These findings suggest that the recommended dose schedule should be altered to one that recommends a less rapid titration (over 6 days to a week) and that the dose increments consist of 0.5-2 mg/day.
Using computerized pharmacy, laboratory, and hospitalization data from a large state psychiatric hospital system, this study examined physician responses to laboratory studies obtained in the course of therapeutic drug monitoring. Computerized monitoring modules based on physician-developed guidelines identified out-of-range laboratory values and searched for appropriate corresponding physician responses within clinically driven, mathematically adjusted time frames. Valproate monitoring in four metropolitan hospitals showed that appropriate physician responses were associated with shorter hospital stays for patients and were predictive of length of stay in a multiple regression analysis (p<.001). After physicians received didactic feedback, the percentage of appropriate responses to low serum valproate levels increased.
Pharmaceutical care in psychiatry is a specialized area of practice within the field of pharmacy and has been selected for Board Certification in the near future. In order to be maximally effective in this clinical setting, mental health pharmacists must combine their knowledge of psychopharmacology, pathophysiology, laboratory data, standardized assessment tools, and federal Health Care Financing Administration requirements, with non-pharmacological treatments to function within a treatment team concept. This treatment team concept aims at maximizing individual clinical outcomes while at the same time minimizing adverse side effects of the treatment regimen.
The new atypical antipsychotic medications represent major advances in the treatment of schizophrenia and other psychoses, 1-3 and the data supporting their cost-effectiveness appear promising. 4 However, the promise of improved clinical and pharmacoeconomic outcomes can be undercut by real-world problems in continuity of care in the delivery of mental health services. 4,5 Medical effectiveness studies 6-8 with atypical antipsychotic agents reveal that, even with these newer medications, continuity of treatment can remain a significant problem. Naturalistic follow-up studies 6-8 find patients with psychotic illnesses changing medications at rates inconsistent with optimal care, with some receiving no medications for extended periods of time. 5, 8 To investigate, describe, and begin to quantify the magnitude of this problem, we studied patients discharged from state hospitals in Illinois while taking risperidone during the first year of the medication's commercial availability. By and large, this is a population of patients with severe mental illness and low socioeconomic status. Tracking medication use, we looked at the following:1. What proportion of patients continued to receive risperidone at outpatient follow-up?Objective: To investigate continuity of outpatient antipsychotic pharmacotherapy with risperidone in patients discharged from state psychiatric hospitals.Methods: Of 1,201 patients discharged from Illinois state psychiatric hospitals while taking risperidone during the first year of the medication's commercial availability, 627 public aid-eligible patients were trackable on the basis of public aid billing data. Data on risperidone continuation and other medication use for these patients were collected for the two-year period following each patient's discharge.Results: Forty-four percent of the patients discontinued risperidone within two weeks of hospital discharge, with one-half receiving no medications and most of the remainder switching to other antipsychotics. More than 75% of the patients discontinued risperidone within one year of hospital discharge, and fewer than 1% received continuous risperidone pharmacotherapy for the two-year follow-up period. Conclusions:Although the study methods do not permit us to draw conclusions regarding specific reasons for risperidone discontinuation in this patient sample, 66% of whom had a diagnosis of schizophrenia or schizoaffective disorder and 86% of whom had psychotic diagnoses, the rapid drop-off and discontinuity in medication management following hospital discharge is almost certainly inconsistent with optimum clinical care for this group of patients. Discontinuities in maintenance pharmacotherapy may compromise medical effectiveness, even for newer antipsychotic medications such as risperidone.
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