Collaborative Care: Pharmacists Make a Difference in Mental Illness

Susan Farley
Published Online: Monday, September 1, 2008

Ms. Farley is a freelance medical writer based in Wakefield, Rhode Island.


More than a quarter of adults in the United States suffer from a diagnosable mental illness; in fact, 13% of the top 300 most frequently prescribed medications are psychotropic medications. Health care providers, including pharmacists, work tirelessly to help this patient population, when it is possible that they will never see results.

Xuan Cung, PharmD

Xuan Cung, PharmD

As pharmacist specialist at a busy mental health facility, Xuan Cung, PharmD, adeptly manages these difficult cases. Her work is at the Santa Clara Valley Health and Hospital System (SCVHHS) in San Jose, California, a county facility that sees 18,000 mental health clients a year. Their emergency psychiatric service (EPS) sees 10,000 patients per year. Cung?s role as a medication expert comes into play as these patients may present with both medical and mental illness.

After graduating from the University of the Pacific, Cung started at SCVHHS dispensing in an ambulatory pharmacy before getting into management. Eventually she took on a clinical role in psychiatry. ?When I first graduated, I did not have an interest and was not mentally ready to get into psychiatry.? After 10 years, she was ready for the challenge.

Day-to-day Efforts

Weekly group sessions allow Cung to discuss medications and side effects directly with her patients. She manages their care indirectly through medication monitoring and consultation with the other health care staff. When she is not in the EPS or inpatient unit, Cung works regular hours catching up on patient files, communicating with the medical staff on medication reviews, and providing updates on the latest medication news. Collaboration between pharmacist, psychiatrist, and social worker is a vital part of treating mentally ill patients, she says.

?In the process of educating patients, you have to listen and learn from your patients. These patients are chronically mentally ill. They have had the disease for longer than I have been a pharmacist. It is almost an education for you, because they have had the disease for so long,? says Cung. ?You know the textbook version, and they live it,? she adds.

Challenges Faced

One of the biggest challenges and perhaps the biggest disappointments in this job is the high recidivism rate. SCVHHS? EPS has a 54% readmission rate. ?In the younger population, there is higher recidivism. Many are not compliant.? Cung says that patients stop taking their meds for a variety of reasons, such as cost and paranoia, which leads to relapse. ?A big issue is polysubstance abuse. An event causes them to relapse into drugs and alcohol.?

Besides these frustrating statistics, the environment can be a challenge. ?The inpatient unit gets to be stressful. Patients can get violent. This is where the maturity comes in. The more exposure you get to this patient population, the better off you are,? advises Cung.

?You have to understand that it is not personal,? she explains. ?You need a tougher exterior. Mentally ill patients may get better in the hospital, but once they are out, they are back to the way they were. In other areas of pharmacy, you see patients take your advice and get better, but not here.?

The Heart of the Matter

Ultimately, dosing, compliance, and side effects are the crux of Cung?s work. She says, ?The biggest challenge is that there are no lab tests available to gauge how patients are doing. Dosages are adjusted based on qualitative assessments. We have only the interaction between provider and patient. That is where the collaboration becomes so important.

?This patient population is the most difficult to help due to the mental illness, not the person. You must be able to differentiate that.?

She is quick to add, however, ?The reward is that you are participating in the chain of care that helps them get better and fully functional. This is not possible for all patients. Although you may not see that right away, know that the support you give helps them achieve the quality of life that best suits them.?



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