Pharmacotherapy for Treating Mental Illness

Troy Trygstad, PharmD, MBA, PhD: Let’s step back for a second. Carla, I want to ask you to give us a brief history of pharmacotherapy with mental illness. It strikes me, even since I graduated from school, that there have been some pretty solid advances. Prior to that, we didn’t have a whole lot of it in our armament. We still don’t have a whole lot in our armament, but there are some therapies that work for a lot of folks. What does that brief history look like, and where are we at today?

Carla Cobb, PharmD, BCPP: Yes, so the treatment of mental illness goes back, I think, to the early 50s when lithium was first…

Troy Trygstad, PharmD, MBA, PhD: Mental illness has been around for a long time. Let’s just restate that. Our treatment of mental illness didn’t start until the 1950s. Isn’t that something?

Carla Cobb, PharmD, BCPP: Yes. So, lithium was one of the first treatments. Thorazine (chlorpromazine) we all remember. And then, for schizophrenia, the antipsychotics had so many problems associated with it. The mood disorder side effects were very debilitating for patients. In some cases, it caused worse symptoms than the illness itself.

Troy Trygstad, PharmD, MBA, PhD: And you wonder how much of today’s stigma is a result of side effects from medication, right?

Carla Cobb, PharmD, BCPP: And it’s interesting. Now, young pharmacists coming up have never seen the effects of those older medications, like the tardive dyskinesias. Some of our students have never seen anybody with tardive dyskinesia. So, we’ve made a lot of progress since then. And then with the advent of the second-generation antipsychotics, that’s where we have seen a lot of improvement, but also a whole different set of adverse effects, with metabolic side effects—the weight gain, the diabetes, the lipid panel changes—that although most people consider them an improvement, there’s still a lot of other adverse effects, and drug interactions that go along with these newer medications. Really, there haven’t been any since clozapine came out. And then some of the second-generation antipsychotics, other than different formulations, there haven’t been many major advances in the last 30 years.

Troy Trygstad, PharmD, MBA, PhD: Thirty years, right. So, amplification, and variation from that sentinel moment when clozapine came out. And now we have a lot of progenitors, if that was a progenitor. Then we have a lot in our armament that is in orbit of clozapine but nothing beyond that at this point still today.

Carla Cobb, PharmD, BCPP: Yes, and I think it’s important to point out that we tend to lump second-generation antipsychotics into a class.

Troy Trygstad, PharmD, MBA, PhD: Because it’s easy to do.

Carla Cobb, PharmD, BCPP: Right. Just to categorize them. But they are very different. And so, I think it’s important for everyone, for pharmacists, to understand the significant differences in adverse effect profiles, which can affect your choice of medication for an individual patient.

Troy Trygstad, PharmD, MBA, PhD: So, really, this gets to this whole idea of personalized, or precision, medicine, which, when I think of precision medicine, certainly I think of advances, and biomedical engineering, and so on and so forth. But I also think about precision being, 'how am I putting your care plan together?' And to your point, we don’t just lump them all together and say 'Me too, me too, me too, me too,' or even with administration, oral injectable, etc. How am I coming up with an individualized plan that this patient’s going to respond to? And because we don’t have great markers or labs, this issue of working with a professional over time consistently, to stabilize on a medication, just like you have a unique fingerprint, it almost seems to me that what you’re describing is each patient has a uniqueness profile when it comes to using these behavioral health medications. So, how did you implement that in your practice over these years?

Carla Cobb, PharmD, BCPP: I think it’s important to become very comfortable and knowledgeable about each medication and the type of adverse effects that it has. And then really, I think the most important thing is working with the patient, not making a decision without their input. Using motivational interviewing, and other techniques that really get the patient’s input and buy-in about what’s important to them, who should we be to decide that whether diabetes or akathisia or whatever other side effect is the most important one. That really takes the input of the patient to help make that decision.

Troy Trygstad, PharmD, MBA, PhD: Right. Adrienne, a newly diagnosed patient comes in, they have a prescription. Do you counsel them on, 'Hey, we’re hopeful that this will work for you, but we want to get to an individualized plan, so it may require a lot of going back to Dr. Cobb or coming back to the pharmacies here, and it may take a while for us to figure out exactly what it is that works for you well?' Is that the kind of conversation that you’re having when somebody’s new to this world, and new to therapy?

Adrienne Cervone, PharmD: Oh, absolutely. We make sure that they know up front that it is not 1-and-done. It’s probably going to change. It probably will change. Not only the dose itself, but the medicine. It may be an add-on, maybe this one’s not going to work at all. And we have to give it time. I think that’s what’s hard about it. It’s not something that we give today, and we see a change tomorrow. Trying to help the patient through that process of, 'You have to stick with it so that we see if it’s working or not before we make a change,' that’s what’s really hard.

Troy Trygstad, PharmD, MBA, PhD: Right. We don’t have the dentist advantage, right? You have a cavity, I take it out, it’s gone, we’re done, and successful.