Board Certified Psychiatric Pharmacists (BCPPs) practice in a variety of inpatient and outpatient health care settings as part of collaborative, multidisciplinary teams. The American Association of Psychiatric Pharmacists (AAPP) has promoted the expansion of psychiatric pharmacy through the development of psychotropic stewardship programs (PSPs). Based on the standards developed during the creation and expansion of antimicrobial stewardship programs, psychotropic stewardship promotes the safe and appropriate use of psychotropic medications. AAPP envisions every patient with a psychiatric diagnosis will have their medication treatment plan reviewed, optimized, and managed by a psychotropic stewardship team with a psychiatric pharmacist as a co-leader. Because of variations in practice site resources, patient populations, and provider collaboration, the creation and implementation of PSPs should be based on site-specific needs and opportunities. Initial patient identification could prioritize those prescribed multiple medications, high-risk psychotropics, or comorbid medical diagnoses. However, every patient prescribed a psychotropic medication should have the opportunity to work with a PSP. Incremental implementation may be required during the planning stages of stewardship teams. Use of clinical practice-related core outcomes will allow for the optimization of program resources, increased recognition, and improved patient outcomes. PSPs should be patient-focused and integrate patients' preferences and access to recommended treatment options. The eventual goal of PSP implementation is official recognition by key regulatory agencies as a standard of care for patients who receive a diagnosis of a psychiatric or substance use disorder.

The study of pharmacogenomics is rapidly growing, particularly in the field of mental health. Understanding pharmacogenomic principles can be a challenge for many clinicians. Most mental health genomic data concentrates on variability (response, side effects) with antidepressants and atypical antipsychotics. Current pharmacogenomic practice and research primarily focuses on two areas: pharmacodynamics and pharmacokinetics. Based on the current literature, genetic polymorphisms of pharmacodynamics and pharmacokinetics parameters likely influence medication efficacy, therefore affecting the therapeutic benefit. Additionally, certain pharmacodynamic and pharmacokinetic polymorphisms have been linked to an elevated risk of side effects and adverse events with these medications. In this review, specific pharmacodynamic and pharmacokinetic polymorphisms related to antidepressants and atypical antipsychotics will be discussed, as well as the potential clinical effect these genomic abnormalities have within psychiatric care.

Clozapine remains the definitive gold standard for treatment-resistant schizophrenia despite limitations in use because of hematological abnormalities. Neutropenia or leukopenia are often treated with interruption of clozapine treatment, frequently resulting in clinical decompensation, hospitalization, increased burden to patient care, and increased risk of suicide. Colony-stimulating factors, including granulocyte colony-stimulating factors and granulocyte-macrophage colony-stimulating factors, are cytokines that stimulate proliferation and differentiation of myeloid precursor cells. Their use in the prevention and treatment of clozapine-associated neutropenia presents an alternative to clozapine discontinuation in certain cases. We present a case report of successful periodic granulocyte-macrophage colony-stimulating factor use with clozapine in a patient with treatment-resistant schizophrenia, as well as discussion of a practical approach to patients with possible clozapine-induced neutropenia or leukopenia.

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