Pharmacy's Societal Mission and the Need for a Forum
Mr. McAllister is a health-systems consultant based in Chapel Hill, NC.
The headline read "Mentally Ill Children Boost Drug Sales." I have read other articles on this topic in the lay press, but the charts and graphs in this one were eye-catching and startling. According to the article, the number of children younger than the age of 19 who have been diagnosed with bipolar disorder has increased by 4000% in 9 years. The report also noted that the number of prescriptions for these agents for children doubled between 2003 and 2006.
This class of agents has been a boon to the treatment of bipolar disorders and has helped thousands of patients. The safety and efficacy of these drugs may not be superior to those of the agents used more than a decade ago. Yet, their side-effect profile excludes severe neurologic side effects and likely has improved adherence and thus helped more people. Many of these drugs, however, have been implicated with increased suicidality, and their use in children has been associated with the development of obesity, as well as an increased risk of diabetes and other metabolic disorders.
The Code of Ethics for Pharmacists, the oath we take on graduation, the mission and vision statements of our professional associations, and very likely our institutional missions all include, directly or indirectly, a responsibility for optimizing drug use for the community and society in addition to individual patients.
Nevertheless, we have been ineffective at managing trends such as this logarithmic growth in the use of antipsychotic drugs. The simple truth is that we do not have a forum by which we can collectively coordinate our individual efforts.
It seems to me that the following strategies should be considered:
1. Validate that schools of pharmacy are devoting adequate curricular time to psychiatric disorders and their management.
2. Continue to encourage the growth in specialty residencies in psychiatry.
3. Collaborate with drug manufacturers to encourage appropriate drug use, and insist on phase 4 clinical trials that evaluate actual use.
4. Determine whether the use of these drugs should require concomitant psychotherapy by a trained professional.
5. Collaborate with pharmacy benefit managers to monitor the global use of these agents and to develop strategies to minimize drug overuse.
6. Collaborate with the FDA and appropriate advisory panels to improve appropriate drug prescribing and use.
7. Collaborate with professional associations of psychiatrists to develop guidelines for patient selection and use, including the application of nondrug strategies for improving patient outcomes.
Individual practitioners need to continue to do their best to optimize drugtherapy outcomes on an individualpatient basis, but it will likely take time for an impact to be felt. What we need is an organization that spans the profession and has a mission to represent us all in broad professional issues, as well as having the respect of and recognition by other health-related professions, organizations, and government agencies.
We have similar opportunities with respect to the overuse of analgesics, antimicrobials, and other drug classes. Even if we cannot agree on some practice- specific issues, surely we can agree on meeting our societal covenant. What do you think?