The “What I Wish I Knew” series of articles is a service of CPNP’s Resident and New Practitioner Committee. Articles are intended to provide advice from experts for students, residents, and new practitioners. Articles are not intended to provide in-depth disease state or pharmacotherapy information nor replace any peer-reviewed educational materials. We hope you benefit from this “field guide” discussing approaches to unique problems and situations.
Dr. Bishop is Associate Professor of Experimental and Clinical Pharmacology at the University of Minnesota (UMN). He conducts psychiatric pharmacogenomics research activities in the UMN College of Pharmacy Pharmacogenomics Laboratory with a primary focus on symptom response, cognitive response, and side effects to medications. He has clinical experience in the treatment of psychosis and mood disorder populations and is also a contributing member to the Clinical Pharmacogenomics Implementation Consortium, the University of Minnesota Precision Medicine and Health Consortium the University of Minnesota Pathway-Driven UofM Alliance (PUMA) Institute for Personalized Medicine.
Practice environments for psychiatric pharmacists have existed for some time in the hospital setting. Traditionally this has been in the context of working with inpatient treatment teams. However, there have been increasing opportunities for psychiatric pharmacists to practice within hospital-based outpatient clinics, injection clinics, and emergency departments. There continues to be a great need for individuals well-versed in psychiatric pharmacy to contribute to the care of individuals in community environments, including involvement in both primary care and assertive community treatment (ACT) team settings. With notable shortages of mental health care providers, particularly in rural areas, there is a growing opportunity for pharmacists to support both primary care providers and psychiatric specialists. The number of psychiatric pharmacists utilizing collaborative practice agreements in outpatient clinics continues to increase, as do the opportunities for pharmacists to be reimbursed for the provision of comprehensive medication management. For patients who may struggle with mental health and other medical conditions with complex medication regimens, the optimization of this therapy is essential.
Additionally, there are evolving opportunities for psychiatric pharmacists in industry. Individuals with advanced training and clinical experience in psychopharmacology are increasingly recognized as important members of drug development and medical affairs teams in the pharmaceutical industry. With a unique knowledge of the medications and clinical scenarios in which they are used, psychiatric pharmacists provide essential input into the development of new products, optimization of existing drugs, and the education provided to people using these medications in clinical care.
Other unique opportunities for psychiatric pharmacists exist in assisted living or residential treatment facilities, long-term care, or institutional settings where psychotropic medications are often used and require close monitoring for appropriate, effective, and safe use.
To understand what the future holds, it is helpful to broadly look at some trends in pharmacy practice. The recently published 2014 Pharmacist Workforce Survey identified a slight decrease in the workforce demand for pharmacists from 2002-2015 while the proportion of practicing pharmacists who completed residency training has increased from 7 to 13% from 2004-2014 (Mott 2016). The proportion of time spent dispensing has decreased slightly while non-dispensing activities including education and other patient care services have increased. A dramatic increase in other services was observed from 2004-2014 including health screenings, disease state management, medication reconciliation, medication therapy management, and immunizations. These all point to trends of pharmacists taking a larger role in care delivery. This is being done in a health care environment where pharmacists continue to work toward provider status recognition, which could open up additional payment models for services. I imagine this will change in the near future and open up opportunities for psychiatric pharmacists to find additional support in their provision of care to patients, particularly in outpatient settings.
Advances in mobile technology will provide opportunities for medication and symptom monitoring. Telepharmacy opportunities will hopefully expand for psychiatric pharmacists just as they have for psychiatrists. This will increase the availability of pharmacists for both prescriber and patient consultations, particularly in rural areas or in regions with lower densities of psychiatric pharmacy specialists.
Pharmacist prescribing already exists in some environments like Veteran’s Administration Medical Centers. I doubt that there are going to be broad near-term expansions of pharmacist prescribing, but I anticipate that there will be an increase in collaborative practice agreements which will provide opportunities for limited prescriptive activities.
Precision medicine seems to be the ‘it’ thing right now which evolved from the term ‘personalized medicine’. At the higher level they both seem to mean the same thing, but we’ve really been trying to ‘personalize’ treatment for patients all along by taking into account the nuances of an individual’s clinical presentation. The spirit of ‘precision medicine’, then, is to incorporate additional technologies to improve treatment by making them more ‘precise’. Current trends include the study of incorporating mobile (e.g. wearable monitors, ‘smart’ watches, smartphone applications, etc), or biological (e.g. genetic data or real time monitoring of drugs or other substances in the body) technologies into patient care (Bishop 2017).
One aspect of precision medicine that has recently taken off is that of pharmacogenetic testing. We have a growing understanding of how genetic variation influencing drug metabolism and pharmacodynamics may influence dosing or drug selection. This is particularly relevant to psychiatric pharmacy for a couple of reasons. The first is that in the absence of a robust drug development pipeline for mental health conditions, we need to optimize the treatments that are currently available. Many patients require multiple medication trials to find a drug that is tolerable and efficacious. The second is that the most commonly used medications in psychiatry are antidepressants and antipsychotics, most of which undergo extensive hepatic metabolism through enzymes with notable genetic variation (Drozda, 2014). We can now very reliably identify those who are genetic fast or slow metabolizers with clinical pharmacogenetic tests.
This has resulted in a dramatic increase in commercial testing companies with pharmacogenetic testing products for psychiatric medications. The caveat to this is that there are many clinically available tests that are all slightly different. And the application of the test results to patient care requires some knowledge of what the test results mean in the context of current and potential future drug selections for the patient. In an attempt to make these tests ‘user friendly’ the test results are often accompanied by decision support tools that try to simplify the findings. But these tests are often ordered for clinical scenarios which are not so ‘simple’. In my mind this necessitates an additional level of interpretation, and education (to both patients and prescribers) that may be optimally provided by the psychiatric pharmacist. The use of these tests will likely increase over time and as the technologies improve, and the costs are lowered, there will be an evolution of current ‘reactive’ testing to more ‘prospective’ testing where genetic/pharmacogenetic information will be readily available to guide patient care, likely with additional information gathered from novel mobile monitoring technologies. We need to be prepared for this. And we will be.