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ABSTRACT: Major depressive disorder is a common mood disorder and presents increased morbidity and mortality risks for patients with comorbid cardiovascular disease (CVD). Selective serotonin reuptake inhibitors (SSRIs) are a cornerstone of treatment for major depressive disorder, given their relative safety and affordability compared with other antidepressant classes, and SSRIs frequently are used in patients with CVD. However, clinicians should carefully weigh safety considerations before prescribing SSRIs in these patients. This article reviews the safety of SSRIs in patients with CVD and discusses SSRI selection.

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PURPOSE: To determine if a correlation exists between the medication regimen complexity index (MRCI) and quality of life (QoL) in patients with heart failure (HF) assessed using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). METHODS: Retrospective chart review from July 2012 through June 2018 identified patients for inclusion who completed an MLHFQ. Baseline and, if available, follow-up MLHFQ scores were collected. The medication list documented on the date of the MLHFQ was used to calculate the MRCI. RESULTS: Patients with a documented MLHFQ score were included (n = 72) in the primary analysis. No correlation existed between baseline MRCI and MLHFQ (r = 0.07; p = 0.55). A secondary analysis of correlation between change in MRCI and MLHFQ was conducted for patients (n = 30) with a follow-up MLHFQ score. A moderate, negative correlation (r = -0.47; p = 0.009) existed between change in MRCI and MLHFQ from baseline to follow-up. CONCLUSION: No significant correlation between MRCI and MLHFQ scores were found at baseline. Patients with follow-up MLHFQ scores demonstrated improvements in QoL, despite increasingly complex medication regimens. Medication regimen complexity alone is likely an insufficient marker for predicting QoL in patients with HF.

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INTRODUCTION: Harm reduction is a term for strategies that minimize the negative outcomes of drug use. Given the progressing opioid epidemic, identifying barriers to harm reduction dispensing in community pharmacies is essential. METHODS: This online, survey-based study assessed community pharmacist attitudes toward harm reduction and perceived dispense rates of both naloxone and needles/syringes to patients without verifiable injectable prescriptions. The online survey was distributed to members of the Bexar County Pharmacist Association and university alumni. The survey collected demographics, perceived dispense rates of naloxone, needles and syringes, availability of pharmacy protocols for dispensing these products, and Likert-scaled attitudinal questions. Responses were collected for 6 weeks. RESULTS: Thirty-two survey responses were analyzed. Participants were generally white (n = 14) or Hispanic/Latino (n = 14), had a median age of 37 years (interquartile range, 32-49 years), and had a median graduation year of 2011 (interquartile range, 1988-2016). Most pharmacists agreed or strongly agreed they should be involved in harm reduction (n = 26) and that pharmacies are an appropriate place to access these resources (n = 26). However, most reported never or rarely dispensing both naloxone (n = 19) and needles and syringes (n = 22). Naloxone or needle and syringe protocol use was reported by 66% (n = 21) and 47% (n = 15) of pharmacists, respectively. Pharmacy protocols significantly enhanced the likelihood of naloxone dispensing (P = .007) but not needle and syringe dispensing (P = .24). CONCLUSION: Community pharmacists exhibited positive attitudes toward harm reduction but reported low rates of dispensing both naloxone and needles and syringes. Pharmacy protocols could be enhanced to better support community pharmacists in this area.

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Due to the well-defined risks of abrupt discontinuation of certain psychiatric medications, such as withdrawal and worsening symptoms, guideline recommendations describe evidence-based strategies for tapering some psychiatric medications, such as antidepressants. Despite widespread use of acetylcholinesterase inhibitor (ACHEI) therapy in the management of dementia, guideline recommendations for discontinuation of these therapies are very inconsistent. Specifically, studies and evidence-based recommendations for discontinuing ACHEIs in patients with dementia with Lewy bodies (DLB) are severely lacking. This deficit is problematic in that emerging reports suggest several adverse outcomes, such as worsening cognition and behavioral symptoms, are associated with abrupt switching and discontinuation of ACHEI therapy in this population. A case of rapid cognitive and functional decline following both abrupt switch and discontinuation of donepezil in a patient diagnosed with DLB is presented. A literature review of outcomes following changes in ACHEI therapy in DLB is also presented.

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OBJECTIVES: Combination opioid and benzodiazepine (BZD) therapy is associated with poor treatment outcomes and increased risk of overdose death. There is currently limited literature detailing well-implemented strategies to minimize dual prescribing of these agents. The following describes the implementation processes and outcomes of a health system quality improvement project that aimed to reduce combination BZD and opioid therapy. STUDY DESIGN: A retrospective chart review-based quality improvement project. METHODS: All patients within a single healthcare system of the Department of Veterans Affairs treated with long-term (>90 days) combination therapy were identified. A psychiatric pharmacist submitted a 1-time chart review note for each patient, which briefly outlined patient-specific considerations and recommendations for alternatives to BZD treatment. After a 30-day period following entry of the chart review notes, data were collected regarding the number of providers who (1) acknowledged the chart review notes by providing their additional signature and (2) committed to the recommended interventions by initiating taper schedules. RESULTS: During the 30-day follow-up period, 47.5% (n = 29) of chart review notes were acknowledged and 11.5% (n = 7) of prescriptions were tapered by providers. Mental health providers were less likely to provide their additional signature to the chart review notes (χ2 = 4.62, df = 1, P = .0316; Fisher exact test, P = .0215) and to initiate taper schedules (χ2 = 5.51, df = 1, P = .0189; Fisher exact test, P = .0410) compared with primary care providers. CONCLUSIONS: Chart review note recommendations were frequently disregarded by providers and are likely insufficient as a primary intervention tool for reducing long-term combination BZD and opioid therapy.

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BACKGROUND: Second-generation antipsychotics (SGAs) are prescribed for a variety of indications and are strongly associated with adverse metabolic effects. Studies of pediatric outpatients have revealed several deficiencies in monitoring practices for adverse effects associated with SGAs. OBJECTIVE: Our objective was to characterize SGA prescribing and metabolic parameter monitoring (MPM) in an inpatient pediatric population. METHODS: Patients aged <18 years and discharged on SGA treatment between 1 November 2013 and 30 April 2014 from an inpatient psychiatric institution in Pittsburgh, PA, USA were included. Electronic medical records (EMRs) were reviewed for patient age and weight and for parameters used by the International Diabetes Federation (IDF) to define metabolic syndrome: waist circumference, fasting blood glucose, triglycerides, high-density lipoprotein, and blood pressure. The primary outcome was the percent of patients with completed MPM, defined as all parameters being available within the patient's EMR in any form, except estimates. Secondary outcomes included percent of patients with existing metabolic syndrome or obesity according to IDF criteria, average total daily dose of individual SGAs, and frequency of individual SGA utilization. Data were analyzed utilizing univariate descriptive statistics. RESULTS: A total of 243 patients met inclusion criteria and were included in the analysis. For the primary outcome, 13.2% (n = 32) of patients had completed MPM for all parameters. Blood pressure was the most frequently documented parameter (n = 241; 99.2%), whereas waist circumference was the least (n = 67; 28%). Risperidone was the most commonly prescribed SGA (n = 99; 41%; average daily dose 1.92 mg). CONCLUSIONS: Compared with outpatient studies, rates of documented MPM for certain parameters (i.e., fasting blood glucose, lipids) is higher for pediatric inpatients treated with SGAs. However, several monitoring deficiencies are still noted.

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OBJECTIVE: This pilot study evaluated the utility of branched-narrative virtual patients in an interprofessional education series for psychiatry residents. METHODS: Third-year psychiatry residents attended four interprofessional education advanced psychopharmacology sessions that involved completion of a branched-narrative virtual patient and a debriefing session with a psychiatric pharmacist. Pre- and post-assessments analyzed resident learning and were administered around each virtual patient. Simulation 4 served as a comprehensive review. The primary outcome was differences in pre- and post-assessment scores. Secondary outcomes included resident satisfaction with the virtual patient format and psychiatric pharmacist involvement. RESULTS: Post-test scores for simulations 1, 2, and 3 demonstrated significant improvement (p < 0.05) from pre-test scores. Scores for simulation 4 did not retain significance. Resident satisfaction with the branched-narrative virtual patient format and psychiatric pharmacist involvement was high throughout the series (100 %; n = 18). CONCLUSIONS: Although there are important methodological limitations to this study including a small sample size and absence of a comparator group, this pilot study supports the use of branched-narrative virtual patients in an interprofessional education series for advanced learners.

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Doctor of pharmacy programs across the country strive to prepare culturally competent pharmacy professionals who are trained to provide compassionate and evidence-based care to a variety of patients. Within the Accreditation Council for Pharmacy Education 2016 Standards and Key Elements for the Doctor of Pharmacy Degree, pharmacy schools are charged with the task of developing professionals who can identify and diminish health care disparities. Transgender persons represent one of the most underrepresented and underserved communities within the modern health care system, yet very little information is available for training future pharmacists to care for the transgender community. A literature search using the MeSH terms transgender persons or trans-sexualism and pharmacy education was conducted, and it revealed 1 article published by Parkhill and colleagues in the American Journal of Pharmacy Education. A Google® search of the phrase "transgender education in pharmacy school" was conducted and produced 1 additional published article as well as an online transgender education program launched in November 2016. The following commentary outlines the current literature and practices that involve integration of transgender health education into pharmacy schools in North America and a discussion on areas for future study.

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INTRODUCTION: Proper psychiatric evaluation of patients necessitates that the clinician be vigilant in ruling out secondary causes of symptoms, such as substance-induced symptoms. Immunoassay-type urine drug screens (UDSs) offer clinicians rapid drug screen results, ease of use, and inexpensive cost. Unfortunately, these screens are not without their limitations. This review aims to outline the nuances and limitations of immunoassay UDSs and to provide the clinician with information that facilitates more accurate interpretation of UDS results. Specifically, false positive results associated with psychiatric medications and the availability and methods for acquisition of commercialized UDS masking agents will be reviewed. METHODS: A literature review was conducted to identify false positive UDSs associated with psychiatric medications. References for each article identified were also reviewed. Additionally, a Google® search was conducted to identify commercially available preparations used to mask UDS results and the methods of acquisition of these products. RESULTS: A total of 14 articles were identified using PubMed. No articles for mood stabilizing agents were identified. Entering the phrase how to pass a drug test into Google® search yielded about 12.6 million results, and select references were reviewed based on relevance and user reviews. DISCUSSION: Several psychiatric medications are documented as potential sources of false positive UDSs. Additionally, several agents are available for consumer purchase that may result in false negative UDSs. The clinician must be vigilant in interpreting immunoassay UDS results and should utilize more advanced forms of testing as clinically appropriate.

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Antidepressant medications are associated with a variety of genitourinary and adverse sexual effects, such as urinary hesitation, priapism, and delayed ejaculation. Here, we report a case of priapism and renal colic following initiation of duloxetine in a patient with history of tolerated selective serotonin reuptake inhibitor treatment. To our knowledge, this represents the first report of priapism and renal colic associated with duloxetine use. This case contributes to the current body of evidence describing adverse genitourinary and sexual effects associated with antidepressant medications.