Patrick R. Finley

Evaluating the Impact of Pharmacists in Mental Health: A Systematic Review

Efforts to improve the outcomes of patients with mental illness often have involved incorporating the skills of a variety of health care professionals into collaborative care models. For over 30 years, clinical pharmacists have contributed to these care models in capacities ranging from educator to consultant to provider. This systematic review evaluates the quantity and quality of medical literature examining the impact of pharmacists in mental health from 1972–2003. Although we identified approximately 35 publications describing the roles of clinical pharmacists in this regard, only 16 were of sufficient scientific rigor to permit evaluation and comparison. The 16 studies were divided equally between inpatient and outpatient settings and were conducted in a variety of health care organizations (e.g., Veterans Administration, health maintenance organizations, community mental health clinics, and nursing homes). Nine of the studies examined the role of pharmacists in providing treatment recommendations and patient education, five featured pharmacists as providers (with prescriptive authority), and the remaining two described the impact pharmacists have in delivering education to the psychiatric staff. Six of the 16 studies were prospective, but only three of these incorporated a randomization procedure for patients or facilities. Collectively, the results of the 16 studies were positive, demonstrating improvements in outcomes, prescribing practices, patient satisfaction, and resource use. Unfortunately, most of the investigations were small, and significant limitations in study design limited further comparison. Given the long history and anecdotal success of pharmacists in mental health care settings, additional multicenter cost‐effectiveness trials are warranted to further support the role of the psychiatric pharmacist.

Selective Serotonin Reuptake Inhibitors: Pharmacologic Profiles and Potential Therapeutic Distinctions

OBJECTIVE: To review the respective pharmacologic profiles of the selective serotonin reuptake inhibitors (SSRIs), with particular emphasis placed on clinically relevant distinctions. DATA SOURCES: A MEDLINE search was conducted to identify English language literature published within the last five years on the four SSRIs (fluoxetine, sertraline, paroxetine, fluvoxamine). Previous review articles were scrutinized for additional citations, and manufacturers provided a contemporary bibliography of more recent material. STUDY SELECTION/DATA EXTRACTION: Studies were selected for specific citation on the basis of comparative research merit and the contribution of this original literature to the pharmacologic profile(s) described. DATA SYNTHESIS: All SSRIs appear to be more efficacious than placebo for the acute treatment of major depressive disorder (MDD). Short-term (six-week) efficacy was comparable with that of tricyclic antidepressants for the amelioration of MDD regarded as moderate in severity. Further comparative trials are clearly indicated to demonstrate the therapeutic benefits of SSRIs in specific populations (e.g., geriatric, severely ill) and to demonstrate sustained benefit with long-term prophylaxis. Other potential indications for SSRIs include obsessive-compulsive disorder, panic disorder, bulimia, and chronic pain syndromes. Pharmacokinetic profiles of the four SSRIs reveal similar parametric values, and most quantitative differences are of limited clinical significance. Adverse effects are common but ordinarily mild and transient, primarily restricted to the gastrointestinal tract and central nervous system. Important differences in the prevalence or severity of these adverse effects await the accumulation of further clinical experience and the completion of additional comparative trials. Similarly, the relative propensity of SSRIs to inhibit the metabolism of other medications is currently under investigation. CONCLUSIONS: The four SSRIs studied appear to be more similar than they are different. Slowly, important distinctions are beginning to emerge with regard to adverse effect profiles and potential drug interactions. Given that the costs of these respective medications are comparable, such differences may ultimately serve to establish the preferential selection of individual agents in specific clinical situations.

Risk of seizures associated with psychotropic medications: emphasis on new drugs and new findings.

Psychotropic medications in the classes of antidepressants, antipsychotics and mood stabilisers have been recognised in the literature and clinical settings as having high epileptogenic potential. Among these three classes, clozapine, tricyclic antidepressants (TCAs) and lithium are agents that clinicians have historically recognised as precipitants of drug-induced seizures. There are few reports that review the epileptogenic risk of newer psychotropic agents; in this qualitative review, the authors provide an update on the most recently published reports on seizures associated with antidepressants, antipsychotics, mood stabilisers, anxiolytics and sedative-hypnotics. In general, the epileptogenic risks of the newer psychotropic agents appear to be quite low as long as dosing strategies are consistent with recommended guidelines. Whilst newer psychotropic medications appear to be safe in patients with epilepsy, few studies have specifically addressed this population. In addition, the potential for drug interactions between antiepileptic drugs and psychotropics may be substantial with certain agents. For example, many psychotropes are both substrates and inhibitors of cytochrome P450 (CYP450) isoenzymes, whilst many antiepileptic drugs are both substrates and inducers of CYP450 activity. Every attempt should be made to minimise potential interactions when these agents are concomitantly administered.

Pharmacologic treatment for postpartum depression: a systematic review.

During the past decade, the medical community has expressed a growing concern over the high prevalence of postpartum depression and the tragic repercussions of untreated illness. However, many questions persist about the pathogenesis of postpartum depression, the natural course of the illness, and the safety and effectiveness of available treatments. To summarize the data on pharmacologic treatments for postpartum depression, we performed a systematic review of four major databases to identify original research published from 1960‐September 2009 that featured pharmacologic treatments for depression detected in women during the 12 months after delivery. Pharmacologic treatments included prescription drugs (antidepressants and hormones), herbal remedies, and dietary supplements. Case reports, studies examining the prevention of postpartum depression, and those including diagnosed episodes of depression preceding the postpartum period (i.e., antepartum onset) were excluded. Treatment randomization or the presence of a control group was not required for inclusion in this review. Fourteen investigations met inclusion criteria. Nine studies examined the effects of prescription antidepressants, two investigated hormones, and three featured omega‐3 fatty acid supplementation. Significant heterogeneity was evident in study design and prevented a pooled quantitative analysis of treatment effects. The power of most investigations was limited, and numerous confounding biases were evident. Therapeutic effects were documented for prescription antidepressants and hormone supplementation (estrogen derivatives). Tolerability of the interventions in depressed mothers and breastfed infants was not well described. The effectiveness of omega‐3 fatty acids was not evident in postpartum depression trials, although significant limitations in study methodology were apparent. Postpartum depression is a common and serious medical problem, but most cases go undetected and untreated. The need to identify safe, effective, and convenient treatments for postpartum depression is urgent, but the current state of the medical literature describing pharmacologic interventions is not impressive. Preliminary evidence documenting the effectiveness of serotonergic antidepressants and hormone supplementation should serve as an impetus for rigorous controlled investigations in the future.

Clinical and economic outcomes of a pilot project examining pharmacist-focused collaborative care treatment for depression

OBJECTIVE To assess the clinical and economic impact of a pharmacist-focused health management program for patients with depression. DESIGN Prospective, nonrandomized, proof-of-concept investigation. SETTING Asheville, NC, from July 2006 through December 2007. PARTICIPANTS Employees or adult dependents with depressive symptoms who agreed to enroll in an employer-sponsored treatment program conducted at two ambulatory clinics where consultative services were provided. Participants were included in the analysis if they participated in the program for at least 1 year and had two or more documented visits with a pharmacist. INTERVENTION Outpatient-based pharmacists provided assessment, self-management services follow-up, and treatment recommendations to primary care providers within a collaborative care management model. MAIN OUTCOME MEASURES Changes in severity of depressive symptoms and impact on overall health care costs for employers and beneficiaries. RESULTS Of the 151 beneficiaries referred to the program, 130 (82%) remained under pharmacist care for a minimum of 1 year and were included in the aggregate analysis. Statistically significant improvements were observed for Patient Health Questionnaire (PHQ)-9 scores from baseline to endpoint (11.5 ± 6.6 to 5.3 ± 4.7 [mean ± SD], P < 0.0001). The clinical response rate was 68% with a 56% remission rate. In economic subgroup analysis (n = 48), annual medical costs decreased from an average of

Precipitation of Benzodiazepine Withdrawal following Sudden Discontinuation of Midazolam

6,351 per enrollee to

Detection and treatment rates for perinatal depression in a state Medicaid population

5,876, which was lower than the projected value (

Clinical and economic outcomes associated with olanzapine for the treatment of psychotic symptoms in a county mental health population

7,195). Total health care costs to the employer increased from

Antidepressants, Suicide, and the FDA: A Loose Association

7,935 per enrollee to

Enhancing our understanding of perinatal depression

8,040, which was lower than the projected value (