Pharmacists are key in managing mental health and substance use disorders, said Christopher Thomas, PharmD, BCPP, BCPS and Capt. Ted Hall, PharmD, at the ASHP (American Society of Health-System Pharmacists) 54th Midyear Clinical Meeting & Exhibition, in a session titled “Mental Health Issues and Pharmacist Involvement, Suicide Prevention, and Substance Use Disorders.”

Thomas, a clinical pharmacy specialist in psychiatry at Chillicothe Veterans Affairs (VA) Medical Center in Ohio, said 51% of patients with a substance use disorder also have a mental health disorder, and that chronic pain is estimated to double the risk of death by suicide. Understanding the root cause of a patient’s pain or mental health disorder is vital, he added.

“When a mental health pharmacist becomes activated, and becomes involved with a patient, the most important thing is having a diagnosis up front,” Thomas said. “Once the diagnosis is procured, the mental health pharmacist can begin treating the patient.”

Mental health pharmacists should be involved across the spectrum of mental health care, whether it’s a level 1 facility with primary care-based mental health services, or a level 5 inpatient facility, according to the presentation.

In addition to handling issues such as depression, post-traumatic stress disorder, suicide screenings, and anxiety, many mental health pharmacists deal with typical metabolic conditions, such as hypertension and diabetes, Thomas said. This wide range of skills can be a major selling point for health systems looking to add mental health pharmacists to their employees.

“We tend to be a pretty versatile employee,” Thomas said.

Some key strategies for integrating a mental health pharmacist provider include identifying the needs and gaps of care within the facility; optimizing CPS and care coordination; and marketing yourself to patients.

“The patients are really going to like the services you provide,” Thomas said. “I hear it daily.”

According to Thomas, mental health pharmacy is a rapidly growing field. There are currently about 440 mental health clinical pharmacy specialists within the VA system, up from less than 250 in 2015. Mental health encounters by a pharmacist increased from approximately 63,000 in the first quarter of 2015 to nearly 90,000 in the fourth quarter of 2018.

In his work with the VA, Thomas said the most important aspect is having a scope of practice, fostering care coordination between the pharmacy and mental health care teams, and ensuring oversight by the executive committee of the medical staff.

Suicide prevention is a major component of his job, Thomas said. Younger veterans, female veterans, veterans in a period of transition, veterans with exposure to suicide, and veterans with access to lethal means are at the most risk, according to VA data cited by Thomas. According to the data, the rate of suicide was 1.8% higher for female veterans compared with nonveteran adult women in the US, and the rate was 1.4% higher for veteran men compared with nonveteran adult men.

Not only are pharmacists experts on medication-related treatments for severe depression, and mental health concerns, but they are also well positioned to discuss dangers and provide counseling to patients and their families. As an example of nonmedical interventions, Thomas said he has distributed gun locks to patients with suicidal ideation or severe depression. 

“Of course, they still have the key, but it gives 30 more seconds to reconsider while they unlock the safe,” Thomas said. “That can be the difference between life and death.”

Following Thomas’s discussion on suicidality and mental health in the VA community, Hall discussed his research and practice dealing with substance use disorders. Hall is a member of the United States Public Health Service Commissioned Corps, and the Indian Health Services, and works specifically with the Ho-Chunk Nation Health Department in Wisconsin.

After a patient receives a diagnosis, Hall said, obtaining treatment and remaining adherent can be a challenge. Of veterans with an alcohol use disorder diagnosis, 91% are not being treated, Hall said. Similarly, 62.3% of veterans with an opioid use disorder diagnosis are not receiving treatment.

In 2014, Hall developed a Medical Assisted Treatment Program for Alcohol Use Disorder and Opioid Use Disorder, in order to investigate the efficacy of a long-acting injection and oral naltrexone. Following each injection, patients took a survey to examine how much their cravings were affecting quality of life measures.

On a scale of 1 to 10, with 1 being ‘not at all’ and 10 being ‘extremely,’ patients consistently rated their cravings’ effects less and less after each injection. For example, following the first injection, patients rated the effects an 8 for how much they affected enjoyment of life. Following the second injection, they rated it at approximately 1 out of 10.

By gathering this data and understanding how best to treat patients with opioid and alcohol use disorders, Hall said he hopes to be able to implement better and more effective treatments for veterans, Native American populations, and broad populations in general.

“You can see where pharmacists, we make impact,” Hall said. “Not just within the walls of the pharmacy, but in the whole community.”


REFERENCE

Thomas C, Hall T. Federal Forum Keynote: Mental Health Issues and Pharmacist Involvement, Suicide Prevention, and Substance Use Disorders. Presented at: ASHP (American Society of Health-System Pharmacists) 54th Midyear Clinical Meeting & Exhibition; Las Vegas, NV: December 9, 2019.