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Background: Long-acting injectable (LAI) antipsychotics (APs) each have an oral equivalent formulation, while aripiprazole, olanzapine, and ziprasidone each also have a short-acting injectable (SAI) equivalent formulation. Inpatient prescribing patterns of LAIs and their oral/SAI equivalents are less characterized in populations other than Medicaid, Medicare, and Veterans Affairs populations. Mapping out inpatient prescribing patterns remains an important first step to ensure appropriate use of antipsychotics during this critical juncture of patient care prior to discharge. This study determined inpatient prescribing patterns of first- (FGA) and second-generation antipsychotic (SGA) LAIs and their oral/SAI formulations. Methods: This was a large retrospective study using the Cerner Health Facts® database. Hospital admissions due to schizophrenia, schizoaffective disorder, or bipolar disorder from 2010 to 2016 were identified. AP utilization was defined as the proportion of inpatient stays during which at least 1 AP was administered to the total number of inpatient visits over the observed period. Descriptive analyses were used to determine prescribing patterns for APs. Chi-square tests were used to determine utilization differences across years. Results: 94,989 encounters were identified. Encounters during which oral/SAI of SGA LAIs were administered were most common (n = 38,621, 41%). Encounters during which FGA LAIs or SGA LAIs were administered were the least common (n = 1,047, 1.1%). Prescribing patterns differed across years (p < 0.05) within the SGA LAI subgroup analysis (N = 6,014). Paliperidone palmitate (63%, N = 3,799) and risperidone (31%, N = 1,859) were the most frequently administered. Paliperidone palmitate utilization increased from 30% to 72% (p < 0.001), while risperidone utilization decreased from 70% to 18% (p < 0.001). Conclusions: Compared with their oral or SAI formulations, LAIs were underutilized from 2010 to 2016. Among SGA LAIs, the prescribing patterns of paliperidone palmitate and risperidone changed significantly.

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This study reports the process of telephonic medication reviews conducted by community pharmacists for patients with asthma. The study occurred at an independent community chain in association with a Missouri Medicaid consulting group. Participants were identified utilizing claims data and met the National Quality Forum criteria for uncontrolled moderate-to-severe persistent asthma. A pharmacist performed the initial encounter via telephone which included a knowledge questionnaire, symptom control assessment, and medication review. Pharmacists identified drug-related problems (DRPs) and faxed recommendations to patients' primary care providers (PCPs). Thirty days later, pharmacists called to follow up with the patients and faxed PCPs to resolve any outstanding DRPs, new DRPs, or recommendations. Questionnaire scores and symptom control assessments were compared and analyzed utilizing a paired t-test, Chi-squared test, or Fisher's exact test. The number and categories of DRPs, recommendations made by pharmacists, and intervention time were reported. Fourteen participants completed initial encounters with twelve completing follow-up. The majority answered 'yes' to at least one symptom control assessment question indicating partially controlled to uncontrolled asthma. The average knowledge assessment score was 5.17 out of 7 initially and 5.42 for the follow-up. Pharmacists identified 43 DRPs and made 41 recommendations with a mean intervention time of 65 min.

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Problem description: When course evaluations and student feedback demonstrated a decline in student perceptions of a Top 200 Drugs course, proposed modification focused on curricular alignment to impact those perceptions in a positive manner. Quality improvement methods: Student course evaluations and feedback from student leaders were reviewed to determine elements of course structure and design for modification. The following areas were identified: quantity of assessment content, frequency of class meetings, in-person vs. online, and self-paced vs. instructor-guided learning. Changes in student perceptions were determined through comparison of subsequent course evaluations to those of the previous four years. Course evaluations focused on coordinator availability, course organization, exam management, and achievement of course objectives. Results of CQI inquiry: The review of course evaluations showed improvement in all focus areas following modifications to course structure and design. Student free-text comments provided further insight for descriptive analysis. Interpretation and discussion: The evaluation score improvement was consistent with student comments. Contributing factors included curricular alignment, frequency of examinations, examination content, and faculty-guided learning through lecture and active learning. Alignment to pharmacology courses highlighted the relevance and value through the union of pharmaceutical sciences, clinical sciences, and pharmacy practice instruction. Conclusions: The alignment versatility of Top Drugs makes it ideal for bridging pharmaceutical and clinical sciences to bring relevance and value to students. The instructors will continue to offer the Top Drugs course in this format. Further plans for research include additional layers of curricular alignment and innovative active learning.

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INTRODUCTION: The use of smartphones throughout the United States continues to rise. Although smartphones have increased our capacity to access information, there is concern if excessive use may impact mental health. The purpose of this study was to examine whether a relationship exists between smartphone use and the presence of obsessive-compulsive symptoms (OCS) or behaviors. METHODS: A 33-item online survey was developed with 19 items relating to Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for obsessive-compulsive disorder (OCD). A survey response was considered positive for possible OCS if participants answered at least 3 questions as Most of the time or All of the time for the OCD-related questions structured around the DSM-5 criteria for OCD while also using their smartphone for greater than 2 or more hours per day. RESULTS: A total of 308 of 550 subjects identified spending 2 or more hours on their smartphone per day and also answered positively on 3 or more questions designed to identify OCS. A statistically significant difference was discovered between those who used their smartphone for 2 or more hours per day and those who met 3 or more positive criteria for OCS compared to those who used their smartphone less than 2 hours per day (P < .00001). DISCUSSION: The results of this study demonstrate a possible relationship between smartphone use and OCS. Additional research needs to be conducted to further investigate these results to determine their significance in clinical practice.

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OBJECTIVES: To describe a community pharmacist-led transitions of care process for patients discharged from the inpatient to the outpatient setting. SETTING: Independent community pharmacy chain in northwestern and central Missouri and a rural nonprofit hospital in Marshall, Missouri. PRACTICE DESCRIPTION AND INNOVATION: This innovative transitions of care service model relies on the inpatient pharmacy team for recruitment and referral of patients who use Red Cross Pharmacy. On discharge, patient information was transmitted to Red Cross Pharmacy via direct messaging in the form of a continuity of care document. Pharmacists used the patients' continuity of care documents to perform telephone-based medication reconciliations and comprehensive medication reviews. Drug-related problems and pharmacists' recommendations were documented in a subjective, objective, assessment, and plan (SOAP) note that was transmitted to the hospital and primary care provider. EVALUATION: The number and type of drug-related problems and pharmacists' recommendations were assessed with the use of descriptive statistics. Pharmacists' time spent was tracked, and its relationship to alternate variables was assessed with the use of bivariate correlations. RESULTS: Pharmacists identified 69 drug-related problems and made 145 recommendations for the 35 patients meeting study criteria. The mean time for total service completion was 65 minutes and positively correlated with a number of variables, including identification of the drug-related problem and unnecessary drug therapy and recommendation to decrease the dosage of a medication. CONCLUSION: Community pharmacists have the ability to identify drug-related problems and make recommendations for patients moving from the inpatient to an outpatient setting. In addition, the data suggest that when given adequate time, pharmacists performing service responsibilities may identify more drug-related problems, resulting in additional recommendations.

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OBJECTIVES: To explore community pharmacist involvement in the transition of care (TOC) process for patients discharged with acute myocardial infarction (AMI), heart failure (HF), pneumonia, chronic obstructive pulmonary disease (COPD), or elective total hip or knee arthroplasty (THA/TKA). SETTING: Patients discharged from a 60-bed acute care hospital located in rural Missouri were seen by a community pharmacist in 2 independent community pharmacy locations. PRACTICE INNOVATION: Patients admitted with 1 of the 5 qualifying conditions and identifying the participating pharmacy as their primary pharmacy spoke with a community pharmacist within 72 hours of discharge to complete a comprehensive medication review. A follow-up telephone call occurred 7 days after the encounter to evaluate for drug-related problems, adherence, and key information recalled from the previous visit. A final telephone call occurred on the 30th day after discharge to assess for hospital readmissions and emergency department (ED) visits. EVALUATION: Number of patients readmitted or visiting the ED within 30 days after discharge. RESULTS: Of the 9 patients completing the study, none were readmitted or visited the ED within 30 days after discharge. All of the participants were satisfied with the care and education provided by pharmacists. The majority of patients recalled points related to specific medication education topics. Based on the adherence tool, 8 of the 9 study participants had at least 1 barrier to medication access or adherence that could lead to post-discharge medication-related problems. CONCLUSION: Community pharmacist involvement in the TOC process may help to prevent readmissions for patients with AMI, HF, pneumonia, COPD, and elective THA/TKA. Patients are overall satisfied with community pharmacist involvement as they move from inpatient care to home. In addition, there are multiple barriers affecting access and adherence to medication therapy while at home, providing opportunities for pharmacist intervention and assistance.

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The use of antipsychotic medications has now expanded to multiple mental health conditions beyond schizophrenia. This has increased the overall population exposure to these medications, which have been associated with both metabolic changes and adverse cardiovascular effects. QTc prolongation, torsades de pointes, sudden cardiac death, myocarditis, and cardiomyopathy are all very real concerns that clinicians face on a regular basis. One must take these risks into consideration when selecting antipsychotic therapy and also when determining whether therapeutic changes and adjustments are necessary. This review examines a number of cardiac-associated concerns, the role that antipsychotics may play in contributing to these adverse events, and suggested management interventions.

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OBJECTIVES: (1) To identify physicians' preferences in regard to pharmacist-provided medication therapy management (MTM) communication in the community pharmacy setting; (2) to identify physicians' perceived barriers to communicating with a pharmacist regarding MTM; and (3) to determine whether Missouri physicians feel MTM is beneficial for their patients. METHODS: A cross-sectional prospective survey study of 2021 family and general practice physicians registered with MO HealthNet, Missouri's Medicaid program. RESULTS: The majority (52.8%) of physicians preferred MTM data to be communicated via fax. Most physicians who provided care to patients in long-term care (LTC) facilities (81.0%) preferred to be contacted at their practice location as opposed to the LTC facility. The greatest barriers to communication were lack of time and inefficient communication practices. Improved/enhanced communication was the most common suggestion for improvement in the MTM process. Approximately 67% of respondents reported MTM as beneficial or somewhat beneficial for their patients. CONCLUSIONS: Survey respondents saw value in the MTM services offered by pharmacists. However, pharmacists should use the identified preferences and barriers to improve their currently utilized communication practices in hopes of increasing acceptance of recommendations. Ultimately, this may assist MTM providers in working collaboratively with patients' physicians.

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OBJECTIVES: To determine patient perceptions of using a demonstration application (app) of mobile technology to improve medication adherence and to identify desired features to assist in the management of medications. METHODS: A qualitative study using key informant interviews was conducted in a community pharmacy chain for patients aged 50 and older, on statin therapy and owning a smart device. KEY FINDINGS: Three main themes emerged from 24 interviews at four pharmacy locations, which included benefits, barriers and desired features of the app. Benefits such as accessibility, privacy, pros of appearance and beneficiaries were more likely to lead to usage of the app. Barriers that might prevent usage of the app were related to concerns of appearance, the burden it might cause for others, cost, privacy, motivation and reliability. Specific features patients desired were categorized under appearance, customization, communication, functionality, input and the app platform. CONCLUSIONS: Patients provided opinions about using a mobile app to improve medication adherence and assist with managing medications. Patients envisioned the app within their lifestyle and expressed important considerations, identifying benefits to using this technology and voicing relevant concerns. App developers can use patient perceptions to guide development of a mobile app addressing patient medication-related needs.

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BACKGROUND: A patient's health literacy is not routinely assessed during visits with a health care provider. Since low health literacy is a risk factor for poor health outcomes, assessing health literacy should be considered as part of the standard medical workup. OBJECTIVES: To evaluate the health literacy levels and medication adherence of patients treated by pharmacists in both the general medicine and the chronic care clinics at an urban free health clinic. METHODS: Eligible patients from the free health clinic completed the Rapid Estimate of Adult Literacy in Medicine (REALM), a health literacy measurement tool, during their clinic visit in 2011. Medication adherence was self-reported by the patients. RESULTS: A total of 100 patients participated (mean age = 48). The majority of participants were female (56%) and white (55%). Most (64%) of the patients scored at a high school reading level according to REALM. Only 21% of participants read at a seventh- to eighth-grade level. Overall medication adherence rate was 73%. Forgetting to take medication was the most popular reason given for nonadherence. CONCLUSION: Disease state and adherence were significantly related in patients with HIV/AIDS and hypertension. Patient's ethnicity was significantly associated with literacy levels (P < .05). Although patients' literacy levels were not significantly associated with self-reported adherence in this population, availability of a patient's baseline health literacy level as a part of the medical record may help clinicians to individualize their interaction based on the patient's health literacy level in order to achieve better health outcomes, including improved medication adherence, especially for underserved populations.

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Formal guidelines for mentoring faculty members in pharmacy practice divisions of colleges and schools of pharmacy do not exist in the literature. This paper addresses the background literature on mentoring programs, explores the current state of mentoring programs used in pharmacy practice departments, and provides guidelines for colleges and schools instituting formal mentoring programs. As the number of pharmacy colleges and schools has grown, the demand for quality pharmacy faculty members has dramatically increased. While some faculty members gain teaching experience during postgraduate residency training, new pharmacy practice faculty members often need professional development to meet the demands of their academic responsibilities. A mentoring program can be 1 means of improving faculty success and retention. Many US colleges and schools of pharmacy have developed formal mentoring programs, whereas several others have informal processes in place. This paper discusses those programs and the literature available, and makes recommendations on the structure of mentoring programs.

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BACKGROUND: Schizophrenia and bipolar disorder are both prevalent types of psychiatric illness in the United States. As second-generation antipsychotics have become a more viable first-line treatment option, their use has been associated with a new era of adverse events (AEs), most notably metabolic and cardiovascular concerns. Although treatment options for schizophrenia and bipolar disorder have arguably improved, there continues to be a need for medications that achieve and maintain desired efficacy with minimal AEs. OBJECTIVES: This article serves as a comprehensive review of the pharmacologic profile of the second-generation antipsychotic asenapine, as well as a review of its efficacy and safety profiles based on the findings from clinical trials in schizophrenia and bipolar disorder. METHODS: Searches of Ovid MEDLINE, EMBASE, and IDIS were conducted (January 1996 to November 2011) to identify clinical studies and other primary literature sources with the following search terms: asenapine, bipolar disorder, antipsychotic, psychosis, dopamine, and schizophrenia. Only studies of asenapine and placebo and/or active-comparator arms were included. RESULTS: The literature search yielded 67 unique articles, including review articles, which were excluded. The efficacy of asenapine was reported in 3 clinical studies in patients with schizophrenia, 1 each in acute and long-term settings, measured as significant changes in Positive and Negative Syndrome Scale scores over 6 and 52 weeks. Asenapine also had reported efficacy in the prevention of relapse in schizophrenia during a 26-week extension study. In addition, efficacy of asenapine was reported in 2 studies in acute mania as well as extension phases of both 9 and 40 weeks, as determined by significant changes in Young Mania Rating Scale scores. The most commonly reported AEs in these studies were somnolence (13%-24%), extrapyramidal symptoms (EPS) (7%-12%), and dizziness (11%). CONCLUSIONS: The findings from multiple studies have suggested that asenapine is efficacious in the acute treatment of schizophrenia. Asenapine has reported long-term efficacy for this indication and the potential to reduce the incidence of relapse. Asenapine efficacy was also reported in the treatment of acute manic or mixed states associated with bipolar I disorder. Asenapine had an acceptable safety profile across the different disease states studied, although it was not devoid of metabolic and EPS-related AEs.

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Neuroleptic malignant syndrome (NMS) is a physiologic phenomenon that has been associated with the use of both first- and second-generation antipsychotics resultant to their ability to block dopamine blockade in the basal ganglia and hypothalamic regions of the brain. The typical reaction involves the presentation of muscle rigidity, changes in mental status, temperature elevation, labile blood pressure, and elevations in creatinine kinase and white blood cell counts. The reaction is most often reported early in the course of therapy but is well documented to have the potential to occur at any point in time. Untreated NMS can be fatal, often from secondary causes such as deep venous thrombosis and pulmonary embolism. Treatment involves immediate discontinuation of the offending agent, supportive therapy of clinical symptoms, and may include the use of the skeletal muscle relaxant, dantrolene sodium, or the dopaminergic agents bromocriptine or amantadine. In this case, we present a patient who developed symptoms of NMS during the cross-taper and conversion from quetiapine to clozapine. The patient was treated for NMS; however, his clinical diagnosis was never able to be definitively determined as he was initially evaluated for septicemia and later treated for suspected bacterial infection with antibiotics, and clozapine-associated side effects cannot be ruled-out as a contributing source to the clinical presentation. The estimated Naranjo Scale score for this case report is 3.

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The role of the psychiatric pharmacist in the care of the mentally ill has continually evolved since the late 1960s and early 1970s. Pharmacists in the field of psychiatric pharmacy work to improve the health, safety, and welfare of those impacted by one or more psychiatric conditions. Specialty residency training programs are accredited to establish minimum training standards and a board-certification process ensures that individuals provide a high level of quality of care. It is the position of the College of Psychiatric and Neurologic Pharmacists (CPNP) that Psychiatric Pharmacy residency programs obtain American Society of Health-System Pharmacy (ASHP) accreditation and help the profession move forward as a recognized specialty.

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BACKGROUND: Traditional treatment approaches for the management of restless legs syndrome (RLS) and Parkinson's disease (PD) include the use of medications that either directly or indirectly increase dopamine levels. In turn, a potential adverse event that could be expected is the development or exacerbation of psychiatric-related symptoms. OBJECTIVE: To evaluate and describe the incidence of psychosis and associated behavioral features in patients taking ropinirole for RLS or PD. METHODS: Patients were identified from a computerized database search of outpatients being treated with ropinirole for 1 of 2 medical conditions: PD or RLS. Data were collected in a retrospective manner from 95 patients who were tracked over the course of their therapy to determine whether psychosis or associated behavioral symptoms developed as a result and whether an intervention was needed to adjust ropinirole dosing or if additional medications had to be added to control features associated with psychosis. RESULTS: A total of 284 patients being treated for RLS or PD were identified; of this group, 95 patients were identified as being treated for PD or RLS with ropinirole. Of the 95 patients being treated with ropinirole, 13 developed psychotic features that required therapeutic intervention with either the use of an antipsychotic or dose adjustment of ropinirole. PD patients included in this study were numerically more likely to develop psychotic features compared with RLS patients; however, the difference was not statistically significant (p = 0.122). The results do suggest that this risk is increased when ropinirole is used as part of a dual therapy approach with dopamine agonists in the treatment of either PD or RLS (p = 0.003). DISCUSSION: Dopamine agonists have long been used as preferred treatment in the management of PD and RLS. When treating either PD or RLS in the psychiatric population, the concern arises that increased activity at dopamine receptors may induce or exacerbate psychiatric features. A potential clinical concern with the use of ropinirole is the potential for patients to develop psychiatric features, although there are few data available to demonstrate whether stimulation of targeted individual dopamine receptors is linked to the development or exacerbation of psychotic features. It is also undetermined whether concurrent antipsychotic treatment provides any protective benefit against psychosis, especially in patients already being treated for psychotic symptoms. CONCLUSIONS: Our findings suggest that ropinirole may play a role in inducing or exacerbating psychosis and its associated features, although a number of confounding variables prevent the determination of a clear association and suggest that further investigation is warranted in controlled clinical trials.

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OBJECTIVE: To report the development of neutropenia in a patient after almost 8 years of being stabilized on delayed-release divalproex sodium (DVPX). CASE SUMMARY: A 45-year-old man had been maintained on DVPX for nearly 8 years, with serum valproic acid concentrations of 85-128 mg/L and normal white blood cell (WBC) counts and absolute neutrophil counts (ANCs). Five months prior to the development of neutropenia (defined as ANC <1800 cells/microL), the patient's DVPX dosage was decreased by 250 mg to 1250 mg every morning and 1500 mg every evening. After 2 months of that regimen, the DVPX dosage was increased back to 1500 mg twice daily. Three months after that increase, the patient's WBC count dropped to 3.7 x 10(3)/microL and ANC was 1199 cells/microL. Although the ANC was below 1800 cells/microL, he showed no physical manifestations consistent with neutropenia. DVPX was discontinued, and 2 weeks later the patient's WBC count was 7.2 x 10(3)/microL and ANC was 2290 cells/microL. DISCUSSION: Although a complete blood cell count with differential is a commonly accepted form of therapeutic drug monitoring with DVPX, the monitoring is considered most necessary to identify dose-related thrombocytopenia. However, neutropenia has been rarely associated with the use of DVPX and could contribute to the development of different types of infection, including those of a bacterial, viral, or fungal origin. Although neutropenia is generally mild in severity, potentially severe DVPX-associated neutropenia can occur any time during the course of therapy, although it is most common within the first few months of treatment. In this case, DVPX was the probable cause of the neutropenia, according to the Naranjo probability scale. However, this case of neutropenia is atypical with respect to the timeframe in which it developed and was identified. Although the documented laboratory findings suggest neutropenia, the patient did not experience any clinical complications as a result. The late onset of the patient's neutropenia is unlike other cases that have been documented in the literature. CONCLUSIONS: Hematologic therapeutic drug monitoring continues to be clinically important regardless of whether the patient is early in therapy or even years later in the course. In this patient, continued regular therapeutic drug monitoring identified a suspected drug-related complication and the medication was able to be discontinued without the development of clinical complications.

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An issue under much clinical debate is whether treatment with two antipsychotic agents simultaneously is advantageous for optimizing response in patients whose previous monotherapy with antipsychotic agents has failed. Minimal evidence supports treatment with multiple antipsychotics, even when the agents have different mechanisms of action. The standard of care for treating schizophrenia is to first use monotherapy of adequate dosage and duration, including a trial of clozapine before adding a second agent. We report the case of a 32-year-old man whose monotherapy with various antipsychotic agents failed. During attempted conversion from aripiprazole to clozapine, the patient experienced a significant reduction in psychiatric features. Despite this improvement, the patient became resistant to the clozapine titration schedule due to complaints of sedation. Aripiprazole combined with low-dose clozapine as maintenance therapy resulted in a positive clinical outcome despite a clozapine serum level that is generally considered subtherapeutic. This case emphasizes the importance of making interventions based on individual patient response.

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Aripiprazole is a novel antipsychotic with a mechanism of action different from those of traditional first- and second-generation antipsychotics. We describe three patients with long histories of treatment for schizophrenia or schizoaffective disorder in whom conversion to aripiprazole was being attempted. After they started aripiprazole, their psychosis, agitation, anxiety, or aggression worsened. Although the cause of the increased agitation was unclear, it may have been related to long-term use of dopamine-blocking antipsychotics and resultant upregulation of postsynaptic dopamine receptors. The mechanism of partial dopamine agonism observed with aripiprazole may increase dopaminergic activity and worsen positive dopamine-associated symptoms, such as paranoia, agitation, and aggression. The treatment of schizophrenia is often a clinical challenge, particularly when patients have a long history of noncompliance and poor response. Clinicians face difficult decisions in finding an effective and well-tolerated regimen. These cases magnify some of the challenges and provide insight into the clinical implications of converting to therapies with different pharmacodynamic effects.

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Bipolar disorder can be a devastating disease state for individuals with the disease and also for family members. Proper recognition and treatment is vital to the successful management of this disease state. Through increased community and practitioner awareness, along with efforts to increase awareness for proper assessment, the rate of diagnosed bipolar disorder is increasing. Recent years have brought about the introduction of several new medications with approved indications for the treatment of bipolar disorder. In addition to new agents, traditional mood stabilizing medications have also been released in different formulations to better enhance tolerability without jeopardizing efficacy. One particular product is extended-release divalproex sodium. In the following article, we review the clinical presentation of bipolar disorder, its epidemiology, and the pharmacokinetics and mechanism of action for divalproex. In addition, we specifically review the role of extended-release divalproex in bipolar disorder through a critical analysis of the currently available published primary literature.