Clinical Profile of a Patient With Serious Mental Illness

Troy Trygstad, PharmD, MBA, PhD, and Carla Cobb, PharmD, BCPP, discuss the challenges in diagnosing serious mental illness and outline the treatment protocols at a community health center.

Troy Trygstad, PharmD, MBA, PhD: When we talk about the patient profile—you’ve had a long, and distinguished career in psychiatric, and neurologic pharmacy—how would you describe the clinical profile? Somebody comes to you in your practice, they’ve either been referred as having SMI or they’re coming in and it’s maybe even something else. And then you say, “Wow, this person may have SMI and I’m going to go grab somebody and we’re going to work on this patient.” What does that clinical profile look like?

Carla Cobb, PharmD, BCPP: So, the diagnosis is often made using clinical criteria. There aren’t usually lab tests or any kind of measures that will identify somebody with a mental illness. It’s usually symptomatic. Often, they can be in denial about their condition. And so, it’s often a family member or they had an encounter with somebody in law enforcement or something unusual happens that brings them to the attention of the medical community, and that’s when the diagnosis starts to be unwound.

Troy Trygstad, PharmD, MBA, PhD: So, is it more often that it’s a triggering event—law enforcement, some sort of crisis or episode—that somebody gets in and becomes diagnosed? Or do you have cases where folks walk in and say, “I can hear voices” or “I’m displaying symptoms that I don’t think are normal. Can you help me figure out what this is?” Is there sort of a proportion that you can think about? Is it about half-and-half or 1 or more of the other?

Carla Cobb, PharmD, BCPP: Yes. I think it depends on the diagnosis. So, for people with schizophrenia or bipolar disorder who are in a manic episode, often those are identified initially by some kind of crisis of some episode at home or some interaction with law enforcement or hospitalization that will bring that to light. If you’re talking about severe depression, that is something that people may present to their physician with and ask for help.

Troy Trygstad, PharmD, MBA, PhD: And now you’ve worked in a psychiatric practice. Can you describe what your practice has been over these years? Is it co-located or is it mostly a psychiatric practice? Or what’s the environment you were working in?

Carla Cobb, PharmD, BCPP: So, my practice setting has been the community health center. It’s a primary care practice that has a family medicine practice embedded in it. And so, it is not a mental health practice, but many of our patients do have mental illnesses. And so, my practice has been as a psychiatric pharmacist embedded in this practice where we treat patients with all kinds of diagnoses. And as a pharmacist in that practice, my job is to look at all of their medications to make sure that they’re on the correct medications, that we’re looking for appropriateness of therapy, side effect management, dosing adjustments, drug interactions, and whether it’s their mental health medications or their other medical conditions. We take a broad look at all of their medications.

Troy Trygstad, PharmD, MBA, PhD: And so, you didn’t necessarily have a psychiatrist in residence at the community health center.

Carla Cobb, PharmD, BCPP: We did not have a psychiatrist.

Troy Trygstad, PharmD, MBA, PhD: I’m guessing, actually, because you’re in a generalist environment, did you become the de facto expert in pharmacology when it came to behavioral health medications?

Carla Cobb, PharmD, BCPP: We have a very nice system set up. It’s very much a team-based approach to care. Several years ago, we added integrated behavioral health. We have licensed counselors and social workers on staff as well. And so, it’s very much a team approach. And the nice thing is we also have access to community psychiatrists who can help. So, it’s very much a tiered approach. There are primary care physicians who feel very comfortable in managing the less severe mental illnesses, and as it becomes apparent that somebody is not responding to treatment or is having more severe symptoms, then that’s when they may pull in a psychiatric pharmacist like myself or they might consult with the community psychiatrist.

Troy Trygstad, PharmD, MBA, PhD: I bet there’s a lot of community health centers out there that would love to have a psychiatric specialized pharmacist.

Carla Cobb, PharmD, BCPP: Yes, it’s something that I feel like I happened into this position many years ago and felt like it was an excellent fit for me because it’s an area where many primary care physicians aren’t that comfortable, don’t have a lot of training or background in mental health conditions, and really seek out the other members of the team to help treat those patients.

Troy Trygstad, PharmD, MBA, PhD: So, paint me a picture: You walk into a community health center. Who and how do I get diagnosed with serious mental illness? Is it kind of 1 general way or can it come about in a lot of different ways? I either get triggered into it or I come in because I’m exhibiting symptoms or I’m self-aware or a family member has noticed. How does that diagnosis take place? Because to your point, what’s a little bit unique about this disease state is (1) the effect it has on a person’s life tends to be quite immediate, yet it can still be chronic, and (2) we don’t have a definitive lab. We have survey instruments and assessments and so on and so forth. And then (3) all of us have interacted probably regularly with primary care physicians, endocrinologists, cardiologists, and so on and so forth, but a psychiatric specialist just seems kind of so far away for some reason. It just seems different. So, for the audience, give us a sense of where that diagnosis happens and what that journey looks like to that point of diagnosis.

Carla Cobb, PharmD, BCPP: Diagnosis is often very difficult. Many patients with bipolar disorder, for example, go many years often before they’re correctly diagnosed. They may be initially diagnosed with depression or anxiety or other conditions, but it takes some time before you can actually make that correct diagnosis. Part of the diagnosis of any serious mental illness is a pattern of change of behavior and symptoms over time. So, often it can’t be diagnosed in a single visit. It’s observation over time. You mentioned rating scales. That is something that can be used. Many centers now, community health centers anyway, are using rating scales routinely to screen for depression, and anxiety in particular. And so, that’s a way to start to identify people sooner with less severe symptoms and something that then we can address before it turns into a crisis.

Troy Trygstad, PharmD, MBA, PhD: That’s the neat thing. You’re in a primary care environment and they’re screening for that. I took my son to a pediatrician the other day, and they did a PHQ (patient health questionnaire), which I thought was great just to screen folks. Why not, right? Let’s catch them, and remove the stigma. It may help patients who don’t have that but they’re aware that it exists, and if they’re being screened, maybe that helps, right?