Questions for pharmacist providers in clozapine clinics: Ott and Williams

Dr. Ott: My clinic has been in operation since May 2009. I was invited by the attending psychiatrists to be a part of the launch, as well as a continuing team member for the clinic with a collaborative practice agreement. My role continues to grow as our research program expands, studies often include me as a co-investigator with similar study responsibilities to our physicians, including research and clinical visits and rating scales.

Dr. Ott: I started in psychiatric pharmacy almost 18 years ago, moved into it from long-term care pharmacy, so I did not do a residency after my post-BS PharmD. I was asked to provide consulting pharmacist services to 2 free-standing psychiatric hospitals (chains that no longer exist) and subsequently left to provide director of pharmacy services in geriatric psychiatry in a veterans' home. I began teaching psychiatric therapeutics at Purdue several years before I became a full-time faculty member.

Dr. Ott: I think my greatest impact on the patients I see in my clinic is in evaluation of their medication regimen, symptom evaluation, and ensuring that the patient's voice is the most important on regarding making treatment decisions. I usually offer the patient a few therapeutic choices, including sometimes not taking medications, with all of the benefits and consequences, then get their opinion. I often think that my patients haven't been offered this kind of control over their illness from their providers before and it empowers them to be more engaged in the clinic.

Drs. Ott and Williams: I spend 3 half-days per week in clinic seeing patients, as well as clinical treatment team and research meetings. We have one clinical team meeting and one research meeting per week with the entire clinic staff, which helps us to triage patients, as well as evaluate those who might be interested in research. I have 2 hours of actual patient time per day for appointments, as well as interacting with other treatment team members to solve problems, apply for patient assistance where necessary, do pharmacy intakes, review labs, and talk to patients and families. For our clozapine patients, it is my responsibility in clinic to know when labs are due, ensure the patients have the laboratory orders they need, evaluate the CBC/ANC, and call in prescriptions to their pharmacy.

Dr. Ott: I don't bill at this time. Indiana passed new collaborative practice legislation for ambulatory care clinical pharmacists in July 2011 and billing is still being evaluated for state-funded health care patients. We can bill on the “facility” fee, but I have not set this up, as it just shifts money around, but does not increase the level of payment for our clinic services.

Drs. Ott and Williams: My favorite part of clinic is the patients we see. They are young, between the ages of 16 and 30, and are new to their illness. They are trying to accept and understand their illness and we can have the greatest impact on their outcomes by helping them to maintain remission as long as possible. It's a great thing to have a patient continue to return to clinic because they feel they are a part of their care, and they are really open to communicating their illness to me, including side effects of medication, their willingness to continue medications, barriers they have to treatment, and, often, just their daily lives. We get to know their families and friends that they bring with them to clinic and we are able to bolster the continued support of these vital individuals. I can also help patients maintain continuity with their medications by understanding their financial and health insurance challenges and working to be proactive in helping them with and my providers with patient assistance programs and prior authorizations.

Drs. Ott and Williams: We have a significant research program in conjunction with the Psychotic Disorders Research program at Indiana University, focused for us on the prevention and treatment of early psychosis. We belong to a group of like clinics who are developing and implementing multi-site research ideas into clinical trials for the treatment of first-episode schizophrenia. We also have studies that focus on preventing brain volume loss with medications, with studies including fMRIs to evaluate brain volume.

Drs. Ott and Williams: Not all of my patients take clozapine, but we open our minds to the early use of more effective interventions of all types for our patients, including clozapine. While my attendings came to me to develop and be a part of this clinic, providers in other outpatient clinics access myself and our other 2 psychiatric clinical pharmacists for consults. If I were to set up a program with our clozapine nurses working in our though disorders clinic, I would present my clinic model to them, what services I provide, and the ways that the nurse and I could work together to streamline the process.

Dr.Ott: I have students and PGY1 and PGY2 residents on rotation with me. Students generally observe patient interactions, with myself, our attendings, nurse, or psychiatry residents. PGY1 residents observe, but also attend clinical and research meetings, develop education for our patients, families, and clinical staff, and do pharmacy intakes. PGY2 residents do everything the PGY1 residents do, but are also able to do patient follow-up visits that requires them to evaluate drug therapy and make therapy recommendations, as well as work on documentation. I try to recognize the differing levels of experience between students and PGY1 and PGY2 residents in tailoring the experience for them.

Drs. Ott and Williams: There are references that mostly focus on the more chronic patient with schizophrenia who is being treated with clozapine, focusing on laboratory monitoring and efficacy. I would encourage psychiatric pharmacists to consider clozapine use in early psychosis, effectiveness and the unique challenges that clozapine therapy can present. We have found in our clinic that we need to focus on lower dosing, lower CBC/ANCs, and a recognition of issues like benign neutropenia, that may keep some of our patients from being eligible for clozapine. The Maudsley Prescribing Guidelines, 10^th edition, has a good overview chapter on using clozapine that seems more inclusive than most references.