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 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 Pharmacogenetics 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 medication therapy management-related services. For patients who may struggle with mental health and other medical conditions with complex medication regimens, the optimization of drug therapy is essential.
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.
An area of significant recent growth 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.
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 2024). 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 complicated. In my mind this necessitates an additional level of interpretation, and perhaps education (to both patients and prescribers) that the psychiatric pharmacist is well positioned to provide. The Veterans Affairs Healthcare Association is an example of one large national organization that has targeted hiring or training clinical pharmacy specialists to provide pharmacogenetic test interpretation (Wu 2024). Most of the pharmacogenetic 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.
