Andrea L. Murphy

International Consensus Study of Antipsychotic Dosing

OBJECTIVE Potency equivalents for anti-psychotic drugs are required to guide clinical dosing and for designing and interpreting research studies. Available dosing guidelines are limited by the methods and data from which they were generated. METHOD With a two-step Delphi method, the authors surveyed a diverse group of international clinical and research experts, seeking consensus regarding antipsychotic dosing. The authors determined median clinical dosing equivalents and recommended starting, target range, and maximum doses for 61 drugs, adjusted for selected clinical circumstances. RESULTS Participants (N=43) from 18 countries provided dosing recommendations regarding treatment of psychotic disorders for 37 oral agents and 14 short-acting and 10 long-acting parenteral agents. With olanzapine 20 mg/day as reference, estimated clinical equivalency ratios of oral agents ranged from 0.025 for sulpiride to 10.0 for trifluperidol. Seventeen patient and treatment characteristics, including age, hepatic and renal function, illness stage and severity, sex, and diagnosis, were associated with dosing modifications. CONCLUSIONS In the absence of adequate prospective, randomized drug-drug comparisons, the present findings provide broad, international, expert consensus-based recommendations for most clinically employed antipsychotic drugs. They can support clinical practice, trial design, and interpretation of comparative antipsychotic trials.

Bridging the Gap: Knowledge Seeking and Sharing in a Virtual Community of Emergency Practice

Disparities exist between rural and urban emergency departments with respect to knowledge resources such as online journals and clinical specialists. As knowledge is a critical element in the delivery of quality care, a web-based learning project was proposed to address the knowledge needs of emergency clinicians. One objective of this project was to evaluate the effectiveness of the online environment for knowledge exchange among rural and urban emergency clinicians. Descriptive and content analysis of the online discussion board revealed 202 postings with rural participants contributing the largest number of postings (75%; 152/202). Postings were used to establish a clinical presence (87/202), seek clinical information (52/202), and share clinical information (63/202). Postintervention survey results indicate that this modality introduced participants to new clinical experts and resources. The results provide direction for design of a virtual community of practice, which may reduce current knowledge resource disparities.

Canadian guidelines on pharmacotherapy for disruptive and aggressive behaviour in children and adolescents with attention-deficit hyperactivity disorder, oppositional defiant disorder, or conduct disorder

Objective: To develop evidence-based guidelines on pharmacotherapy for severe disruptive and aggressive behaviour in children and adolescents with attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), or conduct disorder (CD). The guidelines assume that psychosocial interventions have been pursued but did not achieve sufficient improvement. Method: A multidisciplinary consensus group used the Grading of Recommendations Assessment, Development and Evaluation approach for rating evidence quality and for grading recommendations. We conducted a systematic review of medications studied in placebo-controlled trials for treating disruptive and aggressive behaviour in children and adolescents with ADHD, ODD, or CD. We followed consensus procedures to make 1 of 4 recommendations for each medication: strong, in favour (↑↑); conditional, in favour (↑?); conditional, against (↓?); and strong, against (↓↓). Results: For children and adolescents with disruptive or aggressive behaviour associated with ADHD, psychostimulants received a strong recommendation in favour of use, while atomoxetine and alpha-2 agonists received a conditional recommendation in favour of use. If these patients do poorly with ADHD medications, the medication with the most evidence is risperidone. Risperidone also has the most evidence for treating disruptive or aggressive behaviour in the absence of ADHD. However, given risperidones major adverse effects, it received only a conditional recommendation in favour of use. We recommended against using quetiapine, haloperidol, lithium, or carbamazepine because of the poor quality of evidence and their major adverse effects. Conclusion: When severe disruptive or aggressive behaviour occurs with ADHD, medications for ADHD should be used first. Other medications have major adverse effects and, with the exception of risperidone, very limited evidence to support their use.

Evidence review and clinical guidance for the use of ziprasidone in Canada

While indicated for schizophrenia and acute mania, ziprasidone’s evidence base and use in clinical practice extends beyond these regulatory approvals. We, an invited panel of experts led by a working group of 3, critically examined the evidence and our collective experience regarding the effectiveness, tolerability and safety of ziprasidone across its clinical uses. There was no opportunity for manufacturer input into the content of the review. As anticipated, ziprasidone was found to be effective for its indicated uses, although its utility in mania and mixed states lacked comparative data. Beyond these uses, the available data were either unimpressive or were lacking. An attractive characteristic is its neutral effect on weight thereby providing patients with a non-obesogenic long-term treatment option. Key challenges in practice include the need for dosing on a full stomach and managing its early onset adverse effect of restlessness. Addressing these issues are critical to its long-term success

Community pharmacists' experiences in mental illness and addictions care: a qualitative study.

BackgroundCommunity pharmacists are accessible health care professionals who encounter people with lived experience of mental illness and addictions in daily practice. Although some existing research supports that community pharmacists’ interventions result in improved patient mental health outcomes, gaps in knowledge regarding the pharmacists’ experiences with service provision to this population remain. Improving knowledge regarding the pharmacists’ experiences with mental illness and addictions service provision can facilitate a better understanding of their perspectives and be used to inform the development and implementation of interventions delivered by community pharmacists for people with lived experience of mental illness and addictions in communities.MethodsWe conducted a qualitative study using a directed content analysis and the Theoretical Domains Framework as part of our underlying theory of behaviour change and our analytic framework for theme development. The Theoretical Domains Framework facilitates understanding of behaviours of health care professionals and implementation challenges and opportunities for interventions in health care. Thematic analysis co-occurred throughout the process of the directed content analysis. We recruited community pharmacists, with experience dispensing psychotropics, at a minimum, through multiple mechanisms (e.g., professional associations) in a convenience sampling approach. Potential participants were offered the option of focus groups or interviews.ResultsData were collected from one focus group and two interviews involving six pharmacists. Theoretical Domains Framework coding was primarily weighted in two domains: social/professional role and identity and environmental context and resources. We identified five main themes in the experiences of pharmacists in mental illness and addictions care: competing interests, demands, and time; relationships, rapport, and trust; stigma; collaboration and triage; and role expectations and clarity.ConclusionsPharmacists are not practicing to their full scope of practice in mental illness and addictions care for several reasons including limitations within the work environment and lack of structures and processes in place to be fully engaged as health care professionals. More research and policy work are needed to examine better integration of pharmacists as members of the mental health care team in communities.

A theory-informed approach to mental health care capacity building for pharmacists

BackgroundPharmacists are knowledgeable, accessible health care professionals who can provide services that improve outcomes in mental health care. Various challenges and opportunities can exist in pharmacy practice to hinder or support pharmacists’ efforts. We used a theory-informed approach to development and implementation of a capacity-building program to enhance pharmacists’ roles in mental health care.MethodsTheories and frameworks including the Consolidated Framework for Implementation Research, the Theoretical Domains Framework, and the Behaviour Change Wheel were used to inform the conceptualization, development, and implementation of a capacity-building program to enhance pharmacists’ roles in mental health care.ResultsThe More Than Meds program was developed and implemented through an iterative process. The main program components included: an education and training day; use of a train-the-trainer approach from partnerships with pharmacists and people with lived experience of mental illness; development of a community of practice through email communications, a website, and a newsletter; and use of educational outreach delivered by pharmacists. Theories and frameworks used throughout the program’s development and implementation facilitated a means to conceptualize the component parts of the program as well as its overall presence as a whole from inception through evolution in implementation. Using theoretical foundations for the program enabled critical consideration and understanding of issues related to trialability and adaptability of the program.ConclusionsTheory was essential to the underlying development and implementation of a capacity-building program for enhancing services by pharmacists for people with lived experience of mental illness. Lessons learned from the development and implementation of this program are informing current research and evolution of the program.

Pharmacy students' experiences in provision of community pharmacy mental health services.

Background: Little information is available describing the pharmacy student’s experience working in community practice with people with lived experience of mental illness. Students’ perspectives as observers, learners, technical staff and future pharmacists are important. Objective: To gain a better understanding of the pharmacy student experience in community pharmacy–based service provision to people with lived experience of mental illness. Methods: We conducted a qualitative study using interpretive description and application of the Theoretical Domains Framework. Focus groups were held with third- and fourth-year undergraduate pharmacy students from one Canadian university. Results: Two student focus groups were held in the fall of 2012 with 11 students (7 third year and 4 fourth year), 6 women and 5 men, mean age 24.5 (range, 21 to 30) years, averaging 3.2 years (range, 2 weeks to 7 years) of cumulative, mostly part-time, community pharmacy experience. Three broad themes emerged from the pharmacy student experience: (1) business tension; (2) roles, responsibilities and relationships; and (3) stigma. Students discussed their own roles, responsibilities and relationships in a pluralistic identity experience (i.e., pharmacy student, technician, future pharmacist). Application of the Theoretical Domains Framework demonstrated numerous influences on behaviour. Conclusions: From the students’ description of community pharmacy–based care of people with lived experience of mental illness, significant issues exist with current practices and behaviours. Advancing the role of pharmacists and pharmacy students to meet the needs of people with mental illness will require strategies to address multifactorial influences on behaviour.

Public perceptions of pharmacist expanded scope of practice services in Nova Scotia

Background: Community pharmacists have been transitioning from traditional dispensing roles toward a much broader scope of practice. The objective of this research was to explore public perceptions of expanded scope of practice (ESOP) services as they relate to pharmacy and pharmacist characteristics. Methods: The Survey on New Services Offered by Nova Scotia Pharmacists was developed and deployed using in-pharmacy intercept surveys and online public surveys in Nova Scotia. The survey focused on 4 key ESOP elements/services: 1) prescribing for minor ailments (ambulatory conditions), 2) injections and vaccinations, 3) prescription renewals and 4) medication reviews. Data were analyzed using comparisons between groups (multivariate analysis of variance) and principal component analysis. Results: A total of 385 surveys were obtained from the public regarding their perceptions and use of ESOP services (online n = 237, in-pharmacy intercept n = 148). A number of significant differences were found on the basis of respondent sex, age and the location of survey deployment. Discussion: Overall, public perceptions of pharmacists’ knowledge and skills in providing ESOP services are positive. A pharmacist’s ability to communicate, protect confidentiality and provide quality information regarding medications is important to the public. Conclusion: Respondents who already have a good relationship with their pharmacist are more likely to see value in ESOP services. Future public education strategies should focus on factors positively affecting the public’s perceptions of ESOP services and should encourage public use of these services through intentional patient education of the benefits of ESOP services and strengthening of the patient-provider relationship.

Youth, Caregiver, and Prescriber Experiences of Antipsychotic-Related Weight Gain

Objectives. To explore the lived experience of youth, caregivers, and prescribers with antipsychotic medications. Design. We conducted a qualitative interpretive phenomenology study. Youth aged 11 to 25 with recent experience taking antipsychotics, the caregivers of youth taking antipsychotics, and the prescribers of antipsychotics were recruited. Subjects. Eighteen youth, 10 caregivers (parents), and 11 prescribers participated. Results. Eleven of 18 youth, six of ten parents, and all prescribers discussed antipsychotic-related weight gain. Participants were attuned to the numeric weight changes usually measured in pounds. Significant discussions occurred around weight changes in the context of body image, adherence and persistence, managing weight increases, and metabolic effects. These concepts were often inextricably linked but maintained the significance as separate issues. Participants discussed tradeoffs regarding the perceived benefits and risks of weight gain, often with uncertainty and inadequate information regarding the short- and long-term consequences. Conclusion. Antipsychotic-related weight gain in youth influences body image and weight management strategies and impacts treatment courses with respect to adherence and persistence. In our study, the experience of monitoring for weight and metabolic changes was primarily reactive in nature. Participants expressed ambiguity regarding the short- and long-term consequences of weight and metabolic changes.

A scoping review of community pharmacists and patients at risk of suicide

Background: Medications are commonly used in suicide attempts. Pharmacists are inextricably linked to medications and may have roles in helping those at risk of suicide. We conducted a scoping review to characterize the existing literature and make recommendations about future research. Methods: We used a 6-step approach based on an existing scoping review methodological framework, including identifying the research question; identifying relevant studies and other literature; study and literature selection; data charting; collating, summarizing and reporting results; and dissemination of results. We searched electronic databases, various grey literature sources and mobile app stores. Results: Thirty-five articles were included following screening of 1013 database citations. Of 1085 results from grey literature searches, we included 12. Most publications were opinion pieces (n = 22), followed by survey studies (n = 9), primarily assessing pharmacists’ knowledge and attitudes. Themes included education and training to impact knowledge and attitudes, gatekeeping of medication supply, collaboration and integration, and role perception. Public perspectives on pharmacists’ roles were limited. Conclusions: Research regarding pharmacists’ roles in the care of people at risk for suicide is limited. The areas that have dominated the literature include legal liability, especially with respect to gatekeeping medications, ethical decision making and education and training. Research is needed to determine what methods, outcomes and measures are required to best serve in building the evidence base for policy and practice decisions in this area.