However, with only 800+ Board Certified Psychiatric Pharmacists (BCPP) 8, collaboration with pharmacists who specialize in ambulatory care and other specialties may be beneficial.

Ambulatory Care Pharmacists can assist patients with mental illnesses in multiple ways:

  • Refer to mental health services to confirm diagnosis (e.g., depression, substance use disorder, dementia)
  • Consult/collaborate with a pharmacist specializing in psychiatry, if available, to determine possible courses of action and/or make appropriate recommendations for nonpharmacologic and pharmacologic treatment
  • Exercise clinical judgment to treat patients with coinciding mental and chronic illnesses
  • Recommend tobacco cessation treatment programs
  • Recommend/prescribe/provide patient education for naloxone kits
  • Administer screening tools such as the PHQ-2 and/or PHQ-9
  • Conduct medication reconciliations to determine if pharmacologic treatments for mental illnesses are optimal/efficacious/properly monitored
  • Coordinate home-based/telehealth services for monitoring mental illnesses (e.g., depression)

Recently, a PGY-2 Ambulatory Care Resident discussed the intimidation she experienced in the wake of treating a patient’s substance abuse and depression prior to treating Type 2 Diabetes Mellitus. The resident was very appreciative of the insight provided and the coachable moment that occurred. It is from an exposure during training and treating an array of patients that I have learned of the benefits and improvement in overall health of a patient once mental illnesses are treated and stabilized. From an ambulatory care perspective, many areas regarding mental health are already assessed on the board certification examination to include: special order drug systems ( e.g., Clozaril®), collaborative drug therapy management via protocol, integrated disease-state management as well as focused disease-state management (e.g., mental health), and wellness and preventive programs for individual patients (e.g., tobacco cessation program).10

It is postulated that limited expertise in psychiatric pharmacy is a barrier to providing assistance. Yet, one could aspire to build an expertise in a new field if desired, or if perceived as a return on investment. One of the proposed steps for building an expertise in a new field is persuading experts to share11 which I hope to accomplish by authoring this article. I would like to encourage any pharmacist/trainees specializing in psychiatry to empower pharmacists/trainees specializing in other areas to assist in the treatment of mental illnesses. Invite them to participate in events or education such as suicide risk assessment training. Initiate open dialogue about psychiatric services that could be rendered by non-psychiatric pharmacists. If interest evolves, educate other pharmacists to identify problems related to mental health and processes for referrals as well as community resources in which patients may participate. I am aware that this article was authored from a slightly biased perspective as I already had an existing interest in psychiatry. It is my hope that others will become interested and join in our proclivity to provide psychiatric services in some capacity.

Mental illnesses should be treated with the same if not more urgency than physical illnesses. The Oath of a Pharmacist suggests that we will accept the lifelong obligation to improve our professional knowledge and competence 12 no matter the specialty. Will you accept the challenge to utilize the knowledge, skills and experiences afforded to encourage other pharmacists to become involved in treating mental illnesses?

References

  1. Carroll, Lewis, Hugh Haughton, and Lewis Carroll. Alice's Adventures in Wonderland; And, Through the Looking-Glass and What Alice Found There. New York: Penguin Classics, 2009. Print.
  2. “Mental Health and Chronic Diseases CDC.” Fact Sheet. Center for Disease Control. October 2012. Atlanta, GA. Web.
  3. Melek SP, Norris DT, Paulus J. Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry. Milliman American Psychiatric Association Report. 2014
  4. Chapman DP, Perry GS, Strine TW. The vital link between chronic disease and depressive disorders. Prev Chronic Dis [serial online] 2005; 2(1). http://www.cdc.gov/pcd/issues/2005/jan/04_0066.htm. Accessed December 1, 2015.
  5. American Heart Association. Depression and Heart Health Web Site; http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Depression-and-Heart-Health_UCM_440444_Article.jsp. Accessed December 1, 2015.
  6. Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: A population-based prevalence study. JAMA. 2000;284(20):2606-10. PubMed PMID: 11086367.
  7. Gonzlez JS, Safren SA, Cagliero E, Wexler DJ, Delahanty L, Wittenberg E, et al. Depression, Self-Care, and Medication Adherence in Type 2 Diabetes. Diabetes Care. 2007 Sept; 30 (9): 2222-2227.
  8. College of Psychiatric and Neurologic Pharmacists [homepage on the Internet]. https://cpnp.org/faq/24914/how-many-psychiatric-and-neurologic-pharmacists-are-there-united-states. Accessed December 1, 2015.
  9. Center for Disease Control [homepage on the Internet]. CDC Report: Mental Illness Surveillance Among U.S. Adults. http://www.cdc.gov/mentalhealthsurveillance/. Accessed December 1, 2015.
  10. Board of Pharmacy Specialists [homepage on the Internet]. http://www.bpsweb.org/pdfs/AmbulatoryCareContentOutline.pdf. Accessed December 1, 2015.
  11. Leonard D. Harvard Business Review Blog [Internet]. How to Build Expertise in a New Field. 2015 April [cited 2015 December]. Available from: https://hbr.org/2015/04/how-to-build-expertise-in-a-new-field
  12. American Pharmacists Association [homepage on the Internet]. Oath of a Pharmacist. Available from: http://www.pharmacist.com/oath-pharmacist. Accessed December 1, 2015.

 

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