lence of psychiatric illnesses on college campuses, and that approximately one ..... College Health Association (Orlando, FL, June 2008). For comments and ...
JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 58, NO. 4
Clinical & Program Note
The Role of a Psychiatric Pharmacist in College Health Charles F. Caley, PharmD, BCPP; Donna Webber, APRN; Michael Kurland, MSPH; Paula Holmes, APRN
lished over the past several years.2–6 The College Student Mental Health Survey7 also reported that depression was the most common psychiatric diagnosis on campus (14.9% of 939 completed surveys). In addition, this cohort was also experiencing a wide spectrum of other psychiatric illnesses ranging from eating disorders (6.1%) and attention deficit hyperactivity disorder (4.2%), to bipolar illness (2.6%) and psychosis (1.7%). Benton et al8 have also concluded that the number of university students who are coming to campus with complex mental health care needs is growing. For example, the proportion of students over a 13-year period (n = 13,257) who received counseling center treatment for depression, anxiety, or suicide increased from 21.1% to 40.7%, 36.3% to 62.9%, and 4.8% to 8.9% respectively. More and more university students also appear to be receiving medication management for their psychiatric illness. Benton et al indicated that between the years of 1988 and 1992, an average of 9% of college students were receiving medication for their psychiatric illness—but between 1996 and 2001 that average was 22%.8 Schwartz published similar findings from his study in which he reported that in the mid-1980s, 3% to 4% of students were receiving psychotropic medications, yet by the 2001–2002 academic year, 23% were receiving medications for their mental illness.9 Growth in the numbers of students exposed to psychotropic medications translates, in part, to a greater number of students at risk for adverse effects from these treatments. Safety concerns that accompany psychotropic medication use include routine adverse effects, pharmacokinetic and pharmacodynamic drug-drug interactions, an expanding number of Food and Drug Administration (FDA) warnings (eg, antidepressants and suicide, psychostimulants and cardiovascular safety), and substance abuse concurrent with prescription medication use. Collectively, these safety concerns point to the importance of monitoring college students receiving these treatments.
Abstract. Published evidence indicates there is a growing prevalence of psychiatric illnesses on college campuses, and that approximately one quarter of students may be taking psychotropic medications. But attracting and retaining experienced mental health care professionals to college health settings is a challenging task. The psychiatric pharmacist is one professional resource that can serve as both a clinical and educational consultant for college mental health services. A pilot psychiatric pharmacist service project is described. Keywords: anxiety, depression, medication, mental health, pharmacist, psychiatric pharmacist, psychiatric pharmacotherapy, psychotropic, service, student
T
he mental health care needs of university students have been an important issue for many years. In part, this is due to the growing presence of psychiatric illnesses on college campuses. The most recent survey data1 published by the American College Health Association (ACHA) indicates that depression and anxiety continue to be among the most common health problems that university students experience during the course of an academic year. In 2008, 17.0% and 13.2% of students who completed the ACHA survey (n = 80,121) reported that they had experienced depression and anxiety respectively.1 Further, students completing this survey also indicated that depression and anxiety frequently impeded their academic performance.1 These data are consistent with previously published ACHA survey results pubDr Caley is Associate Clinical Professor at the School of Pharmacy, University of Connecticut, Storrs, Connecticut. Ms Webber is with the Counseling and Mental Health Services, Student Health Services, University of Connecticut, Storrs, Connecticut. Mr Kurland is Director of the Student Health Services at University of Connecticut, Storrs, Connecticut. Ms Holmes is Director of the Eating Disorders Program, Institute of Living in Hartford, Connecticut. Copyright © 2010 Taylor & Francis Group, LLC 393
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The main campus of the University of Connecticut (UConn; a land grant university) is located in a rural part of the state. It is a university with approximately 20,000 students, and 55% of these are reported to be in residence on the main campus. Because of its location, public transportation is poor, and there are few mental health care services nearby. This intensifies the need for mental health care services for students. Additionally, like other universities, UConn is faced with the difficulty of identifying and retaining experienced mental health care professionals (particularly psychiatrists and psychiatric nurse practitioners). Although the rural setting might not be the main explanation for this, salaries that are not competitive with the private sector and high service volumes (eg, 6,500 student visits in the 2006–2007 academic year) are. Given the growing presence of mental illness and psychotropic medication use on college campuses, higher education’s need for experienced mental health care professionals is significant. It seems intuitive then that mental health care services for college students should include access to qualified experts in psychotropic drug safety and efficacy. The psychiatric pharmacist has a skill set capable of meeting this service need and of supporting and enhancing how mental health care is provided to college students. As the pharmacy profession moves forward in its evolution towards a greater role in direct patient care, the psychiatric pharmacy specialty will be available to patients with mental health care needs. Psychiatric pharmacists have cultivated a specialized skill and knowledge base that is geared towards providing patients an enhanced level of care. A properly trained psychiatric pharmacist (ie, with either a residency or equivalent practical experience) who is board certified also has the ability to teach patients about their mental illnesses, recognize psychiatric target symptoms, assess patients for treatment efficacy and safety, evaluate and apply the psychiatry/psychopharmacology literature, and serve as a clinical psychopharmacology consultant. In some cases (outside of college health), psychiatric pharmacists have also achieved successful collaborative practice agreements with psychiatrists. More information about the clinical activities of psychiatric pharmacists has been published previously.10–15 The goal of this paper is to describe a pilot psychiatric pharmacist service program that has been implemented at student health services on the main campus of the University of Connecticut. METHODS In October 2006, a collaborative relationship was established between a pharmacy practice faculty member (also a board certified psychiatric pharmacist) from our institution’s School of Pharmacy, and 2 psychiatric nurse practitioners in the Counseling and Mental Health Services (CMHS) Department of Student Health Services (SHS). The parties involved agreed that a standing 1-hour meeting between them would occur weekly. The purpose of each meeting was for the psychiatric nurse practitioners to present clinical cases to the 394
TABLE 1. Services Provided by the Psychiatric Pharmacist Consultant Consultation with record review, patient interview, and written treatment recommendations in the patient’s medical record Consultation with record review and verbal discussion with the referring practitioner Providing direct patient education about medications, illnesses, and the health care system Attending a weekly meeting with psychiatric nurse practitioner(s) Researching drug information questions with or without literature retrieval Providing in-service presentations as requested.
psychiatric pharmacist for consultation, and to ask drug information questions. As a result of the fall 2006 meetings, a mutual decision was made by the administrations of both Student Health Services and the School of Pharmacy to generate and sign a letter of agreement that would outline a clinical project where the psychiatric pharmacist would provide up to 8 hours/week of in-kind clinical consultation and education service to CMHS/SHS staff during the 2007 spring semester. At the end of the spring 2007 semester, a presentation and written report to the administrations and staff of Student Health Services and School of Pharmacy describing the project results was given by the psychiatric pharmacist. Subsequently it was decided that CMHS clinical consultation and education services being provided by the psychiatric pharmacist would continue for the 2007–2008 academic year and be financially compensated. Consultation and education services were successfully provided during this time frame and continue presently. Table 1 describes the types of services that the psychiatric pharmacist provides. The purpose of this project has been to support and enhance mental health care service to University of Connecticut students with mental health care needs who present for treatment at CMHS. This project is also a demonstration of the role that a pharmacy specialist can play within Student Health Services, and to stimulate consideration of having a psychiatric pharmacist present full time. Patient referrals for consultation has been at the discretion of the psychiatric nurse practitioner(s) providing treatment to students at CMHS. Students have typically had one or more of the following as a reason for their referral: history of multiple treatment trials, nonresponsive psychiatric illness, difficulty tolerating medications, at risk for drug-drug interactions, questions about medications and/or diagnosis, and/or comorbid substance abuse. Psychiatric pharmacist services have been provided for a total of 86 hours over the course of 3 semesters (Spring 2007 through Spring 2008). Services are provided 1 day per week, with most days requiring an average of 3 on-site hours. When patients are interviewed, the clinical consultation includes up to 1 hour of record review time, up to 1 hour of meeting with the patient directly, and JOURNAL OF AMERICAN COLLEGE HEALTH
Psychiatric Pharmacist and College Health
then generating a written note with treatment recommendations in the patient’s chart. If a patient is not interviewed, then typically there is a record review of up to 1 hour, and then verbal consultation with the referring practitioner to discuss the next step of the treatment process for the patient in question. In this situation, the psychiatric nurse practitioner then typically documents the recommendations communicated by the psychiatric pharmacist. Each day the psychiatric pharmacist is present, there is also a 1-hour meeting to discuss additional clinical questions and for follow-up on patients who have been previously consulted on. Last, the psychiatric pharmacist and the psychiatric nurse practitioners maintain communication via e-mail or phone as needed on days when the psychiatric pharmacist is not present on site. Occasionally, this has led to the psychiatric pharmacist being scheduled for a patient appointment on an off day. RESULTS Over the course of 3 semesters, the psychiatric pharmacist has consulted on a total of 27 patients. These patients have been both undergraduate and graduate students, have ranged in ages from 18 to 42 years, and have been mostly female (75%). Depression and/or anxiety spectrum disorders have been the most common presenting illness. Recommendations made by the psychiatric pharmacist have been accepted and implemented in 88% of cases. Most commonly, recommendations have included one or more of the following: changing the dose of an existing medication, changing from one medication to another in the same therapeutic class, starting a new medication, and/or providing direct patient education. Educational services by the psychiatric pharmacist have also included providing staff in-services and researching clinical drug information questions. There have also been 3 1-hour in-services provided to Student Health Service staff. The topics presented were mechanisms of psychotropic drug intolerability, drug-drug interactions between commonly prescribed medications and over-the-counter medications, and a review and update on the serotonin syndrome. Clinical drug information questions that have been presented during the standing 1-hour meeting described above have been numerous. One of the more common discussions participants have had is about the clinical pharmacology of a number of different psychotropic medications. Another common question discussed has been how to manage chronic insomnia. Other topics of discussion have included complicated medication regimens and the risk for drug-drug interactions, common and serious adverse effects from psychotropic medications, when to consider having a patient’s drug-metabolizing enzyme system genotyped, and the use of rating scales in the treatment of mental illness. COMMENT Feedback provided by both the psychiatric nurse practitioners and students referred for consultation have been uniformly positive. The nurse practitioners believed that the VOL 58, JANUARY/FEBRUARY 2010
psychiatric pharmacist was very thorough in assessing referred students, provided sound clinical recommendations for patients, and helped to increase their knowledge about pharmacotherapy. Verbal feedback from students to the nurse practitioners commented that clinical interviews were thorough and that the psychiatric pharmacist gave very good treatment recommendations. These student comments were indirectly supported by the fact that a very high proportion of students were willing to follow through with the recommendations provided by the psychiatric pharmacist. Conclusion University student health systems are encountering many patients with mental health care needs and are challenged with the recruitment and retention of experienced psychiatry providers. We believe that the provision of services by a psychiatric pharmacist in a university student health system, as demonstrated in our project, can be successfully incorporated into college health services and can be a useful clinical resource that supports and enhances clinical staff and students. NOTE Results from this project were presented at the annual meetings of both the College of Psychiatric and Neurologic Pharmacists (Scottsdale, AZ, April 2008) and the American College Health Association (Orlando, FL, June 2008). For comments and further information, address correspondence to Dr Charles F. Caley, Institute of Living, 200 Retreat Avenue, Hartford, CT 06106, USA (e-mail: c.caley@ uconn.edu). REFERENCES 1. American College Health Association. American College Health Association National College Health Assessment (ACHANCHA) Spring 2008 Reference Group Data Report (abridged). J Am Coll Health. 2009;57:477–488. 2. American College Health Association. American College Health Association National College Health Assessment (ACHANCHA) Spring 2007 Reference Group Data Report (abridged). J Am Coll Health. 2008;56:469–479. 3. American College Health Association. American College Health Association National College Health Assessment (ACHANCHA) Spring 2006 Reference Group Data Report (abridged). J Am Coll Health. 2007;55:195–206. 4. American College Health Association. American College Health Association National College Health Assessment (ACHANCHA) Spring 2005 Reference Group Data Report (abridged). J Am Coll Health. 2006;55:5–16. 5. American College Health Association. American College Health Association-National College Health Assessment (ACHANCHA) Spring 2004 Reference Group Data Report (abridged). J Am Coll Health. 2006;54:201–11. 6. American College of Health Association. The American College Health Association National College Health Assessment (ACHA-NCHA) Spring 2003 Reference Group report. J Am Coll Health. 2005;53:199–210. 7. Soet J, Sevig T. Mental health issues facing a diverse sample of college students: results from the college student mental health survey. NASPA J. 2006;43:410–431. 8. Benton SA, Robertson JM, Tseng WC, Newton FB, Benton SL. Changes in counseling center client problems across 13 years. Profess Psychol Res Pract. 2003;34:66–72. 395
Caley et al 9. Schwartz AJ. Are college students more disturbed today? Stability in the acuity and qualitative character of psychopathology of college counseling center clients: 1992–1993 through 2001–2002. J Am Coll Health. 2006;54:327– 337. 10. Adler DA, Bungay KM, Wilson IB, Pei Y, Supran S, Peckham E, Cynn DJ, Rogers WH. The impact of a pharmacist intervention on 6-month outcomes in depressed primary care patients. Gen Hosp Psychiatry. 2004;26:199–209. 11. Finley PR, Crismon ML, Rush AJ. Evaluating the impact of pharmacists in mental health: a systematic review. Pharmacotherapy. 2003;23:1634–1644.
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12. Augustin SG, Puzantian T, Caley CF, Marken PA, Richards AL, Levin GM. Psychiatric pharmacists [letter]. Am J Psychiatry. 2001;158:2090. 13. Canales PL, Dorson PG, Crismon ML. Outcomes assessment of clinical pharmacy services in a psychiatric inpatient setting. Am J Health Syst Pharm. 2001;58:1309–1316. 14. Cohen LJ. The emerging role of psychiatric pharmacists. Am J Manag Care. 1999;5(10 Suppl):S621–S629. 15. Crismon ML, Fankhauser MP, Hinkle GH, Jann MW, Juni H, Love RC, Ray MD, Stimmel GL, Wells BG. Psychiatric pharmacy practice specialty certification process. Am J Health Syst Pharm. 1998;55:1594–1598.
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