1. How to Utilize Your Pharmacist In the Inpatient/Hospital Setting Julie Dopheide, PharmD, BCPP Associate Professor USC School of Pharmacy dopheide@usc.edu NAMI 2007 Annual Convention June 22, 2007

2. My experience…. Psychiatric Pharmacist specialist at LAC+USC Inpatient Psychiatric service – 40 bed adult unit, 12 bed adolescent unit – 12 years of clinic experience (1988-2000) Pharmacist Specialist at Kaiser Mental Health Center in Los Angeles, CA – 60 bed adult unit, partial hospitalization program Consulting Clinical Pharmacist at BHC Alhambra Hospital in Rosemead, CA – 25 children, 15 adolescents, 40 adults general psychiatry – Eating Disorders inpatient, partial hospitalization unit

3. Psychiatric Hospitalization 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

4. Role of the Pharmacist Multidisciplinary treatment planning Individual medication review, recommendations – Appropriate medication, dose, duration of tx – Drug intx screening, monitoring, simplify dosing Fill prescriptions for routine and prn medications – Proper labeling, integrity, security of medications Education of patients, treatment team, family – Individual counseling, medication group, discharge counseling, family meetings, new drug inservices

5. Medication Recommendations “Another pair of eyes….” “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

6. Individual Medication Review 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

7. Individual Medication Review 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

8. Individual Med Consultation - SE 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

9. Medication Education Group 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

10. Medication Education Group 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”

11. Discharge Medication Counseling 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

12. Family Meetings 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? What can risperidone liquid be mixed with? Is it safe to take an antidepressant with blood pressure or pain medication?

13. Clinical Pharmacists Improve Care in Hospitals 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

14. Outcomes of Clinical Pharmacist Interventions in Psychiatric Hospital 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

15. Recommendations 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