Vital Role of Compounding Pharmacists in Managing the Side Effects of Psychiatric Medications
Now is a good time to consider reaching out to psychiatrists to establish a collaborative relationship. Working together is the best way to protect and improve the mental health of patients taking psychiatric medications, as the ever-increasing number of psychotropic meds and higher risks of adverse effects are difficult for one clinician to manage alone. The estimated 27 million US adults taking psychiatric drugs account for about 89,000 emergency department visits every year due to adverse drug events. Roughly 20 percent of those visits result in hospitalization. The more involved you are in managing side effects of psychiatric medications, the lower the chances are that patients will end up in the hospital.
Current Issues in Psychopharmacology That Affect Patients
During the 2016 annual meeting of the American Psychiatric Association, psychiatrists discussed a variety of issues and gained info on how to best meet the needs of their patients. Staying abreast of this news is vital for pharmacists, as the knowledge informs how to counsel patients taking psychotropic meds. For example, one seminar emphasized the importance of psychiatrists paying more attention to psychosocial aspects that boost compliance, such as creating a strong therapeutic alliance and involving patients in decision making.1 Pharmacists can follow the same concept during medication reviews, make sure patients are involved and work simultaneously with psychiatrists to facilitate optimal patient outcomes.
Participants at one seminar talked about revising the Neuroscience-based Nomenclature to use the pharmacologic mode of action rather than indication-based nomenclature.2 Giving multiple examples, such as antidepressants that are now used to relieve pain and the anxiolytic diazepam, which is also FDA-approved to treat muscle spasms, the speakers suggested it’s time to revise the nomenclature to reflect multiple uses and eliminate patient confusion. When pharmacists are aware of the confusing nomenclature, they can make it a point to explain to patients why they need a drug that’s labeled for a use unrelated to their diagnosis.
Another workshop at the annual meeting explored whether psychiatric residents need to be better trained in psychopharmacology. One small study found that many third year psychiatry residents lacked experience initiating mood stabilizers and the ACGME Program Requirements for Graduate Medical Education in Psychiatry offer sparse guidelines for psychopharmacology experiences.3 Beyond basic training, it also takes significant time and effort to keep up with this rapidly changing field, as researchers learn more about intracellular mechanisms and new pharmaceuticals are developed. As of May 2016, more than 135 psychotropic medicines were in development—all of them in clinical trials or waiting for FDA approval.4 Psychopharmacology training varies between medical schools—pharmacists can step in to bridge any gaps and protect the patient’s health.
How Pharmacists Can Help with Managing Side Effects of Psychiatric Medications
One of the biggest challenges for psychiatrists is assessing and managing side effects of psychotropic medications. Psychiatric conditions and their comorbidities, whether psychiatric or physical, often affect the presentation of adverse reactions, making it hard to discern cause and effect. As one example, insomnia may be caused by a selective serotonin reuptake inhibitor or it may be due to depression. When pharmacists are part of the treatment team, their perspective may be the piece of information needed to unravel the clues and protect the patient’s health. A short list of adverse effects to screen for include:5
- Antipsychotics: Muscle spasms, tremors, dry mouth, drowsiness, restlessness and blurred vision. Long term use increases the risk of tardive dyskinesia. Antipsychotics are commonly prescribed for psychosis and schizophrenia, but they’re also used to treat aggressiveness in patients diagnosed with autism.
- Atypical antipsychotics: The most common side effects are weight gain, dizziness, dry mouth, blurred vision and constipation. They may also interfere with sleeping or cause tardive dyskinesia over the long run.
- Selective serotonin reuptake inhibitors: These antidepressants may lead to fatigue, insomnia, nausea, diarrhea and sexual dysfunction. Antidepressants also increase the risk of suicidal thoughts and anxiety.
- Serotonin and norepinephrine reuptake inhibitors: Hypertension, fast heart rate, sweating, dizziness, dry mouth, nausea, constipation, somnolence and sexual dysfunction are all potential adverse effects.
- Tricyclic antidepressants: Look for weight gain, drop in blood pressure when standing, dry mouth, constipation, urinary retention, blurred vision and dizziness.
- Stimulants: Typically prescribed for attention deficit hyperactivity disorder, these medications can cause sleep problems, mood swings and loss of appetite.
- Mood stabilizers: The long list of potential side effects for mood stabilizers includes itching, rash, hand tremors, excessive thirst, frequent urination, slurred speech, irregular heartbeat, hallucinations and black-outs.
- Benzodiazepines: Often used for anxiety disorders and panic attacks, these meds may cause drowsiness, dry mouth and impaired memory and coordination.
- Buspirone: An anti-anxiety agent not related to the benzodiazepines, buspirone’s side effects include dizziness, nausea, headache, dysphoria and nervousness.
In addition to adverse effects, pharmacists should assess patients for two other potentially serious psychotropic-related problems:
Discontinuation syndrome: When patients decide to discontinue their psychotropic medications without consulting their doctor, they can experience serious symptoms and may rebound back to pre-treatment levels of their psychiatric disorder. Suddenly stopping antipsychotics can cause panic attacks and palpitations, while discontinuing antidepressants leads to flu-like symptoms, dizziness and insomnia. Pharmacists can safely and accurately taper meds by compounding smaller doses in liquid form.
Psychiatric drug-drug interactions: Patients taking more than one medication are at risk for drug-drug interactions.6 Serotonin syndrome, which is potentially fatal, is likely to occur when drugs such as antidepressants, CNS stimulants, triptans, dextromethorphan, opioids and herbal products such as St. John’s wort are mixed. That’s just one example out of many possibilities, so when you refill prescriptions, always remember that people with psychiatric disorders have a high risk for drug interactions and side effects.
Expertise of Pharmacists Covers Multiple Patient Concerns
It goes without saying that you’re the expert in pharmaceuticals, but psychiatrists and patients also rely on your knowledge of costs and insurance. Patients want to know if a treatment will work and its side effects, but they also have questions about how much the medication costs and whether it’s covered by insurance. Psychiatrists understand their patients may be concerned about medication costs, but they tend not to discuss it when prescribing meds. By being upfront with information and staying in touch with patients, compounding pharmacists significantly influence their patient’s willingness to stick with their treatment plan.
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- “Is Your Prescribing Really Evidence Based?” May 2016, http://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.PP5b4 ↩
- “Are You Ready to Change the Way You Think About Psychiatric Medication?” May 2016, http://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.PP5b5 ↩
- “How Can We Better Prepare Residents for Psychopharmacologic Treatment Planning?” May 2016, http://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.pp5b2 ↩
- “Cost of Mental Illness Underscores Need for New Treatments,” May 2016, http://catalyst.phrma.org/cost-of-mental-illness-underscores-need-for-new-treatments ↩
- “Mental Health Medications,” January 2016, http://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml ↩
- “Psychiatric Drug-Drug Interactions: A Refresher Course,” November 2012, https://www.uspharmacist.com/article/psychiatric-drug-drug-interactions-a-refresher ↩