Guidance on evaluating contraceptive options for patients with psychiatric conditions
In an interview with Pharmacy Times, Veronica Vernon, PharmD, BCPS, BCACP, MSCP Assistant Professor and Vice Chair of Pharmacy Practice Butler University College of Pharmacy and Health Sciences Indianapolis, IN, discusses her presentation at the 2024 American Association of Psychiatric (AAPP) Conference. Vernon shares contraceptive considerations and counseling strategies for patients with psychiatric conditions. She outlines key medication interactions with various contraceptive methods and emphasizes patient preferences. Vernon also addresses challenges such as limited inpatient options and ensuring adherence. Throughout, she stresses the importance of shared decision-making, inclusion, and empowering patients and other providers.
Pharmacy Times
What are the primary considerations pharmacists should keep in mind when selecting contraceptive methods for patients with chronic psychiatric conditions, especially concerning the higher risk of unplanned pregnancies and potential medication interactions?
Veronica Vernon, PharmD, BCPS, BCACP, MSCP
One of the first things I say this, goes for all patients is making sure that you are honoring the patient's goals, desires and their plan. That's the first thing to do— should be top of mind. What does the patient want? What have they tried before? What are they interested in? What are their goals in terms of pregnancy? Do they want to get pregnant? Or are they wanting contraception for other things like endometriosis, or dysmenorrhea. Drug interactions are really important. I think from a psychiatric medicine perspective, that's top of mind after patient preferences as there are several drug interactions, unfortunately. We think of things like carbamazepine, phenytoin oxcarbazepine, that all interact with her estrogen containing contraception and make it less effective. But then we have other drugs like clozapine, and lamotrigine, where their concentrations can be impacted by estrogen containing contraception’s. We also have a few interactions, but not quite as much with our progestin only options. So, it is important to screen every patient asked what drugs they're on, including those for psychiatric conditions and other conditions to make sure we're avoiding those drug interactions and minimizing any adverse reactions for our patients.
0:00:13 - The importance of honoring patient goals and preferences
0:01:22 - Advantages and disadvantages of various contraceptive methods
0:01:34 - Communicating risks and benefits to patients effectively
0:03:48 - Common challenges pharmacists may face and how to address them
0:05:30 - Strategies for promoting patient engagement and shared decision making
Pharmacy Times
Could you briefly outline the key advantages and disadvantages of various contraceptive methods for this patient population?
Pharmacy Times
Our estrogen containing products, those are the most widely used in the United States today— especially the combined oral contraceptive pill that has estrogen and progestin, but it does have quite a few drug interactions. I talked a lot about oxcarbazepine, carbamazepine, primidone, topiramate, those can all make estrogen containing contraception that less effective. They may also interfere with progestin only contraception, and there's some evidence to show topiramate might be impacted. Topiramates labeling was just changed actually to include progestin only pills. To the extent of what the unintended pregnancy rate looks like with that drug interaction, we don't have that data yet. It's hard to tell, I can say you can still use it judiciously. That's what I would do in my practice. Our long-acting reversible contraception is quite nice, as it doesn't have nearly as many drug interactions, especially our intrauterine devices, or IUDs, or the implant, the etonogestrel implant, also known as Nexplanon. And those can be great options, as well as the injection depot medroxyprogesterone acetate, is going to have fewer drug interactions. However, that's not going to work for all of our patients. And those options may not be accessible to all. So, sometimes we have to just mitigate the risks as much as we can. I have patients where I think, IUD, this will be a great option for you, and that's not what they want. It's really important that we don't coerce patients or try to convince them otherwise that we go with what they're comfortable with and what they desire.
Pharmacy Times
How can pharmacists effectively communicate the potential risks and benefits of different contraceptive options to patients with psychiatric conditions, considering their unique circumstances and concerns?
Veronica Vernon, PharmD, BCPS, BCACP, MSCP
I think one of the most important things to do is just provide information. Have educational handouts, have signage. Some of our patients are nervous to ask about some of this or don't know what to ask. We never want to put that burden on the patient of having them tell us what questions they have. But I like to lay it out like it's a menu. These are the options that I have available. What would you like to start with first? Do you want to start with pills? Do you want to talk about rings? Do you want to talk about transdermal patches, you want to talk about injection or IUD? What do you want to do? First, I think it's important to lay it out like a menu and not put it in any order except what the patient wants to talk about first, because we don't want to influence our patients one way or try to coerce them. Just think these are your options, I'm here to support you and help you make sure that you're picking something that isn't going to cause unnecessary risks for you.
Pharmacy Times
What are some common challenges pharmacists may encounter when assisting patients with psychiatric disorders in managing contraception, and how can these challenges be addressed?
Veronica Vernon, PharmD, BCPS, BCACP, MSCP
Some of the challenges are when we have patients that get admitted for an inpatient stay, that we don't always have access to contraception that some of our inpatient units or hospitals don't have all the methods on formulary. And that can be a concern for somebody who may not be able to take the birth control pills while they're there. So, then the question is, can somebody bring them to the hospital and use the patient's own supply? Some states allow that some don't, some hospital policies don't permit it. That is a concern is, is your patient going to take anything while they're there? We're not trying to prevent pregnancy at that time, but we might be trying to control their menstrual cycle. I think that's important to keep in mind that that can cause some significant dysphoria for patients if they're having heavy bleeding and spotting and we're not able to control those symptoms during their inpatient admission. Drug interactions, like we've already talked about are a big component, and then thinking about what works best for them in terms of adherence. What's something that they can take every day that they can manage themselves, that they feel comfortable with? And a regimen they're confident that they can manage? I think it's really important to make our patients feel like they are in control because they are and they're using a method that they can take and then they can decide they can start and stop. Or perhaps they want something that you put in the uterus like an IUD, and they forget about it, or you put in the implant for three years, and then they can forget about it until it's time to change. I also think about what other things they have going on. Are they worried about acne? Are they worried about how heavy their periods are? Do they want to even have periods anymore, and trying to find a regimen that meets all of those checkboxes they have.
Pharmacy Times
As pharmacists play a vital role in contraceptive counseling and management, what strategies do you recommend for promoting patient engagement and shared decision-making in the selection of contraceptive methods for individuals with chronic psychiatric conditions?
Veronica Vernon, PharmD, BCPS, BCACP, MSCP
I want more pharmacists to feel empowered to have these conversations. I think sometimes we think my specialty is psychiatry, or my specialty is gynecology. I'm going to stay in that lane. I think it's important that we step outside and think what can I do with my education, training and experience? How can I reach the greatest number of patients and help increase access? Psychiatric pharmacists are in such an amazing position to help patients with contraceptive choices. You're talking about patient autonomy. You can start just by striking up a conversation with your patients. Hey, have you ever thought about contraception? Are you interested in having children now or in the future? Or do you have heavy periods? Do you want to talk about how I can help you with that? I think that's important just approaching patients and talking, but then making sure you're having signage and educational materials in your clinics and on your units to let patients know that it's time to talk about it. I think that's something we can also train the rest of our medical staff with on initiating those conversations— asking patients are you interested in contraception? Is this something that's crossed your mind? We'd love to support you. I think it's also important for our transgender and gender diverse folks that we make sure we're using inclusive language and letting them know that we can assist them with their contraceptive needs as well.
