Improving Outcomes: Providing Care for Patients with Mental Illness

Behavioral health pharmacy can utilize an embedded co-management model.

Patients being treated for mental illnesses require a health care team that is prepared to address their particular needs, and the expertise of pharmacists is crucial to that team. A 2013 survey by the Substance Abuse and Mental Health Services Administration reported that 10 million people in the United States suffer from a serious mental illness.¹ Another survey of urban primary care practices indicated that up to 40% of patients met the criteria for a mental health disorder.² In many communities across the United States, access to psychiatric care is limited, and patients often prefer to be treated by their primary care practitioner for all of their health care conditions. The guidance of pharmacists can help to ensure positive outcomes for patients who are receiving medication therapy for mental illness and comorbid conditions. With the right program in place, quality of care can improve.

RiverStone Health, a federally qualified health center and National Committee for Quality Assurance—recognized patient-centered medical home, serves a large population of patients with psychiatric and substance use disorders. The clinic employs a board-certified psychiatric pharmacist and a pharmacotherapy specialist, in addition to physicians, physician assistants, nurse practitioners, nurses, dietitians, care coordinators, behavioral health counselors, and a licensed addiction counselor. It houses a family medicine residency program and serves as a training site for medical and pharmacy students. There is also an on-site community pharmacy.

Clinical pharmacists work with the health care team to provide services to better meet the needs of patients with comorbid medical and psychiatric or substance use disorders. Pharmacists and pharmacy students provide point-of-care drug information, patient education, anticoagulant dosing adjustments, and medication reconciliation, and accept warm handoffs from primary care physicians for pharmacist-provided comprehensive medication management. In these clinic appointments, a patient’s medications are reviewed to ensure that they are appropriate, effective, safe, and convenient, and to resolve any drug therapy problems.

In addition, the psychiatric pharmacist and a licensed professional counselor meet jointly with patients after discharge from psychiatric facilities to make recommendations for follow-up care. The psychiatric pharmacist serves on a multidisciplinary controlled substance committee and coordinates monthly psychiatrist consultations, providing physicians the opportunity to present cases and obtain recommendations. The psychiatric pharmacist also serves as a resource to other clinical pharmacists, providing education and consultations for patients with mental illnesses.

Each patient care team, which includes a pharmacist, meets monthly to review population reports that identify and establish outreach to patients not meeting clinical goals of treatment. Pharmacists also provide regular didactic education to all members of the health care team. All of these team-based services provide support to physicians and improve the care and outcome for patients with psychiatric disorders.

The results of a 2013 pilot program support the role of the pharmacist on the team approach to caring for patients with mental illnesses. These patients were seen by a pharmacist for comprehensive medication management as described by the Patient Centered Primary Care Collaborative guidelines.³ All medications were reviewed to identify and resolve any drug therapy problems. Updated medication lists and recommendations to resolve the problems were sent to all of the patient’s physicians. The patient received a copy of his or her medication list, organized by disease state, along with recommendations for self-management activities. The program improved the number of patients reaching clinical goals, reduced overall health care costs, and improved patient satisfaction with care.⁴ The most common drug therapy problems identified were adverse effects, unnecessary medications, excessive doses, and poor adherence. The estimated return on investment was $2.80 for every dollar spent on the service.

Services in community pharmacies and health systems for patients with mental illness can also be improved. Rarely a day goes by that a pharmacist does not dispense an antidepressant, mood stabilizer, anxiolytic, hypnotic, or antipsychotic. Pharmacists must become familiar with benefits, adverse effects, drug interactions, and monitoring of medications used to treat psychiatric disorders. They must also become comfortable in providing patient education. If a pharmacy provides disease state management for patients with diabetes or cardiovascular conditions, people with psychiatric disorders will undoubtedly be included, as co-occurring chronic conditions are common in patients with psychiatric disorders. Likewise, people with chronic illnesses have a higher prevalence of depression. The pharmacy staff needs to make people with psychiatric disorders feel welcome in the pharmacy and other health care settings. All employees should be educated and trained in working with people with mental illnesses to help reduce their stigma and encourage respectful and compassionate care.

There is an enormous opportunity for pharmacists to improve care for patients with mental illnesses and substance use disorders. Primary care providers and health care teams welcome the expertise of knowledgeable and compassionate pharmacists.

Carla Cobb, PharmD, is a board-certified psychiatric pharmacist at RiverStone Health and the Montana Family Medicine Residency in Billings, Montana, where she has practiced for 17 years. She is a clinical professor in pharmacy practice at the University of Montana. Carla is a past president of the College of Psychiatric and Neurologic Pharmacists (CPNP) and is currently the chair of CPNP’s Government Affairs Council. She earned her Doctor of Pharmacy degree from the University of Texas.

References

• Substance Abuse and Mental Health Services Administration. Behavioral Health Barometer: United States, 2014. HHS Publication No. SMA-15-4895. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015. www.samhsa.gov/data/sites/default/files/National_BHBarometer_2014/National_BHBarometer_2014.pdf.
• Fogarty CT, Sharma S, Chetty VK, Culpepper L. Mental health conditions are associated with increased health care utilization among urban family medicine patients. J Am Board Fam Med. 2008;21(5):398-407.
• McInnis T, Strand LM, Webb CE. The Patient Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes. 2nd ed. Washington, DC: Patient Centered Primary Care Collaborative, 2012. www.pcpcc.org/sites/default/files/media/medmanagement.pdf.
• Cobb C. Optimizing medication use with a pharmacist-provided comprehensive medication management service for patients with psychiatric disorders. Pharmacother. 2014;34(12):1336-1340. Published online October 20, 2014. doi: 10.1002/phar.1503.