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 Table of Contents    
GUEST EDITORIAL  
Year : 2017  |  Volume : 59  |  Issue : 2  |  Page : 138-140
Psychiatry and clinical pharmacy: A logical partnership


1 Clinical Director, Ward Medication Management, Melbourne, Australia; Adjunct Faculty, JSS University, Mysore, Karnataka, India
2 Department of Pharmacy Practice, JSS College of Pharmacy, JSS University, Mysore, Karnataka, India

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Date of Web Publication17-Jul-2017
 

How to cite this article:
Alderman CP, Lucca JM. Psychiatry and clinical pharmacy: A logical partnership. Indian J Psychiatry 2017;59:138-40

How to cite this URL:
Alderman CP, Lucca JM. Psychiatry and clinical pharmacy: A logical partnership. Indian J Psychiatry [serial online] 2017 [cited 2017 Aug 18];59:138-40. Available from: http://www.indianjpsychiatry.org/text.asp?2017/59/2/138/210727


The principle of multidisciplinary care is fundamental to achieving optimal patient outcomes across a wide range of disciplines, and it is clear that this holds true for psychiatry as much as any other specialty. Any psychiatrist with a busy practice understands the competing priorities that require attention during any standard psychiatric consultation, regardless of the setting where the patient is seen. Establishing rapport, gathering history, arranging for further investigations, providing psychoeducation, and arranging follow-up all vie for attention, and at the same, it is often necessary to select and safely prescribe a rational choice of pharmacotherapy, depending on the nature of presentation. To be able to accomplish all of this in a timely fashion presents a significant challenge for any clinician.

Perhaps, the biggest change that has impacted on the management of mental illness in recent times has been the exponential developments that have been witnessed in psychopharmacology.[1] From relatively modest beginnings in the 1950s, new generations of antidepressants and antipsychotics have been embraced in psychiatric practice, and various other drugs such as anticonvulsants have been repurposed and have emerged as legitimate alternatives for use in the management of psychiatric illnesses. Consequently, the range of psychotropic drugs prescribed by the average clinician has expanded, and there are now dozens of alternative pharmacotherapy approaches for common psychiatric presentations. Furthermore, as well as the originator brands of most psychotropic drugs, in many cases, there is a multiplicity of competing generic products for each molecular entity, meaning that the prescriber may need to familiarize themselves with even more products to have a complete understanding of the treatment used by their patients. Many people with significant mental illness will also have serious medical comorbidities such as cardiovascular disease, diabetes mellitus, chronic obstructive pulmonary disease, or chronic pain syndromes.[2],[3],[4] These patterns of comorbidity may occur spontaneously, as a result of genetic predisposition, or may also be the result of the influence of various epigenetic factors (among these, the effects of psychotropic drug treatment). In reality, many people who require pharmacotherapy for a psychiatric illness will also require concurrent treatment for medical comorbidities. The cumulative effect of these phenomena is that management of drug therapy for those who consult a psychiatrist has become a very complex task indeed.

An approach that has been advocated as a means to achieve the best possible outcomes from pharmacotherapy has been described as incorporating the so-called “quality use of medicines” (QUM) principles.[5] Summarized succinctly, these principles advocate three key approaches: selecting management options wisely (considering the place of medicines in treating illness and maintaining health, recognizing that there may be better options than medicine in many cases), choosing suitable medicines where necessary (taking into account patient preferences, the nature of the clinical condition, risks and benefits, dosage and duration of treatment, coexisting conditions and other drug treatments, monitoring considerations, and costs), and using medicines safely and effectively (monitoring outcomes, minimizing misuse, and improving consumers' ability to solve problems related to medication). Logic dictates that the philosophies of the QUM principles are sound, and equally, it is self-evident that these principles are applicable when prescribing in psychiatric practice. Even so, when the QUM principles are deconstructed it becomes apparent that their application in any form of prescribing requires a broad range of skills, experience, and knowledge. To be able to safely and effectively prescribe treatment in accordance with QUM principles doubtlessly requires an understanding of pharmacology, incorporating a working understanding of dose-response relationships, and adverse drug reaction and drug interaction profiles, but it is clear that considerably more than this is needed to prescribe psychotropic drug therapy. It can be argued that the judicious use of psychotropic drugs requires a sound insight into many other sciences including pharmaceutical formulation pharmacokinetics, pharmacodynamics, pharmacogenomics, and pharmacoepidemiology. Considering the competing demands on the time and expertise of a prescribing psychiatrist that have been alluded to earlier in this piece, a serious question remains as to whether a busy psychiatric clinician can summons and effectively apply all of these elements in the context of a brief consultation?

It would seem that there are three options available to busy prescribers in relation to the QUM principles. One option is to wade right in, strive to do good and to do no harm, relying upon clinical acumen and intuition guided by years of experience and clinical wisdom – no doubt laudable and indubitably well-intentioned, but given the breadth of skills and knowledge required and the serious time pressure, the successful application of this approach is challenging. Alternatively, a prescriber might simply skim over the details, do their best but nevertheless risk the possibility that they may well miss the opportunity to incorporate a nuanced approach to treatment optimization that is most likely to yield the desired therapeutic outcome and at the same time, avert potential disasters that can arise from various issues not addressed. A busy prescriber might well reason that his kind of tactic is justified in the interests of maintaining throughput so that people who need help can access expert clinical advice, but there are other ways of viewing this approach that suggest it is hard to defend. If a patient suffers serious drug-related harm because a clinician is unable to identify potentially adverse consequences of prescribing choices, is that patient better off than one who is unable to access a prescriber at all?

There is, of course, middle ground that is increasingly embraced in many of the world's most sophisticated health systems, and with good reason. This approach involves recruiting expert help, using assistance from professional colleagues for whom expert knowledge of medication-related matters is inherent to their training, expertise, and experience – these people are clinical pharmacists. Clinical pharmacy and psychiatry are natural partners for a number of reasons. The drugs used in psychiatry are powerful and complex, with a multiplicity of adverse effects and clinically significant drug interactions involving other drugs used in psychiatry as well as those used in general medicine. The prevalence of serious medical comorbidity among people with mental illness is high, meaning that polypharmacy is common and meticulous attention is needed to avoid adverse outcomes. People affected by mental illness are indeed very vulnerable, with the potential for medication issues compounded by factors such as cognitive dysfunction and its adherence. Pharmacists with appropriate training can substantially assist psychiatrists in delivering safe and effective drug treatment for their patients. The US Board of Pharmaceutical Specialities recognize psychiatric pharmacy as one of nine specialty practice areas in which pharmacists can earn international accreditation through rigorous competency-based assessments.[6] In the meantime, Indian Colleges of Pharmacy now produce graduates from Pharm D programs certified by respected international credentialing agencies,[7] practitioners who are equipped to assist in various clinical specialties, including psychiatry.

An example of a collaborative initiative between the Departments of Clinical Pharmacy and Psychiatry has been launched as a special counter in psychiatry outpatient department at JSS hospital Mysore, as part of world health mental day celebrations. The objectives of this collaborative initiative, “JSS” Medication Information for Neuropsychiatric Disorders and Sensitization (MINDS) is to provide information and education to patients on the safe use of medication, improve medication adherence, and quality of life in patients with mental health diseases and also to provide telephonic reminders on follow-up visits and medication refilling through a dedicated phone number. The program has now been running successfully for the last 6 months. About 700 patients have received the service, and 75% of them sustained follow-up and scheduled their next visit, confirming their satisfaction. All psychiatric consultant involved also articulate their satisfaction with quality and quantity of the services provided by the clinical pharmacy and psychiatry collaborative model. The “JSS MINDS” is suitable for replication as a model of collaborative clinical pharmacy and psychiatry practice in other parts of the country.

Going forward, the complexity of psychotropic drug therapy would be expected to increase, and the challenges inherent to the safe pharmacological treatment of mental disorders will expand. The merits of a partnership approach with collaborative work involving psychiatrists and pharmacists have been established,[8],[9],[10] and for these reasons a path forward for cooperation lies ahead, inviting participation from both partner groups.

 
   References Top

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Medrano J. Historical perspective of psychotropic drug use. In: Unax Lertxundi, Juan Medrano and Rafael Hernández, eds Psychopharmacological Issues in Geriatrics. [book on the Internet]. 2015. p. 3-15. Available from: available from http://www.eurekaselect.com. [Last accessed on 2017 Jun 15].  Back to cited text no. 1
    
2.
Sanna L, Stuart AL, Pasco JA, Kotowicz MA, Berk M, Girardi P, et al. Physical comorbidities in men with mood and anxiety disorders: A population-based study. BMC Med 2013;11:110.  Back to cited text no. 2
[PUBMED]    
3.
Forty L, Ulanova A, Jones L, Jones I, Gordon-Smith K, Fraser C, et al. Comorbid medical illness in bipolar disorder. Br J Psychiatry 2014;205:465-72.  Back to cited text no. 3
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Manuel CM, Rao PP, Rebello P, Safeekh AT, Mathai PJ. Medical comorbidity in patients with psychiatric disorders. Muller J Med Sci Res 2013;4:12-7.  Back to cited text no. 4
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Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/nmp-quality.ht. [Last accessed on 2017 Apr 18].  Back to cited text no. 5
    
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Available from: http://www.bpsweb.org/bps-specialties/psychiatric-pharmacy>. [Last accessed on 2017 Apr 18].  Back to cited text no. 6
    
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Ghilzai NM, Dutta AP. India to introduce five-year doctor of pharmacy program. Am J Pharm Educ 2007;71:38.  Back to cited text no. 7
    
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Alderman C. Some thoughts about psychotropic drugs and psychiatric pharmacy services. J Pharm Pract Res 2016;46:101-2.  Back to cited text no. 8
    
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Jenkins MH, Bond CA. The impact of clinical pharmacists on psychiatric patients. Pharmacotherapy 1996;16:708-14.  Back to cited text no. 9
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Goldstone LW, DiPaula BA, Caballero J, Park SH, Price C, Zasadzki Slater M. Improving medication-related outcomes for patients with psychiatric and neurologic disorders: Value of psychiatric pharmacists as part of the health care team. Ment Health Clin 2015;5:1-28.  Back to cited text no. 10
    

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Correspondence Address:
Jisha M Lucca
Department of Pharmacy Practice, JSS College of Pharmacy, JSS University, Shivarathreeshwara Nagar, Mysore - 570 015, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_205_17

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