Characterization of Flumazenil Utilization in Electroconvulsive Therapy

Michelle Yang, PharmD; Daniel McGraw, PharmD, BCPP; Clint Ross, PharmD, BCPP

Medical University of South Carolina Health, Charleston, South Carolina

Type: Original research. Background: Flumazenil is a benzodiazepine reversal agent that is suggested to have a periprocedural role in electroconvulsive therapy (ECT) for patients on concomitant benzodiazepines. However, there is limited information available regarding its efficacy and appropriate use in this patient population. The primary objective of this study was to evaluate the efficacy of flumazenil administered postbenzodiazepine prior to a patient receiving ECT. The secondary objective was to analyze general practice of flumazenil administration in this patient population. Methods: This retrospective chart review included patients who received at least 1 dose of a benzodiazepine within 18 hours prior to undergoing ECT while admitted to a behavioral health unit from July 1, 2018, to June 30, 2023. Patients were excluded if they received ECT outpatient or received a benzodiazepine outside the time frame or if key outcomes were not documented. The primary outcome examined seizure duration. Secondary outcomes included flumazenil dose, change in lead placement, change in induction agent, change in ECT machine, addition of caffeine, and use of midazolam intravenous post-ECT. Results: A total of 852 patient encounters were included in the final analysis with 407 encounters with flumazenil and 445 without flumazenil prior to ECT. The average seizure duration was 39.1 seconds for those who received flumazenil compared with 41 seconds for those that did not receive flumazenil. The average dose of flumazenil administered was 0.37 mg. Patients who received flumazenil were more likely than not to experience a change in the lead placement (n = 17, 4.18% versus n = 5, 1.12%), an initiation of caffeine (n = 6, 1.47% versus n = 2, 0.45%), and a change in ECT machine (n = 9, 2.21% versus n = 0, 0%). Conclusions: Among inpatient encounters in which an ECT session was preceded within 18 hours by a benzodiazepine, approximately half received periprocedural flumazenil. There is a numerical trend indicating that flumazenil-associated encounters required more interventions to improve ECT effects compared with nonflumazenil encounters, including lead placement change and caffeine provision. These results could suggest inadequate seizures despite flumazenil administration or patient-specific variables not attributable to benzodiazepine use prior to ECT.

Psychotropic Stewardship: Review of Antipsychotic Polypharmacy at Discharge From a Freestanding Psychiatric Hospital

Kristin Manley, PharmD, MHSA; Bridgette Gleisner, PharmD, BCPP; Michael Mandarino, PharmD, BCPS, BCPP; Lauren Stummer, PharmD, BCPP; Victoria Vargas, PharmD, BCPS; Carol Aboud, PharmD

Department of Pharmacy, McLean Hospital, Belmont, Massachusetts

Type: Original research. Purpose: Examine adherence to practice guidelines associated with Hospital-Based Inpatient Psychiatric Services 5 (HBIPS-5) measures of The Joint Commission Standards on antipsychotic polypharmacy (APP) at discharge from a freestanding psychiatric hospital. Methods: This quality improvement study included adults discharged from inpatient units between April 1, 2023, and September 30, 2023. Subjects with 2 or more standing antipsychotics were identified utilizing electronic health record reports. Discharge summaries were reviewed to determine if APP was appropriate per practice guidelines and HBIPS-5 documentation. The primary outcome was rate of clinically inappropriate APP per total subjects discharged on any standing antipsychotic. Secondary outcomes included 30-day readmission rate, discharge chlorpromazine equivalents, clinical rate of inappropriate versus appropriate APP at discharge, and rate of provider documentation discrepancies at discharge. Descriptive statistics were performed to present findings. Results: A total of 939 subjects were discharged on at least 1 standing antipsychotic, of which 90 were on APP (9.58%). There were 46 subjects discharged who did not have clinically appropriate APP per practice guidelines (4.49%). Subjects with inappropriate APP were mostly male (63.04%), median age of 33 years (interquartile range [IQR]: 28, 50), with length of stay of 14 days (IQR: 8, 23). Of the appropriate APP population, subjects were mostly male (56.82%), median age of 37 years (IQR: 27.75, 47), with length of stay of 24.5 days (IQR: 12, 38.25). Individuals discharged with appropriate APP had a 30-day readmission rate of 3.61% compared with 1.12% with inappropriate APP. The median total chlorpromazine equivalents were higher in the appropriate APP group compared with the inappropriate APP group ([625 mg (IQR: 500 mg, 833.33 mg)] versus [500 mg (IQR: 333.33 mg, 800 mg)]), respectively). The rate of inappropriate APP (n = 46) compared with appropriate APP (n = 44) was 51.1%. There were provider documentation discrepancies identified in 53.33% of discharges reviewed. Conclusions and Future Directions: Study findings show a low frequency of inappropriate APP with larger discrepancies observed in provider documentation. An inpatient pharmacist-driven protocol will be developed to reduce inappropriate APP and optimize provider discharge documentation. A postimplementation quality improvement study will be conducted to evaluate the effectiveness of pharmacist intervention of psychotropic stewardship on APP.

A Novel Advanced Pharmacy Practice Experience: Scientific Writing With a Focus in Psychiatric Pharmacotherapy

Leigh Anne Nelson, PharmD, BCPP; Valerie L. Ruehter, PharmD, BCPP

University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri

Type: Innovative practices. Background: Strong written communication skills are critical to the pharmacy profession. The practice of written communication in pharmacy curricula is required by the Accreditation Council for Pharmacy Education. An advanced pharmacy practice experience (APPE) was created to develop and enhance scientific writing skills with a focus in psychiatric pharmacotherapy. Description of Innovative Service: This 1-month, elective APPE was designed to provide insight into the writing process, teach the fundamentals of effective scientific writing, and provide an opportunity to develop a manuscript suitable for publication. The rotation specifically focuses on (1) expanding the knowledge base of a psychiatric pharmacotherapy topic; (2) learning to write effectively, concisely, and clearly; (3) writing a scientific manuscript; and (4) submitting the manuscript to a peer-reviewed journal. During week 1, students complete an online course through Coursera titled “Writing in the Sciences.” This is a free, beginner-level, 30-hour course designed to teach “scientists” to become more effective writers, using practical examples and exercises. Students are also oriented to Zotero, which is an open-access, easy-to-use reference management tool. In week 2, students conduct a literature search on the assigned topic, retrieve and analyze information, develop a detailed outline, select a journal, and review the author guidelines. During week 3, students write a draft of the manuscript. In week 4, students revise the manuscript based on the preceptor’s feedback, finalize the manuscript and other documentation (eg, cover letter, title page), and submit the manuscript to a peer-reviewed journal. Impact: Nine students completed the rotation from 2021 to 2023. Feedback from students has been positive. Most of the manuscripts are review articles. Topics include antipsychotic-induced hyperprolactinemia, dexmedetomidine, psychotropic medication-induced hyperhidrosis, COVID-worsening of diabetic outcomes in psychiatric inpatients, zuranolone, CBD-THC drug interactions with psychiatric medications, xylazine, and metformin use in prevention of antipsychotic-induced weight gain. Five articles have been published in the following journals: Annals of Pharmacotherapy, CNS Drugs, and Current Psychiatry. One manuscript has been accepted for publication, and 3 manuscripts written in late 2023 have been submitted to journals with decisions pending. Conclusion: This novel APPE focused in scientific writing provides hands-on training and may encourage students to incorporate writing into their career plans.

Integration of a Psychiatric Clinical Pharmacist Practitioner into A Virtual Long-Term Opioid Therapy Reassessment Clinic

Audrey A. Abelleira, PharmD, BCPS, BCPP1,3; Alissa Scalise, PharmD, BCPS, BCPP1,4; Alyssa Falleni, PharmD2,3

1 Veterans Integrated Services Network 1 Clinical Resource Hub, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut; 2 Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut; 3 Yale School of Medicine, New Haven, Connecticut; 4 University of Rhode Island College of Pharmacy, Kingston, Rhode Island

Type: Innovative practices. Background: The intersection of chronic pain (CP) and psychiatric disorders presents a unique set of therapeutic needs. CP often accompanies psychological distress, fostering conditions such as depression, anxiety, and insomnia. Similarly, chronic pain and substance use or misuse often co-occur. Understanding this overlap through a biopsychosocial framework is crucial to improve patient outcomes and well-being. Psychiatric pharmacists are well suited to provide medication to address the needs of this patient population. Description of Innovative Service: The Opioid Reassessment Clinic (ORC) is a multidisciplinary team providing telehealth to rural veterans with CP throughout New England who are already on long-term opioid therapy (LTOT) or considering initiation of LTOT. The multidisciplinary team evaluates the veteran in a collaborative intake visit, assessing multimodal pain management, substance use, and mental health treatment needs. The team includes medical providers, clinical psychologists, a registered nurse, and board-certified psychiatric clinical pharmacist practitioners (CPP). Following the intake, veterans may then continue follow up with a CPP through video telehealth. CPP services include prescribing and management of LTOT, medications for opioid use disorder and alcohol use disorder, transition from full agonist opioids (FAO) to buprenorphine, and management of co-occurring psychiatric diagnoses. Effect on Patient Care: From August 1, 2023, through December 31, 2023, a total of 16 veterans were seen for an intake visit with the ORC. Veterans ranged from 46 to 80 years old, and 4 were female. Thirteen veterans continued medication management with a CPP, ranging from 1 to 16 follow-up visits. Six veterans exhibited signs of opioid misuse, and 5 exhibited concerning use of nonopioid substances at intake. All veterans seen by ORC had at least 1 comorbid psychiatric diagnosis; however, only 5 were engaged in mental health care. In total, 11 veterans were transitioned from FAO to buprenorphine, psychotropic medications were adjusted for 8 veterans, and opioid risk mitigation strategies were updated for 12 veterans. Conclusion: The psychiatric pharmacist’s specialized training and expertise enables comprehensive medication management that considers the interplay between pain, psychiatric symptoms, and substance misuse. Collaboration with health care team members allows for implementation of multimodal treatment strategies, enhancing therapeutic outcomes and increasing access to care.

From Mute to Multilingual: Successful Treatment of Benzodiazepine-Refractory Chronic Catatonia With Memantine

Jessica Jones, PharmD, BCPP, APh

San Diego County Psychiatric Hospital, San Diego County Health & Human Services Agency, San Diego, California

Type: Therapeutic case report. Background: There is sparse data on the management of benzodiazepine-refractory chronic catatonia. Whereas electroconvulsive therapy (ECT) is a first line option, there are numerous systemic, legal, and social barriers to implementation. Memantine, an N-methyl-d-aspartate receptor antagonist, may be helpful for patients with catatonia by assisting in the equilibration of excitatory-inhibitory imbalance. Patient History: A 38-year-old transient Somali-American male, on conservatorship, with a history of schizophrenia (diagnosed at age 23) and methamphetamine dependence presented to the emergency department with police after assaulting his case manager. Upon initial evaluation, the patient was noted to have an “intense blank stare” without spontaneous speech. Patient continued to demonstrate persistent mutism, stiffness, waxy flexibility, and posturing despite 106 days of oral lorazepam ranging from 2 to 10 mg/day for presumptive catatonia. The team considered ECT, which was determined not to be feasible given systemic and legal barriers. Memantine 5 mg daily was initiated on hospital day 107, and the patient was continued on lorazepam 1 mg twice daily. Improvement in eye contact, spontaneous speech, and flexibility were noted as early as day 109. On day 112, the patient started speaking Dutch (which he had spoken in earlier years), and his engagement in the milieu improved markedly. On day 114, memantine was increased to 10 mg/day with no reported or observed side effects. Review of Literature: There is scant literature regarding the use of memantine in chronic benzodiazepine-refractory catatonia. It is hypothesized that chronic excessive GABA can induce disproportionate inhibition of the mesocortical dopaminergic pathway, which is then unable to supply an adequate release of dopamine in the prefrontal cortex, inducing negative and cognitive symptoms. There is one randomized trial that proposes lorazepam is not effective in the treatment of chronic catatonia, which suggests that there may be an alternative neurobiological basis. Memantine is safe, well tolerated, and has a unique mechanism of action, warranting consideration as a second line agent if benzodiazepines do not adequately resolve symptoms and/or ECT is not possible. Conclusion: Memantine may be helpful in patients with chronic benzodiazepine-refractory catatonia for whom ECT is not feasible.

High-Dose Vilazodone for the Treatment of Major Depressive Disorder: A Case Report

Dozie Dike, PharmD, BCPP1,2

1 Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; 2 Baylor College of Medicine, Houston, Texas

Type: Therapeutic case report. Background: Vilazodone is a novel antidepressant approved for the treatment of unipolar major depressive disorder (MDD) with a dosing range of 10 to 40 mg/day. In clinical practice, occasionally antidepressants are dosed above their manufacturer labeled maximum doses for therapeutic benefit of various psychiatric conditions. However, the use of high-dose vilazodone has not been previously evaluated in literature. Patient History: The patient is a 47-year-old Hispanic male with a past medical history of MDD, adjustment disorder, other specified trauma or stressor-related disorder, fatty liver disease, obstructive sleep apnea, urinary incontinence, irritable bowel syndrome–diarrhea, gastroesophageal reflux disease, and erectile dysfunction. He was diagnosed with MDD on December 27, 2007. He previously trialed citalopram (ineffective), paroxetine (ineffective), fluoxetine (rash), sertraline (numbing), and venlafaxine (worsened sexual dysfunction). On June 30, 2016, he was titrated to vilazodone 40 mg daily. Vilazodone dose was subsequently titrated to 70 mg daily on July 16, 2019, and the patient remains on this dose currently as of Octobe 13, 2023. Other current psychotropic medications include bupropion immediate release 150 mg daily, gabapentin 300 mg daily, prazosin 1 mg twice daily, and trazodone 200 mg at bedtime. His social history was noncontributory. He denied tobacco and illicit substance use and reported drinking one 12-oz. beer twice per month and one 12-oz. cup of coffee daily. His recent Patient Health Questionnaire-9 score was 4, indicating minimal depression. The patient did not meet the Hunter criteria for serotonin syndrome. No mania/hypomania symptoms were reported. Sexual dysfunction, diarrhea, dizziness, restlessness, nocturnal hyperhidrosis, and xerostomia were reported. Review of Literature: A PubMed search revealed no published literature of vilazodone use greater than 40 mg/day for the treatment of MDD. Vilazodone prescribing information states that 80 mg once daily may be utilized when used concomitantly with strong CYP3A4 inducers for greater than 14 days. Conclusion: In this case report, vilazodone 70 mg daily was noted to be effective for the treatment of MDD. There were some potential confounders that may be the culprit of some side effects reported, such as the patient’s comorbid conditions and concurrent medications. Additional studies are needed to validate these findings.

Tranq: Perceptions of Xylazine and Harm-Reduction Practices Among People Receiving Treatment for Substance Use Disorders

Aaron Salwan, PharmD, MPH, BCPP

Montefiore Nyack Hospital, Nyack, New York

Type: Work in progress. Background: Xylazine, commonly known as “tranq,” is a veterinary tranquilizer added to opioids to extend the opioid effect on the central nervous system. Use of xylazine-adulterated fentanyl is linked with an increase in overdose deaths and a withdrawal syndrome that does not respond to usual treatment. From 2018 to 2021, overdose deaths involving xylazine-adulterated fentanyl rose from 102 to 3 468. Purpose: This study aims to assess the knowledge, attitudes, and beliefs surrounding xylazine among individuals undergoing inpatient treatment for substance use disorders and explore their effect on engagement in harm-reduction behaviors. Methods: This is a cross-sectional, prospective study conducted at a community hospital. An electronic-based survey instrument was developed aimed at assessing knowledge of xylazine, exposure to and/or use of xylazine, xylazine-seeking behavior, and engagement in various harm-reduction practices. The Health Belief Model served as the theoretical framework for survey item development. Demographics and past month substance use history were also collected. Participants were eligible to participate in this study if they were receiving inpatient treatment for a substance use disorder that was not primarily alcohol use disorder. Survey items were reviewed with patients with opioid use disorder for clarity and adjusted prior to survey dissemination. Outcomes: By utilizing a behavioral theory, we hope to gain a better understanding of the perceived risk and susceptibility to xylazine and if the perceived susceptibility affects engagement in harm-reduction behaviors among people who use drugs. Further, we aim to learn how frequently our patient population interacts with xylazine-adulterated substances.

Do Discharge Medications Prevent Rehospitalization Following Short-Term Crisis Stabilization at a County Psychiatric Hospital?

Kevin Kavanagh, PharmD, BCPP, APh

San Diego County Health & Human Services Agency, San Diego, California

Type: Original research. Purpose: Patients requiring short-term (<48 hour) psychiatric support are commonly placed in the crisis stabilization unit (CSU) of a county psychiatric hospital (CPH) as an alternative to inpatient admission. Upon discharge from the CSU, providers may choose to dispense a limited quantity of medication (typically a 14-day supply) via an on-site meds-to-beds program to bridge the patient until outpatient services can be established. This study evaluated whether dispensing medication upon discharge from the CSU impacted 14-day rehospitalization rates at CPH. Methods: This single-center, retrospective cohort identified all CSU encounters at CPH between January 1, 2021, and December 31, 2022. Patient demographics, diagnoses, length of stay, facility encounter data, and discharge medications (excluding naloxone nasal spray) were collected via the electronic health record. Encounters were excluded if the discharge disposition was to a noncommunity setting or the patient left against medical advice. The primary outcome compared 14-day rehospitalization rates at CPH between patients dispensed medication upon CSU discharge and those discharged without medication. Results: A total of 5195 CSU encounters were identified of which 1581 cases received at least 1 non-naloxone discharge medication. Controls who did not receive discharge medications were matched 1:1 to cases via propensity score matching across baseline characteristics. There was no difference in the 14-day rehospitalization rate between cases and controls (14.6% versus 13.2%, p = .295). These results were independent of the type of medication dispensed (antipsychotic, mood stabilizer, or other). Multivariate regression showed the largest predictors of 14-day rehospitalizations to be 2 or more CPH encounters within 2 years prior to the index encounter (risk ratio [RR] 2.79, 95% confidence interval [CI] 2.30 to 3.39) and homeless status upon discharge (RR 1.61, 95% CI 1.31 to 1.98). Conclusions: There was no difference in the 14-day rehospitalization rate between patients dispensed medication upon discharge from CSU and those who were not. Higher utilizers of CPH services (≥2 encounters in the previous 2 years) and homeless status upon discharge were strongly predictive of the primary outcome. High rates of stimulant use disorder and treatment nonadherence among this patient population likely contributed to these findings.

Comparison of Pharmacist-Led Outpatient Depression Management to Current Prescriber-Led Depression Management

Allison Tiemann, PharmD; Emily N. Gray, PharmD, BCPP; Amanda Hembree, PharmD, BCPS; Andrea Strocen, PharmD; Bobbi Jo Numbers, PharmD, BCPP; Madison Kirkland, PharmD; Teresa Cooper, PharmD, BCPS

Laureate Psychiatric Clinic and Hospital, Tulsa, Oklahoma

Type: Original research. Purpose: In 2019, 15 million physician office visits in the United States occurred with depressive disorder as the primary diagnosis. With the expected decrease in the number of psychiatrists, it is important to examine the pharmacist’s role in improving mental health outcomes. This study evaluated pharmacist treatment of depression in a behavioral health integrated virtual (BHIV) clinic in which patients were generally followed twice monthly compared to standard of care twice yearly primary care management. Methods: A descriptive report from January 1, 2020, to May 31, 2023, identified patients diagnosed with depression managed in the pharmacist-run BHIV clinic and patients managed by prescribers in the internal medicine (IM) clinics. Patients were excluded if they were established with a mental health specialist, diagnosed with a severe mental health disorder, receiving treatment for postpartum depression, pregnant, or only prescribed trazodone at doses less than 100 mg. One hundred forty-two patients were included with 71 patients in each group. The cohorts were compared based on the primary outcome, which was the final Patient Health Questionnaire-9 (PHQ-9) score. Results: Aside from higher benzodiazepine use (20/71, 14% versus 5/71, 7%; p = .002) and greater total depression and anxiety medication trials (4, SD, 1.8; 2, SD, 1.8; p ≤ .001) in the BHIV cohort, the groups were similar at baseline. The average initial PHQ-9 score was equal in both groups (13, SD, 4.5; 13, SD, 5.5; p = .8). The average final PHQ-9 score was similar between groups (7, SD, 5.6; 6, SD, 6.6; p = .7). The average time to remission and response in weeks was shorter in the BHIV group (9, SD, 6.4; 27, SD, 20.5; p ≤ .001; 7, SD, 5.9; 29, SD, 26.0; p ≤ .001). Conclusion: This study is limited due to the small sample size and omission of documentation of certain outcomes including PHQ-9 score. Patients in the BHIV clinic were able to achieve remission and response rapidly compared with the IM group demonstrating the benefits of medication management by a pharmacist. Clinical outcomes were comparable between cohorts at the final assessment. Overall, this shows that pharmacists can provide close follow-up and improve patient’s quality of life by providing rapid symptom resolution.

Development and Validation of an Instrument to Assess Patient Experience of Pharmacist-Led Patient Medication Education Groups

Joseph Cusimano, PharmD, BCPP1,2; Jennifer Alastanos, PharmD, BCPP, BCPS3; Susie Park, PharmD, BCPP, FCSHP4; Andy Williams, PharmD, BCPP, BCGP4; P. Brittany Vickery, PharmD, BCPP, BCPS5

1 Shenandoah University, Winchester, Virginia; 2 Winchester Medical Center, Winchester, Virginia; 3 St. Joseph’s Behavioral Health Center, Tampa, Florida; 4 Riverside University Health System, Moreno Valley, California; 5 AdventHealth Hendersonville, Hendersonville, North Carolina

Type: Original research. Purpose: Psychiatric pharmacist-led patient medication education groups (PMEGs) are a form of psychoeducation designed to educate patients about the use of psychiatric medications. There are no guidelines or standardized manuals for conducting PMEGs with little known about the experience of participants. A validated instrument would permit quantitative assessment of PMEGs, which can demonstrate their value to stakeholders, assess trainee competence, and improve patients’ experience. The objective was to develop and validate a patient experience instrument for assessment of PMEGs. Methods: A preliminary, 3-facet instrument was developed by 9 psychiatric pharmacists with PMEG experience. The instrument was refined following focus groups with n = 31 psychiatric inpatients and surveys of n = 21 psychiatric providers from 5 sites. The final, 10-item instrument was administered at 4 inpatient psychiatric units following completion of routine PMEGs. Results: After removal of n = 13 “straight-lined” responses and n = 2 blank forms, N = 247 final instrument responses were analyzed. The majority (70%) were age 18 to 50, female (66%), and White (76%). Most participants had a high school diploma or equivalent (39%) or some college credit (21%). Differences in responses for 9 items were statistically significant between sites A, B, or C versus site D by Kruskal-Wallis test followed by a Dunn multiple comparisons test and Bonferroni correction. Mean (±standard deviation) facet composite scores (maximum possible score = 5) were 4.2 ± 0.76 for facet 1 (motivated), 4.2 ± 0.75 for facet 2 (informed), and 4.5 ± 0.71 for facet 3 (professional) for an instrument composite score 4.1 ± 0.56. Reliability analysis found adequate (>0.70) Cronbach’s alpha for facet 1 (0.847) and facet 3 (0.895), with facet 2’s alpha (0.675) improving to 0.826 upon removal of a negative item used to detect straight-lined responses. Conclusions: The development and validation of the PMEG patient experience instrument in a large sample of general psychiatric inpatients allows quantitative assessment of PMEGs with adequate internal reliability. Testing in outpatient psychiatric settings would expand generalizability. Advanced statistical techniques, such as factor analysis, would help confirm the instrument’s dimensionality. Qualitative analysis of investigators’ field notes, with retesting, may provide insights into PMEG quality improvement.

Analysis of Experiential Education Absence Policies for Mental Health Criteria

Paula Paseiro, PharmD Candidate 2024; Suzanne C. Harris, PharmD, BCPP, CPP; Kathryn A. Fuller, PharmD, BCPS

UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina

Type: Original research. Purpose: Whereas attendance policies at schools of pharmacy accommodate medical conditions, the lack of explicit language emphasizing mental health can leave students uncertain about what is considered excused. This ambiguity may lead to hesitancy to seek accommodations, potentially endangering their well-being and academic success. This study explores the language used in experiential education resources and identifies how mental health is framed in the context of experiential education attendance policies. Methods: This is a narrative review of experiential education resources regarding mental health–related absences. Online student handbooks, experiential education syllabi, and other guidance documents from 144 Accreditation Council for Pharmacy Education (ACPE)–accredited schools of pharmacy were obtained after a thorough search of institutional websites. Content was analyzed to extract data on policies, procedures, and accommodations explicitly related to mental health absences. Key themes used were coded to identify the inclusion of mental health language within these documents. Results: Among the 144 ACPE-accredited schools of pharmacy, experiential education resources were accessible 77% of the time with Doctor of Pharmacy student handbooks being the most common resource (43%). Of the available resources, only 55% were policies explicitly stating attendance requirements within experiential education. Additionally, only 2 (3%) of the experiential education absence policies included explicit mental health terminology as criteria for absences. The most commonly used terms in the experiential education absence policies were nonmental health–specific and included “illness” and “medical emergency.” Example excerpts of experiential education absence policies with mental health terminology will be shared. Conclusion: These early results unveil that, whereas many pharmacy schools address the importance of accommodating illness, sickness, and medical emergencies, an evident lack of explicit language emphasizing mental health inclusion persists within experiential education attendance policies. Further research should explore students’ perceived interpretation of existing attendance policy language and its impact on requesting absences for mental health reasons. This research contributes to the ongoing discussion on enhancing mental health support in higher education and can serve as a catalyst within experiential programs by normalizing pharmacy student mental health as a criterion for excused absences.

Are Rapid Eye Movement Biomarkers Appropriate for Assessing Clinical Improvement in Major Depressive Disorder?

Karina E. Huereca, BS; Arianna S. Beltran Vega, BS; Kari Franson, PharmD, PhD, BCPP

University of Southern California, Los Angeles, California

Type: Original research. Purpose: Rapid eye movement (REM) suppression has been linked to disturbed sleep, a common symptom in those with major depressive disorder. Antidepressants’ effects on sleep architecture and treatment response have been briefly explored. Since the mid-20th century, improving sleep has been shown to coincide with symptom improvement, indicating patients’ progress. Past studies show a correlation between treatment responses and improved REM latency in the standard 8 to 12 weeks. This review evaluates whether early REM improvement correlates with overall treatment response. Methods: We conducted a systematic literature review analyzing drug effectiveness prior to the standard 8 to 12 weeks and its correlation to REM improvement. We assessed articles from 1992 to 2023 regarding commonly used antidepressant medications. Results: Lechinger et al compare baseline REM levels before and after antidepressant therapy and show a positive correlation between REM and the use of antidepressants. By the end of a standard treatment timeline, drugs such as escitalopram, mirtazapine, and nefazadone show an increase in REM sleep, whereas bupropion sustained release, paroxetine, and citalopram have minimal effect in increasing REM sleep. Wilson et al show REM changes as early as 3 days after taking citalopram or paroxetine, suggesting that improvement in a patient’s sleep might be a notable marker in a patient’s early depression symptom improvement. Once-a-day trazodone, evaluated over 5 weeks with weekly measurements, showed significant reduction in Hamilton Depression Rating Scale scores and early improvement in sleep disturbances within 1 week compared with venlafaxine extended release (XR) or placebo. Symptoms were sustained even after 56 days when on trazodone, suggesting great antidepressant efficacy. In contrast, once-a-day venlafaxine XR exhibited significant treatment response by the second week, but 35% of patients experienced insomnia with no correlation with REM. Newer treatments, such as zuranolone, bupropion/dextromethorphan, and ketamine, demonstrate improved depressive symptoms in 2 weeks, 1 week, and 24 hours, respectively, but studies evaluating their effect on REM sleep could not be found. Conclusion: Findings suggest analyzing and evaluating REM sleep can be considered as a valuable marker for assessing patients’ treatment response but have yet to be used in the newer therapies purporting quicker onset of action.

Assessing Documentation of Clozapine Trials in Patients Prescribed Antipsychotic Polypharmacy Regimens at Discharge

Nathan Weller, PharmD; Christine Rarrick, PharmD, MBA, BCPP, BCPS; Sophie Robert, PharmD, BCPP

Medical University of South Carolina, Charleston, South Carolina

Type: Original research. Purpose: Despite decades of research supporting the use of clozapine in treatment refractory primary thought disorders, it remains an underutilized medication. Alternatively, providers may instead select antipsychotic polypharmacy for treatment-resistant cases. This study sought to determine rates of prior clozapine trials and characterize reasons for not initiating clozapine among patients discharged from an inpatient psychiatric unit on antipsychotic polypharmacy. Methods: This retrospective chart review included patients who were initiated on and discharged with antipsychotic polypharmacy, here defined as use of 2 or more scheduled antipsychotics, during hospitalization on an inpatient psychiatric unit between January 1, 2019, and August 1, 2023. Patients were excluded if they had documented pregnancy during their hospitalization or were prescribed antipsychotic polypharmacy prior to their hospitalization, clozapine as part of their polypharmacy regimen, or antipsychotic polypharmacy for indications other than the treatment of a primary thought or mood disorder. The primary outcome was documentation of prior clozapine trial in the medical record. Secondary outcomes included characterization of reasons for not initiating clozapine and documentation of antipsychotic polypharmacy in compliance with The Joint Commission (TJC) quality measures. Results: A total of 47 patients were included in the final analysis. The majority of patients were male (30, 63.8%) and identified as Black (28, 59.6%). Median patient age was 39 years (interquartile range 26 to 47.5). The most common patient diagnoses were schizoaffective disorder (24, 51.1%) and schizophrenia (15, 31.9%). A total of 36 patients (76.6%) did not have documentation of prior clozapine trials. Of these patients, most (29, 80.6%) had no documented explanation for not trialing clozapine, and the majority of all patient encounters (43, 91.5%) did not include justification for antipsychotic polypharmacy in compliance with TJC quality measures. Documented reasons for not initiating clozapine, when available, varied widely. Conclusions: Over an approximately 4-year period, the majority of patients discharged on newly initiated antipsychotic polypharmacy did not have documented prior trials of clozapine nor justification for the use of polypharmacy per TJC quality measures. This study further outlines the potential underutilization of clozapine and opportunity to limit antipsychotic polypharmacy among patients admitted at an inpatient psychiatric facility.

Assessment of Psychiatric Patients’ Actual QTc Intervals Versus Predicted QTc Prolongation Risk

Samara White, PharmD; Tammie Lee Demler, PharmD, MBA, BCGP, BCPP; Eileen Trigoboff, RN, PMHCNS-BC, DNS, DABFN

Buffalo Psychiatric Center, Buffalo, New York

Type: Original research. Purpose: Many psychiatric inpatients have complex medication regimens due to the refractory nature of psychiatric illness and the high incidence of medical comorbidities. Among the many inherent issues of these regimens, a concerning adverse drug reaction is QTc prolongation and the potential sequelae torsades de pointes. Many medications are associated with QTc prolongation, and of these, antipsychotics and antidepressants are some of the most highly implicated and commonly prescribed agents in this population. This study builds on previous research that validates the MedSafety Scan (MSS) QT prolongation risk scoring tool by predicting theoretical clinical risk. The objective of this study was to compare patients’ MSS risk score to their actual QTc interval to assess the degree of correlation between them, validating the predictive effect and objective clinical value of the MSS tool for the purpose of informing safe prescribing in the psychiatric inpatient population. Methods: Data from 251 subjects were extracted from a state adult inpatient psychiatric facility’s electronic medical record system from February 1, 2018, through September 30, 2023. The inclusion criteria included inpatients with a documented electrocardiogram during the study period. The exclusion criteria were patients with a criminal procedure law designation. A retrospective analysis was conducted to assess the relationship between subjects’ QTc Δ (the calculated difference from measured QTc intervals to gender-specific QTc prolongation thresholds: women = 470 ms, men = 450 ms) and a calculated QTc prolongation risk score from the online MSS tool. Data were analyzed using a one-way analysis of variance (ANOVA) with alpha set to 0.01. Results: The data from the ANOVA that compared QTc Δ to MSS risk score were found to be significant (p-value < .01). Discussion/Conclusion: This study shows that the MSS tool accurately reflects the relationship between patients’ measured QTc intervals and their predicted risk scores, which objectively validates the predictive effect and clinical utility of this tool. The MSS is a valuable tool for clinicians in psychiatric inpatient settings because it is free, easy to use, and patient specific and provides accurate clinical decision-making support that can help inform and increase safe prescribing habits.

Comparing Effectiveness Between Different Antidepressants in Preventing Psychiatric Rehospitalization

Hannah Mei, PharmD Candidate; Amanda Sowinski, PharmD Candidate; Jackie Rowe, PharmD; Daniel J. Greer, PharmD, BCPP

Rutgers Ernest Mario School of Pharmacy, Piscataway, New Jersey

Type: Original research. Purpose: Major depressive disorder (MDD) is a common psychiatric condition that can have a significant effect on patients’ health. Patients with multiple hospitalizations tend to have a worse predicted disease prognosis, and health care costs are a large economic burden in patients with MDD. There are many first line treatment options for MDD, and finding an optimal treatment regimen is required to improve outcomes and prevent readmissions. The purpose of this trial is to compare the readmission rates of patients discharged on different antidepressants. Methods: This is an institutional review board–approved single-center, retrospective chart review of patients with MDD discharged between August 1, 2020, and June 30, 2023. The primary outcome was psychiatric readmissions within 30 days of first admission. Secondary outcomes included 6-month and 1-year readmission rates. Descriptive statistics were utilized to analyze the primary and secondary outcomes. Statistical significance was defined as P < .05. Results: Over the time frame analyzed, 36 out of 319 admissions (11.3%) led to readmissions. Patients discharged on sertraline had lower odds of readmission than patients discharged on other antidepressants (odds ratio [OR]: 0.2282, 95% confidence interval [CI]: 0.0533 to 0.9777, p < .05). Patients discharged on more than 1 antidepressant had higher odds of readmission than patients discharged on 1 antidepressant (OR: 4.517, 95% CI: 1.581 to 12.908, p < .05). Patients discharged on all other antidepressants did not show a statistically significant association with readmission. Conclusion: This study demonstrates that sertraline may be associated with fewer readmissions compared with other antidepressants, whereas patients receiving multiple antidepressants are readmitted more frequently. Further research is needed with larger sample sizes and longer time frames to help determine the optimal treatment for MDD.

Comparison of Kloxxado® and Narcan® Usage Following Updates to Computerized Patient Record System

Alexa L. Wade, PharmD; Maria G. Shelley, PharmD, BCPS; Hugh A. Franck, PharmD, BCPS, BCPP

Psychiatric Pharmacy Service, North Florida/South Georgia Veterans Health System, Gainesville, Florida

Type: Original research. Purpose: A medication use evaluation (MUE) conducted within a veterans health system in June 2023 compared prescribing incidence of Kloxxado® (naloxone 8 mg nasal spray) and Narcan® (naloxone 4 mg nasal spray) ordered between March 1, 2022, and February 28, 2023. Analysis determined that Kloxxado® was potentially underutilized, namely, in patients with high risk for overdose per Veterans Affairs pharmacy benefits management recommendations. Following the completion of the MUE, changes were implemented to the Computerized Patient Record System (CPRS) on September 12, 2023, in order for prescribers to more readily access Kloxxado® as a medication option and educate them on appropriateness of use. The purpose of this study was to determine if Kloxxado® prescribing increased following these changes. Methods: A report was generated to identify each time naloxone nasal spray (4 and 8 mg doses) was dispensed between September 12, 2023, and December 12, 2023. Descriptive statistics were collected to compare the frequency of Kloxxado® and Narcan® prescribing prior to and following the changes to CPRS. Every naloxone order from the report was included in the data set even if prescribed more than once to the same patient during this time frame. A chart review was conducted to determine prescriber specialty. Results: Of the prescriptions analyzed for the MUE, 98.9% were for the 4 mg nasal spray and 1.1% were for the 8 mg nasal spray. Following the implemented changes to CPRS, 3244 prescriptions for naloxone were dispensed between September 12, 2023, and December 12, 2023. Of these prescriptions, 3199 (98.6%) were for naloxone 4 mg and 45 (1.3%) were for naloxone 8 mg. Most orders were prescribed by providers in primary care, surgery, and mental health service. Of the 45 prescriptions for Kloxxado®, 29 (65.9%) were ordered by a clinical pharmacy specialist (CPS). Conclusions: The results of this study did not demonstrate a significant increase in Kloxxado® prescribing following updates to CPRS. Most Kloxxado® orders were prescribed by a CPS, indicating other specialties may require further intervention. The data collected demonstrates a need for continued provider education. Additional changes to CPRS may be necessary to ensure that veterans receive an appropriate dose of naloxone.

Effect of Clozapine for Depressive Symptoms in Black Patients With Schizophrenia or Schizoaffective Disorders

Makenzie Harrison, PharmD1; Matthew Glassman, MS2; Ikwunga Wonodi, MD, MBA2; Richard Adebayo, MBBS3; Gopal Vyas, DO2; Charles M. Richardson, MD2; Evaristus Nwulia, MD4; Heidi J. Wehring, PharmD, BCPP2; Taiwo Oduguwa, MBBS, MBA3; Marie Mackowick, PharmD, BCPP1; Maria Mananita S. Hipolito, MD4; Olawunmi Peters, BPharm, FPCPharm3; Narayan Rai, MBBS, MHSA4; Jaeboon Park, PharmD, BCPP1; Adeola O. Adebayo, MSc3; Shuo Chen, PhD2; David A. Gorelick, MD, PhD2; Elaine Weiner, MD2; Fang Liu, MA2; Ann Marie Kearns, MS2; Heather A. Adams, PsyD2; Raymond C. Love, PharmD, BCPP1; Ayodeji Olaniyan, BSc3; Darius McKoy, BS2; Rahman Lawal, MBBS, MPH3; Robert W. Buchanan, MD2; Bethany DiPaula, PharmD, BCPP1; Deanna L. Kelly, PharmD, BCPP2

1 University of Maryland School of Pharmacy, Baltimore, Maryland; 2 Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, Maryland; 3 Federal Neuropsychiatric Hospital Yaba, Lagos, Nigeria; 4 Howard University, Washington, DC

Type: Original research. Background: Depressive symptoms in schizophrenia occur in 25% to 81% of patients and result in reduced functional outcomes and poorer quality of life. Changing from depressed to nondepressed status is associated with improved medication adherence, life functioning, and satisfaction and reduced substance use and suicidality. Objectives: The purpose of this study is to analyze the effect of clozapine for depressive symptoms in Black patients with schizophrenia or schizoaffective disorder, describe variables that predict the occurrence of depressive symptoms, and determine factors that increase symptom response to clozapine. Methods: This study is a secondary analysis of a 24-week, multicenter, prospective, open-label trial of clozapine in Black patients. Two hundred nine patients with a confirmed diagnosis of schizophrenia (n = 161) or schizoaffective disorder (n = 48) were included in the sample. Patients were stratified into depression or nondepression groups with a major depressive episode (MDE) defined as a Calgary Depression Scale for Schizophrenia (CDSS) score ≥6 at baseline. Results: Nineteen of the 209 patients included (9.1%) met criteria for MDE. Patients were more likely to have depression if they had a higher Brief Psychiatric Rating Scale (BPRS) total score (χ2 = 10.1, p = .0015), were female (χ2 = 5.19, p = .023) or had a lower education level (χ2 = 4.45, p = .035). Those meeting criteria for MDE also had a significantly higher BPRS anxiety/depression subfactor score compared with nondepressed patients (10.3 ± 2.4, 5.6 ± 2.7, p < .001). The primary endpoint, change in CDSS score, was significantly improved from baseline to end of study in the depression group compared with the nondepressed group (time by group effect, F = 4.57, df =  6, 296, p = .002). Seventeen of the 19 patients (89.5%) with depression at baseline had a resolved MDE at study conclusion. The mean time to treatment response was 2.7 ±  1.9 weeks. Conclusions: In Black patients eligible for clozapine treatment, depression occurred in 9.1% of the sample population with female sex, lower education level, and greater severity of illness being factors predictive of depression. Clozapine significantly improved depressive symptoms in patients who met criteria for MDE at baseline. Symptom response was enhanced by concomitant antidepressant use.

Establishing a Database to Examine the Real-World Impact of Psychiatric Pharmacogenomic Testing in a Large Health System

Lusi Zhang, PharmD, MHI1; Kaliya C. Jones1; Laylia J. Yang, BS1; Anthony J. Tholkes, MS2; Gretchen K. Sieger, BA2; Pawel Mroz, MD, PhD3; Steven G. Johnson, PhD4; Jeffrey R. Bishop, PharmD, MS, BCPP1

1 University of Minnesota College of Pharmacy, Department of Experimental and Clinical Pharmacology, Minneapolis, Minnesota; 2 University of Minnesota, Clinical and Translational Science Institute, Minneapolis, Minnesota; 3 University of Minnesota Medical School, Department of Laboratory Medicine and Pathology, Minneapolis, Minnesota; 4 University of Minnesota, Institute for Health Informatics, Minneapolis, Minnesota

Type: Original research. Background: Pharmacogenomics (PGx) offers significant potential to advance precision prescribing. Food and Drug Administration (FDA) labeling and guidelines from the Clinical Pharmacogenetics Implementation Consortium (CPIC) and the Dutch Pharmacogenetics Working Groups (DPWG) provide recommendations for several commonly used psychiatric medications. However, integrating PGx data into electronic health records (EHR) and clinical workflows remains challenging. Relevance of testing to current treatments and whether existing PGx results are effectively utilized in real-world clinical settings have not been clarified. Objective: The objective is to develop an EHR-based research database to determine the real-world impact of psychiatric PGx testing. Methods: A comprehensive search was conducted on a large health system’s EHR data from 2012 to 2023 through the institute’s Best Practices Integrated Informatics Core with data extracted and analyzed within a secure data shelter. PGx-related terms identified test result PDF files. Results were all scanned PDFs requiring manual data extraction. Genotype-to-phenotype translations were harmonized using consensus standards. Demographic and clinical data were merged with PGx results. Relationships between clinical characteristics and PGx results were analyzed with descriptive and inferential statistics. Genetic interactions with psychotropic medications were determined based on FDA, CPIC, and DPWG guidance. Results: Of 7304 PDFs, 6392 contained results of a commonly used commercial PGx test for 3471 unique patients. Of these, 2815 had test results for psychotropics and were treated with at least 1 medication at the time of testing. Most test receivers were adults (80.6%), female (67.2%), and white (88.3%). The top psychiatric diagnoses were depression (47.0%) and anxiety (34.8%) spectrum illnesses. More than 93% of patients had genetic variants impacting clinically actionable pharmacogenes for psychotropic medications (CYP2B6, CYP2D6, CYP2C19, CYP2C9, CYP3A4, HLA-A*31:01, HLB-B*15:02) with 21.8% having extreme enzymatic activities (ultrarapid/poor metabolism) or HLA positivity. Clinically actionable drug-gene interactions (DGIs) for psychotropic medications were identified for 10.3% of patients. The positive prediction rate for DGIs was higher in pediatric than in adult patients (15.0% versus 9.3%, χ2 = 5.13, p = .023). Conclusion: PGx test results were stored as scanned PDFs, requiring informatics approaches for identification in the EHR and manual extraction of genotype results. One in 10 patients tested had results potentially impactful for current psychiatric medications highlighting the clinical relevance of testing.

Evaluating the Impact of Photovoice on Self-Stigma Levels Among Individuals with Substance Use Concerns

Ingrid Swanson, PharmD Candidate 2025; Audrey Long, PharmD Candidate 2024; Taylor Garrett, PharmD Candidate 2026; Amy Werremeyer, PharmD, BCPP

North Dakota State University, Fargo, North Dakota

Type: Original research. Purpose: Photovoice is a research methodology in which participants are encouraged to capture and caption images related to personal issues of concern. This methodology has not been studied as an intervention for self-stigma among those with substance use concerns. Self-stigma, characterized by internalized negative attitudes and shame, has been linked with decreased health care service use and poorer health outcomes. This study evaluated if photovoice is an effective intervention for reducing self-stigma levels in individuals with substance use concerns. Methods: Individuals who self-identified as having previous or current substance use concerns were recruited for this study. At baseline, the participants took a presurvey using the previously published Substance Abuse Self-Stigma Scale (SASSS) to identify baseline self-stigma levels. The SASSS comprises 4 subscales, and the total score is the sum of these subscales. Total scores range from 40 (minimal self-stigma) to 200 (high self-stigma). Participants were then instructed to post 3 to 5 captioned images to the SNAP the Stigma website and take a postsurvey using identical questions to the presurvey. Results: Eleven participants (n = 11) completed the presurvey, posting of images, and postsurvey portions of the research study. Of these, 72% (8/11) were aged 18 to 24 years, and 55% (6/11) had a highest level of education of a high school or general equivalency diploma. Participant-reported substance use prior to completing the presurvey ranged from: <1 month prior (n = 4, 36%), 1 to 6 months prior (n = 2, 18%), or >6 months prior (n = 4, 36%). Upon completion of the presurvey, each participant posted a minimum of 3 photos with an accompanying caption. The average presurvey total SASSS score of all 11 participants was 93.636 and average postsurvey total was 93.818 (p = .971). Individual participant changes in pre to post total SASSS scores ranged from -31 to 17. No statistically significant differences were observed between the presurvey and postsurvey individual subscales or total SASSS scores. Conclusions and Future Direction: No statistically significant changes in self-stigma levels were found. Further investigation is warranted, potentially with larger sample sizes and inclusion of qualitative analysis, to better examine the lack of change from this intervention.

Evaluating the Impact of Pre and Post Exams on Psychiatry Pharmacy Student Rotations: A Comprehensive Analysis

Paul Price, PharmD, BCPP

Creighton University School of Pharmacy and Health Professions, Omaha, Nebraska

Type: Original research. Background and Objectives: Psychiatry pharmacy rotations are integral components of pharmacy education, providing students with opportunities to develop clinical skills and competencies in the field of mental health. This study explores the efficacy of implementing pre and post exams as a pedagogical tool to enhance the learning experience and assess the knowledge acquisition of pharmacy students during their psychiatry rotation. Methods: The study involved pharmacy students enrolled in a psychiatry rotation, in which they participated in both pre and post exams designed to evaluate their baseline knowledge and measure their progress over the rotation period. The exams consisted of multiple-choice questions covering topics related to psychopharmacology, psychiatric disorders, and clinical decision making. Results: The findings suggest that the use of pre exams before the rotation provided students with an opportunity to identify their knowledge gaps and set personal learning goals. This self-assessment process contributed to increased motivation and engagement during the rotation as students were more focused on specific areas of improvement. Moreover, the pre exam results served as a baseline for evaluating knowledge growth throughout the rotation. The post exams administered at the end of the rotation revealed improvements in students’ knowledge and comprehension of psychiatric pharmacy concepts. The comparative analysis of pre and post exam scores demonstrated a statistically significant increase in overall performance, indicating that the rotation had a positive impact on the students’ understanding of psychiatry pharmacy. Additionally, qualitative data collected through student feedback and reflections indicated that the pre and post exams encouraged self-directed learning and reflective practice, fostering a deeper understanding of the subject matter and enhancing clinical reasoning skills. Students reported increased self-confidence. Conclusions: In conclusion, the incorporation of pre and post exams in psychiatry pharmacy student rotations appears to be a valuable educational strategy for promoting self-assessment, motivation, and knowledge acquisition. These assessments provide a structured means of tracking student progress and can serve as a valuable tool for educators in tailoring their teaching methods to meet the evolving needs of pharmacy students during their psychiatric pharmacy rotations. Further research is warranted to explore the long-term effects of this pedagogical approach on student learning outcomes and clinical practice.

Evaluation of Intentional Overdose Trends Among Youth in Pennsylvania Before and During the COVID-19 Pandemic

Paige Dorvè-Lewis, PharmD1; Andreea Temelie, PharmD, BCPP1; Tanya J. Fabian, PharmD, PhD, BCPP1; Kelsey Bero, LPC, NCC1; Victoria Winkeller, MD, FAAP1; Anthony Jaworski, PharmD, BCCCP, DABAT2; Amanda Korenoski, PharmD, MHA, BCCCP3

1 University of Pittsburgh Medical Center Western Psychiatric Hospital, Pittsburgh, Pennsylvania; 2 The Poison Control Center at Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; 3 Pittsburgh Poison Center, Pittsburgh, Pennsylvania

Type: Original research. Purpose: The number of deaths attributed to overdoses has been increasing since 2000, including in the child and adolescent population. Both the mental and physical health of this age group were impacted by the COVID-19 pandemic due to changes in routine, caregiver absences, financial instability, illness, and more. The purpose of this study was to evaluate rates of intentional overdose and related morbidity and mortality before and during the COVID-19 pandemic. Additional aims were to identify overdose trends based on age, gender, socioeconomic status, and substance. Methods: Data from cases reported to the 2 regional poison centers in Pennsylvania were extracted from the National Poison Data System. Cases included intentional exposures to any substance for individuals between the ages of 6 and 19 years old reported between October 1, 2017, and September 30, 2022. Data elements collected included age, sex, ZIP code, substance, and outcome. Case overdose trends were analyzed quarterly with the onset of the COVID-19 pandemic defined as March 2020. Results: A total of 12 973 intentional overdose cases were reported during the 5-year study period. There was an increasing trend in intentional overdoses reported after the onset of the COVID-19 pandemic with the highest incidence reported in quarter 1 of 2022 (n = 877). Two thirds of cases occurred within 15- to 19-year-olds, 31% within 10- to 14-year-olds, and 3% within 6- to 9-year-olds. Almost three quarters of cases involved females. ZIP codes with median household incomes of $25 000 to $75 000 also had higher rates of youth overdose. There were 630 unique substances identified with one third of cases involving more than 1 substance. Death or major effects occurred in 2.8% of cases with the top 3 substances being antidepressants, acetaminophen, and anticonvulsants. Conclusions: As expected, intentional overdose trends among youth increased at a steeper rate during the COVID-19 pandemic underscoring the impact of the pandemic on youth mental health. In addition to the onset of the COVID-19 pandemic, female gender and age 15 to 19 years old were additional risk factors identified in the rising rates of intentional overdose in the Pennsylvanian youth population.

Evaluation of Lithium Utilization at an Inpatient Mental Health Facility to Optimize Patient Outcomes

McKenna Geesey, PharmD Candidate 2024; Kinsey Mertens, PharmD Candidate 2024; Michael McGuire, PharmD, BCPP

College of Pharmacy and Health Sciences, Belmont University, Nashville, Tennessee

Type: Original research. Introduction: Lithium is a first line mood stabilizer that requires monitoring in an acute inpatient setting due to its narrow therapeutic window and high potential for adverse effects. Lithium requires prompt and accurate levels; however, the inpatient mental health facility does not currently have a protocol for the monitoring of lithium. A study by Johnson et al shows the benefit of a pharmacist- versus provider-managed lithium protocol in an inpatient medical center for biochemical and safety outcomes. Pharmacist-managed patients were more likely to receive lithium levels within 24 hours of admission, receive a pregnancy test if indicated, have an identified drug interaction affecting lithium levels, and receive pharmacy-provided education. Objective: The objective is to retrospectively review lithium use at an inpatient mental health facility for the purpose of improving patient outcomes and patient safety. Methods: The Belmont University institutional review board reviewed the study and verified it as exempt. A retrospective review of 160 charts was performed from March 1, 2022, to September 1, 2023. Patients were included if they were at least 18 years of age and were maintained or initiated on lithium during admission. Data analysis was performed using descriptive statistics. Conclusions: Of the 127 patients who were admitted with a home medication of lithium, only 51.2% had their serum concentration drawn upon admission. Of the 51.2%, 80% had their concentration drawn at the appropriate time. Of the 132 patients who were eligible for a steady state serum concentration, only 47% had their serum concentration drawn. Of the 47%, 83.9% had their concentration drawn at the appropriate time. Sixty-one labs were drawn unnecessarily resulting in increased work for staff, cost, and patient inconvenience. Several labs were drawn with no concentration reported in the patient chart.

Glucagon-Like Peptide-1 Receptor Agonists and Risk for Depression Relapse

Caroline F. Hartman, PharmD1; Kaitlin M. Hanken, PharmD, BCPP1; Brian C. Lund, PharmD, MS1,2

1 Iowa City Veterans Affairs Health Care System, Iowa City, Iowa; 2 Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City, Iowa

Type: Original research. Purpose: Liraglutide, semaglutide, and tirzepatide are glucagon-like peptide-1 receptor agonists (GLP-1RAs) that are Food and Drug Administration–approved initially for type 2 diabetes and later for weight management. Concern for worsening depression and suicidal ideation from label warnings based on a small number of events has led to some hesitancy to prescribe GLP-1RAs to patients with depression. Our objective was to determine whether initiation of GLP-1RAs is associated with depression relapse among patients receiving stable antidepressant therapy, relative to comparator medications. Methods: Using national administrative data from the Veterans Health Administration, we identified 36 360 patients with depression who initiated a GLP-1RA, dipeptidyl peptidase 4 inhibitor (DPP-4i), or sodium-glucose cotransporter 2 inhibitor (SGLT2i) between January 1, 2013, and December 30, 2021, and also receiving stable antidepressant monotherapy for 6 months. The primary outcome of depression relapse was defined by a subsequent change in the preexisting maintenance antidepressant regimen within 12 months. Cox proportional hazard regression was employed adjusting for demographics, comorbidity, and pharmacotherapy. Results: Depression relapse within 12 months of initiation was observed in 28.4% (1912/6722) and 26.2% (3332/12 730) initiating a GLP-1RA versus a DPP-4i, respectively (hazard ratio [HR]  = 1.11; 95% confidence interval [CI]: 1.04, 1.18). After adjustment, the HR was 1.06 (95% CI: 0.99, 1.14), failing to demonstrate a significant increase in risk for depression relapse following initiation of a GLP-1RA compared with DPP-4i. Patient characteristics independently associated with depression relapse in the multivariable model included age (<55 years: HR = 1.57; 95% CI: 1.48, 1.70; 55 to 64 years: HR = 1.22; 95% CI: 1.13, 1.31; relative to age 65 to 74), female sex (HR = 1.17; 95% CI: 1.07, 1.28), comorbid generalized anxiety disorder (HR = 1.16; 95% CI: 1.04, 1.30) or posttraumatic stress disorder (HR = 1.17; 95% CI: 1.10, 1.25), and concomitant use of benzodiazepines (HR = 1.22; 95% CI: 1.09, 1.36). In a secondary analysis using a different comparator medication, GLP-1RAs were also not associated with increased depression relapse risk (HR = 1.05; 95% CI: 0.98, 1.12) relative to SGLT2is. Conclusion: We observed a small increase in risk of depression relapse following GLP-1RA initiation relative to therapeutic alternatives. However, this effect was not statistically significant after adjustment for confounding factors and unlikely to be clinically meaningful.

Impact of Combinatorial Pharmacogenomic Testing on Hospitalization Rates in a Real-World Data Set of Patients With Major Depressive Disorder

Andria L. Del Tredici, PhD1; Priya Maheshwari, MS, RPh1; Alexander Gutin, PhD1; Devika Chawla, PhD1; Katie Johansen Taber, PhD1; Holly L. Johnson, PhD1; Andrew A. Nierenberg, MD2

1 Myriad Genetics, Salt Lake City, Utah; 2 Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

Type: Original research. Purpose: Although pharmacogenomic (PGx) testing improves response and remission rates for patients with major depressive disorder (MDD) in controlled trials, less is known about its impact in real-world settings. The current study determined (1) the proportion of MDD patients taking medications with significant gene-drug interactions pre and post combinatorial PGx testing and (2) health care use patterns in a large US administrative claims data set. Methods: Commercially insured and Medicare Advantage patients who received combinatorial PGx testing were linked with deidentified administrative claims data from a nationwide (United States) data warehouse. Patients were included in the study if they received combinatorial PGx testing between January 1, 2015, and September 30, 2021, had an MDD diagnosis code, were age ≥18 years, and had continuous enrollment with both medical and pharmacy benefits ≥360 days prior to and ≥180 days after the PGx test result date. The PGx test report organized psychiatric medications into these categories: no known gene-drug interactions, moderate gene-drug interactions, and significant gene-drug interactions. Hospitalizations (total, psychiatric, and nonpsychiatric) were compared in the 180 days pre and post PGx testing. Results: A total of 20 933 patients were identified that met inclusion criteria. Patients had an average age of 46 years and were predominantly female (∼70%). Psychiatric comorbidities were observed in ∼93% of patients with anxiety being the most common (∼78%). Of the 20 933 total patients, 16 965 patients (81%) were prescribed medications in both the 90-day pre and post PGx testing periods. At pre versus post testing, respectively, 27% versus 47% of patients were taking medications with no gene-drug interactions, 46% versus 37% with moderate gene-drug interactions, and 26% versus 16% with significant gene-drug interactions. The proportion of patients with hospitalizations for any reason and psychiatric-related hospitalizations showed a decrease of 29% and 39% in the 180-day posttest period relative to the 180-day baseline, respectively (p < .001). The proportion of patients with nonpsychiatric hospitalizations did not significantly change. Conclusions and Future Directions: Post PGx testing, fewer patients were prescribed medications with significant gene-drug interactions and health care resource utilization was reduced compared with pre-PGx testing. Future directions include investigating the impact of post-PGx medication selection on health economics.

Investigating the Inhibitory Effects of Cannabis Smoke Condensate on Cytochrome P450 in the Human Lung

John S. Markowitz, PharmD1,2; Qingchen Zhang, MS1; Philip W. Melchert, PharmD1; Barry Setlow, PhD3; Christopher R. McCurdy PhD, FAAPS4

1 Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida; 2 Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida; 3 Department of Psychiatry, University of Florida, Gainesville, Florida; 4 Department of Medicinal Chemistry, University of Florida, Gainesville, Florida

Type: Original research. Purpose: Smoked cannabis flower is the primary form of medical cannabis (MC) dispensed for various qualifying conditions in the state of Florida and elsewhere and the most common form used recreationally. MC is frequently used for chronic conditions including amyotrophic lateral sclerosis, cancer, Crohn disease, epilepsy, glaucoma, and others. The use of conventional medications, including lung therapeutics, concurrently with MC raises concerns about drug-drug interactions. This study focuses on the collection and characterization of cannabis smoke condensate (CSC) and an assessment of its in vitro inhibitory effects on 6 major cytochrome P450 enzymes (CYP) expressed in the lung. Methods: Three standardized cannabis cigarettes sourced from the US National Institute of Drug Abuse Drug Supply Program were consecutively combusted in an enclosed smoke exposure system. Generated smoke was routed through an ultra-cold condenser permitting the collection of CSC. The CSC was weighed and analyzed for the presence of 8 major cannabinoids (CBs) via liquid Chromatography with tandem mass spectrometry. In vitro enzyme inhibition studies were conducted/ongoing using human lung S9 to evaluate the potential inhibitory effect of CSC on CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP2B6, and CYP2E1. Results: A total of 14.6 mg (4.87 mg per cigarette) of CSC was collected, containing 0.022% CBD, 1.163% CBN, 9.317% THC, 0.193% CBG, and 0.008% 11-OH-THC of the total weight. The half-maximal inhibitory concentration (IC50) of CSC for CYP3A inhibition was determined to be 17.85 μM with Δ9-tetrahydrocannabinol (THC) as the index substrate. Conclusions and Future Directions: The study revealed that the relative CB content of cannabis smoke is substantially different from that of uncombusted cannabis flowers. Furthermore, CSC produced a mild inhibitory effect on CYP3A activity. Further investigations are ongoing to elucidate the inhibition mechanisms and assess the inhibitory effects on other CYPs.

Lithium and Antipsychotics in Postpartum Psychosis: Utilization of Pro re Nata Medications on an Inpatient Psychiatric Perinatal Unit

Valeria Laboy Collazo, PharmD; Robyn Dryer, PharmD; Morgan Bizzel, PharmD; Elizabeth Taber, PharmD, BCPP

University of North Carolina Medical Center, Chapel Hill, North Carolina

Type: Original research. Introduction: Postpartum psychosis is a term that encompasses a set of symptoms within the bipolar spectrum that occurs after childbirth. The estimated prevalence of postpartum psychosis is 1 to 2 cases per 1000 childbirths and is associated with a high risk of suicide and infanticide. Standardized treatment regimens have been developed but need to be evaluated in clinical settings. Therefore, this study aimed to evaluate current treatment regimens and add to existing literature for treatment optimization. This study implemented a single-center, retrospective chart review to measure the difference in pro re nata (PRN) medication use in patients treated with antipsychotics, lithium, and combination therapy for postpartum psychosis. Methods: Fifty-one patients with postpartum psychosis treated at the University of North Carolina Medical Center peripartum perinatal psychiatry inpatient unit from January 1, 2019, to August 31, 2022, were categorized into either receiving lithium monotherapy (n = 5), antipsychotic monotherapy (n = 21), or combination therapy (n = 25). The primary outcomes for this study were the amount of PRN antipsychotic use in chlorpromazine equivalents or benzodiazepine use in lorazepam equivalents. Secondary outcomes included postpartum psychosis medications and dosage prescribed at discharge. Results: The average dose of PRN antipsychotics was not found to statistically differ for patients across the lithium monotherapy (40 mg), antipsychotic monotherapy (74.6 mg), and combination therapy (191.3 mg) groups (p = .29). Similarly, there was no statistical difference among the average PRN benzodiazepine dose between lithium monotherapy (0.4 mg), antipsychotic monotherapy (1.6 mg), and combination therapy (3 mg) (p = .29). A total of 30 patients were discharged on lithium, and 44 patients were discharged on antipsychotic medications, including aripiprazole, fluphenazine, haloperidol, lurasidone, olanzapine, paliperidone, quetiapine, and risperidone. Patients were discharged on an average of 201.7 mg of chlorpromazine equivalents and 960 mg of lithium. Conclusion: This retrospective review did not see a significant difference between PRN medication use between the 3 treatment groups, suggesting a role for lithium monotherapy. This outcome is evidence to support the current proposed treatment algorithms. Future studies are warranted to further evaluate therapy efficacy for the treatment of postpartum psychosis.

Long-Acting Injectable Antipsychotic Use and Discontinuation Rates in Pediatric Patients Using Medicaid Claims Data

Taylor Ward, PharmD Candidate1; Jianing Xu, MS2; Daniel B. Hall PhD2; Xianyan Chen PhD2; Henry N. Young, PhD1; Joshua Caballero, PharmD1

1 Department of Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, Georgia; 2 Department of Statistics, University of Georgia Franklin College of Arts and Sciences, Athens, Georgia

Type: Original research. Purpose/Objectives: The primary objective was to analyze the prescribing of long-acting injectable (LAI) antipsychotics among pediatric populations. The secondary objective was to assess if discontinuation rates differed between LAI agents. Methods: International Classification of Diseases, 10th edition, codes were used to discern pediatric patients (2 to 17 years old) who received LAI antipsychotics between January 1, 2017, and December 31, 2021, using Merative® MarketScan® Multi-State Medicaid Databases. LAI antipsychotics were identified using National Drug Code numbers for all doses using brand and generic names. Race/ethnicity was classified as Black, Hispanic, White, other, or missing, and gender was defined as female or male. Based on Food and Drug Administration pediatric drug legislative guidance, age was separated into two groups: children (2 to 11 years) and adolescents (12 to 17 years). Kaplan-Meier survival curves were examined and stratified log-rank tests conducted to compare the time until discontinuation distributions across LAI antipsychotics. Significance level set at <.05. Results: A total of 1277 out of 67 502 patients met the inclusion criteria and were included in the final analysis. There were approximately 97% adolescents (n = 1233) and 3% children (n = 44). The average age was 15.4 ± 1.7 years (range 7 to 17 years). Approximately 59% were male (n = 747) with 48% Black (n = 610), 38% White (n = 491), 3% Hispanic (n = 37), 3% other (n = 34), and 8% missing (n = 105). Prescribing of LAI second generation antipsychotics (SGA) occurred in about 94% of the population. The most common LAI SGA antipsychotics prescribed included paliperidone (40%), aripiprazole (38%), and aripiprazole lauroxil (10%). When controlling for age group, gender, and plan type, the discontinuation rate for paliperidone and aripiprazole formulations did not differ. Conclusion and Future Directions: Despite the limited sample size, this study explored the prescribing rates and discontinuation rates between LAI antipsychotics in a pediatric population. The study also shed light on what the emerging use of LAI SGA may have on the care for pediatric patients. Among the most used agents, there did not appear to be differences in discontinuation rates. Future studies may further explain the unique challenges (eg, reasons for discontinuation) and economic impact LAI antipsychotics present within pediatric psychiatric treatment.

Long-Acting Injectable Antipsychotic Use in Pediatric and Adolescent Patients With Psychiatric Disorders

Christina Sun, PharmD1; Andreea Temelie, PharmD, BCPP1; Hannah Goulding, PharmD, BCPP1; Christine Clark, PharmD, BCPP1; Melanie Yabs, PharmD, MS, BCPP1; Tanya Fabian, PharmD, PhD, BCPP1,2

1 University of Pittsburgh Medical Center Western Psychiatric Hospital, Pittsburgh, Pennsylvania; 2 University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania

Type: Original research. Background: Long-acting injectable antipsychotics (LAIAs) are widely known to be an effective treatment option for adult patients with schizophrenia, schizoaffective disorder, and bipolar disorder. However, literature regarding LAIA use in pediatric and adolescent patients is very sparse. There are currently no LAIAs Food and Drug Administration–approved for use in patients less than 18 years of age; however, case reports and studies documenting off-label use suggest clinical benefit in this patient population. Purpose: The objective is to describe the use of LAIAs in pediatric and adolescent patients with psychiatric disorders. Methods: This quality improvement–approved retrospective chart review included patients less than 18 years of age discharged from an acute psychiatric hospital between October 1, 2015, and October 31, 2022. Patients were included if they had an inpatient or day-of-discharge order for a new start LAIA during their hospitalization. Patient information (age at admission, date of birth, sex, race) and hospital encounter information (admission and discharge dates, diagnoses at discharge) was collected. Descriptive statistics were utilized for data analysis. Results: A total of 6402 unique pediatric and adolescent patients were discharged from the acute psychiatric hospital within the specified time frame. Of these, 45 patients (0.70%) were newly initiated on a LAIA. Monthly paliperidone palmitate was the most commonly prescribed LAIA (n = 21), followed by aripiprazole monohydrate (n = 15), aripiprazole lauroxil (n = 7), haloperidol decanoate (n = 1), and risperidone microsphere (n = 1). The most common diagnoses for LAIA therapy by International Classification of Diseases, 10th revision, code included bipolar disorder (n = 14), unspecified psychotic disorder (n = 7), schizophrenia (n = 5), schizoaffective disorder (n = 5), and autistic disorder (n = 5). Most patients (71%) received a loading dose or oral overlap regimen consistent with adult package-insert dosing. Conclusions and Future Directions: Prescribing rates of LAIAs in pediatric and adolescent patients with psychiatric disorders is low, accounting for less than 1% of all adolescent and pediatric patients discharged within the 7-year study period. Further research is needed to identify barriers to use of LAIAs in this patient population. Future directions for this project include evaluation of clinical outcomes, such as LAIA efficacy, tolerability, and impact on antipsychotic adherence and persistence.

Long-Term Follow-up of Implementation of Psychotropic Medication Utilization Parameters for Children and Adolescents in Texas Foster Care

M. Lynn Crismon, PharmD, BCPP1; Nina J. Muse, MD2

1 College of Pharmacy and Dell Medical School, The University of Texas at Austin, Austin, Texas; 2 Child Psychiatry Consultant, Austin, Texas

Type: Original research. Background: Attention has focused on the use of psychotropic medication in children. Youth in foster care are a vulnerable population that are often fraught with emotional distress and mental disorders. Improved use of psychotropic medications in this population is needed. Methods: Subsequent to legislative action, the Texas Department of Family and Protective Services (DFPS) appointed a task force to develop psychotropic utilization parameters for foster children. The first edition was published in 2005 with succeeding editions in 2007, 2010, 2013, 2016, 2019, and currently under review. The parameters were developed by an interprofessional task force with external peer review. Whereas an evidence-based approach was used, expert consensus was used to fill in missing gaps of evidence. Using the Texas Medicaid database, utilization was monitored on a quarterly basis. The parameters were initially disseminated by DFPS, and in 2008, a single mental health managed care organization (Superior Healthplan) implemented a system to utilize these parameters as a component of prospective quality of care assessment and clinician feedback. Results: The use of psychotropic medication for >60 days in foster children decreased from 31.4% of children in fiscal year (FY) 2004 to 17.9% in FY 2021. Within class polypharmacy decreased from 6.2% in FY 2004 to 2.9% in FY 2021. The percentage of children receiving >5 psychotropic medications decreased from 2.2% in FY 2004 to 0.8% in FY 2021, and the percentage receiving >4 medications decreased from 6.3% in FY 2004 to 2.9% in FY 2021. The percent of children <4 years of age receiving psychotropics >60 days decreased from 4.2% in FY 2004 to 1.5% in FY 2021. Change in Parameters: In 2013, the parameters were