Introduction:Federal and state policymakers, accreditation organizations, and mental health agencies developed standards for evidence-based use of psychotropic medications among youth in foster care. Despite these efforts, foster youth are vulnerable to psychotropic polypharmacy, high dosing, and low rates of monitoring. This manuscript aimed to (1) analyze state-specific psychotropic oversight programs, and (2) examine specific state approaches and outcomes. Methods:State guidelines, including all 50 United States and Washington, DC, were identified via Google search and a Center for Health Care Strategies, Inc., 2018 technical assistance tool. For each state, authors documented whether guidelines were specific to foster care and whether they included thresholds related to polypharmacy, metabolic monitoring, age-based prescribing, maximum dosages, and any distinctive characteristics. Results:Most states (61%) have published a foster care psychotropic guideline; 9 states (18%) do not have a one, and the authors were unable to locate guidelines for the remaining 11 states (22%). More than one-third of foster care youth (38%) live in states with no psychotropic monitoring requirements. Sixty-three percent (n = 32) of states require a prior authorization (PA) or drug utilization review (DUR) for youth prescribed more than 1 psychotropic. Forty-seven states have age-based prescribing support in place, with PA (n = 28) and DUR (n = 9) being the most common oversight processes. Conclusions:States have a wide range of age restrictions, approaches to PA and DUR, and prioritization of monitoring. Some states lack guidelines entirely. Variability in state psychotropic oversight programs, reporting methods, and data collection contributes to barriers to successful optimization of psychotropic prescribing among youth in foster care.
Polypharmacy, gaps in transitions of care, and inconsistent medication monitoring contribute to inappropriate psychotropic prescribing among youth in foster care. Additionally, foster care psychotropic prescribing regulations are complex and insufficient. Acknowledging these concerns, pharmacists have been identified as essential advocates for youth in foster care given their expertise in medication therapy management, medication reconciliation, patient/caregiver education, and interprofessional collaboration. Specifically, inclusion of board-certified psychiatric pharmacists (BCPPs) on the foster care team could allow for the implementation of best practices, including psychotropic stewardship, collaborative telemedicine services, telemedicine teaching initiatives, comprehensive medication management, and procurement of accurate medical and medication histories, amongst others. It is critical that child welfare administrators, health system administrators, and the foster care team consider inclusion of a BCPP to better support prescribing practices of psychotropic medications among youth in foster care.
Introduction:Clozapine-induced constipation may occur in at least 60% of patients, with first-line options typically involving polyethylene glycol or sennosides. However, there may be adherence barriers to an over-the-counter bowel regimen due to the dosage form, lack of insurance coverage, or lack of benefit. One possible solution to address these adherence barriers may include prescribing a secretagogue laxative. However, there is limited literature supporting the use of secretagogue laxatives in clozapine-associated constipation. A case series is presented in which adherence barriers impeded the use of over-the-counter laxatives, and a secretagogue laxative was implemented to manage clozapine-induced constipation. Case Report:In 4 cases, lubiprostone or linaclotide was initiated, either as monotherapy or in combination with over-the-counter laxatives. Reasons for secretagogue laxative initiation included: (1) reducing a complex over-the-counter laxative regimen, (2) a lack of insurance coverage of over-the-counter laxatives, (3) dissatisfaction with polyethylene glycol's palatability, and (4) cognitive impairment leading to decreased adherence to polyethylene glycol. Discussion:It is important that clozapine-induced constipation is managed adequately to prevent severe consequences of gastrointestinal hypomotility. In addition to timely initiation and titration of constipation pharmacotherapy, adherence should be assessed. When adherence barriers to the use of over-the-counter laxatives are present, the use of a secretagogue laxative may be an option, recognizing there is limited evidence to guide this decision. Conclusion:In these cases, adherence barriers to over-the-counter laxatives were identified. A secretagogue laxative was implemented, well-tolerated, and able to be continued for the duration of follow-up.
Introduction:Manufacturer labeling for haloperidol decanoate recommends an initial dose of 10 to 20 times the daily oral dose; however, significant heterogeneity in dosing practices exists. The purpose of this medication use evaluation was to assess initial haloperidol decanoate dosing in psychiatric inpatients. Methods:An institutional review board-exempt retrospective chart review was conducted using data from University of California Health Data Warehouse (UCHDW) from June 1, 2014, to June 1, 2024. Inpatients diagnosed with schizophrenia or schizoaffective disorder aged 18 years or older receiving an initial dose of haloperidol decanoate were included. Patients on dual antipsychotics or those without oral haloperidol within 24 hours before decanoate administration were excluded. The primary outcome was the proportion of patients receiving 10 to 20 times the oral haloperidol dose as per the manufacturer's package insert. Secondary outcomes included dosing characterization and incidence of extrapyramidal symptoms. Descriptive statistics were employed. Results:A total of 147 eligible patients were included, with a mean age of 49 years; 62% of participants were male. The mean oral dose of haloperidol before decanoate initiation was 20.7 mg, and the mean initial dose of haloperidol decanoate was 178 mg. The primary outcome was observed in 47.6% of patients. Of those who received doses outside of the recommended range, 41.5% received a dose less than 10 times the oral haloperidol dose, while 10.9% received a dose exceeding 20 times the oral dose. Conclusion:Fewer than half of the patients evaluated received an initial dose of haloperidol decanoate as recommended by the manufacturer's labeling. These findings underscore the need to further investigate clinician attitudes, comfort, and knowledge on haloperidol decanoate prescribing.
Introduction:Olanzapine doses in adults with treatment-resistant schizophrenia or treatment-resistant schizoaffective disorder have been compared in a few open-label trials, with higher doses associated with increased symptom improvement. The most significant adverse effects observed at off-label doses above 30 mg/day have been weight gain, sedation, or drowsiness. Methods:This single-center, retrospective cohort study aimed to evaluate patient factors and outcomes in adult patients admitted to a county psychiatric hospital that received high-dose olanzapine therapy (HD-olanzapine, ≥40 mg/day) compared with standard-dose olanzapine (SD-olanzapine, 5-30 mg/day). Patients 18 years or older were included if they received at least 5 days of scheduled olanzapine treatment for psychotic symptoms or psychosis while admitted. Results:Subjects on HD-olanzapine (n = 139) and SD-olanzapine regimens (n = 70) were on average 35 years of age, and most were White. There was no statistical difference regarding 30-day all-cause readmissions, 30-day all-cause emergency-treatment service visits, or average duration of olanzapine therapy. The average length of stay was longer in the HD-olanzapine group (31.3 days vs 14.5, P = 0.009). Constipation was more common in the HD-olanzapine group (8.6% vs 1.4%, P = 0.0418). Discussion:Although 30-day all-cause readmissions and emergency-treatment service visits were similar between groups, patients who received olanzapine doses of 40 mg/day or greater for at least 5 days of treatment experienced significantly longer average length of stay and more constipation during an admission.
Introduction Inhalant use disorder is a substance use disorder that involves the inhalation of volatile hydrocarbons (VHCs) to experience intoxication. Despite its prevalence and potential for adverse events, pharmacotherapy research for inhalant use disorder is limited. Acamprosate is a medication used for alcohol use disorder (AUD) that may provide benefit for inhalant use disorder. Acamprosate, alcohol, and inhalants all modulate glutamatergic and GABAergic pathways to produce their effects. Reported is a case of inhalant use disorder with comorbid AUD treated successfully with acamprosate. Case Report Patient A is a 39-year-old male consuming 16 cans of computer duster per day, having escalated use over the course of 2 weeks following a period of sobriety. He has been abstaining from alcohol with the help of disulfiram therapy. Following medical management, chronic inhalant use disorder pharmacotherapy was established with acamprosate 666 mg twice a day and later increased to 999 mg twice a day. Discussion Similarities in effect may lead to the comorbid use pattern of inhalants and alcohol for our patient. As disulfiram did not address the inhalant use, acamprosate was chosen in hopes of reducing cravings and encouraging abstinence in the long term. Conclusion Inhalant use disorder represents an understudied substance use disorder, and acamprosate may be a promising medication to investigate for broader safety and efficacy. Patients with comorbid AUD may be an especially likely population to benefit from acamprosate therapy due to the possibility of dual benefit from the FDA-approved AUD indication.
Hyperammonemia is an idiosyncratic adverse effect associated with valproic acid (VPA). We report 2 patients with neurocognitive disorder who were prescribed low doses of VPA for neuropsychiatric symptoms associated with neurocognitive disorder, and they presented with changes in behavior. On workup, both patients had elevated ammonia concentrations. The aims of the case report are to highlight the importance of laboratory testing for ammonia concentrations in patients with altered mental status especially in the setting of VPA therapy irrespective of the dosage and to discuss possible mechanisms associated with VPA-induced hyperammonemia.
Introduction At present, there is a shortage of clinicians providing substance use disorder (SUD) treatment, thereby limiting access to evidence-based care. Board-certified psychiatric pharmacists (BCPPs) are doctorate-level, advance trained experts in psychopharmacology and psychiatric disorders, including SUDs. Methods This narrative review describes the contributions of BCPPs in SUD care and summarizes evidence demonstrating their impact across health care settings. It highlights their roles in comprehensive medication management, including the management of co-occurring psychiatric disorders, long-acting injectables, telehealth services, and transitions of care. Other key contributions include harm reduction services, education, and psychotropic stewardship. Results Integration of BCPPs on teams providing SUD care can reduce other practitioners’ workloads, expedite care, and increase access to life-saving pharmacologic intervention. BCPPs can optimize medication-related outcomes and safety and, with prescriptive authority, may prescribe controlled substances including buprenorphine. They are well-positioned to take on additional responsibilities in SUD care and have adopted successful treatment models across practice settings. Discussion Evidence shows that BCPPs can improve the quality of SUD care. BCPPs should be regarded as essential members of interprofessional teams providing SUD treatment as their involvement can drive advancements in clinical practice and expand access to care for patients with SUDs.
Introduction:Lithium has long been considered the gold standard mood stabilizer in the treatment of acute mood episodes related to bipolar (BD) and schizoaffective disorder. Previous research has primarily focused on lithium loading strategies and their effects on symptom severity and inpatient length of stay (LOS). However, less is known about specific prescribing practices at lithium initiation that may influence LOS. Methods:This retrospective study aimed to evaluate three initiation-related prescribing factors of lithium and their association with changes in LOS among adult inpatients experiencing acute mood episodes of BD or schizoaffective disorder. The factors were lithium initiation within 48 hours of admission, achieving a therapeutic level-producing dose within 48 hours of admission, and receiving intensive initial lithium dosing (≥900 mg/day). The Mann-Whitney U test was used to assess statistical significance. The timing of antipsychotic coprescribing in mania was also evaluated. Results:Sixty-eight patients were included in this study. Lithium initiation within 48 hours of admission significantly decreased hospital LOS (7.2 vs 13.4 days; P < 0.001). Lithium optimization to a dose that produced a therapeutic drug level within 48 hours of admission also significantly decreased LOS (6.2 vs 9.1 days; P < 0.01). Intensive initial dosing did not significantly affect LOS. Of patients with mania, 51.5% were trialed on antipsychotics before starting lithium. Conclusion:Early lithium initiation and optimization in patients with acute bipolar mood episodes significantly reduced hospital LOS. Prospective studies are needed to address potential confounders to confirm whether early lithium optimization directly reduces LOS.
Introduction Pro re nata (PRN) medications can be administered for the treatment of agitation. Evidence-based recommendations for the pharmacologic treatment of agitation in children and adolescents admitted to a behavioral health unit are limited. The primary objective of this study was to analyze medication use patterns for managing agitation in a pediatric and adolescent inpatient behavioral health unit. The secondary objective was to evaluate the effectiveness and safety of commonly administered PRN medications in this population. Methods This retrospective chart review included patients who received a 1-time or PRN medication for agitation while admitted to a pediatric and adolescent behavioral health unit between July 1, 2020, and June 31, 2022. Primary outcomes examined agents administered and the route and rate of concurrent medication administration. Secondary outcomes included administration of subsequent medications, the use of restraint or seclusion as a surrogate marker for effectiveness, and rate of adverse events for safety. Results A total of 191 patients were included in the final analysis. There were 1238 doses of 1-time or PRN medication administered for agitation during the study period. Antipsychotics were administered most frequently (661, 53.4%). However, the most commonly administered medications were diphenhydramine (327, 26.4%), lorazepam (235, 19%), and olanzapine (224, 18.1%). Antipsychotic-induced extrapyramidal symptoms (EPS) occurred in 3 instances (0.24%), with all being managed with diphenhydramine. Discussion When treating agitation in pediatric and adolescent patients admitted to an inpatient behavioral health unit, antipsychotics were administered most frequently. It appears that most doses were well tolerated, except for EPS in a subset of patients.
Introduction When discontinuing benzodiazepines, treating withdrawal symptoms can be challenging. Some anti-seizure medications (ASM) may mitigate withdrawal symptoms. This article reviews the literature regarding adjunctive ASM use during benzodiazepine tapering and discontinuation. Methods A PubMed search focusing on the use of ASMs as adjunctive agents to mitigate benzodiazepine withdrawal symptoms was conducted. Key search teams identified relevant articles, and the references of included articles were evaluated to identify potential additional publications for inclusion. In total, 21 articles met the inclusion criteria, and 44 articles were excluded for various reasons. Results Several clinical trials, observational studies, case reports, and case series were identified. Carbamazepine was more effective than placebo at 3 months (74% benzodiazepine free vs 52% for placebo). Oxcarbazepine enabled successful rapid detoxification with minimal withdrawal symptoms in a small, noncontrolled study. Valproate, pregabalin, and gabapentin showed improvements in benzodiazepine-free rates, but the results were inconsistent. Discussion Evidence for ASM in benzodiazepine withdrawal is limited, emphasizing the need for provider discretion. Additional larger clinical trials are warranted to identify optimal agents to mitigate withdrawal symptoms and enhance successful benzodiazepine cessation.
Introduction Emerging real-world evidence suggests that folate supplementation may reduce suicidal ideation and behavior. We conducted a scoping review to evaluate current hypothesis-testing literature on folate supplementation and outcomes related to suicide. Methods We searched PubMed, Cochrane Library, APA PsycNet, ClinicalTrials.gov, and the International Clinical Trials Registry Platform from inception to February 15, 2025, to identify hypothesis-testing studies (ie, randomized, cohort, or case-control studies) that examined any oral folate formulation and reported a suicide-related endpoint. Results Five studies met inclusion criteria: 1 randomized controlled trial (n = 475), 2 case-control studies (n < 20 each), and 2 large within-person cohort analyses (>800 000 adults). Interventions included folic acid 1 to 5 mg/day (3 studies) or folinic acid 1 to 2 mg/kg/day (2 studies). Three studies reported significant reductions in suicidal outcomes. One within-person cohort study found a 44% lower hazard of suicide-related emergency or hospital visits after treatment with folic acid (hazard ratio = 0.56) (and none in a parallel analysis of vitamin B12). A second within-person stratified reanalysis showed benefit in both patients with and without psychiatric histories. One case-control study of patients with a history of suicidal behavior and ideation found lower suicidal ideation questionnaire scores with folinic acid (P < 0.01). The randomized controlled trial and the other case-control study reported no significant benefit for suicide-related endpoints. Discussion Evidence linking folate supplementation to reduced suicidal behavior is promising but limited by heterogeneity in design, sample size, folate formulation, and outcome measurement. Robust conclusions await large, pragmatic trials or extended real-world studies that integrate both suicidal behavior and mortality while comparing folate across diverse populations.
Introduction:Psychiatric pharmacists are advanced practice clinical pharmacists who specialize in mental health treatment. Board Certified Psychiatric Pharmacist (BCPPs) are those who have demonstrated their level of expertise through testing and a commitment to ongoing professional education. There is limited literature evaluating the impact of BCPPs within consultation liaison psychiatry (CLP). CLP involves providing psychiatric treatment to patients within general medical settings. Methods:The goal of this project was to identify the impact of integrating a BCPP into a CLP service. A BCPP was integrated into a CLP team providing psychiatric services to patients admitted to a medical unit within a Veterans Affairs hospital. The impact of the BCPP was assessed through a retrospective review of patients encountered between September 1, 2023, and August 31, 2024. Results:There were 306 consults evaluated by a BCPP during the review period. The 306 consults generated 586 encounters between initial and follow-up encounters. Of these encounters, 64.5% were seen without a psychiatrist, estimating 252 hours/year of saved psychiatrist time and approximately $14 797/year in cost savings. The BCPP encounters resulted in pharmacotherapy interventions to optimize evidence-based pharmacotherapy for a psychiatric condition in 96% of the patients encountered. Discussion:A BCPP was successfully integrated into a CLP service and operated with a high level of autonomy.
Introduction Fentanyl, a synthetic opioid, is frequently found as a contaminant in illicit substances, significantly increasing overdose risk. A growing trend toward intentional fentanyl use further complicates the opioid crisis. This study aimed to identify patterns of local fentanyl use and contamination and evaluate harm-reduction interventions provided by psychiatric teams to patients at high risk of opioid overdose. Methods This observational study combined prospective surveys with retrospective chart review. Adults with a positive fentanyl urine drug screen within 6 months of a psychiatric hospitalization or emergency department encounter were eligible. Participants completed a 10-question survey on substance use patterns, fentanyl risk awareness, and willingness to engage with harm-reduction tools. Electronic health records were reviewed upon patient discharge for demographic and clinical data, including prescribed harm reduction interventions. Results Eighteen participants completed the survey; 77.8% were male with a mean age of 41 years. Intentional fentanyl use was reported by 77.8% of participants. Commonly codetected substances included amphetamines (44.4%), cannabinoids (38.9%), cocaine (33.3%), and other opioids (27.8%). Whereas more than 90% recognized the overdose risk from fentanyl, nearly half did not perceive themselves to be at personal risk. Most participants were discharged with naloxone (88.9%) and/or prescribed medication for opioid use disorder. Willingness to use fentanyl test strips was high (72.2%). Discussion The findings of this study underscore the need for the increased availability of harm-reduction strategies, including fentanyl detection tools and tailored education, to address gaps in overdose risk perception and enhance patient safety.
Symptoms of opioid withdrawal with buprenorphine inductions pose significant challenges when trying to transition a patient from a full agonist opioid. There are numerous strategies to reduce the risk including traditional induction, microdosing, and macrodosing. Whereas there is an abundance of literature on successful strategies, there is limited literature on risk factors that identify those who are likely to fail transition to buprenorphine and should be cautioned. We present a case of a 43-year-old male on high-dose methadone who was rapidly transitioned to buprenorphine. He experienced significant withdrawal symptoms, resulting in hospitalization, multiple relapses, and suicidal ideation. He was ultimately transitioned back to methadone and restabilized. The primary factors likely resulting in this treatment failure are high-dose opioid use prior to transition, rapid transition, and patient reluctance to transition at time of buprenorphine initiation.
Introduction Trained pharmacists could play a key role in suicide prevention. Suicide prevention programs for pharmacists and students have been described in published literature. This study aimed to determine the effect of an online training program and a simulation on student pharmacists’ self-perceived knowledge and confidence regarding suicide prevention. Methods Third-year student pharmacists participated in online Question, Persuade, and Refer (QPR) Gatekeeper training followed by a simulation using standardized patients with depression and suicidality. Students completed a 15-item survey that assessed self-perceived knowledge and confidence regarding suicide prevention before online training, after online training, and after the simulation (1 cohort). A Mann-Whitney U test and a two-sample t test of unequal variances were used to provide a conservative estimate of the statistical significance of between-stage differences. Results Pre- and post-QPR training surveys were completed by 295 (100%) students. Postsimulation surveys were completed by 67 (90.5%) students in the 1-cohort group. Post-QPR scores were statistically significantly increased versus pre-QPR scores on all 15 items. Postsimulation scores were statistically significantly increased versus pre-QPR on 13 items. Postsimulation scores were statistically significantly less versus post-QPR scores on 13 items. Discussion Student pharmacists’ self-perceived knowledge and confidence regarding suicide prevention were increased by QPR training. In general, their self-perceptions decreased after the simulation although they were still increased compared with baseline. The online training program and simulation had a positive impact on student pharmacists’ knowledge and confidence.
Introduction The Lt. Col. Luke Weathers, Jr. Veterans Affairs Medical Center (Memphis VAMC) expanded clinical pharmacy mental health services to Primary Care Mental Health Integration (PCMHI) in July 2023. This expansion provides an opportunity for further evaluation of the specialized Clinical Pharmacy Practitioners’ (CPP) impact on providing patient-centered healthcare and improving mental health outcomes. This study aimed to assess the impact of adding a CPP in PCMHI. Methods A retrospective chart review of computerized medical records from the Memphis VAMC was conducted from August 1, 2023, to August 1, 2024, in patients seen by the PCMHI CPP who had pre- and post-intervention PHQ-9 scores. The primary objective of this study was to assess changes in PHQ-9 scores. Secondary objectives were to analyze pharmacotherapy agents used, concomitant psychotherapy usage, changes in other measurement-based care (Generalized Anxiety Disorder-7 item scale [GAD-7] and Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition [PCL-5]), reported side effects and adherence, and disposition after treatment. Descriptive statistics were used to analyze demographic data and outcomes. Results A total of 376 patients were screened, and 199 patients enrolled. PHQ-9 scores improved in 78.4% of patients, with a median score improvement of 5 points (interquartile range [IQR] 1-10). In patients with documented pre- and post-CPP intervention GAD-7 (n = 173) and/or PCL-5 (n = 8) scores, the median score improvement was 5 points (IQR 1-10) and 19 points (IQR 8.75-28.5), respectively. Discussion PHQ-9, GAD-7, and PCL-5 scores improved after incorporating a CPP in the PCMHI clinic. These findings suggest patients benefit from CPP expertise in assessing the efficacy of mental health pharmacotherapy and improving mental health symptomology.
