Concepts for selection and utilization of psychiatric medications in pregnancy

Psychiatric illness may develop or relapse during pregnancy, and understanding best practices is paramount. In 2017, the British Association for Psychopharmacology (BAP) consensus guidance on the use of psychotropic medication preconception, in pregnancy, and postpartum was released. The BAP guidelines provide concise evidence and additional insight and flexibility for use of psychiatric medication. Key takeaways of these guidelines are highlighted serving as a concise reference for practitioners. Additionally, practice points, such as recommendations for rapid tranquilization and the role of long-acting injectable antipsychotic medications as well as additional insights to the growing body of literature associated with psychiatric medications in pregnancy since 2017 are summarized. Providers are strongly encouraged to stay up to date to provide optimal care for pregnant patients and their babies.

Evaluating the perceptions of a required didactic Mental Health First Aid training course among first-year pharmacy students

BACKGROUND AND PURPOSE

Mental Health First Aid (MHFA) training was designed to help participants identify mental health challenges and provide support to those in need. The objective of this study was to evaluate the perceptions of a required first-year didactic MHFA course and to determine if MHFA reduces stigma and increases confidence in first-year pharmacy students' abilities to offer help to those experiencing a mental health challenge or a crisis.

EDUCATIONAL ACTIVITY AND SETTING

Participants were first-year doctor of pharmacy students at a single site in the United States. Methods include the utilization of a survey-based study among a single pharmacy program. Students enrolled in this required MHFA training were asked to voluntarily complete pre- and post-training surveys.

FINDINGS

A total of 69 first-year pharmacy students participated in the MHFA training. Results demonstrated that students agreed with being able to identify stigmatizing words associated with mental health disorders and that they will work to reduce or avoid using words that can be perceived as stigmatizing related to mental health (P < .001). Students reported increased confidence in their ability to start a conversation with someone who may need mental health help compared to their confidence level before the training (P < .001).

SUMMARY

Completing MHFA training during the early phases of didactic education can help reduce stigma and increase confidence in abilities to help those experiencing a mental health challenge. Programs should consider implementing MHFA or similar training early in the didactic curriculum.

Increasing access to psychiatric care during the COVID-19 pandemic through mental health clinical pharmacy specialist services

Introduction

Higher rates of mental health conditions, increased incidence of psychiatric diagnoses, and symptom relapse with minimal access to psychotherapeutic services are reported during the COVID-19 pandemic. A local area clinic in the United States that exists to serve underprivileged patients helps to combat poor psychiatric outcomes by offering psychiatric clinics, pharmacotherapy management, and medications at reduced or no cost.

Methods

Recruitment and data collection were conducted from May 3, 2021, to March 3, 2022. Patients were seen by psychiatrists or the mental health clinical pharmacy specialist (MHCPS), and consent was obtained for the completion of satisfaction surveys. Five-point Likert scale comparisons were utilized to assess patient-perceived differences in clinician care. The primary study objective was to determine if access to care could be increased with the addition of an MHCPS, and secondary objectives included evaluating patient perceptions of clinician care as well as reporting MHCPS interventions.

Results

Participant baseline demographics and common psychiatric diagnoses are reported. An MHCPS was incorporated into the clinic during the study allowing for 1 additional patient care period per month. The most frequent score among all surveys was 4.8 (P > .05) on a 5-point scale, indicating no statistically significant differences between clinician care. MHCPS interventions are reported.

Discussion

The addition of an MHCPS allowed for additional patient care appointments for the clinic each month. MHCPS care offered no significant differences from psychiatrist care based on patient satisfaction surveys, highlighting the utility of pharmacist involvement for managing psychiatric disease states and increasing access to mental health services.

Differentiating probable nitrofurantoin-induced drug fever from antipsychotic-induced hyperthermia in a patient receiving clozapine

Nitrofurantoin (NIT) is a commonly utilized antibiotic for the treatment of UTIs. Although well tolerated, NIT is not without potential adverse reactions. This case report details the observation of probable NIT-induced drug fever in a patient receiving clozapine. A 61-year-old female with treatment-refractory schizoaffective disorder was admitted to a psychiatric unit with paranoia and auditory hallucinations, prompting clozapine initiation during day 1 of hospitalization. Due to worsening hallucinations and anxiety, antibiotic therapy with NIT for a presumed UTI was initiated 8 days after admission. Febrile episodes were observed beginning on hospital day (HD) 9, leading to concern for possible neuroleptic malignant syndrome (NMS), which led to clozapine discontinuation. The patient received a total of 3 doses of NIT with continued fever until discontinuation on HD 10. No further complications were encountered, and clozapine was safely resumed on HD 13. Although sparsely described in the medical literature, occurrences of drug fever attributable to NIT are previously reported. A review of the medical literature identified only 5 previously published articles specific to NIT-induced drug fever, none of which specified interruptions of psychotropic therapy for a patient with acute psychiatric decompensation. This case highlights the differential diagnosis of fever related to NIT in a patient receiving clozapine when NMS was initially suspected.

Incorporating Pharmacist Interns Into a Study of Fall-Risks

INTRODUCTION: Inpatient falls continue to have detrimental effects on patient care and recovery. Because controllable and uncontrollable factors impact fall rates, predicting which patients are at the greatest risk can be challenging. One method includes the incorporation of student learners to help identify which patients are at the greatest risk for falls.<br/> OBJECTIVE: To generate a scoring metric and investigate its reliability for appropriately identifying geriatric and medical psychiatric patients at risk for falling while hospitalized.<br/> METHODS: In this single-center, quasi-experimental study, pharmacist-interns led a fall-prevention initiative at a community hospital within two behavioral health units.<br/> RESULTS: A total of 96 patients were analyzed over the study period, revealing no notable trends for either geriatric or medical psychiatric patients. There was no significant change in the odds of falling for each fall score point increase for either the geriatric-psychiatric unit (odds ratio [OR] = 0.95; 95% confidence interval [CI] 0.83-1.08) or the medical-psychiatric unit (OR = 1.11; 95% CI 0.91-1.36).<br/> CONCLUSION: This pharmacist-intern-led falls-prevention initiative did not provide a statistically significant reduction in falls. While the scoring metric was helpful in reviewing charts to make recommendations for interventions, the assigned score did not correlate as expected to incidents of falls.

Early detection of an atypical presentation of neuroleptic malignant syndrome: A case report

Neuroleptic malignant syndrome (NMS), which is considered a neurologic emergency, is believed to be caused by exposure to dopamine antagonist or withdrawal from a dopamine agonist. This article reports a case of suspected atypical NMS in a patient following rapid conversion of ziprasidone to risperidone without titration. While the initial presentation did not fully meet the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, diagnostic features, a sequential treatment strategy was initiated and the patient appropriately responded to antipsychotic cessation in addition to combination therapy with dantrolene and bromocriptine. Neuroleptic malignant syndrome diagnostic criteria, treatment, and prognosis are discussed.

Intravenous Carbamazepine for Adults With Seizures

Objective: To review the pharmacology, pharmacokinetics, efficacy, safety, dosage and administration, potential drug-drug interactions, and place in therapy of the intravenous (IV) formulation of carbamazepine (Carnexiv) for the treatment of seizures in adult patients. Data Sources: A comprehensive PubMed and EBSCOhost search (1945 to August 2017) was performed utilizing the keywords carbamazepine, Carnexiv, carbamazepine intravenous, IV carbamazepine, seizures, epilepsy, and seizure disorder. Additional data were obtained from literature review citations, manufacturer’s product labeling, and Lundbeck website as well as Clinicaltrials.gov and governmental sources. Study Selection and Data Extraction: All English-language trials evaluating IV carbamazepine were analyzed for this review. Data Synthesis: IV carbamazepine is FDA approved as temporary replacement therapy for treatment of adult seizures. Based on a phase I trial and pooled data from 2 open-label bioavailability studies comparing oral with IV dosing, there was no noted indication of loss of seizure control in patients switched to short-term replacement antiepileptic drug therapy with IV carbamazepine. The recommended dose of IV carbamazepine is 70% of the patient’s oral dose, given every 6 hours via 30-minute infusions. The adverse effect profile of IV carbamazepine is similar to that of the oral formulation, with the exception of added infusion-site reactions. Conclusion: IV carbamazepine is a reasonable option for adults with generalized tonic-clonic or focal seizures, previously stabilized on oral carbamazepine, who are unable to tolerate oral medications for up to 7 days. Unknown acquisition cost and lack of availability in the United States limit its use currently.