Treating Serious Mental Illness (SMI) With Long-Acting Injectable Medications - Episode 9

Unmet Needs in Treating Serious Mental Health

Troy Trygstad, PharmD, MBA, PhD; Tripp Logan, PharmD; Adrienne Cervone, PharmD; and Carla Cobb, PharmD, BCPP, discuss the unmet needs in treating patients with serious mental illness, including the lack of psychiatrists to diagnose and treat these patients and how pharmacists can help fill in the gap for this care.

Troy Trygstad, PharmD, MBA, PhD: Let’s step back a little bit and remind ourselves why this is so important for this population. So, again, severely mentally ill. There are certainly a lot of functioning folks with severe mental illness, but there’s a lot of folks not functioning well because their severe mental illness is not being treated, undertreated, undiagnosed, or diagnosed with prescription(s) but still untreated. Just to the panel, I’ll throw this out there—probably the easiest question of the day but the hardest to answer, so to speak—what are the biggest unmet needs in this population? We’ve all interfaced with them frequently, and in our gut, we know that there’s a lot of unmet needs. But let’s help the audience with the variety of unmet needs in this population. So, let’s just go around the table and start.

Tripp Logan, PharmD: I’m going to go first since I’m kind of the novice in this area compared to any others. This is a good panel, and I’m learning so much. My notes here aren’t what I’m going to say, it’s like listening to you guys. So, that’s where that is. In my community, it’s catching substance abuse, mental behavioral health, primary care in a pharmacy, and making sure that everybody is taking care of the same person. And that the resources are available to take care of this person. It’s so hard.

And then you look at, from the prescription side, pharmacies in the community, if they’re going somewhere else to get their long-acting injectable and then there’s, “I don’t know what all they had.” And then you throw substance abuse in the middle of it, which is what we see a lot of in this population. And we’re working with that, too. We’ve got our Narcan protocol that we’re doing and we’ve got a lot that we’re trying to focus, and then, how do we just work all this stuff in together in the form of a program? You’re giving a great example of a program. We’re offering support. We need to have like a mechanism in place, a program, and substance abuse bubbles to the top with me in this.

Troy Trygstad, PharmD, MBA, PhD: So, certainly, the intersection between mental illness and substance abuse is an unmet need. If you’re fortunate enough to have a behavioral health prescriber in the community, do you also have a management specialist, or somebody that specializes in treatment, MAT or other? And, again, you both come from rural areas. Do you see similar unmet needs? You said that you’re blessed to have a more-than-normal number of behavioral health providers in your community, what does your substance abuse treatment and pain management offerings look like in your community?

Adrienne Cervone, PharmD: There are barely any. That is a huge downfall in the area. We’re hurting for them.

Troy Trygstad, PharmD, MBA, PhD: So, you’ve got this successful program with these patients now. Presumably some portion of them have substance abuse concerns or issues. How are you dealing with them, and they’re right in front of you?

Adrienne Cervone, PharmD: They are right in front of us. We work with them as best as we can with the knowledge that we have and with the ability of the level of what they’re coming forward with, what they’re telling us. We can only go so far with that.

Troy Trygstad, PharmD, MBA, PhD: You do wonder if to administer these drugs, and because you’re meeting with them frequently, again, it’s almost like a Coumadin clinic in the sense that when you get past the disease state and the drug, there’s this idea of regular scheduled visits with the patient. How many different drug therapy problems were discovered? Or advances for a patient occurred in a Coumadin clinic that didn’t have anything to do with anticoagulation because of that frequent contact, and you’re not just doing that one thing. So, I’ve got to believe that they developed a bit of trust with you, which is so critical when it comes to the substance abuse disorders, correct?

Adrienne Cervone, PharmD: Absolutely.

Troy Trygstad, PharmD, MBA, PhD: But are you making referrals or is it just managing it day-to-day?

Adrienne Cervone, PharmD: We are making referrals. But that’s it, we have to refer out. We don’t have anything local like that.

Troy Trygstad, PharmD, MBA, PhD: So, that’s certainly one. Any other unmet needs that might not come to mind that would be insights that you might have, Carla?

Carla Cobb, PharmD, BCPP: Well, to me, the biggest unmet need, and we’ve touched on it, is the lack of access to psychiatrists. There’s a recent paper, March of last year, National Council for Behavioral Health, The Medical Director Institute put out a paper trying to address the psychiatric shortage. And there are numerous causes, but it was nice to see for a change that it was physicians actually suggesting that pharmacists can be part of that solution. So, that’s really nice to see instead of us just always tooting our own horns, that others are starting to recognize the value of having pharmacists on the team.

And so, across the nation—and it varies from state to state—we probably have less than half of the psychiatrists we need with increasing population and increasing access to mental health treatment and substance use treatment because of changes in insurance plans and all of that, there’s a bigger demand. And clearly, that demand is not being met. There just aren’t enough programs, aren’t enough psychiatrists. And I always say that as pharmacists, we’re obviously not going to be able to solve this by ourselves, but adding the pharmacist to the team and seeing community pharmacists…How many pharmacists are there across the nation, 120 thousand or something? I don’t know what the number is exactly. But certainly, as part of the team, we can very much improve access to care by some of the kinds of services that Adrianne is describing and others.

Troy Trygstad, PharmD, MBA, PhD: There are a lot of towns in the United States with pharmacies and EMS, and that’s the health care system for towns of 600 or 800 or 1000 or 1200. Let’s hope that they are able to sustain and survive because they’re it. So, that’s interesting. Maybe one of the things you’re saying to the broader pharmacist profession is if you want to have the greatest influence on practice, go to the patients with the greatest need and biggest barriers. And if that’s how you want to develop an advanced pharmacist care, then join CPNP, right, and get into the behavioral health pharmacy. So, can you describe maybe for a few minutes what CPNP is and how you’re involved and how they’re on the frontlines of helping address these issues?

Carla Cobb, PharmD, BCPP: So CPNP stands for the College of Psychiatric and Neurologic Pharmacists, and it’s a small national pharmacy organization, mostly made up of people who are psychiatric specialists, board certified psychiatric pharmacists, or who work in, mostly, a mental health setting. And the organization provides education, it provides the training for those who want to become board certified in psychiatric pharmacy, and the recertification products for that as well, but also a lot of education, a lot of resources to help pharmacists who are interested in this area get up to speed. And I feel like that is really something important. I think we look for opportunities in pharmacy to be able to provide services and let people know the role that pharmacists can have, but as part of the team in caring for these patients.

But I also feel like it’s a responsibility that pharmacists need to assess their stigma. Stigma is a problem not only in the general population but also as healthcare providers. So, I’d encourage pharmacists to take a look internally and ask, “What is your role or your pharmacy’s role in continuing the stigma?” That’s something that we all have to take a look at. But then also increasing your knowledge and your competence and your comfort in working with these patients. And even if it’s not treating their mental illness or their substance use disorder, many of these patients with serious mental illness die years younger than their peers in the general population because of…

Troy Trygstad, PharmD, MBA, PhD: Twenty-six years, right?

Carla Cobb, PharmD, BCPP: Twenty-five, 26 years, you see different numbers. But yes.

Troy Trygstad, PharmD, MBA, PhD: Twenty-six years.

Carla Cobb, PharmD, BCPP: Much earlier.

Troy Trygstad, PharmD, MBA, PhD: That’s one-third of a lifespan, right?

Carla Cobb, PharmD, BCPP: And it’s usually not related to their mental health condition. It’s usually partly due to the side effects of medications that we use to treat it. So, the diabetes, lung cancer, and other medical conditions. I urge pharmacists that even if you’re not going to provide some of the specialty services, at least get comfortable in talking to these patients. You know, treating them with respect and compassion, and helping them manage all of their health conditions, not just focused on the mental health conditions.