A novel study on clinical pharmacist and psychiatrist collaborative pharmacotherapy management services among elderly population with psychiatric illness.

Background: Geriatric psychiatry has yet to receive its due recognition in India. There is increasing evidence of a rise in morbidity, mortality, hospitalization, and loss of functional status related to common mental disorders in the elderly patients. Collaborative care approach, including a clinical pharmacist, is one of the possible approaches to cope with geriatric patients with psychiatric patients. Objective: The study aimed to assess the impact of pharmacotherapy management of geriatric patients in collaboration with pharmacist and psychiatrist. Materials and
Methods: A prospective interventional study was conducted in the psychiatry outpatient department of a tertiary care hospital in Mysore over 6 months. Geriatric patients who were newly diagnosed with depression, bipolar affective disorder (BPAD) and alcohol dependency syndrome (ADS) were included in this study. The clinical pharmacist scrutinized the patients for their participation in the study. Included patients were followed up on monthly basis for up to 4 months. Pharmacotherapy management was provided to the enrolled patients. Interventions provided were discussed with the psychiatrist. Descriptive analysis was performed for categorical variables.
Results: A total of 84 geriatric patients were enrolled in the study. Majority of the enrolled patients were female (n = 46, 54.7%). Nearly half of the patients were illiterate (n = 40, 47.6%) and unemployed (n = 38, 45.2%). Among the enrolled patients, half of the study participants were diagnosed with depression (63.09%) followed by BPAD (27.38%), Schizophrenia (7.14%), and ADS (2.38%). A total of 155 medication information services were provided to 84 patients including patient counseling (n = 84, 100%), pharmacist interventions (n = 48, 30.96%) and medication information (n = 23, 14.83%). Most of the interventions were adverse drug reactions followed by drug-drug interactions, failure to receive drugs, untreated indication, subtherapeutic dose, drug use without indication, and overdose. Majority of the interventions (n = 46, 95.8%) provided were accepted by the psychiatrist.
Conclusion: The study findings indicate that pharmacotherapy management services provided by the clinical pharmacist in collaboration with the psychiatrist benefited the geriatric psychiatric patients. Copyright:

INTRODUCTION

Geriatric mental health is an enormous public health problem for India. The geriatric population rose from approximately 20 million in 1951 to 77 million in 2001–83, 58 million in 2006, and is expected to rise to 173 million in 2026.[1] Evidence from various epidemiological studies indicates a high degree of morbidity of mental health of geriatrics.[234567] Geriatric mental health in India has yet to get its proper recognition and it is afflicted by several obstacles which prevent its programs from improving and advancing.[8] In geriatrics, obstacles are seen at both diagnosis and treatment stages, rising in medication consumption and polypharmacy frequency, generating a need for pharmacotherapy-collaboration approaches which is varying from recognizing a mental health issue and seeking help to being successful with therapy.[9] The progression in medication therapy leading to the encountering of new pharmacotherapeutic management approaches for the medical issues, meanwhile, it also discusses the therapeutic uses of pharmaceutical medications and pharmacotherapy management. Pharmacotherapy management services includes patient counseling on medications and diseases, detection and reporting of medication-related problems such as adverse drug reactions, drug-drug Interactions, medication errors and strategies to prevent medication-related problems. Henceforth, medication-related problems knowingly or unknowingly have an impact on the overall quality of life. The clinical pharmacist provides pharmacotherapy management and also patient counseling to ensure the adherence, and related drug-related problems (DRP), which is commonly observed in the psychiatric patient. Studies have proved improved inpatient care and outcome when the pharmacists work as a multidisciplinary team in collaboration with a psychiatrist.[1011]

MATERIALS AND METHODS

Study design and patient enrolment

A prospective interventional study was conducted in the psychiatry outpatient department of a tertiary care hospital in Mysore over 6 months. The clinical pharmacist reviewed geriatric patients who visited the psychiatry outpatient department. Patients aged more than 60 years of any gender and diagnosis with psychiatric illness with at least one psychotropic medication prescribed were enrolled in the study. Patients with terminal comorbidity and not having a proper medical record of their illness were excluded from the study.

Study procedure

The Patients who met the study criteria were enrolled in the study after they consulted with psychiatrist. The demographics, diagnosis, medications, dose, frequency, type of medication-related problem, suggestions, clinical discussion, and outcome of medication-related problems identification were collected in the suitable data collection form. In the assessment, proper intervention and suggestions were made by the clinical pharmacist such as identified medication dose adjustment, medication instruction, and adverse medication reaction. Following categories are the suggestion provided for the DRP: Change in medication dose, change in dosage form, addition of medication, change in route of administration, discontinuing the medication, the substitution of medication, change in frequency of administration, and change in the duration of therapy and others.

Ethics

The study protocol was approved by the Institutional Ethics Committee and the hospital authority prior to its start.

RESULTS

During the study, 84 geriatric patients were enrolled, majority of them were female (n = 46, 54.76%). Most of the patient population were illiterate (n = 40, 47.61%) and unemployed (n = 38, 45.23%). Half of the study participants were diagnosed with depression (63.09%) followed by bipolar affective disorder (27.38%), Schizophrenia (7.14%), and alcohol dependency syndrome (2.38%). The patients’ demographic characteristics are presented in Table 1.

Table 1

Demographic details of geriatric psychiatry patients

Category	n=84, n (%)
Gender
Female	46 (54.76)
Male	38 (45.23)
BMI
<16 severe thinness	1 (1.19)
16-17 moderate thinness	2 (2.38)
17-18.5 mild thinness	8 (9.52)
18.5-25 normal	46 (54.76)
Overweight 25-30	20 (23.8)
Obese class I 30-35	5 (5.95)
35-40 obese class II	2 (2.38)
>40 obese class	0
Education
Professional	6 (7.14)
Graduate	9 (10.71)
Intermediate/PUC/diploma	4 (4.76)
High school	8 (9.52)
Middle school	6 (7.14)
Primary school	11 (13.09)
Illiterate	40 (47.61)
Occupation
Agriculture and fishery	21 (25)
Clerks	1 (1.19)
Craft and trade	2 (2.38)
Plant and machine operators	3 (3.57)
Professional	5 (5.95)
Semi-professional	8 (9.52)
Skilled worker	6 (7.14)
Unemployed	38 (45.23)
Income
≤3,907	27 (32.14)
3,908-11,707	6 (7.14)
11,708-19,515	11 (13.09)
19,516-29,199	6 (7.14)
29,200-39,032	13 (15.47)
39,033-78,062	5 (5.95)
≥78,063	16 (19.04)
SES
Upper (I)	2 (2.38)
Upper middle (II)	30 (35.71)
Lower middle (III)	6 (7.14)
Upper lower (IV)	25 (29.76)
Lower (V)	21 (25)
Residency
Rural	26 (30.95)
Urban	58 (69.04)
Co-morbidities
Yes	36 (42.85)
No	48 (57.14)
Diagnosis
Depression	53 (63.09)
BPAD	23 (27.38)
Schizophrenia	6 (7.14)
ADS	2 (2.38)
Number of medication
Only 1	11 (13.09)
2-5 medications	24 (28.57)
5 and more	49 (58.33)
Medication adherence
Yes	44 (52.38)
No	40 (47.61)

BMI – Body mass index; BPAD – Bipolar affective disorder; ADS – Alcohol dependency syndrome; SES – Socioeconomic status; PUC – Pre-University college

Pharmacotherapy management services

Clinical pharmacist spent an average of 15 min per patient during the study. From a total of 84 patients, patient counseling was provided to all patients (n = 84, 100%) where the clinical pharmacist explained patients on the use of medications, importance of medication adherence, when and how to take medications, and the most common adverse effects, pharmacist intervention was provided in more than half of the patients (n = 48, 57.14%) followed by medication information (n = 23, 27.38%). Overall, 155 pharmacotherapy management services were provided in 84 patients with an average of two services per patient. The details of the pharmacotherapy management service are presented in Figure 1.

Figure 1

Pharmacotherapy management services

Clinical pharmacist intervention, acceptance rate, and level of significance

Of the 48 clinical Pharmacist interventions [Table 2] provided to patients majority of interventions were adverse drug reactions (23, 47.91%) followed by drug-drug interactions (9, 18.75%), failure to receive drugs (6, 12.5%), untreated indication (4, 8.3%), subtherapeutic dose (3, 6.25%), drug use without indication (2, 4.16%) and overdose (1, 2.08%). A total of 37 (77.08%) interventions were accepted and change in the therapy. Majority of the interventions were moderate (n = 22, 45.83%) followed by minor (n = 19, 39.58%) in the level of clinical significance. The acceptance rate and level of the clinical significance of interventions made are summarized in Table 3.

Table 2

Medications involved in various interventions

Intervention	Number of drug-related problem (n=48), n (%)	Medication involved (number of DRP)	Adverse event
Adverse drug reaction	23 (47.91)	Quetiapine (5)	Constipation (2), Somnolence (2), Increased triglycerides (1)
		Lithium (4)	Headache (2) tremors (1), Muscle weakness (1)
		Olanzapine (3)	Increased appetite (1), Orthostatic hypotension (1), Dizziness (1)
		Amisulpride (2)	Blurred vision (1), Somnolence (1)
		Escitalopram (2)	Xerostomia (1), Diarrhea (1)
		Risperidone (2)	Akathisia (1), Insomnia (1)
		Desvenlafaxine (2)	Fatigue (1), Nausea (1)
		Sertraline (1)	Vomiting (1)
		Carbamazepine (1)	Drowsiness (1)
		Amitriptyline (1)	Eosinophilia (1)
Drug-Drug Interaction	9 (18.75)	Haloperidol + chlorpromazine (1)	Increase the QT interval (1)
		Sertraline + haloperidol (1)	Neurotoxicity (1)
		Risperidone + metformin (1)	Hyperglycemia (1)
		Omeprazole + disulfiram (1)	Disulfiram toxicity (1)
		Aripiprazole + lorazepam (1)	Increase sedation (1)
		Phenytoin + risperidone (1)	decrease level by P glycoprotein reflex transporter (1)
		Citalopram + aspirin (1)	Increase risk of Upper GI bleeding (1)
		Clozapine + sulfamethoxazole (1)	Agranulocytosis (1)
		Oxazepam + lorazepam (1)	Increases sedation (1)
Failure to receive drug	6 (12.5)	Clonazepam (1)	-
		Lithium (1)	-
		Haloperidol (1)	-
		Paroxetine (1)	-
		Flupentixol (1)	-
		Escitalopram (1)	-
Untreated indication	4 (8.33)	-	Gastritis (1)
		-	Low hemoglobin (1)
		-	Constipation (1)
		-	Headache (1)
Sub therapeutic dose	3 (6.25)	Olanzapine (1)	-
		Quetiapine (1)	-
		Risperidone (1)	-
Drug use without Indication	2 (4.16)	Ferrous sulfate (1)	-
		Domperidone (1)	-
Overdose	1 (2.08)	Clonazepam (1)	-

DRP – Drug related problems

Table 3

Acceptance rate and level of significance of clinical pharmacist intervention

	Minor (n=19), n (%)	Moderate (n=22), n (%)	Major (n=7), n (%)	Total (n=48), n (%)
Accepted and change in therapy	15 (78.94)	17 (77.27)	5 (71.42)	37 (77.08)
Accepted and no change in therapy	3 (15.78)	4 (18.18)	2 (28.57)	9 (18.75)
Not accepted	1 (5.26)	1 (4.54)	0 (0)	2 (4.16)

Medication information

Overall, 23 drug information services, majority of doctors enquired about the availability of medications (11, 47.82%) followed by drug interactions (5, 21.73%) and adverse drug reactions of medications (4, 17.39%). The primary beneficiary of medication information services was doctors (n = 6, 50%) followed by psychiatry postgraduates (n = 5, 41%). The major mode of medication information queries was direct access (n = 11, 91.6%). Further details of drug information services provided are presented in Table 4.

Table 4

The summary of drug information requests

	Category	n=23, n (%)
Enquirer	Consultant	6 (26.08)
	PG medical students	12 (52.17)
	Intern	5 (21.73)
Mode of request	Direct access	11 (47.82)
	Telephone	12 (52.17)
Drug information
DI parameters	Category	n=23, n (%)
Question category	Availability of drug and cost	11 (47.82)
	Drug interaction	5 (21.73)
	ADR	4 (17.39)
	Efficacy	1 (4.34)
	Mechanism of action	1 (4.34)
	Indication	1 (4.34)
Purpose of inquiry	Better patient care	19 (82.61)
	Update knowledge	4 (17.39)

PG – Postgraduate; ADR – Adverse drug reactions; DI – Drug information

DISCUSSION

A study by Chan et al.,[12] conducted in Australia says that there are around 15% to 20% drug-related hospital admission annually. The role of clinical pharmacy in psychiatric setting was well explained by Canales et al. In a randomization study where the intervention group which was receiving clinical pharmacy services along with regular consultation has proved much improvement that the control group.[13] In this study, we observed that drug-related problem frequently occurs in geriatric patients. A similar result was found in Ahmad et al. study, which was conducted to identify the DRP in geriatric patients.[14] The average DRP for 84 patients was 1.70. Approximately similar (1.54) result was found in a study conducted by Celin et al.[15] for 108 patients. Also, in this study it was found that more than three fourth (77.08%) of the interventions were accepted by the psychiatrist and similar findings were observed in other studies.[1617] Whereas, No change in therapy was in 18% of the total intervention. Much of the interventions were of moderate clinical significance, which is contradictory in Hussain et al.[18] and Bieszk et al.[19] studies. Antipsychotics and antidepressants were the most widely used type of medications, with more adverse effects predicted to occur in the same type as other studies.[2021] In our study, around 45% of the drug-related problem identified was adverse drug reactions similar result was found in Wali et al. study.[22] The high rate of ADRs further confirms in the observations of Creswell et al., who found that a risk factor for ADRs was number of drugs used by older patients.[23] Following the literature, in our research, the proportion of drug-drug reactions was around 7.2 per case. In the Paulino et al. and Vinks et al. reports, the amount of drug-drug reactions recorded ranges from 0.05 per patient to 1.4.[2425] The majority of the queries were enquired by the psychiatric postgraduates and psychiatrists, which were maximum on the availability of medication, cost, and drug-drug interaction. A similar finding found in an analysis of drug information queries Hare et al. study conducted on.[26]

The results found in the current study confirm that a higher number of the DRP occurs in the age group enrolled in this study, which might lead to increase risk of hospital admission, mortality, and cost of living. It is essential to develop intervention strategies using comprehensive tools to identify DRP.

CONCLUSION

Pharmacist and psychiatrist collaborative care are essential in pharmacotherapy management, and the clinical pharmacist has substantial responsibility for reducing DRPs in psychiatric patients. Pharmacotherapy management services may minimize the risk of comorbidity, duration of stay, and expenditure on health services, all of which contribute to the increased treatment of patients, especially in older patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.