Dr. Austin Smith, PharmD, BCPP
Mental Health and Substance Use Disorders – Clinical Pharmacy Practitioner
Robert J. Dole Veterans Affairs Medical Center
Dr. Suzanne Azzazy, DO
Geriatric Psychiatrist
Veterans Affairs Tennessee Valley Healthcare System
Dr. Austin Smith earned her Doctorate of Pharmacy Degree from Creighton University in 2018. She completed a PGY-1 pharmacy residency followed by a PGY-2 psychiatric pharmacy residency at Veterans Affairs Tennessee Valley Healthcare System (VA TVHS). In her current role, Dr. Smith practices under a scope of practice prescribing medications to Veterans with a variety of mental illnesses.
Dr. Azzazy is a Staff Psychiatrist at VA TVHS and an Assistant Clinical Professor of Psychiatry in the Department of Psychiatry and Behavioral Sciences at Vanderbilt University Medical Center. She received her degree from Lincoln Memorial University DeBusk College of Osteopathic Medicine, completed a psychiatry residency at East Tennessee State University, and completed a geriatric psychiatry fellowship at Vanderbilt University Medical Center. Dr. Azzazy is board-certified in psychiatry and geriatric psychiatry.
The role of pharmacists in community and hospital healthcare settings continues to expand. Shortages of clinicians, gaps in care, and specific pharmaceutical knowledge have all contributed the expanding role of pharmacists on the health care team. This shift has also allowed for growth of pharmacists’ responsibilities. Many pharmacists practice under collaborative agreements with physicians or other licensed healthcare providers which allow pharmacists to provide expanded treatment for a variety of disease states. Other pharmacists, such as the outpatient psychiatric pharmacists at the VA, practice under a scope of practice which allows for autonomous prescribing of certain medications.
Importance of Diagnostic Reasoning
One important distinction between pharmacists and physicians and other healthcare providers is that pharmacists are not diagnosticians. While pharmacists do not diagnose, they can play a critical role in diagnostic assessment. It is important for pharmacists to have strong knowledge of diagnostic criteria for treatment purposes. In 2014, the Joint Commission of Pharmacy Practitioners (JCPP) released the “Pharmacists’ Patient Care Process” which details the importance of assessment in patient care. Part of the “assess” aspect of patient care describes the importance of collecting information, prioritizing problems, and providing optimal care based on gathered information.1
Diagnostic skill, sometimes referred to as “diagnostic reasoning”, is important for a variety of reasons. Pharmacists should be able to determine severity of presenting issues, consider potential diagnoses, and monitor for diagnostic error.2 Pharmacists can also play a great role in identifying medication contribution to presenting symptoms. A patient may present to the mental health outpatient clinic with a symptom suggestive of one diagnosis, while the underlying cause is actually a medication interaction or side effect. As an example, a geriatric patient may present with new symptoms of mania. The patient’s home medication list should be reviewed closely for medications which have been known to cause or exacerbate mania such as levodopa or steroids.
When to Refer
Similarly, it is important that pharmacists are aware of instances when patients should be referred to a physician or other diagnosing provider. Within the outpatient mental health clinic at the VA, psychiatric pharmacists may encounter patients who present with new onset psychosis, mania or hypomania, trauma-related symptoms, or other acute changes in mental status which may warrant referral for further work up by a physician or other diagnosing provider. An example that frequently occurs within the mental health outpatient clinic at the VA and demonstrates the importance of diagnostic reasoning by pharmacists: a younger patient presented with symptoms of depression including decreased motivation, feelings of hopelessness, and lethargy. The patient was diagnosed with major depressive disorder, moderate severity based on an initial assessment with a psychologist. The patient was interested in initiating medication treatment and agreed to meet with the team psychiatric pharmacist, who prescribed the patient a commonly utilized antidepressant (i.e. sertraline). At the next follow-up, the patient has pressured speech and stated, “I’ve been feeling amazing – I have so much energy – I haven’t even needed sleep”. In this case, the pharmacist asks questions to identify potential presentation of mania. The pharmacist determines the current symptom report is suggestive of mania. The next step should involve the original diagnostician or another diagnosing provider on the healthcare team, such as a psychiatrist. After further evaluation, the provider can provide input and may include a new diagnosis for the patient (i.e. bipolar II disorder).
There are other scenarios pharmacists may encounter in an outpatient mental health clinic. Patients may be assigned to pharmacists on a rotating basis or in a random allotment in some outpatient clinics. It is important to remember patients should always be seen by a diagnostician initially and periodically in the course of care. Specific examples include patients presenting with unexplained psychosis, several rule-out diagnoses being considered, or those whose presenting symptoms do not align with past diagnoses. It is important for pharmacists to consider appropriate patients for their clinics in this setting. In such patients, a collaborative approach to treatment may work best. For example, a psychiatrist may be able to best provide diagnostic expertise, a social worker or psychologist may be trained to identify psychosocial contributors to symptoms, and a pharmacist may consider medications which could be contributing to symptoms. Team discussion, joint appointments with multiple healthcare professionals, or visits with a variety of providers may be helpful in complicated patient cases such as these.
Summary
While not diagnosticians, being familiar with diagnostic criteria and refining diagnostic reasoning skills is important for psychiatric pharmacists within the mental health outpatient setting. Psychiatric pharmacists should spend time familiarizing themselves with diagnostic criteria of commonly encountered disease states and in understanding their role in the diagnosis process.
