The “What I Wish I Knew” series of articles is a service of CPNP’s Resident and New Practitioner Committee. Articles are intended to provide advice from experts for students, residents, and new practitioners. Articles are not intended to provide in-depth disease state or pharmacotherapy information nor replace any peer-reviewed educational materials. We hope you benefit from this “field guide” discussing approaches to unique problems and situations.
Dr. Bishop is Associate Professor of Experimental and Clinical Pharmacology at the University of Minnesota (UMN). He conducts psychiatric pharmacogenomics research activities in the UMN College of Pharmacy Pharmacogenomics Laboratory with a primary focus on symptom response, cognitive response, and side effects to medications. He has clinical experience in the treatment of psychosis and mood disorder populations and is also a contributing member to the Clinical Pharmacogenomics Implementation Consortium, the University of Minnesota Precision Medicine and Health Consortium, the University of Minnesota Institute for Personalized Medicine, and an affiliate member of the Implementing Genomics in Practice (IGNITE) network.
Practice environments for psychiatric pharmacists have existed for some time in the hospital setting. Traditionally this has been in the context of working with inpatient treatment teams. However, there have been increasing opportunities for psychiatric pharmacists to practice within hospital-based outpatient clinics, injection clinics, and emergency departments. There are also a growing number of medications with unique FDA Risk Evaluation and Mitigation Strategies (REMS) that may present opportunities for pharmacist-focused or pharmacist-led clinics to improve the accessibility of these medications. There continues to be a great need for individuals well-versed in psychiatric pharmacy to contribute to the care of individuals in community environments, including involvement in both primary care and assertive community treatment (ACT) team settings. With notable shortages of mental health care providers, particularly in rural areas, there is a growing opportunity for pharmacists to support both primary care providers and psychiatric specialists. The number of psychiatric pharmacists utilizing collaborative practice agreements in outpatient clinics continues to increase, as do the opportunities for pharmacists to be reimbursed for the provision of comprehensive medication management. For patients who may struggle with mental health and other medical conditions with complex medication regimens, the optimization of drug therapy is essential.
There continue to be evolving opportunities for psychiatric pharmacists in industry. Individuals with advanced training and clinical experience in psychopharmacology are increasingly recognized as important members of drug development and medical affairs teams in the pharmaceutical industry. With a unique knowledge of the medications and clinical scenarios in which they are used, psychiatric pharmacists provide essential input into the development of new products, optimization of existing drugs, and the education provided to people using these medications in clinical care.
Other unique opportunities for psychiatric pharmacists exist in assisted living or residential treatment facilities, long-term care, or institutional settings where psychotropic medications are often used and require close monitoring for appropriate, effective, and safe use.
To understand what the future holds, it is helpful to broadly look at some trends in pharmacy practice. The recently published 2019 National Pharmacist Workforce Survey identified a 12% increase in the proportion of pharmacists providing patient care relative to five years ago and dispensing and related activities roles has decreased slightly from 40% five years ago, to 34% in 2019. Finally, the area of greatest growth over the past 10 years has been in ambulatory care pharmacy and the provision of patient care in this environment (Schommer 2020). These continue to point to trends of pharmacists taking a larger role in care delivery. This is being done in a health care environment where pharmacists continue to work toward provider status recognition, which could open up additional payment models for services. I imagine this will change in the near future and open up opportunities for psychiatric pharmacists to find additional support in their provision of care to patients, particularly in outpatient settings. A last significant development from 2020 to the present is the COVID-19 pandemic, which has had profound impact on the healthcare system as well as our social and professional interactions as a society. The negative impacts of COVID-19 infection as well as the societal impacts of the virus on mental health present an evolving landscape that may increase the numbers of people requiring psychiatry focused pharmacotherapy.
Advances in mobile technologies and point of care testing are now providing increased opportunities for medication, symptom monitoring, and communication. Telepharmacy and video consultation opportunities will expand for psychiatric pharmacists just as they have for psychiatrists and other health care providers in this new era of remote assessments. This will increase the availability of pharmacists for both prescriber and patient consultations, particularly in rural areas or in regions with lower densities of psychiatric pharmacy specialists. This along with the recent pre-pandemic growth of ambulatory care pharmacy collectively predicts a growing role for the psychiatric pharmacist in the community/ambulatory care environment.
Pharmacist prescribing already exists in some environments like Veteran’s Administration Medical Centers. Whether there are going to be broad near-term expansions of pharmacist prescribing beyond that environment is not clear, but I anticipate that there will be an increase in collaborative practice agreements which will provide opportunities for limited prescriptive activities.
Precision medicine continues to be a popular concept. The spirit of ‘precision medicine’ is to incorporate additional technologies to improve treatment by making them more ‘precise’. Current trends include the study of incorporating mobile (e.g., wearable monitors, ‘smart’ watches, smartphone applications, etc,), or biological (e.g., genetic data or real time monitoring of drugs or other substances in the body) technologies into patient care (Bishop 2017).
One aspect of precision medicine that has taken off, but remains controversial, is that of pharmacogenetic testing. We have a growing understanding of how genetic variation influencing drug metabolism and pharmacodynamics may influence dosing or drug selection. This is particularly relevant to psychiatric pharmacy for a couple of reasons. The first is that in the absence of a robust drug development pipeline for mental health conditions, we need to optimize the treatments that are currently available. Many patients require multiple medication trials to find a drug that is tolerable and efficacious. The second is that the most commonly used medications in psychiatry are antidepressants and antipsychotics, most of which undergo extensive hepatic metabolism through enzymes with notable genetic variation (Drozda, 2014). We can now very reliably identify those who are genetic fast or slow metabolizers with clinical pharmacogenetic tests and there is growing evidence to support the use of this information to inform drug selection and dosing when it is available (Bousmman 2021).
This has resulted in a dramatic increase in commercial testing companies with pharmacogenetic testing products for psychiatric medications. The caveat to this is that there are many clinically available tests that are all slightly different. Furthermore, the application of the test results to patient care requires some knowledge of what the test results mean in the context of current and potential future drug selections for the patient (Bishop 2021). In an attempt to make these tests ‘user friendly’ the test results are often accompanied by decision support tools that try to simplify the findings. But these tests are often ordered for clinical scenarios which are not so ‘simple’. In my mind this necessitates an additional level of interpretation, and perhaps education (to both patients and prescribers) that may the psychiatric pharmacist is well positioned to provide. Most of the testing relating to mental health is occurring in outpatient clinics, again reinforcing a potential role for psychiatric pharmacists in the ambulatory care environment. The use of these tests will likely increase over time and as the technologies improve, and the costs are lowered, there will be an evolution of current ‘reactive’ testing to more ‘prospective’ testing where genetic/pharmacogenetic information will be readily available to guide patient care, likely with additional information gathered from novel mobile monitoring technologies. We as a psychiatric pharmacy community need to be prepared for this.