Brooke D. Butler, PharmD, BCPP, BCGP
Mental Health Clinical Pharmacist Specialist
Carl Vinson VA Medical Center
Dublin, GA
Dr. Brooke Butler has been a licensed pharmacist since 2011 and completed a PGY-1 residency at the Carl Vinson VA Medical Center in Dublin, GA. She was hired post-residency as a Clinical Pharmacist and practiced in Ambulatory Care clinic for 2 years until an amazing opportunity arose to specialize in an area closer aligning with her interests—mental health. In 2014, she accepted the position as her facility’s first outpatient Mental Health Clinical Pharmacist Practitioner (CPP) where she continues to provide medication management services as a licensed independent prescriber with a panel of patients. She became a BCPP in 2016, followed by BCGP in 2017. She also serves as CVVAMC’s PGY-2 Psychiatry Residency Program Coordinator and has over a decade of experience precepting APPE students, PGY-1, and PGY-2 residents and is an assistant clinical professor at her alma mater, South University School of Pharmacy. Aside from general psychiatry, she was previously a consultant for the facility’s dementia unit because of her strong interest in neurodegenerative diseases. She currently serves as the Pharmacogenomics Site Champion for her facility and is excited to introduce pharmacogenetic testing into VA practice. Other clinical interests include pain management, particularly autoimmune diseases, and she is a certified provider of Auricular (Battlefield) Acupuncture.
When a student graduates from pharmacy school or a Pharm.D. resident completes residency, they typically exit with the following: determination, ambition, and expectations. Upon gaining a scope of practice (prescriptive authority) in mental health and obtaining a full panel of patients, I began to face many situations where reality contradicted my expectations. Since you may find yourself in similar scenarios, I would like to share some of the realities I learned early in my practice.
Expectation: Patients will listen to everything you say and adhere to their medication regimens.
Reality: Some will not.
You will have perfectly adherent patients in practice— ones who follow your directions to a T—and for those we are certainly thankful. However, many of them will not and you may find yourself feeling frustrated and discouraged. Giving a patient tips on how to remember to take their medications, offering a pill organizer, explaining the importance of adherence, are all things you will reiterate ad nauseum. Patience with your patients will be required. It is important to remember that all human beings are fallible and some things take practice, especially building good habits.
If you have never been required to take medication multiple times daily, consider participating in a simulation experiment. Set up a pill organizer with several different types of small candy “TID-style”, then try taking them without fail for a set duration of time. During this experience you may gain insight into your patients’ daily struggles. In clinical practice, and the ability to empathize is an invaluable skill. While your recommendations may not always result in the desired outcomes, it is important to remember that their non-adherence is not a failure on your part as long as you’ve educated and encouraged. Continuing to persist and encourage your patients to achieve the desired outcome or to create a new habit is all you can do in some cases. It’s not a reflection on you as a provider, but it is an opportunity for you to improve your motivational interviewing skills and develop creative solutions.
Expectation: Patients will always get well if they follow your instructions.
Reality: Some do not.
Setting realistic treatment goals in your own mind is important as well. Many studies (such as the infamous STAR*D trial) reflect this reality—sometimes, even with multiple medication trials, remission is not achievable. In practice, it is advisable to make no promises about patients’ potential treatment outcomes up front. During your initial visit, it may be helpful to create realistic expectations by saying, “We may not be able to get rid of all your symptoms, but we will try. If you work with me, I will continue to help you until your symptoms go away or become manageable to you.” Setting realistic treatment goals can be done together through shared decision-making, and the use of functionality as a marker may be a useful tool in this decision-making model. Mental health assessment tools (e.g., PHQ-9, PCL-5, GAD-7) can be extremely helpful in guiding clinical decisions, but it is also important to truly listen to your patient’s words as well as observe their behavior. Assuring that you will give patients your full attention and care to the best of your clinical ability is one promise you should be able to make and easily keep.
Expectation: All patients want to get well.
Reality: They don’t.
When a patient establishes care, it’s easy to believe you both have one clear goal in mind: to get well. However, that may not always be true. For example, some patients may be court-ordered to see MH. Some patients may present in denial about their illnesses. Some may not even be there willfully, but under external pressure from friends or family. Some may come in to ensure documentation is added to the record that they’re attending MH visits and receiving medications for some type of personal gain but not therapeutic benefit. When you encounter one of these scenarios, it’s important to know that not everyone will be there for help in the sense you are expecting. As able, try to get the patient’s loved-ones or caregiver(s) involved in visits. Include them (with the patient’s permission) in treatment plans. Sometimes it helps to have more than just you to encourage them. Help the patient as much as you are clinically able, within your ability, but don’t get discouraged if they refuse to listen. Remember, at the end of the day, you cannot control the actions of others.
Expectation: You will never deviate from what you were taught in pharmacy school.
Reality: You will.
Believe it or not, you may find yourself telling a patient to “hold off” on quitting smoking because it would cause additional stress while you’re attempting to psychiatrically stabilize them. You may acceptthat trying to convince your patient with schizophrenia to cease nicotine use may be futile. Sometimes you may have to compromise with patients to reach their goals and not your own expectations.
For example, a covering provider during my absence pressed one of my patients firmly about quitting the use of cannabis. In response, my patient shut down and insisted she never talk to that person again. While the provider’s reasoning was correct, sometimes doing what you were taught in school may not always be in the individual’s best interest because it can drive a wedge between the two of you. Your responsibility is to educate and try not to lecture. In a scenario like this, I recommend reviewing safety risks, issues surrounding legality, and setting reasonable limits; but not pushing the patient in a direction they are not willing to go at the time. My response to this situation was as follows: “When you’re ready to quit, I am here for you.” Damaging rapport with your patient has the potential to cause irreparable harm to your therapeutic relationship, and without that foundation, it will be difficult to achieve treatment goals.
Expectation: You will always follow clinical practice guidelines.
Reality: You will not.
Guidelines are designed to guide your thinking, not make clinical decisions for you. While extremely helpful and often useful—you may occasionally find yourself deviating from what is printed in black-and-white because it is in the best interest of your patient. Especially in psychiatry, using medications off-label is commonplace in practice. I once had a patient with posttraumatic stress disorder (PTSD) transfer his care to me from a retiring psychiatrist. The patient was stable and doing well on his current medication regimen which included quetiapine. While it was not something I would personally have selected for this patient, he was adamant about continuing the medication as written. Although I explained why I would prefer we trial something different and educated him on the risks versus benefits of continuation, he expressed his desire to remain on the quetiapine. We compromised to continue regular monitoring and table the discussion of a taper in the future. Several months later, after multiple visits together, I pointed out his weight had slightly increased, and the patient agreed to trial a different agent.
As previously mentioned, time and patience are required—a patient comfortable with their regimen and previous provider may need some time to warm up to your suggestions. You will find yourself facing clinical conundrums such as this and discover that fully adhering to guidelines 100% is not always practical in the real world for various and often unforeseen reasons.
These are only a few examples of common “realities” a clinician may face. With time and practice, you will face unique challenges of your own; thus, creating your own solutions. You should strive for proficiency in the art of collaboration with your patient—instead of solely designing a plan for your patient— to reach your shared goals. Ultimately, learned experiences will be more valuable than anything I can advise you by writing. However, as you set forth into your psychiatric pharmacy career, I encourage you to reflect on your own expectations and when the time comes, consider being flexible enough to adapt to the realities you encounter.
