Opportunities to partner with clinical pharmacists in ambulatory psychiatry

In this article, we highlight key steps that were needed to integrate clinical pharmacy specialists at an academic ambulatory psychiatric and addiction treatment center that serves pediatric and adult populations. Academic stakeholders identified addition of pharmacy services as a strategic goal in an effort to maximize services offered by the center and increase patient access to care while aligning with the standards set out by the patient-centered medical home (PCMH) model.

We outline the role of clinical pharmacists in the care of adult patients in ambulatory psychiatry, illustrate opportu­nities to enhance patient care, point out possible challenges with implementation, and propose future initiatives to optimize the practitioner-pharmacist partnership.

Background: Role of ambulatory pharmacists in psychiatry
Clinical pharmacists’ role in the psychiatric ambulatory care setting generally is associated with positive outcomes. One study looking at a collaborative care model that uti­lized clinical pharmacist follow-up in managing major depressive disorder found that patients who received phar­macist intervention in the collaborative care model had, on average, a significantly higher adherence rate and patient satisfaction score than the “usual care” group.¹ Within this study, patients in both groups experienced global clini­cal improvement with no significant difference; however, pharmacist interventions had a posi­tive impact on several aspects of the care model, suggesting that pharmacists can be used effectively in ambulatory psychiatry.

Furthermore, a systematic study evalu­ating pharmacists’ impact on clinical and functional mental health outcomes iden­tified 8 relevant studies conducted in the outpatient setting.² Although interven­tions varied widely, most studies focused on pharmacists’ providing a combination of drug monitoring, treatment recommen­dations, and patient education. Outcomes were largely positive, including an overall reduction in number and dosage of psy­chiatric drugs, inferred cost savings, and significant improvements in the safe and efficacious use of antidepressant and anti­psychotic medications.

These preliminary positive results require replication in larger, random­ized cohorts. Additionally, the role of the pharmacist as medication manager in the collaborative care model requires further study. Results so far, however, indicate that pharmacists can have a positive impact on the care of ambulatory psychiatry patients. Nevertheless, there is still considerable need for ongoing exploration in this field.

Pre-implementation
The need for pharmacy services. Various initiatives and existing practices within our health care system have underscored the need for a psychiatric pharmacist in the outpatient setting (Table 1).

A board-certified psychiatric pharma­cist (BCPP) possesses specialized knowl­edge about treating patients affected by psychiatric illnesses. BCPPs work with prescribers and members of other disci­plines, such as nurses and social workers, to optimize drug treatment by making pharmacotherapeutic recommendations and providing appropriate monitoring to enhance patient satisfaction and quality of life.^3,4

Existing relationship with pharmacy. Along with evidence to support the posi­tive impact clinical pharmacists can have in caring for patients with mental illness in the outpatient setting, a strong existing relationship between the Department of Psychiatry and our adult inpatient psychi­atric pharmacist helped make it possible to develop an ambulatory psychiatric phar­macist position.

Each day, the inpatient psychiatric pharmacist works closely with the attend­ing psychiatrists and psychiatry residents to provide treatment recommendations and counseling services for patients on the unit. The psychiatry residents highly valued their experiences with the pharmacist in the inpatient setting and expressed disappointment that this col­laborative relationship was no longer available after they transitioned into the ambulatory setting.

Further, by being involved in initia­tives that were relevant to both inpa­tient and outpatient psychiatry, such as metabolic monitoring for patients taking atypical antipsychotics, the clini­cal pharmacist in inpatient psychiatry had the opportunity to interact with key stakeholders in both settings. As a result of these pre-existing collabora­tive relationships, many clinicians were eager to have pharmacists available as a resource for patient care in the outpatient setting.

Pharmacist perspective: Outreach to psychiatry leadershipRecognizing the incentives and oppor­tunities inherent in our emerging health care system, pharmacists became integral members of the patient care team in the PCMH model. Thanks to this effort, we now have PCMH pharmacists at every primary care health center in our health system (14 sites), providing disease man­agement programs and polypharmacy services.

PCMH pharmacists’ role in the primary care setting fueled interest from specialty services and created opportunities to extend our existing partnership in inpa­tient psychiatry. One such opportunity to demonstrate the expertise of a psychi­atric pharmacist was fueled by the FDA’s citalopram dosing alert⁵ at a system-wide level. This warning emerged as a chance to showcase the skill set of psychiatric phar­macists and the pharmacists’ successes in our PCMH model. The partnership was extended to include the buy-in of ambula­tory pharmacy leadership and key stake­holders in ambulatory psychiatry.