Role of a Psychiatric Pharmacist in a Los Angeles “Skid-Row” safety-net clinic

Abstract

Limited access to a psychiatrist prompted a collaborative practice agreement between a psychiatric pharmacist, a psychiatric pharmacy resident, and primary care physicians at the Center for Community Health, a safety-net clinic providing comprehensive care to the homeless in Skid Row, Los Angeles, CA, USA. From July 2009 to February 2010, 36 (75%) of the 48 patients referred to the psychiatric pharmacy resident met the criteria for the chart review. Twenty-six (54%) were seen for regular follow-up care over 7 months. Most referrals were for depression, bipolar disorder, and posttraumatic stress disorder. The types of drug therapy problems, pharmacist interventions, and clinical mental health outcomes are discussed.

The Center for Community Health (CCH) is a safety-net clinic in Los Angeles’ Skid Row district that serves as a “medical home” for approximately 3,000 patients, 96% are homeless.¹ Most medications are provided free of charge via Patient Assistance Program or Medicaid/Medicare.

Information regarding the role of psychiatric pharmacists in safety-net clinics is lacking. A study in South Texas describes a psychiatric pharmacy clinic for indigent patients but does not provide clinical outcome data.² More information is needed regarding the role of psychiatric pharmacists in a safety-net clinic serving a more diverse population of patients and using psychiatric rating scales to evaluate outcomes.

A pharmacist-run primary care clinic was able to show improved outcomes in diabetes management compared to usual care patients.³ This success, combined with lack of consistent access to psychiatrist referrals, prompted the development of the psychiatric pharmacist-run clinic at CCH.

A provider survey conducted in 2008⁴ found that primary care physicians (PCP) were uneasy regarding management of psychiatric illnesses or refilling psychotropics. In response to their disclosures and a growing need for psychiatric care, a collaborative protocol with psychiatric pharmacists from the University of Southern California (USC) School of Pharmacy was established starting September 2008. Medications may be initiated, changed, or discontinued by the psychiatric pharmacist under the physician-directed protocol. Psychiatric pharmacists undergo specialized training in patient assessment and psychopharmacology. Most complete residencies in psychiatry, and many are board certified by the Board of Pharmaceutical Specialties.⁵

The psychiatric pharmacist and the post graduate, year two (PGY2) psychiatric pharmacy resident, are fully funded by USC, so services incurred no cost to CCH. Up to 8 hours per week were allocated for services, including: patient assessment, medication therapy management, monitoring for adverse effects, identifying drug–drug interactions, assessment of laboratory results, patient education, referral to other services to reduce psychosocial stressors, and psychosocial support.

The chief aims of this study are to: (1) identify the most common drug therapy problems, (2) describe interventions performed in response to drug therapy problems, and (3) analyze clinical outcomes using validated psychiatric rating scales.

Methods

This study was approved by the University of Southern California’s Institutional Review Board. The charts of 48 patients referred to the psychiatric pharmacist at CCH were reviewed for a 7-month period between July 15, 2009 and February 24, 2010. Each patient’s demographics, drug therapy problems, and interventions performed by the psychiatric pharmacists were noted. Clinical psychiatric outcomes documented in the progress notes, using a self-administered 10-item Patient Health Questionnaire (PHQ)-9 for patients referred for depression and a clinician-administered clinical global impression severity score (CGI-S) and clinical global impression–improvement (CGI-I) scales for all diagnoses, are analyzed. Wilcoxon signed rank sum test was performed for PHQ-9 at baseline and at the end of the 7-month study period. Statistical analysis was performed using SAS 9.2, and statistical significance was assessed using an alpha of 0.05 (two-tailed).

Patients may be referred to the psychiatric pharmacist by any CCH provider. The psychiatric pharmacist notes history of present illness, psychiatric/medical history, past medications, allergies, family psychiatric illness, social history, and mental status. A CGI-S is assigned as a baseline for all psychiatric diagnoses. Patients diagnosed with depression are also assigned a baseline PHQ-9 score. Vitals, height, and weight are recorded at baseline and at each visit. The treatment plan is coordinated in collaboration with the PCP.

After a 60- to 75-minute initial assessment, 30 to 45 minutes is allocated for follow-up appointments. Compliance is assessed by evaluating refill histories. Drug–drug interactions are assessed, and adverse effects are monitored and managed. Those patients who are on antipsychotic drugs long term are monitored for tardive dyskinesia (TD) using Abnormal Involuntary Movement Scale (AIMS) every 3 months. Rating scales are performed at every visit, using CGI-I for overall impression of clinical changes, and PHQ-9 is administered at every visit for those diagnosed with depression. Also, during follow-up, patients receive counseling regarding their illness as well as their medications. Laboratory results are assessed and explained to the patient, and treatment plans are reviewed with the patient and the PCP. The rating scales were selected based on validity and ease of use.

Results

In total, there were 48 patients referred to the psychiatric pharmacist during the 7-month period. Thirty-six (75%) patients were seen at least once, and 26 (54%) were seen every 2–6 weeks for follow-up appointments during a 7-month period. Of the ten people who were seen only once, five preferred to continue treatment elsewhere and five others did not attend their second appointment. The patients regularly seen (≥2 visits) included eight females and 18 males. The mean ± S.D. age was 47.4 ± 9.3 years; 50% were African American, 27% were Hispanic, and 19.2% were Caucasian. Approximately 42.3% were not on any psychotropic at the time of referral. Twenty-one (80.7%) of the patients had a substance abuse history, and over half had comorbid medical conditions, namely hypertension or dyslipidemia, 14 (53.8%) and 15 (57.7%), respectively. Over half (53.8%) were obese. Each patient was on an average of 8 ± 5.6 total medications.

Fifty percent had more than one psychiatric diagnosis. Ten (38.5%) patients received the diagnosis of major depressive disorder with an average baseline PHQ-9 score of 16.4 ± 4.6. The score indicates a moderately severe depression. The clinical outcome table (Table 1) documents baseline CGI-S scores for all diagnoses and averages 4.5 ± 0.7 which indicates moderately ill to markedly ill symptomatology, with noticeable and modest to distinctly impaired functioning.

Table 1.

Clinical outcomes table (n = 26)

CGI-S (severity scores) assessed at baseline
Normal—not ill (1)	0
Borderline mentally ill (2)	0
Mildly ill, clear symptoms (3)	2
Moderately ill, overt symptoms (4)	11
Markedly ill, intrusive symptoms (5)	12
Severely ill, disruptive pathology (6)	1
Most extremely ill, drastic interference in function (7)	0
CGI-I (improvement scores) after 7 months
Very much improved (1)	3
Much improved (2)	8
Minimally improved (3)	9
No change (4)	4
Minimally worse (1)	1
Much worse (6)	1
Very much worse (7)	0

CGI Clinical global impression scales (validated psychiatric rating scales developed by National Institutes of Mental Health)

The most frequent category of drug therapy problems identified relates to adverse drug reactions, either because the medication chosen by the provider was unsafe (n = 19/41 drug therapy problems, 47.5%) or the patient experienced an undesirable reaction from their current medication(s) (n = 16/41 drug therapy problems, 39%). Psychotropic medications accounted for the majority of the medications considered unsafe for the patient (n = 13/19 drug therapy problems, 68.4%). In approximately 30% of the cases, providers chose antipsychotics with higher risk for weight gain and metabolic side effects in patients already suffering from comorbid obesity and dyslipidemia, without earlier trial of antipsychotic(s) with less metabolic risk.

There were several cases where duplication of drug therapy was corrected. Psychotropics were found to produce the most undesirable drug reactions (n = 13/16 drug problems, 81.2%), with half of the cases related to the side effects arising from antidepressant use, notably increased anxiety, or sedation/somnolence.

The second most frequently identified drug therapy problem was the need for additional medication(s) due to an untreated psychiatric disorder. Approximately 42.3% of the patients were not on any psychotropic when referred. One or more psychotropic was started after a thorough assessment. In total, antidepressants were added in 28% of the cases for the treatment of depression, sleep agents were added in 32% of the cases to treat insomnia, antipsychotics were started in 16% of the cases for psychosis, and mood stabilizers were added in 12% of the cases for bipolar disorder. There were several cases of untreated medical conditions that resulted in the prescription of additional medications, for instance, the addition of amlodipine to treat hypertension. The third most frequently identified drug therapy problem was non-compliance assessed by patient report.

The top three interventions performed include: patient education (n = 142/619 interventions, 23%), monitoring for adverse drug reactions (n = 109/619 interventions, 17.6%), and administration of rating scales (n = 108/619 interventions, 17.4%). TD was not observed in any patient taking an antipsychotic (AIMS score = 0 for those taking antipsychotics). Two older patients (>50 years old) previously on haloperidol were preventatively switched to atypical antipsychotic to reduce the long-term risk for TD.

Clinically significant improvements were documented in progress notes. Two patients reached remission from depression as evidenced by a PHQ-9 score of less than 4. Compared to baseline PHQ-9 scores, the mean change in scores were −5.7 ± 5.7 (p = 0.02) at the end of the study period. When all 26 patients were evaluated, nearly 77% showed improvement (CGI-I score of 1 through 3), and three (11.5%) patients achieved a CGI-I score of 1. Two patients showed worsening of psychiatric symptoms when they self-discontinued their psychiatric medications.

Discussion

The psychiatric pharmacist was well received within CCH as part of the multidisciplinary team and was able to function independently as another provider. The primary care provider(s) accepted all of the recommendations/interventions made by the psychiatric pharmacist. The psychiatric pharmacist also referred patients to CCH providers for dental care, psychotherapy, social security application, and to case management for housing needs. Referrals were also made for specialty care outside of the clinic. Periodic interdisciplinary meetings were held to discuss treatment plans and ensure continuity of care.

This study describes a population of homeless patients residing in Los Angeles’ Skid Row, with co-occurring medical and psychiatric diagnoses, which include substance abuse. Patients seen at the CCH often have complex mental health needs with several psychiatric disorders (1.6 ± 0.99). Axis I diagnoses as defined by the DSM-IV-TR⁶ requires functional impairment as a criteria for pathology, which most of the patients readily met, as evidenced by homelessness, history of substance abuse, multiple incarcerations, and/or multiple past inpatient psychiatric hospitalizations. Even though Axis II or personality disorders were not documented in this study, history of trauma such as physical and sexual abuse were common, and most patients (~73%) required referrals to social workers for cognitive-behavioral or trauma-focused therapy to help with these specific areas.

The top chronic medical illnesses found in this descriptive study, which are dyslipidemia (57.7%) and hypertension (53.8%) with comorbid obesity (53.8%), are alarming. Clinical studies have reported rates of obesity in patients with schizophrenia or bipolar disorder of up to 60%.^7,8 In comparison with their non-mentally ill cohorts, patients with schizophrenia and bipolar disorder were almost twice as likely to be obese, even if they were antipsychotic naïve.^7–9 Patients with severe mental illness have increased mortality rates compared with the general population, which is often the result of health conditions associated with their psychiatric illness, including obesity, metabolic syndrome, and diabetes.¹⁰ A combination of factors such as inadequate access to quality care, poor lifestyle choices, and complex medication regimens with serious potential adverse effects can result in worse outcomes. These patients can benefit from a psychiatric pharmacist’s expertise since they are extensively trained in medication therapy management that includes monitoring for adverse drug reactions, interactions, and the need for ongoing medication counseling.^5,10–12

Suboptimal treatment outcomes for depressed primary care patients have been attributed to severe limitation in provider’s time, inaccessibility to specialty services, poor medication optimization/adherence, and perceived deficiencies in medical training.^12–14 One study in an HMO clinic¹⁴ compared psychiatric pharmacist depression management to “usual care” with a PCP and demonstrated higher 6-month medication adherence rates and decreased resource utilization in the psychiatric pharmacist managed group. Future controlled studies are needed to assess significant differences in clinical outcomes.¹⁵ There are several limitations to this study, including a small sample size, lack of cost or quality of life outcome data, and limited study duration (one day per week over 7 months).

Conclusions

The homeless population at CCH can benefit from a multidisciplinary approach involving a psychiatric pharmacist to improve access to quality psychiatric medication follow-up. Other safety-net clinics may benefit from partnering with a psychiatric pharmacist, PGY2 resident, and student training program utilizing a similar collaborative practice model.