College of Psychiatric and Neurologic Pharmacists 2016 Poster Abstracts

All parties are affiliated with the University of Arizona College of Pharmacy

Abstract Type: Original Research. Purpose: Undergraduates involved in social fraternities and sororities have higher rates of nonmedical prescription stimulant use and misconceptions about prescription stimulants. Specific beliefs about the use of prescription stimulants need to be identified and addressed to provide students with accurate information and to reduce abuse or misuse. The purpose of this study was to evaluate the effectiveness of an educational intervention in influencing prescription stimulant attitudes and beliefs of undergraduate students involved in social sororities at a public university. Methods: The intervention, an educational session on prescription stimulant misuse and abuse, was presented to undergraduates involved in social sororities. The following demographic data points were collected: gender, age, ethnicity, race, undergraduate year, grade point average, type of member (e.g. active, pledge, or alumnus), history of an attention-deficit/hyperactivity disorder (ADHD) diagnosis, and previous or current use of prescription stimulants. The participants’ attitudes and beliefs on nine statements regarding prescription stimulant use were queried pre- and post-intervention using a four-point Likert scale ranging from strongly disagree to strongly agree. To analyze change in attitudes and beliefs, a Mann-Whitney U test was used. Results: One hundred sixty-three sorority members participated in the study. The average age of participants was 19 years with the majority of respondents identifying as an active sorority member (81%) and in their first year of undergraduate study (69%). Twelve percent of participants reported having a history of a diagnosis of ADHD. There was a statistically significant change in attitudes and beliefs regarding the safety (p < 0.01) and health risks (p = 0.02) associated with prescription stimulants post-intervention. There was no significant difference in attitudes and beliefs regarding using stimulants to “feel good,” increase concentration, improve academic performance, the ease of addiction, and legality of taking someone else’s prescription medication. Conclusions and Future Directions: Information presented by pharmacy students results in a change in attitudes and beliefs regarding the safety and health risks of prescription stimulants. Future studies should be conducted to determine if this intervention leads to a decrease in prescription stimulant abuse and misuse among high-risk groups such as undergraduates involved in social fraternities and sororities.

1. University of Minnesota, College of Pharmacy, Department of Experimental and Clinical Pharmacology; 2. Rosalind Franklin University of Medicine and Science, Department of Psychology; 3. Northwestern University, Feinberg School of Medicine, Department of Psychiatry and Behavioral Sciences; 4. University of Illinois at Chicago, Department of Psychiatry; 5. University of Chicago, Department of Psychiatry and Behavioral Neuroscience; 6. University of Texas, Southwestern Medical Center, Department of Psychiatry; 7. Yale University, School of Medicine, Department of Psychiatry; 8. University of Georgia, Department of Psychology; 9. Beth Israel Deaconess Medical Center, Department of Psychiatry; 10. Duke University Medical Center, Departments of Psychiatry, Psychology, and Neuroscience; 11. University of Texas Southwestern Medical Center, Department of Psychiatry

Abstract Type: Original Research. Background: Medications with high anticholinergic activity may adversely affect verbal memory and learning. However cognitive relationships with cumulative anticholinergic burden from medication regimens in psychotic disorders have not been systematically examined. Objective: We assessed relationships between anticholinergic burden scored by the Anticholinergic Drug Scale (ADS) and neuropsychological performance in clinically stable patients with psychotic disorders. Methods: Probands with schizophrenia (SZ, n = 308), schizoaffective disorder (SZA, n = 192), and psychotic bipolar disorder (BP, n = 245) 15-65 years of age were examined. Medication lists were collected and anticholinergic burden from medication regimens quantified using the ADS. ADS scores were examined as a continuous variable as well as activity groupings [0 (no activity), 1-2 (moderate), and ≥3 (high)]. Potential effects of disease severity were investigated by examining relationships with antipsychotic doses (chlorpromazine equivalents) and the total number of psychotropic medications taken by participants. Subjects completed all six tests of the Brief Assessment of Cognition in Schizophrenia (BACS). Six measures and a composite score served as measures of neuropsychological performance. BACS scores were adjusted for age, gender, and race. Linear regression models were used to examine relationships between BACS and ADS, while evaluating interactions with diagnosis and controlling for overall medication burden and dosing. Results: Neuropsychological test scores differed significantly across ADS severity groups in all diagnostic categories (SZ F = 5.8, df = 2, 305, p = 0.004; SZA F = 3.8, df = 2, 189, p = 0.024; BP F = 4.6, df = 2, 242, p = 0.011). Anticholinergic burden and antipsychotic dosing were negatively associated with BACS total scores (ADS scores β = -0.109, p = 0.02; dose β = -0.159, p<0.001) with no evidence interactions by diagnosis group. Among subtests of the BACS, ADS scores were negatively associated with verbal learning scores (β = -0.155, p = 0.001), and antipsychotic burden was negatively associated with token motor scores (β = -0.220, p<0.001). Conclusions: ADS scores were associated with deficits in neuropsychological performance and appear to be independent of antipsychotic dosing and overall medication burden. While anticholinergic burden was negatively related to verbal learning, antipsychotic dosing was negatively related to motor speed. These findings are consistent with data from smaller studies indicating that anticholinergic and anti-dopaminergic properties can have adverse impact on different cognitive abilities in a dose-related fashion.

1. Sullivan University, College of Pharmacy; 2. Kentucky Board of Pharmacy; 3. University of Kentucky, College of Pharmacy

Abstract Type: Innovative Practices. Background: Deaths attributable to opioid overdose have been increasing over the past decade and have gained recent attention. Kentucky is listed by the Centers for Disease Control and Prevention as one of the top five states for drug-related deaths. In May of 2015, the Kentucky Board of Pharmacy promulgated administrative regulations outlining the educational requirements for pharmacists to initiate the dispensing of the opioid overdose reversal agent naloxone under a physician-approved protocol. In response, a rapid rollout of programming was designed and implemented to offer accessible and consistent education. Description of Innovative Activity: Starting in June 2015, the Advancing Pharmacy Practice in Kentucky Coalition, a partnership between Kentucky’s Colleges of Pharmacy, the Kentucky Board of Pharmacy, and state and local pharmacist associations, developed and offered educational programming granting a “Naloxone Certified” status. The status allows naloxone dispensing per-protocol without a prescription. The program consists of a 90-minute session covering naloxone access policy, recognition and management of opioid overdoses, protocol development, patient identification, and educational materials. These interactive sessions were offered via webinar and live sessions. Impact on Patient Care: Between June 28, 2015 and November 19, 2015, a total of 746 individuals completed naloxone training through webinar or at one of 15 live events. Of those, 484 were Kentucky licensed pharmacists, 50 were licensed pharmacists from outside of Kentucky, 199 were student pharmacists at the University of Kentucky and Sullivan University Colleges of Pharmacy, and 13 were pharmacy technicians. Approximately 48% of trained Kentucky pharmacists have received “Naloxone Certified” status by the Kentucky Board of Pharmacy. To date, four naloxone protocols have been established in Kentucky, including at a prominent retail chain in northern Kentucky. Conclusions: The rapid deployment of training to a wide variety of pharmacists and student pharmacists has resulted in a substantial number of naloxone-certified pharmacists across Kentucky. As access to pharmacist-prescribed naloxone expands, deaths from opioid overdose in Kentucky should decrease. This educational initiative has a great potential to contribute to the advancement of pharmacy practice across Kentucky and the nation by highlighting the key role pharmacists can play in public health.

Author affiliated with MCPHS University, School of Pharmacy- Boston, Boston, MA; South End Community Health Center, Boston, MA

Abstract Type: Innovative Practices. Background: Depression is one of the most common mental illnesses affecting patients presenting to a primary care (PC) clinic, with an annual prevalence of nearly 7% and lifetime prevalence of 15-25%. Many of these patients receive treatment thru PC settings, where PC providers (PCP’s) have limited time and resources to treat depression. Collaborative treatment of depression in a PC setting has become more common, where patients can receive depression treatment while allowing PCP’s to focus on other patient concerns. Integration of a psychiatric pharmacist in a collaborative care model within a PC clinic to provide medication management of depression would help meet the needs of these patients and the clinic providers. Description of Innovative Service: The program initiated within a private, urban community health center in the summer of 2013. The psychiatric pharmacist is a faculty member at a local pharmacy school, board certified in psychiatric pharmacy with over 10 years clinical experience; he was placed within the PC clinic of the center as his faculty clinical practice site. He obtained a CMM-based collaborative practice agreement and state and federal DEA numbers. Services provided included: patient evaluation for BH conditions, medication assessment and initiation, referral to other BH services as needed, and patient education. All services were provided based upon primary care provider referral. Impact on Patient Care: A 2-year analysis performed in Summer, 2015 showed a significant impact on patients’ depression. Of 440 patients referred to the pharmacist, 107 patients treated had a primary psychiatric diagnosis of depression. Illness severity demonstrated significant changes in 96 patients with repeat PHQ-9 scores from baseline to first follow-up appointment (17.8 to 14.8, p<.001) and maintained changes through follow-up #5 (12.9, p<.0001). Response rates (≥50% reduction from baseline PHQ-9 score) approached 55% by the fifth follow-up appointment also. A 7-question patient satisfaction survey administered to 39 depressed patients showed uniformly high satisfaction scores for patients treated by the pharmacist (mean = 26.8, maximum = 28). Conclusion: Collaborative depression treatment by the pharmacist showed significant effects on patients’ depression. Patients showed sustained improvements in their depression and were satisfied with their treatment.

All parties are affiliated with the Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa

Abstract Type: Therapeutic Case Report. Background: Schizoaffective disorder is a chronic mental health condition characterized by symptoms of schizophrenia and mood disorder. Clinical trials assessing efficacy and safety of paliperidone palmitate used specific guidelines for administration, including site (deltoid or gluteal), frequency (every 28 days), and proper needle length for administration site. Patient History: This is a 36 year old white male with a long standing history of schizoaffective disorder, diagnosed in his early 20’s. He has had numerous inpatient hospitalizations and is followed closely by mental health case management. His clinical picture is complicated by a history of medication non-adherence as well as occasional marijuana and alcohol use. History of medication use included: haloperidol decanoate, haloperidol, aripiprazole, quetiapine, and ziprasidone. Recently, he was switched to paliperidone palmitate 234 mg IM Q28 days. He continued on lithium therapy. Patient reported symptomatic benefit from paliperidone initially. However, after subsequent injections he began reporting intense thoughts of a religious connotation after playing the piano for a church service. Symptoms occurred just prior to date of next maintenance injection, therefore prompting the psychiatrist to inquire as to whether the injection interval could be shortened. A review of the medical record revealed the patient had been receiving paliperidone palmitate injections in the vastus lateralis muscle for nearly all maintenance injection administrations after receiving his initial administration in the deltoid. Records documented inconsistency in the number of days between maintenance injections (28-35 days). Review of Literature: A PubMed search revealed no published data on shortening the interval between injections with paliperidone palmitate. A recently published brief report concluded that administration via deltoid and gluteal muscle are not bioequivalent and therefore are not therapeutically equivalent, suggesting consideration of use of consistent injection site. No data was found regarding administration of paliperidone palmitate in the vastus lateralis muscle. Conclusion: Prior to shortening the administration interval it was recommended to ensure all medication administration recommendations be followed. Consistent administration of paliperidone palmitate into either the gluteal/deltoid muscle every 28 days using the appropriate needle size was advocated. Administration into the vastus lateralis muscle may be associated with more rapid clearance of paliperidone palmitate.

All parties are affiliated with the Providence Veterans Affairs Medical Center

Abstract Type: Therapeutic Case Report. Background: Constipation is a potentially serious side effect of clozapine treatment, likely caused by clozapine’s anti-muscarinic and anti-serotonergic effects. It can progress to ileus, ischemia, and death from perforation and sepsis. Schizophrenic patients may have decreased pain sensitivity and may not report symptoms delaying treatment. Patient History: The patient was a 55-year-old African-American man with schizoaffective disorder, bipolar type with more than 50 hospitalizations dating back to 1994. He exhibited poor social functioning, was a poor historian, and required assisted living. He failed multiple trials of antipsychotics, mood stabilizers, and ECT. His regimen included clozapine 400mg twice daily, quetiapine 400mg daily, bentropine 0.5mg and docusate 50mg/sennosides 8.6mg twice daily with polyethylene glycol as needed. Prior to admission, he was refusing food and reported intermittent abdominal pain. His last bowel movement was 4 days before admission and he denied nausea or vomiting. On admission, his abdomen was softly distended. He was afebrile (97.8F) but orthostatic and tachycardic (110bpm). Imaging showed large amount of stool throughout the colon and non-obstructive bowel gas pattern. He was started on an aggressive bowel regimen and received docusate/sennosides, bisacodyl, lactulose, polyethylene glycol, and mineral oil enema with no effect. On day 2, the bowel regimen was continued without result and manual disimpaction was attempted. The patient subsequently vomited, became hypoxic on room air, then bradycardic and unresponsive. Tracheal intubation was attempted yielding large amounts of gastric contents. Further attempt at intubation was unsuccessful and the patient was pronounced dead. Autopsy showed the large bowel contained large quantities of solid stool and was markedly dilated without perforation. Numerous foreign bodies were noted throughout the lungs consistent with aspiration. Review of Literature: A MEDLINE review revealed 20 case reports of fatalities from clozapine induced constipation with 3 related to aspiration. Conclusion: Severe constipation with fecal impaction led to obstruction and gastric dilatation which resulted in vomiting with aspiration ultimately leading to cardiorespiratory arrest. Patients with constipation from clozapine should be prescribed an aggressive, scheduled bowel regimen with a lower threshold for further workup for poor historians. Additional anti-muscarinic use should be minimized. A new constipation algorithm was created.

1. VA Connecticut Healthcare system; 2. Yale University, School of Medicine, Department of Psychiatry; 3. Abraham Ribicoff Research Facilities

Abstract Type: Original Research. Purpose: Cannabis is increasingly legally available in the United States. However, motor impairments associated with cannabis and its constituents such as Delta-9-tetrahydrocannabinol (THC) may have implications for the individual and the general public but are not fully characterized. This study examined the dose related effects of THC on motor function. Methods: Data are from a three-day randomized, double-blind, placebo-controlled, and within subject crossover study examining the effects of intravenous THC on motor function. On each test day participants received one of the following: low dose ethanol/vehicle (placebo), THC 0.015 mg/kg (low dose), or THC 0.03 mg/kg (high dose) over 10 minutes in a counterbalanced order. Outcome measures included the CANTAB Motor Screening Task (MOT), the Grooved Pegboard (GP), and a paced finger-tapping task (FTT). Results: 23 participants (13 female), age (25.8 years ± 3.8; mean ± SD), completed all study days. No significant difference was seen on performance on the MOT between drug conditions. On the GP, a significant effect of drug was seen in the non-dominant hand on the “Total Score” (placebo 99.6 ± 3.8, low dose 103.6 ± 3.8, high dose 106.1 ± 3.7; p = 0.036). Post-hoc comparisons found significantly lower performance with the high dose THC compared to placebo (p = 0.012). With the dominant hand, there was a trend toward a dose effect (p = 0.0950 such that performance was lower with both doses of THC compared to placebo (placebo 92.7 ± 4.1, low dose 97.1 ± 3.9, high dose 99.1 ± 5.0). On the FTT a significant drug effect was observed for reaction time (placebo 271.1ms ± 1.3, low dose 273.2ms ± 1.6, high dose 289.2ms ± 1.70 p < 0.001). Pair-wise comparisons found significant differences between placebo vs. the low dose (p = 0.044) and high dose (p < 0.001); and low dose vs. high dose (p < 0.001). Conclusions: THC administration resulted in a dose related impairment on motor performance. These data suggest THC may worsen motor coordination and reaction time. This may be concerning when individuals use cannabis and engage in complex motor functions such as driving or handling machinery.

1. Department of Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota, College of Pharmacy, Duluth, Minnesota, USA; 2. Undergraduate Research Opportunity Program (UROP), University of Minnesota, Duluth, Minnesota, USA

Abstract Type: Original Research. Purpose: Analyses of continuous metabolic variables and changes over time will provide clearer assessment of pharmacist comprehensive medication management (CMM) services impact on metabolic markers for diabetes and dyslipidemia. Objective: Determine if significant differences were observed in continuous metabolic health variables in randomized subject groups over 6 and 12 months. Methods: A 12-month, prospective, multi-site study of 120 consenting adults taking antipsychotics were randomized to either “pharmacist CMM services” (PCS) group (n = 60; n = 25/35 male/female) or “no pharmacist CMM services” (NCS) group (n = 60; n = 24/36 male/female). Two-factor multivariate analyses of variance (MANOVA) and analyses of variance (ANCOVA) were used for comparison of changes over time for NCS and PCS males and females from baseline to 6 and 12 months. Multiple mean comparisons were considered statistically significant if the mean differences were significant in both Fisher’s LSD and Tukey’s HSD analyses. Results: A significant difference was observed in NCS and PCS male and female subjects from baseline to 12 months (n = 62, p = 0.048). A statistically significant difference from baseline was observed in the HgbA1c (n = 82, p = 0.0218 at 6 months and n = 86, p = 0.0314 at 12 months) with the effect of group-gender interaction significance (n = 82, p = 0.006) at 6 months and the effect of gender significance (n = 86, p = 0.021) at 12 months. Six month significant differences were observed in NCS and PCS male and female subjects for systolic blood pressure (n = 85, p = 0.012), BMI (n = 84, p = 0.026), and triglycerides (n = 83, p = 0.018) and baseline to 12-month significant differences were observed in NCS and PCS male and female subjects for LDL (n = 73, p = 0.016) and HgbA1c (n = 86, p = 0.021). In PCS females, at 6 and 12 months, mean HgbA1c values (-0.6542%, 95% CI [-1.2117, -0.0967] and -0.7442%, 95% CI [-1.3880, -0.1004] respectively) were significantly reduced compared to PCS males. In PCS males, mean LDL values (-29.56 mg/dL 95% CI [-58.254, -0.866]) were significantly reduced at 12 months compared to PCS females. Conclusion: Pharmacists CMM services can result in improved metabolic markers important in the treatment and monitoring of diabetes and dyslipidemia among female and male patients taking antipsychotics over 12 months.

https://clinicaltrials.gov/ct2/show/NCT02029989

All parties are affiliated with the Veterans Affairs Salt Lake City Health Care System

Abstract Type: Work in Progress. Background: Over the past 20 years, the US has experienced a four-fold increase in the number of prescription opioid overdoses. In response to this epidemic, the Veterans Health Administration developed an Overdose Education and Naloxone Distribution (OEND) program to educate Veterans about opioid safety and overdose response, including take-home naloxone. Significant stigma surrounds opioid overdose and naloxone rescue, due to its association with substance abuse. Addressing this stigma is especially important in primary care, where patients on chronic opioid therapy may not understand their risk of accidental overdose. There is little data examining patients’ rationale for refusal of take-home naloxone and the role that stigma plays in this choice. Objectives: 1) Examine Veterans’ reasons for refusal of take-home naloxone in the primary care setting, with specific interest in stigma-related responses, 2) Determine whether an association exists between patient characteristics and reason for refusal, and 3) Develop strategies to further encourage appropriate patients to accept take-home naloxone Methods: This retrospective chart review at the Salt Lake City VA will examine the Medication Risk Assessment progress note. This note is used to document risk factors for opioid overdose and provision of OEND. When a patient declines, the note template requires the provider to indicate why the patient refused the kit. Reasons for refusal are classified into the following categories: false beliefs about accidental overdose, misunderstanding of personal risk factors for accidental overdose, disagreement in being an appropriate candidate for take-home naloxone, lack of confidence in using naloxone kit, fear of provider judgement or previously feeling judged or stigmatized by a provider, or other. Age, race, gender, psychiatric and physical comorbidities, average daily morphine equivalent dosage (MED), and whether or not the patient has an active concurrent benzodiazepine (BZD) prescription will also be recorded. All Medication Risk Assessment notes of patients who refused take-home naloxone from October 1, 2015 through February 28, 2016 will be included in this study. Outcomes: The primary outcome measured will be the most common reason for patient refusal of take-home naloxone. The secondary outcomes will investigate whether reasons for refusal correlate with patient characteristics.

All parties are affiliated with the University of Arkansas for Medical Sciences, College of Pharmacy

Abstract Type: Original Research. Purpose: According to a 2012 survey developed collaboratively between the College of Psychiatric and Neurologic Pharmacists Foundation and the National Alliance on Mental Illness, 75% of mental health patient respondents reported they did not receive effectiveness or safety monitoring assistance from their pharmacist. Furthermore, 43% of patients taking mental health medications reported not having a strong professional relationship with their pharmacist. This study was to determine the level of social distance of University of Arkansas for Medical Sciences College of Pharmacy student pharmacists towards patients with mental health conditions. Methods: Student pharmacists within the P1-P3 years were asked to complete an anonymous paper survey, which was distributed in each class. P4 students completed an electronic survey; electronic survey invitations were sent via email. The survey remained open for eight days. Data was collected utilizing the Bogardus social distancing survey. Minimal demographic characteristics were collected to ensure anonymity of the participating students. Results: A total of 334 students (70%) in the P1 through P4 program years completed the demographic information and Social Distancing Survey (SDS). Of the students surveyed, 276 (83%) had an SDS survey score ≥ 14, which indicates social distancing between students and mental health. There was no statistical difference noted in the extent of social distancing between pharmacy students in differing professional classes (p = 0.482). Of the survey questions, the most noticeable finding in student answers displaying social distancing was related to trusting someone with mental illness to babysit his/her child (53 students, 16%). The most prominent finding in student answers displaying minimal social distance involved working with (292 students, 88%) and being neighbors with (295 students, 88%) someone with mental illness. Conclusions: Survey results indicate that social distancing is prominent among pharmacy students at this institution. No differences were noted between students in earlier versus later professional program years. Results may be used in the future to help identify solutions for improving social distancing and increasing pharmacy student exposure to mental health education.

1. University of Southern California School of Pharmacy; 2. University of Michigan College of Pharmacy; 3. University of Arizona College of Pharmacy; 4. Southern Illinois University at Edwardsville School of Pharmacy; 5. Touro University College of Pharmacy; 6. Samford University McWhorter School of Pharmacy; 7. University of Texas at Austin Dell Medical School; 8. Nova Southeastern University College of Pharmacy; 9. American Association of Colleges of Pharmacy, 10. University of Colorado Skaggs School of Pharmacy

Abstract Type: Original Research. Purpose: In the United States, approximately 1 in 4 suffer from a psychiatric diagnosis and 1 in 5 suffer from a neurologic condition. Pharmacists require knowledge and skills in the treatment of these disorders, but the breadth and scope of education provided by pharmacy institutions in the U.S. remains largely unknown. National descriptive data on current curricula in psychiatry and neurology will better inform curriculum committees and health care decision makers regarding graduating pharmacists’ knowledge and skills in these key therapeutic areas. Method: An electronic survey was sent to curriculum representatives from accredited U.S. pharmacy institutions asking for information about their 2014-2015 curricula in psychiatry and neurology. Institutions were asked to report the qualifications of faculty, hours of instruction, IPPEs, APPEs, skills taught, and methods utilized. Results: Fifty-six percent (75/133) of institutions submitted at least partial survey data. Clinical faculty teaching topics in psychiatry usually had a BCPP, while BCPS was more common for neurology topics. Didactic lecturing, team-based learning, and case-study activities were the most common teaching methods reported. Institutions devoted more time, on average, to topics such as pain (3.4 hrs) epilepsy (3.4 hrs), depression (3 hrs), and schizophrenia (3 hrs). Topics where NO instruction was offered by institutions: 36/52 (69%) personality disorders, 37/57 (65%) autism spectrum disorder, 35/59 (59%) traumatic brain injury, and 31/61 (51%) eating disorders. Neuropsychiatric content was taught in the P3 year at 60% of institutions and P2 year at 40% of institutions. Institutions varied tremendously in the number of APPE slots offered since the range of available slots in adult inpatient psychiatry and neurology was 0-83 and 0-23, respectively. Similarly, the range of available slots in ambulatory care psychiatry and neurology was 0-43 and 0-16, respectively. Fifty-four percent offered student-driven research projects in psychiatry or neurology, while 48% offered interprofessional education in neuropsychiatry. Conclusions: Pharmacy institutions offer more didactic lecture hours for pain, epilepsy, depression, and schizophrenia. Instruction for personality disorders, autism spectrum disorder, traumatic brain injury and eating disorders can be enhanced. There is wide variation in the number of neuropsychiatry experiential opportunities offered by pharmacy institutions.

1. University of Southern California School of Pharmacy; 2. University of Arizona College of Pharmacy; 3. University of Michigan College of Pharmacy; 4. Touro University College of Pharmacy; 5. Nova Southeastern University School of Pharmacy; 6. University of Texas at Austin, Dell Medical School; 7. Samford University McWhorter School of Pharmacy; 8. Southern Illinois University at Edwardsville School of Pharmacy; 9. American Association of Colleges of Pharmacy, 10. University of Colorado Skaggs School of Pharmacy

Abstract Type: Original Research. Purpose: The number of accredited institutions offering a PharmD in the United States has nearly doubled from 72 to 135 over the past 28 years, increasing the number of faculty needed to teach a wide range of disorders including psychiatric and neurologic conditions. Board certified psychiatric pharmacists (BCPPs) are uniquely qualified to teach or assist faculty on optimal curriculum development for psychiatric and neurologic disorders, yet their recommendations have not been described. Additionally, there are limited data on BCPP instructor opinions and methods currently used to teach psychiatric and neurologic disorders. Method: An electronic survey including 4-point Likert scales was sent to CPNP members who are BCPPs with an academic affiliation. They were asked to describe their teaching involvement in PharmD curricula and provide recommendations on optimal didactic and experiential teaching of psychiatric and neurologic disorders. Results: Sixty-five percent (173/267) of individuals responded to the survey. Only 20% were tenure-track faculty, with 43% non-tenure track and 37% adjunct/affiliate status. The majority (74%) had completed residency and/or fellowship training and 19% reported teaching at multiple pharmacy institutions. Approximately 81% agreed students get adequate instruction in pharmacology/chemistry before therapeutics coursework. Regarding didactics in therapeutics, 74% (mean = 3) agreed there were sufficient faculty qualified to teach psychiatry, while only 50% (mean = 2.55) felt their institution had enough qualified faculty to teach neurology. Similarly, 57% (mean = 2.63) of responders believed their institution had sufficient APPE preceptors for psychiatry, compared to only 30% (mean = 2.07) for neurology rotations. APPE students precepted in psychiatry far outnumbered neurology (1103/38) as expected given that the most commonly precepted APPE experience was inpatient psychiatry (41%). Most respondents recommended 3 hours of therapeutics on schizophrenia, depression and epilepsy; 2 hours for Parkinson’s disease, headache, stroke, pain, dementia, bipolar, sleep, anxiety and substance use disorders; and 1 hour for multiple sclerosis, traumatic brain injury, ADHD, autism spectrum, personality and eating disorders. Seventy-six percent (mean = 2.95) agreed more opportunities for APPEs in psychiatry and neurology are needed. Conclusions: CPNP member BCPPs with academic affiliations recommend increased APPE offerings, particularly more instruction in neurology. Comprehensive survey results including recommendations for course materials and skill development will be reported.

1. University of Oklahoma College of Pharmacy, Tulsa, OK; 2. School of Community Medicine, Department of Psychiatry, University of Oklahoma, Tulsa, OK

Abstract Type: Original Research. Objective: To develop a monitoring program to evaluate the potential for rivaroxaban-associated bleeding and antidepressant (AD) use in patients that may be at risk for increased bleeding and are served by a program of assertive community treatment (PACT). Background: Selective serotonin reuptake inhibitors (SSRIs) causing SSRI-associated abnormal bleeding is a possible adverse drug effect. The identified mechanism is drug-induced inhibition of serotonin uptake in platelets. Serotonin will bind to the receptors on adjacent platelets, facilitating platelet aggregation and vasoconstriction. Although mostly studied in SSRIs, non-selective serotonin reuptake inhibitors ADs may also impact hemostasis and cause an increased risk for bleeding events. Rivaroxaban (RXB) is a target-specific oral anticoagulant that specifically targets Factor Xa in the coagulation cascade by selectively binding to the active Factor Xa site. Concomitant use of strong 3A4 inhibitors will increase RXB concentrations, whereas concomitant use of 3A4 inducers can increase bleeding risk and reduce plasma concentrations of RXB. Methods: Literature retrieval was accessed through OVID, Google Scholar, MEDLINE, and PubMed (1965-September 2015) using the search terms antidepressants, bleeding, bleeds, hemorrhages, rivaroxaban, serotonin platelets, and SSRI bleeding incidence. Four articles were identified for review. Electronic medical record (EMR) data were reviewed for individuals receiving antidepressants and rivaroxaban. Results: Data were reviewed for 75 charts; 3 met criteria. Case 1 was limited to 6-months post deep vein thrombosis (DVT) treatment. Case 2 was secondary prophylaxis for DVT treatment; the patient was lost to follow-up. Case 3 identified potential concurrent orders for warfarin [in use] and RXB [prior authorization pending] in addition to AD use. The potential hazards of concurrent anticoagulant use were addressed. No cases of decrease platelets or reports of increase bleeding symptoms were identified for this cohort. Conclusion: To date, the combined use of RXB and serotonin-inhibitory agents has not been shown to have an increased risk in bleeding events. Our findings are consistent with previous findings. Because more than one serotonergic agent may be prescribed, this patient cohort will continue to be monitored with patient-specific follow-up initiated as needed. Data will be reviewed at least every 6 months and no less than every 12 months.

1. SUNY University at Buffalo; 2. GPI Clinical Research; 3. University of Rochester

Abstract Type: Original Research. Background: An adverse event such as sexual dysfunction has been shown to play a role in adherence of medications used in the treatment of schizophrenia. Although the utilization of atypical LAIs is advancing, there is an absence of data on the sexual side effects of these agents. 30-60% of schizophrenic patients report some sexual dysfunction associated with the use of antipsychotics. Various studies have suggested the prolactin raising antipsychotics have a greater effect on sexual dysfunction then prolactin sparing antipsychotics. This is one of the first studies comparing the sexual dysfunction associated with prolactin raising (PR-risperidone, paliperidone) vs prolactin sparing (PS-aripiprazole, olanzapine) LAIs. Method: A retrospective, matched pairs review analysis of patient charts at a behavioral health network and at a private practice was conducted. Trained raters determined changes in disease status over time with the CGI-S and GAF. In addition, a modified Arizona Sexual Experience scale (ASEX) and serum prolactin were reviewed. Data was analyzed with a Kruskal-Wallis for analysis of variance and a Wilcoxon-Signed Rank Test for significance. Results: 86 adult patients with a DSM-V diagnosis of schizophrenia were selected. 35 matched pairs were identified. Patients were matched for age, gender, ethnicity, symptom severity and duration of treatment (6 months). Subjects were separated by PRLAI or PSLAI. Patient demographics included: age 41 +/- 13, male-21 (60%), African American-10(29%), Hispanic-5(14%), Caucasian-19(54%), Asian-1(3%), and symptom severity (CGI-S = 4.2, GAF = 40). LAIs used include: PRLAIs (Paliperidone -19 (54%), Risperidone-16 (46%) and PSLAIs (Aripiprazole -28 (80%), Olanzapine - 7 (20%). Clinical outcome was measured by CGI-S and GAF scores. There was no statistical difference between groups. Sexual dysfunction was measured by a modified ASEX-(% of subjects with score >18) - (PRLAIs-60.4%, PSLAIs-5.6%, P<.001) and serum prolactin (PRLAIs-31.1 (13.1-60.4), PSLAIs-2.6 (0.5-6.0), P<.001). Conclusion: Exploratory research generally utilizes small sample sizes and, thus, findings are typically not generalizable to the population at large. Nevertheless, the present study strongly suggests that PSLAIs are associated with a lower rate of sexual dysfunction which should have an impact on long-term adherence. A randomized, controlled prospective study is needed to evaluate the role of PSLAIs and sexual dysfunction.

1. SUNY University at Buffalo; 2. GPI Clinical Research; 3. University of Rochester

Abstract Type: Original Research. Background: It is estimated that in the United States almost $2 billion is spent annually on hospital readmissions of patients with schizophrenia. The use of LAIs have demonstrated that they reduce rate of re-hospitalization and decline in social functioning associated with relapse. Unfortunately, there is < 10% utilization of LAIs for the treatment of schizophrenia. This is one of the first studies to evaluate whether the site of initiation, inpatient vs. outpatient, affects re-hospitalization and functioning. Method: This was a retrospective, matched pairs review analysis of patient charts at a behavioral health network and at a private practice. Trained raters documented service utilization by examining inpatient hospitalization records and outpatient visit summary usage for those patients receiving LAIs. GAF and CGI-S scores determined changes in disease status over time. Subjects’ progress notes were reviewed for 1 year post LAI initiation. Service utilization was analyzed with a Kruskal-Wallis for analysis of variance and a Wilcoxon-Signed Rank Test for significance. Results: 169 adult patients with a DSM-V diagnosis of schizophrenia were selected. This is approximately 5% of the total schizophrenic population surveyed. 34 matched pairs were identified. Patients were matched for age, gender, ethnicity and for prior hospitalizations. Subjects were separated by site of initiation of the LAI-inpatient (IP) or outpatient (OP). Clinical outcome was measured by change in CGI-S (IP = 3.49, OP = 4.27, P< .001) and GAF (IP = 51, OP = 39, P = .017). Service utilization was calculated for hospitalization (IP = $424, OP = $5209, P< .001), ER visits (IP = $140, OP = $1155, P<.001), medication costs (IP = $5453, OP = $13530, P< .001), and total costs (IP = $9654, OP = $23104, P<.001). There was no statistical difference between groups in outpatient utilization costs. Conclusion: Exploratory research generally utilizes small sample sizes and, thus, findings are typically not generalizable to the population at large. Nevertheless, the present study strongly suggests that LAIs initiated in an inpatient setting decrease re-hospitalization rates and improve functioning 1 year post initiation. Further research is needed to determine the additional financial and therapeutic merits that could exist with open access to LAIs at inpatient facilities.

1. Faculty of Pharmacy, Mahidol University, Bangkok, Thailand; 2. Faculty of Pharmacy, Siam University, Bangkok, Thailand

Abstract Type: Original Research. Background: Schizophrenia is a chronic psychiatric disorder which needs long-term antipsychotics therapy. In addition, other psychiatric and medical comorbidities are commonly found among patients with schizophrenia that increasing an opportunity for polypharmacy. Pharmacist can play an important role to identify, resolve and prevent drug-related problems (DRPs) which help to maximize efficacy and safety of medication use. Objective: To evaluate the frequency and type of DRPs in patients with schizophrenia Methods: This was an open-label, cross-sectional study in patients who visited at the outpatient department of Somdet Chaophraya Institute of Psychiatry, Thailand during February to June 2015. All patients who aged between 18-50 years whom were diagnosed schizophrenia according to DSM-IV within 10 years previously, had moderate to severe disease severity, received same antipsychotic agent with stable dose for at least 2 months, and gave informed consent by themselves and their caregiver. Patients who had mental retardation, or could not communicate effectively were excluded. DRPs were identified by patient interviewing and chart review by psychiatric pharmacist. Primary outcome was the frequency of DRPs. Results: A total of 41 patients were recruited and analyzed. Most of them were female (68.29%) and their mean age were 37.07 years. The mean duration of illness was 5.08 years. A total of 84 DRPs were identified (mean 2.05 DRPs per patient). Unnecessary drug therapy was the most commonly identified DRPs (50%) such as using anticholinergics for prevention of extrapyramidal side effects, combined long-acting injection with oral antipsychotics. Adverse drug reactions, inappropriate compliance, dosage too low, wrong drug and need additional drug therapy were found in 25, 10.72, 5.95, 4.76, and 3.57%, respectively. Conclusions and Future Directions: DRPs are very common in patients with schizophrenia. Pharmacist can play an important role to provide pharmacotherapy suggestion for resolving and prevention DRPs. Thus, further studies should be done to confirm that decreasing of DRPs in patients with schizophrenia can improve patient safety and treatment outcomes.

All parties are affiliated with Shodair Children’s Hospital, Helena, MT

Abstract Type: Original Research. Purpose: Aggression is defined as overt behavior that has the intention of inflicting physical damage on another individual. Amantadine is a noncompetitive NMDA receptor antagonist which also increases synaptic dopamine. Amantadine has a growing body of evidence for use in aggressive behavior in patients with traumatic brain injury, autism spectrum disorder, and intellectual disability. We describe our experience with amantadine treatment for aggressive behaviors in eight hospitalized pediatric patients. Methods: We conducted a retrospective chart review of psychiatric inpatients admitted between 2013 and 2015 who were initiated on amantadine for the management of aggressive behaviors. Included patients received amantadine for a minimum of twenty days. Patients were excluded from this series if they were initiated on amantadine for an indication other than aggressive behavior or were taking amantadine prior to hospital admission. Results: The majority of patients were male (n = 7) with age ranging from 6 to 10 years (mean 8.5). The most common diagnoses were attention-deficit/hyperactivity disorder (n = 6), intermittent explosive disorder (n = 4), oppositional defiant disorder (n = 4), and bipolar disorder (n = 3). Six patients had borderline intellectual functioning and four had suspected in utero substance exposure. Multiple classes of medications had been tried prior to amantadine initiation. Mean adjunctive amantadine starting dose was 2.6 mg/kg/day and mean discharge dose was 6.7 mg/kg/day. The treating physician described five patients as significantly improved and three patients as moderately improved while taking amantadine. Average weekly seclusions were reduced from baseline in the first week of treatment (1.81, 95% CI [1.02, 2.61] versus 0.25, 95% CI [0.00, 0.55]). Weekly restraints and seclusions were reduced from baseline in the second week of treatment (1.56, 95% CI [0.45, 2.68] versus 0.00, 95% CI [0.00, 0.00] and 1.81, 95% CI [1.02, 2.61] versus 0.13, 95% CI [0.00, 0.35]) respectively. Amantadine caused no adverse events. Conclusions and Future Directions: Due to previously reported placebo response rates, our patients taking other mood stabilizing medications, and other limitations associated with retrospective reports, further evidence is needed to demonstrate the efficacy of amantadine for treatment of pediatric aggression.

1. Partnership for Health Analytic Research, LLC, Beverly Hills, CA; 2. Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ; 3. Lundbeck LLC, Deerfield, Illinois

Abstract Type: Original Research. Background: Although several second generation antipsychotics are available, heterogeneity of treatment response warrants the introduction of additional therapies. The objective was to examine the cost-effectiveness of brexpiprazole, a new antipsychotic, as monotherapy treatment of schizophrenia from a US payer perspective. Methods: A decision-analytic model estimated clinical outcomes and costs over 6 weeks in adults receiving (1) brexpiprazole 2mg; (2) brexpiprazole 4mg; (3) lurasidone 120mg; or (4) quetiapine XR 600mg. Clinical data were obtained from comparable phase 3 clinical trials of atypical antipsychotics and product labelling. Placebo-adjusted relative risks were used to estimate treatment efficacy. Costs included product acquisition, adverse event treatment, and patient monitoring. Cost-effectiveness was assessed in terms of cost per mean change in Positive and Negative Syndrome Scale (PANSS) and secondly cost per mean change in Clinical Global Impression – Severity scale (CGI-S) scores. Results: In the base case, treatment with brexpiprazole 2 mg and 4 mg resulted in 6-week, per-patient total costs of $1,569 and $1,585, respectively, and costs for lurasidone and quetiapine XR were $2,084 and $2,102. Mean change in PANSS for each treatment was: brexpiprazole 2 mg (-19.65); brexpiprazole 4mg (-20.93); lurasidone (-18.69); and quetiapine XR (-25.72). Mean change in CGI-S was: brexpiprazole 2 mg (-1.09); brexpiprazole 4 mg (-1.22); lurasidone (-1.03); and quetiapine XR (-1.19). Cost per change in PANSS for quetiapine XR vs brexpiprazole 2mg and 4mg were $88 and $108, respectively. Per CGI-S improvement, quetiapine XR had an incremental cost-effectiveness ratio (ICER) of $5,354 compared to brexpiprazole 2 mg, but brexpiprazole 4mg dominated (i.e., less costly and more effective) quetiapine XR. Brexpiprazole 2mg and 4mg dominated lurasidone in both the cost per PANSS and CGI-S analyses. Sensitivity analyses identified change in PANSS and product cost as drivers of ICERs. The model included a limited time horizon of trial duration (6 weeks) that may not fully capture long-term benefits of treatment. Conclusions: Model suggests treatment with brexpiprazole at both 2 and 4mg results in cost savings and may improve clinical measures such as PANSS and CGI-S. While these rating scales are common in schizophrenia research, CGI-S may be more meaningful for non-research clinicians.

1. University of Maryland School of Pharmacy; 2. University of North Carolina at Chapel Hill; 3. Maryland Psychiatric Research Center, University of Maryland School of Medicine; 4. Departments of Medicine and Physiology, University of Maryland School of Medicine

Abstract Type: Original Research. Background: Patients with schizophrenia have a shorter life span and are twice as likely to die from cardiovascular disease than the general population. Clozapine is the treatment of choice for refractory schizophrenia and has been associated with tachycardia and elevated blood pressure in a few reports. Objectives: To examine the effects of CLZ treatment on blood pressure and heart rate. Methods: This was a retrospective chart review of patients with a DSM-IV diagnosis of Schizophrenia or Schizoaffective disorder initiated on clozapine and treated > 4 months on an inpatient research unit in the past 4 years. Patients were 18 to 75 years old. Primary outcomes were systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse (P) measured 12 weeks before and 24 weeks during clozapine treatment. Demographics, smoking status, and clozapine dose were collected. Results: There were 18 patient records included in this study. They included 11 males, 10 Caucasians, and 12 smokers with a mean age of 36.38 years (SD 12.54 (range 20-56)). Two participants had hypertension before study start. Mean stabilized clozapine dose was 441.67 (SD 171.8) mg. Mean SBP/DBP, P before clozapine 124.8 (SD 12.03)/80.61 (SD 9.93) mm Hg, 90.85 (SD 13.01) bpm and 127.9 (SD 12.17)/83.31 (SD 8.31) mm Hg, 98.38 (SD 11.31) bpm during clozapine. DBP (p = 0.0486) and P (p<0.0001) were significantly higher after clozapine initiation. A trend was noted for SBP (p = 0.0716) increase after initiation. There were no significant differences before and during clozapine in BUN (p = 0.7720), SCr (p = 0.3780), GFR (p = 0.9761), or weight (p = 0.1124). To our knowledge none of these patients had cardiomyopathy. Conclusions: The data suggests clozapine may be associated with a rise in DBP and pulse and possibly SBP. The results of this study align with previous studies that found an increase in SBP/DBP regardless of clozapine dose and that the increase occurred early on in treatment. Due to the high risk of cardiovascular morbidity and mortality in this population more work is needed to determine risk factors and evaluate if patients are at risk for hypertension or tachycardia and understand the mechanism of action that may cause this side effect.

All parties are affiliated with the Southern Illinois University Edwardsville School of Pharmacy, Edwardsville, IL

Abstract Type: Original Research. Introduction: Identification and treatment of addiction remains challenging for the healthcare system. Standard training in pharmacy school may not be sufficient to prepare pharmacists to prevent, identify, and treat addiction. The purpose of this study is to measure the impact of an addiction course on pharmacy students’ knowledge of substances of abuse and treatments. Methods: A 19-question electronic survey was disseminated to current pharmacy students at Southern Illinois University Edwardsville School of Pharmacy. The survey included 4 demographic questions, 4 questions rating confidence on issues in addiction, and 11 fill-in knowledge questions. Group 1 had not completed a psychiatric therapeutics course. Group 2 had completed a psychiatric therapeutics course but not an addiction course. Group 3 completed both courses. Surveys less than 50% complete were excluded. For all knowledge questions, percent correct for each participant was calculated. One-way ANOVA was used to compare all groups. T-tests were used for comparing groups to determine the differences in addiction knowledge. Results: Seventy-two students completed the survey (response rate = 23%); 44 were included in the analysis (Group 1 = 29; Group 2 = 14; Group 3 = 1). Students rated confidence on knowledge of drugs of abuse (scale of 0-5) with averages: Group 1 = 3.8 (SD = 1.2), Group 2 = 3.5 (SD = 1.0), Group 3 = 4; confidence in referring for treatment with averages: Group 1 = 2.8 (SD = 1.4), Group 2 = 3.1 (SD = 1.2), Group 3 = 4. Average correct answer percentages for the knowledge questions: Group 1 = 34% (SD = 19), Group 2 = 48% (SD = 16), and Group 3 = 43%. A one-way ANOVA test found a P-value of 0.07 for all groups, but is confounded by the small sample size. A t-test indicated a statistically significant difference in knowledge after psychiatric therapeutics. Discussion: Additional addiction education in the curriculum is needed to ensure pharmacists’ competency. Students overestimated abilities with high confidence ratings but low knowledge scores. Although knowledge increased after psychiatric therapeutics, proficiency was below 50%. Most common knowledge deficits were noted for common administration of cocaine and in resources for addicted pharmacists. Incorporating resources for addicted pharmacists in required courses is a specific area for improvement. Future studies with larger sample sizes from different schools of pharmacy would validate these results.

1. University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences; 2. Kaiser Permanente Colorado

Abstract Type: Original Research. Purpose: Lithium is the most effective long-term treatment for Bipolar Disorder; however its use is limited by the risk of toxicity. Despite several known risk factors for lithium toxicity, little is known about factors predicting hospitalization for lithium toxicity or prevalence of lithium toxicity. This study identified risk factors for utilizing acute care services (ACS) (hospitalization, emergency department or urgent care visit) and calculated the prevalence of ACS use for lithium toxicity in a large, ambulatory population. Methods: This is a nested case-control study comparing characteristics of lithium users requiring ACS for lithium toxicity (cases) to lithium users who did not utilize ACS for lithium toxicity (controls). Patients were identified using Kaiser Permanente Colorado (KPCO) databases. Inclusion criteria included purchase of ≥ one prescription for lithium between January 1, 2010 and December 31, 2014. Controls were matched to case patients 1:5 based on date of lithium purchase. Lithium toxicity was defined as a lithium level ≥ 1.5 mEq/L, ICD-9 code for lithium toxicity, or toxic clinical presentation based on standardized symptoms and agreement of two independent investigators. The primary outcome was characteristics (duration of lithium use, age, drug-drug interactions (DDIs), gender, chronic disease score (CDS), estimated glomerular filtration rate (eGFR), or total daily lithium dose (TDLD)) associated with use of ACS for lithium toxicity. Multivariate logistic regression analysis was performed to identify these characteristics. The secondary outcome was prevalence of ACS utilization for lithium toxicity. Results: A total of 70 patients utilized ACS for lithium toxicity out of 3,115 individuals with exposure to lithium, for a prevalence of 2.2%. Identified risk factors include age [OR 1.035 (95% CI 1.007-1.064)], newly initiated DDIs [OR 12.672 (95% CI 1.172-137.002)], high CDS [OR 1.115 (95% CI 1.006-1.236], low eGFR [OR 0.975 (95% CI 0.952-0.999)], and increasing TDLD [OR 1.001 (95% CI 1.000 – 1.001)]. Conclusions and Future Directions: Results from this study confirm that previously identified risk factors for lithium toxicity, age and use of interacting medications, are also risk factors for utilization of ACS for lithium toxicity. Clinicians should use extra caution when managing lithium-treated patients at higher risk for serious toxicity.

1. University of California, San Diego (UCSD) Skaggs School of Pharmacy and Pharmaceutical Sciences; 2. University of California San Diego (UCSD) Health System, Pharmacy Department

Abstract Type: Original Research. Introduction: In 2005, the FDA mandated manufacturers of atypical antipsychotics to include a Black Box Warning (BBW) to indicate that these medications are associated with an increased risk of death when used in elderly patients with dementia. This warning was extended to conventional antipsychotics in 2008. Despite the BBW, hospitalized geriatric patients are prescribed antipsychotics for off-label indications. The primary objective of this study is to compare prescribing of antipsychotics for off-label indications in hospitalized geriatric patients admitted to Senior Behavioral Health (SBH) and adult Intensive Care Units (ICU) within University of California, San Diego Health System. Secondary objectives include comparison of the co-prescription of Beer’s Criteria medications with antipsychotics Design: We retrospectively reviewed patient encounters from July 2012 to June 2014 who received at least one antipsychotic for an off-label indication. Patients were included if they were ≥65 years old, and admitted to either SBH or ICU. There were 93 case patients (ICU) and 93 control patients (SBH) randomly selected. Results: Patient demographics for the encounters in SBH versus ICU were similar with the exception of sex, age, and race. The most common off-label indications in SBH were agitation, psychosis and sleep (91%, 29%, 19%). The most common off-label indications in ICU were agitation, delirium, and unknown (86%, 39%, 17%). The percentage of encounters discharged with an antipsychotic was 93% in SBH, of which 41% were new starts, and 50% in ICU, of which 76% were new starts. The most common discharge neuropsychiatric diagnosis was dementia in SBH (68.8%) and delirium in ICU (22.6%). Co-prescription of at least one medication fitting Beer’s criteria was 53.8% in SBH and 78.5% in ICU (p<0.001). Conclusion: Our study found that agitation was the most common indication for off-label prescribing of antipsychotics in SBH and ICU with risperidone being used most frequently in both patient populations. There were numerous new starts on antipsychotics during hospitalization, as well as continued upon discharge. Based on these results, we recommend establishing a protocol for non-pharmacological strategies for delirium prior to initiating antipsychotics, and continuous monitoring in attempt to discontinue antipsychotics prior to discharge if reasonable.

Both parties are affiliated with Oregon State Hospital

Abstract Type: Original Research. Purpose: The purpose of this chart review was to compare recidivism rates of different antipsychotic drug categories to oral monotherapy in order to assess optimal drug therapy for the patient population served at a state hospital in Oregon. Methods: Charts were reviewed for patients discharged between 10/20/11 and 9/23/15 with a diagnosis of schizophrenia, schizoaffective, schizophreniform, psychotic disorder, delusional disorder, bipolar disorder, or mood disorder NOS. Records of admission dates, discharge dates, and discharge antipsychotics were reviewed for each patient back to 1991. Discharge antipsychotics were categorized and compared with oral monotherapy for average days until readmission and percentage of discharges not yet readmitted. The primary endpoint compared recidivism data of long acting injection (LAI) with oral monotherapy within one, three, and five years of discharge. Secondary endpoints compared recidivism data for other drug categories including oral polypharmacy and clozapine monotherapy within one, three, and five years of discharge. Results: A total of 1088 patients were reviewed resulting in 2129 discharges associated with antipsychotic agents. Of these, 1341 patients were readmitted to a publicly funded facility in Oregon, leaving 788 discharges not yet readmitted. The average days to readmission was similar for LAI and oral monotherapy within one year of discharge, but LAI had a 78 and 85 day advantage over oral monotherapy for three and five year data. The percentage of patients not yet readmitted was 6.7% better for long acting injections than oral monotherapy. Oral polypharmacy had similar or better average days to readmission than oral monotherapy, and clozapine monotherapy tended to have a worse average. Clozapine monotherapy had the highest percentage of patients not yet readmitted at 46%. Statistical analysis in progress. Conclusions and Future Directions: From this review, it appears that LAI consistently have better recidivism outcomes than oral monotherapy for the patient population served at Oregon State Hospital. These findings are consistent with current literature and support continued or increased utilization of these drugs. Performing more chart reviews to analyze recidivism rates between different drug categories in other hospitals or patient populations would clarify the validity of this data.

1. St. John’s University College of Pharmacy and Health Sciences, Department of Clinical Health Professions; 2. Zucker Hillside Hospital, Department of Pharmacy

Abstract Type: Original Research. Title: Comparison of rehospitalization rates after receiving paliperidone palmitate versus long-acting injectable risperidone in patients with schizophrenia Background: Medication nonadherence is a strong predictor of risk of readmission to inpatient psychiatric treatment in patients with schizophrenia. Paliperidone palmitate and long-acting injectable risperidone are two second-generation antipsychotics used to mitigate the risk of relapse from medication nonadherence in patients with schizophrenia. To date, there are no head-to-head trials comparing rehospitalization rates between the two. Objective: To evaluate the influence of paliperidone palmitate compared to long-acting risperidone on relapse rates in patients with schizophrenia. Methods: This retrospective analysis will evaluate 100 patients with a diagnosis of schizophrenia, discharged from an inpatient psychiatric facility, who received paliperidone palmitate or long-acting injectable risperidone LAI between January 1, 2013 and March 1, 2016. Patients with a prior history of long-acting injectable use will be excluded. The primary endpoint of this study is rehospitalization rates of paliperidone palmitate compared to long-acting injectable risperidone. Secondary endpoints will include Brief Psychiatric Rating Scale (BPRS) scores on discharge, adverse events, and the number of emergency room and hospital visits post-discharge. Descriptive statistics, student’s t-test, and chi-square analysis will be performed to evaluate the primary and secondary endpoints. Outcomes: The primary outcome of this study is rehospitalization rates among patients with schizophrenia receiving paliperidone palmitate compared to long-acting injectable risperidone. Secondary outcomes will aim to characterize prescribing patterns, assess adverse effects, and determine the time-to-relapse for each group.

All parties are affiliated with University of California at San Diego Health

Abstract Type: Original Research. Purpose: Several recent randomized controlled trials have shown rapid efficacy of intravenous (IV) low-dose (0.5 mg/kg) ketamine infusions for patients with treatment refractory depression (TRD). However, because these studies excluded patients with certain comorbid psychiatric conditions, suicide risk, and concomitant psychotropic medications, the extent to which the results generalize to a more typical TRD population is not known. To address this, we investigated the efficacy and safety of IV ketamine used to treat TRD in a naturalistic outpatient clinical context. Methods: A retrospective chart review of the first 51 TRD patients treated with low-dose IV ketamine at UC San Diego was conducted. Charts of patients > 18 years old and containing a baseline, 1-hour, and 24-hour post infusion Beck Depression Inventory (BDI) scores were included. Demographic and clinical variables were analyzed with descriptive statistics. The primary outcome was reduction in BDI score from baseline to 24-hours post-infusion determined by a paired t-test. Secondary outcomes included reduction in BDI 1-hour post-infusion, response (> 50% reduction in BDI score) and remission (BDI score ≤11) at 24 hours. Results: A total of 51 charts were reviewed yielding 41 meeting inclusion criteria. Mean age was 48.6 ± 12.7 years, 78% white, and 36.6% female. All patients had a diagnosis of major depressive disorder (n = 34) or bipolar disorder (n = 7) and had failed multiple antidepressants. Some had failed ECT (26.8%) or rTMS (24.4%). Significant psychiatric comorbidity existed in 73.1% of patients, with anxiety being most prevalent (58.5%). Concomitant medications included antidepressants (51.2%), antipsychotics (29.3%), mood stabilizers (19.5%), stimulants (26.8%), benzodiazepines (41.5%) and hypnotics (17.1%). Average baseline BDI score was 32.6 ± 8.43. BDI scores decreased by 15.9 ± 12.3 (p < 0.001) and 16.6 ± 14.4 (p < 0.001) at 1-hour and 24-hours post-infusion, respectively. There was a 53.7% response rate and a 36.6% remission rate at 24-hours. Ketamine induced a modest, transient blood pressure elevation. Two patients required an antiemetic for nausea and one patient required lorazepam for anxiety. Conclusions: Ketamine administered in a naturalistic treatment setting was effective and well tolerated for TRD in patients with various psychiatric medications and comorbidities.

1. Michael E. DeBakey Veterans Affair Medical Center; 2. Texas Southern University College of Pharmacy & Health Sciences; 3. Baylor College of Medicine, Department of Psychiatry & Behavioral Sciences

Abstract Type: Original Research. Background: Long-acting injectable (LAI) antipsychotic agents, such as paliperidone palmitate (Invega^® Sustenna^®), have become an important treatment option in reducing hospitalizations and relapse prevention in schizophrenia-spectrum disorders. Despite having similar tolerability and safety profiles between injection sites, current literature has suggested that there can be differences in median plasma concentrations based upon the site of administration of some of the LAI. This study will analyze the effects of varying paliperidone palmitate administration patterns on patient clinical outcomes. Methods: Retrospective data was reviewed from 34 patients admitted to a Veteran’s Affairs Hospital who were administered paliperidone palmitate between August 1, 2014 and August 31, 2015 using the computerized recordkeeping system (CPRS). Patients who received doses of paliperidone palmitate during the evaluation period were identified as potential candidates for study inclusion. Patients excluded from the study included those who were not diagnosed with a psychotic or mood spectrum disorder at initiation of therapy or patients who received maintenance doses of paliperidone palmitate during the admission. Data was reviewed using pharmacy records, laboratory data, physician progress notes, and medication administration logs. Data was analyzed using descriptive and inferential statistics. Results: Of the 34 patients reviewed, 24 were included in the final data analysis. Readmission rates to inpatient psychiatry units were similar between patients who received both intramuscular loading doses in the deltoid (20%) compared to patients who received loading doses in a combination of the deltoid or gluteal areas (36%) [X2 = 0.69, n = 24, p < 0.40]. The duration of treatment was also similar between patients who received both doses in the deltoid and the patients who received a combination of deltoid and gluteal administrations (80 days vs. 77 days, respectively). Conclusions: Higher proportion of patients who received their loading doses of paliperidone palmitate injection in a combination either the deltoid or gluteal areas had higher readmission rates, however this was found not to be statistically significant. Hospital readmission rates and length of treatment appear to not be affected by the site of administration, either deltoid or gluteal, for paliperidone palmitate loading doses.

Both parties are affiliated with University of North Carolina Hospitals

Abstract Type: Original Research. Purpose: Neonatal abstinence syndrome (NAS) is a serious withdrawal condition that may occur in neonates born to women who have consumed opioids while pregnant. Medications for opioid detoxification and medication assisted treatment (MAT), such as methadone, buprenorphine (B), and buprenorphine/naloxone (B/N), can also result in NAS. The historically preferred MAT drug in pregnancy is methadone; however buprenorphine is rapidly gaining favor due to a less severe NAS profile. Traditionally B is preferred over B/N, as there is less in utero safety data for naloxone. No direct-comparison studies between these two medications have been reported. This study aims to evaluate differences in neonatal and maternal outcomes between B vs. B/N. Methods: Thirty six pregnant women age 18-45 with documented use of B or B/N during pregnancy and at least one dose administered inpatient prior to delivery were identified through retrospective chart review. Patients with multiparity were excluded. Fetal and maternal outcomes between B (n = 4) and B/N (n = 32) groups were evaluated using Fisher’s Exact testing and Student’s T testing. Results: Primary outcome: no statistically significant difference in incidence of NAS treatment between neonates exposed to B and B/N was detected (p = 0.125). Secondary outcomes: statistically significant difference was observed for APGAR score at 5 minutes (B = 8, B/N = 8.8, p = 0.027). No statistically significant differences were observed for APGAR score at 1 minute, head circumference, duration of NAS treatment, or duration of hospital stay. There were no statistically significant differences among maternal outcomes between B and B/N groups. Outcomes evaluated include preeclampsia/gestational hypertension, premature labor, and emergent cesarean section. No maternal or fetal/neonatal mortality was observed. Conclusions and Future Directions: No clinically significant differences in neonatal or maternal outcomes were observed between B and B/N. Although a statistically significant difference for APGAR scores at 5 minutes was observed, the absolute difference is less than one point and therefore deemed not clinically relevant. Continued monitoring of these trends is recommended as the study did not reach power to evaluate lack of difference. However, the results of this study suggest buprenorphine and buprenorphine/naloxone have comparable safety in pregnancy.

1. University of California San Francisco School of Pharmacy; 2. San Francisco Department of Public Health Behavioral Health Services

Abstract Type: Original Research. Background: Anxiety and insomnia are common and often chronic disorders. Sedative-hypnotics were the mainstay of treatment for anxiety disorders for many years; however, they are no longer considered first-line treatment due to the availability of safer medications. The sedative-hypnotic medications have been shown to increase morbidity and mortality. Patients taking sedative-hypnotics are 4.5 times more likely to die of any cause compared to those not taking a sedative-hypnotic. In addition to mortality risks, chronic sedative-hypnotic use is associated with memory impairment, decreased cognitive functioning, and increased risk of falls and fractures in the elderly. The risk of motor vehicle accidents is increased by 40-60% with sedative-hypnotic use. Taking into consideration these risks, the San Francisco Department of Public Health Behavioral Health Services (SFDPH BHS) implemented a multi-modal intervention (i.e., provider and patient education, guidelines, and prescription monitoring) in order to decrease chronic sedative-hypnotic prescriptions. Purpose: This study aims to evaluate the impact of the implementation of a multi-modal intervention on outpatient prescribing patterns of sedative-hypnotic medications in the SFDPH BHS. Methods: This is a retrospective cohort study of all patients ≥18 years of age receiving medication-related services between October 2013 and December 2015. The primary outcome is the change in frequency of chronic outpatient prescriptions for sedative-hypnotics in the 3 month pre-intervention period compared to the 3 month periods at 12 and 24 months post-multimodal intervention. The data will be extracted from the SFDPH BHS electronic prescribing record. Various demographic factors will be analyzed for association with the primary outcome. The change in prescribing frequency will be analyzed using the Chi-squared test. The descriptive statistics will be calculated using proportions, means or medians, and interquartile ranges as appropriate. Preliminary Results: A total of 11,512 and 11,003 patients received a medication-related service in the pre- and 12 month post-intervention periods, respectively. Of these, 1,829 (15.89%) and 1,716 (15.60%) received a chronic prescription for sedative-hypnotics in the pre- and 12 month post- intervention periods, respectively. Data for the 24 month post-intervention period, secondary endpoints and analysis are pending and final results will be presented at the conference.

Author affiliated with The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division; University of Texas Health Science Center San Antonio, Pharmacotherapy Education and Research Center; and Texas Department of State Health Services, San Antonio State Hospital, Pharmacy Department

Abstract Type: Original Research. Background: The pharmacology of psychotropic medications includes several dimensions of clinical importance. Two of these are receptor binding affinity and functional activity. The binding affinity for an agonist is described by the dissociation constant (KA) and an antagonist by the inhibition constant (Ki). Functionally, psychotropics can act as agonists, partial agonists, antagonists, inverse agonists, or partial inverse agonists at several receptor sites, transporters, or ion channels. Comprehending the differences between agents is difficult due to complexity created by the number and types of binding sites. Attempts to improve comprehension of psychotropic pharmacology by clinicians have resulted in limited success. Some of these include quantitative concentration versus binding coefficient non-linear regression graphs, proportional binding pie charts, or semi-quantitative qualitative cartoons. All of these have difficulty incorporating both function and binding affinity in a clinically meaningful way. Methods: Binding data are obtained from primary literature, product labels, human cloned receptor binding in PDSP <http://pdsp.med.unc.edu/pdsp.php>, and other sources. Functional data are obtained from primary literature where available. Binding affinity data are converted into ratios relative to the putative primary receptor for that category of agent. For example, antipsychotic binding is referenced to dopamine D2L receptor binding. Binding affinity ratios are used to generate a nominally six-spoked diagram with the center being D2L and the spokes the most avidly bound sites. Binding affinity is displayed as a circle with the diameter determined by the binding ratio. Where functional data are available, they are shown as a pie chart for each binding site’s circle. This system permits the full range of both binding affinity and function to be displayed for the most clinically significant sites. Results: Binding and function diagrams are shown for a variety of psychotropic agents and compared to previous attempts to demonstrate pharmacological comparisons of psychotropics. Discussion: Use of graphic models of psychotropic pharmacology improve clinician comprehension and may serve as an aid to improve rational therapeutics and patient outcomes.

All parties are affiliated with Baptist Medical Center, Jacksonville, Florida

Abstract Type: Original Research. Purpose: Following publication of the Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium (PAD), Baptist Health formed a multidisciplinary task force, the Delirium Management Initiative (DMI). The DMI implemented routine delirium monitoring using the CAM-ICU, created a delirium order set to be utilized in CAM-ICU positive patients, and increased awareness of deliriogenic medications at Baptist Medical Center Jacksonville. The purpose of this study is to determine if the implementation of a multidisciplinary task force dedicated to early delirium detection decreased benzodiazepine utilization in medical surgical critical care patients. Methods: A retrospective chart review was conducted on all adult patients admitted to the medical surgical intensive care unit ≥ 24 hours at Baptist Medical Center Jacksonville from April 2012 to October 2012, pre implementation of the DMI, and from April 2014 to October 2014, post implementation of the DMI. Information collected includes patient demographics, admitting diagnosis, date of admission and discharge, ICU length of stay (secondary endpoint), CAM-ICU status (post DMI group only), and total number of doses of temazepam and lorazepam (primary endpoint), promethazine (secondary endpoint), and diphenhydramine (secondary endpoint). Results: A total of 290 patients in the 2012 arm and 320 patients in the 2014 arm were identified for high risk medication utilization review. After inclusion and exclusion criteria were met, a total of 603 temazepam and lorazepam doses were administered in 2012 and a total of 357 temazepam and lorazepam doses were administered in 2014. However, when the mean number of benzodiazepine doses administered per patient day in the pre and post groups were compared (0.4 vs. 0.29, respectively), this reduction was not found to be statistically significant (p-value = 0.23). Furthermore, none of the secondary outcomes were found to be statistically significant. Conclusions: Overall, the Delirium Management Initiative, a multidisciplinary taskforce detected to early delirium detection, had a positive impact on decreasing benzodiazepine utilization in the intensive care unit through increasing awareness of deliriogenic medications.

1. University of Iowa College of Public Health, Department of Epidemiology; 2. Iowa Geriatric Education Center; 3. Sun Valley Behavioral Health

Abstract Type: Original Research. Purpose: Behavioral and psychological symptoms of dementia (BPSD) pose challenges to healthcare providers and family caregivers. Antipsychotics have long been used to manage these symptoms, but have significant risks. Previously, a team at the University of Iowa and collaborators had developed a training program and toolkit to promote a stepwise approach to management of BPSD and improve the appropriateness of antipsychotic use in dementia. This team received requests for a Spanish language version. Persons of Hispanic or Latino origin comprised approximately 16% of the U.S. population in 2010. In 2006 an estimated 40% were immigrants, predominantly from Mexico. Approximately 3.9% of certified nursing assistants (CNAs) report Spanish as a primary language, which extrapolates to approximately 27,000 CNAs in nursing homes and more in home care settings. Given the apparent need, we developed a Spanish translation of the training and toolkit. Methods: All lectures and resources were translated into Spanish. All translations were reviewed by a Spanish-speaking psychiatrist practicing in the U.S. and Mexico (Dr. Ng). Spanish-speaking dementia care and nursing home providers reviewed translated clinical decision aids and provided feedback via focus groups and surveys. Guides were revised in accordance with feedback. A shared decision-making guide on antipsychotic use for consumers was reviewed by Spanish-speaking patients via focus groups. Results: The training program and toolkit include: a series of brief case-based lectures on the stepwise approach to BPSD management targeting healthcare providers and consumers; clinical decision aids on management of BPSD available as laminated guides, printable documents, and a mobile device application; and three evidence reviews covering assessment and non-pharmacologic management of BPSD, drug therapy for BPSD, and assessment and management of delirium. Conclusions and Future Directions: Both the English and Spanish versions of these products are currently available free to any healthcare provider in the United States. A targeted mailing to all nursing homes in Texas is promoting the use of these products, as will outreach by the Texas A&M Agrilife Extension Service. The uptake of the Spanish language version will be evaluated to determine language preferences of providers reached by these dissemination efforts in Texas.

1. Rutgers University Ernest Mario School of Pharmacy; 2. Monmouth Medical Center, Department of Pharmacy; 3. Jersey City Medical Center, Department of Pharmacy

Abstract Type: Original Research. Purpose: Lurasidone is a second generation antipsychotic (SGA) with a relatively lower risk of weight gain and metabolic side effects. Lurasidone does not have any FDA-approved indications for use in children or adolescents. The purpose of this study is to evaluate the efficacy and tolerability of lurasidone in the child and adolescent psychiatric population at a single, psychiatric facility. Methods: This IRB approved study was a retrospective chart review of patients aged 5-17 years old admitted to the child crisis and intervention service at Monmouth Medical Center between July 1st 2013 and July 1st 2015 who received at least one dose of lurasidone during their stay. Data collection included patient demographics, course of hospital stay, indication for treatment, dose of lurasidone, documented improvement in symptoms, PRN medication use, adverse events, laboratory values, vital signs and changes in baseline weight, blood glucose or lipid panel. Data collected was obtained from the institution’s electronic medical record. Descriptive statistics were used for data analysis. Results: A total of 56 patients were included in the analysis. The mean age of the patients was 14 years. Roughly two thirds (67.9%) of patients were female, and 76.8% were white. Indications for use of lurasidone included: mood stabilization (75%), mood stabilization and psychosis (10.7%), psychosis (8.9%), hallucinations (3.6%), and delusions (1.8%). The average starting dose of lurasidone was 32.8mg while the average ending dose was 53.2mg. Ten out of 56 patients (17.9%) discontinued lurasidone due to ineffectiveness, and 1 (1.8%) discontinued it due to intolerable side effects. In the 45 patients who found lurasidone effective, improvements in symptoms were seen an average of 4.1 days after initiating therapy. In terms of tolerability, 75% of patients experienced no adverse events while on lurasidone. The most common adverse effects were sedation (8 patients), fatigue (4 patients), and muscle stiffness (3 patients). Akathisia (2 patients) was the only form of EPS observed. Conclusion: Though efficacy is not clear, lurasidone has been shown to be generally well tolerated in the child and adolescent psychiatric population. The side effect profile appears similar to what is seen it the adult population.

1. Center for Behavioral Medicine, Kansas City, MO; 2. University of Missouri – Kansas City, School of Pharmacy, Kansas City, MO; 3. Truman Medical Center Behavioral Health (TMC-BH), Kansas City, MO

Abstract Type: Original Research. Background: Psychiatric patients often do not participate in and there is limited research evaluating patient preference for selection of medication for treatment of acute agitation. This study assessed patient preference and acceptability of medication formulations (tablet, orally-disintegrating-tablet [ODT], liquid, injection, inhaled device) for the treatment of acute agitation and examined correlating factors. Methods: Adults with psychotic illness or bipolar disorder receiving emergency or inpatient services at TMC-BH were included. Sociodemographic data was collected. Participants viewed a presentation on medication formulations for acute agitation and were surveyed on acceptability (measured on a five-point Likert scale). The primary outcome variable was the attitudinal measurement of acceptability of each formulation in correlation with the severity of agitation for use in themselves and others. Results: One hundred subjects completed the survey. Subjects rated the following: 1) this medication formulation would be acceptable to treat mild agitation in themselves and others (tablet 85% and 48%; ODT 82% and 55%; inhaled device 78% and 72%; liquid 74% and 51%; injection 53% and 74%) and 2) this medication formulation would be acceptable to treat severe agitation in themselves and others (inhaled device 77% and 72%; tablet 75% and 52%; ODT 74% and 53%; liquid 66% and 53%; injection 61% and 67%). For treating mild agitation, subjects preferred tablets and ODT to the injection (p<0.05) and the inhaled device to liquid or injections (p<0.05) for themselves and all oral formulations were preferred to the injection (p<0.05) for other patients. For severe agitation in themselves and others, preference was significant for the inhaled device and injection versus other formulations (p<0.05) with no difference between the inhaled device and injection (p = n.s.). For mild agitation, African American subjects were less likely to find an injection acceptable (p<0.037) and homeless subjects were 4.7 times more likely to utilize an injection (p<0.015). Bipolar patients were 5.8 times more likely to use an injection during severe agitation (p<0.001). Conclusion: Overall there was higher acceptability for medication formulations other than injection in mild agitation while injection and inhaled device were both acceptable for severe agitation.

1. Institute for Safe Medication Practices Canada; 2. Baycrest Health Sciences; 3. School of Pharmacy, University of Waterloo

Abstract Type: Original Research. Purpose: Medication incidents can lead to significant patient harm and increase the burden on the healthcare system. Antiepileptic drugs (AEDs) may be particularly prone to causing serious medication incidents. This study determined the severity of medication incidents identified with AED use, the types of medication incidents reported with AEDs, and associated contributing factors to medication incidents involving AEDs. Methods: Twelve years of AED medication incident data (Jan 2003–Mar 2015) from the Institute for Safe Medication Practices Canada Medication Incident Database (ISMPC MID) and six years of medication incident data (Nov 2008–Mar 2015) from the Canadian Institute for Health Information National System for Incident Reporting (CIHI NISR) database were extracted for qualitative multi-incident analysis. Data were limited to medication incidents that occurred in hospital for the following AED categories: anticonvulsants, barbiturates, benzodiazepines, carbonic anhydrase inhibitors, hydantoins, succamides and antiepileptics. Results: In total, 2,376 medication incidents (1,982 from ISMPC MID and 394 from CIHI NISR) were identified, of which 917 (838 from ISMPC MID and 79 from CIHI NISR) met inclusion criteria. Of eligible medication incidents from ISMPC MID, 23 (2.74%) resulted in reported harm and one (0.12%) in death; from the CIHI NISR database, 18 medication incidents resulted in adverse outcomes (22.8% in total, comprising mild, moderate, severe, death). Analysis of medication incidents involving AEDs revealed seven main themes: incorrect dose or frequency, dose omissions, incorrect drug given, incorrect patient, drug interactions, problematic intravenous administration, and therapeutic drug monitoring. These themes had several sub-themes (e.g., complex dosing regime, dispensing error, incorrect dose ordered on admission, incorrect drug, drug formulation mix-up, order entered under wrong patient’s name, among other themes) and associated contributing factors (e.g., variable doses for different time of day, requirement for dose titration, lack of systematic medication reconciliation, look-alike packaging and drug name, among other factors). Conclusions and Future Directions: Patients prescribed AEDs often require individualized dosing adjustments, complex dosing regimens and different doses at different times of the day, which increase the potential for error. Findings from this multi-incident analysis could augment local, provincial and national quality improvement initiatives to reduce significant medication incidents involving AEDs.

All parties are affiliated with the Lexington VA Medical Center

Abstract Type: Original Research. Background: There are varying dosing strategies for the administration of benzodiazepines (BZD) in the setting of alcohol withdrawal. In October 2014, a symptom – based alcohol withdrawal protocol (AWP) using the Clinical Institute Withdrawal Assessment of Alcohol, Revised (CIWA-Ar) scale was implemented at one institution. Objective: This study evaluated the safety and efficacy of the AWP. Methods: Retrospective chart review was completed, including patients receiving at least one dose of diazepam for alcohol withdrawal pre- and post-protocol. The primary outcome of this study was the average daily and cumulative dose of diazepam during hospital stay. Secondary outcomes include length of stay, and occurrence of seizures of delirium tremens. Results: The average daily dose and the average cumulative dose of diazepam were significantly lower in the post-protocol group (5.4 vs. 12.1mg, p < 0.001 and 35.0 vs. 77.6mg, p < 0.001, respectively). Length of stay was similar between groups (6.5 vs. 6.4 days, p = 0.91), however, duration of benzodiazepine use was decreased in the post-protocol group (2.2 vs. 4.7 days, p < 0.001). Despite using reduced doses of benzodiazepines, there was no increase in adverse events. Conclusions: The implementation of a symptom – based AWP using the CIWA – Ar scale was associated with a reduced average daily and cumulative dose of diazepam without any apparent safety issues.

1. South Texas Veterans Healthcare System, San Antonio, Texas; 2. University of Texas Health Science Center at San Antonio; 3. Center for Health Quality, Outcomes and Economic Research, Bedford, Massachusetts; 4. Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts

Abstract Type: Original Research. Background: Zolpidem prescribing has steadily increased despite consensus recommendations against its routine use based on emerging safety concerns. Potential adverse effects of zolpidem such as cognitive impairment, traffic accidents, fatal and non-fatal overdose may be especially problematic in population subgroups with complex comorbidities such as Iraq and Afghanistan war veterans (IAVs). Objectives: To describe patients’ characteristics associated with patterns of zolpidem prescribing in a national cohort of IAVs. Methods: This retrospective study included a national cohort of IAVs who received Veterans Health Administration (VHA) care annually in fiscal years 2012 and 2013. We identified individuals who were dispensed zolpidem from VHA and identified prolonged (>30 days) and high-dose (average daily dose >12.5 mg [extended-release formulation]; >10 mg [immediate release formulation]) zolpidem exposures in 2013. We identified baseline demographic and clinical characteristics in 2012, using ICD9-CM codes to identify comorbid conditions. We also identified medications received in 2013. Descriptive statistics and multivariable logistic regression analyses were used to identify variables associated with prolonged/high-dose zolpidem exposure. Results: Of 305,367 IAVs who received care in fiscal years 2012 and 2013, 30,367 were prescribed zolpidem. 77% (N = 23,527) had prolonged exposure while 1.6% (N = 479) received high-dose zolpidem. IAVs with prolonged zolpidem exposure were also more likely to have post-traumatic stress disorder (PTSD; odds ratio [OR] = 1.22; 95% confidence interval [CI] = 1.14,1.30), receive benzodiazepines (OR = 1.43; 95% CI = 1.34,1.53), stimulants (OR = 1.47; 95% CI = 1.30,1.67), or opioids (OR = 1.39; 95% CI = 1.30, 1.48). High-dose zolpidem was associated with PTSD (OR = 2.88; 95% CI = 2.07,4.01), substance use disorder (OR = 1.30; 95% CI = 1.07,1.59), benzodiazepine use (OR = 1.58; 95% CI = 1.30,1.92) and opioid use (OR = 1.31; 95% CI = 1.08,1.59); women had lower odds of high-dose zolpidem exposure than men (OR = 0.69; 95% CI = 0.50,0.96) which is concordant with the latest U.S. Food and Drug Administration warning. Conclusions: This novel analysis of national data from IAVs revealed that nearly 80% of those who received zolpidem had prolonged duration. IAVs with PTSD, opioid and/or benzodiazepine use appear to be at significant risk for both prolonged duration and high-dose zolpidem exposure. The association of substance use disorder and high-dose zolpidem may reflect continued drug-seeking behavior/tolerance. Longitudinal research is required to understand causality in these associations.

1. Samford University McWhorter School of Pharmacy; 2. Samford University Brock School of Business

Abstract Type: Original Research. Background: Prescription drug abuse is a serious problem in the U.S. Pharmacists should be knowledgeable about controlled substances and addiction, and they should have a positive attitude toward their role as healthcare providers in monitoring for prescription drug abuse. Moreover, they should be actively involved in contacting prescribers, counseling patients, and referring patients for addiction treatment. Objectives: To determine the attitudes, behaviors, and perceived knowledge of pharmacists concerning prescription drug abuse. Methods: A voluntary, anonymous survey was offered to pharmacists who attended a large end-of-year continuing education program sponsored by a school of pharmacy. The 26-item survey that was used in the study was adapted from a survey instrument that was previously pilot tested and used in a published study. The research was approved by the university’s Institutional Review Board, and the investigators obtained permission from the authors of the published study to use the survey instrument. Results: The survey was completed by 130 of 150 (87%) pharmacists, who practiced primarily in community (60%) and hospital (19%) settings. Pharmacists were more likely to rate themselves as having much or very much knowledge in pain management/opiates (49%) and ADHD/stimulants (44%) vs. the disease process of addiction (34%) or brain chemistry as relates to addiction (20%). Forty-four percent of pharmacists felt that their job was much or very much affected by patients’ substance abuse, yet most pharmacists reported little or very little activity as relates to contacting physicians about potential substance abuse issues (50%) or counseling patients about substance abuse issues (61%). Interestingly, 34% of pharmacists admitted to having never contacted a physician about possible substance abuse by a patient. Only 20% of pharmacists felt comfortable or very comfortable referring patients to addiction treatment. Many pharmacists perceived their role in monitoring therapy with controlled substances as either more like the police (18%) or equal amounts of policing and providing healthcare (47%). Conclusions: Pharmacists appear to lack the knowledge and comfort level to deal with prescription drug abuse, and their self-reported interventions in such cases are disappointingly low. Additional training of pharmacists in the area of substance abuse appears to be warranted.

1. Tennessee Valley Veterans Affairs Healthcare System; 2. Sullivan University College of Pharmacy

Abstract Type: Original Research. Purpose: Didactic instruction often occurs through lecture, audio-visual presentations and is textbook based. In order to appeal to multiple learning styles, a mental health elective course used various teaching methods to 1) disrupt the typical classroom setting and 2) decrease stigma by enhancing student and faculty exposure to mental health disorders. Methods: In addition to other coursework, 14 students enrolled in the mental health elective were required to attend a Depression and Bipolar Support Alliance (DBSA) peer-run support group and submit a written report and mixed media poster to showcase their reflection. The posters (artwork) were displayed around the college and the images were emailed to students, faculty and staff to spark discussion on mental health. In addition, a social media page entitled “STOPStigma” was created for the class (also open to the public) to promote awareness; participation was optional. A feedback form utilized for the course assessed students’ perceptions about the class activities including the social media opportunity and the DBSA group. Surveys were administered to students (n = 14 in the elective and 149 non-elective students) and faculty (n = 37) to evaluate perspectives of the artwork project. Results: Thirteen (92.9%) elective students completed the feedback form and six (42.9%) actively participated in the “STOPStigma” page (81 “likes” to date). The majority of students had a positive response about social media and agree the DBSA group and reflection assignments should be continued in future years. There was a 31.5% (n = 200) overall response rate from the surveys sent out to all students and faculty. Most respondents strongly agreed/agreed that art projects are a good way to raise awareness on health topics (74.6%), are a useful tool for reflection (79.4%) and are an innovative teaching style (65.1%). Comments included being “more sensitive to those suffering from mental illness” and an increased “understand[ing]…after hearing some of their stories.” Conclusions: It can be difficult to create new avenues of learning for students and to address stigma associated with mental health disorders. Incorporating real patient experiences, unique tools for reflection, and social media into the classroom provided for open and positive expressions from students and faculty alike.

1. Texas Tech University Health Sciences Center, School of Pharmacy; 2. VA North Texas Healthcare System

Abstract Type: Original Research. Background: Antipsychotics are often used to treat behavioral and psychological symptoms of dementia (BPSD) and have shown to have moderate treatment effects. However, antipsychotics are also associated with many adverse effects and a higher risk of mortality in dementia patients. Studies exist demonstrating selective serotonin reuptake inhibitors (SSRI) are effective in treating BPSD. A few head to head studies have even shown similar efficacy to antipsychotics. Objectives: The objective was to evaluate the prevalence of antipsychotic discontinuation 6 months after SSRI initiation for the treatment of BPSD. Secondary objectives included (1) rates of antipsychotic dose reductions at 6 months after an SSRI was initiated, (3) evaluating whether a specific type of SSRI was correlated with antipsychotic discontinuation, and (4) evaluating the tolerability of SSRI therapy. Methods: Patients diagnosed with Alzheimer’s dementia, prescribed an antipsychotic, and later prescribed an SSRI for BPSD during January 1, 2009 through December 30, 2014 were studied. Exclusion criteria included (1) a diagnosis of another dementia besides Alzheimer’s dementia, (2) prescribed scheduled benzodiazepines, mood stabilizers, or non-SSRI antidepressants during the study period, (3) diagnoses of bipolar disorder or psychotic disorders, and (4) diagnosis of delirium during the study period. Patients’ age, gender, race and FAST scores were collected at baseline. The names, doses, and stop dates of SSRIs and antipsychotics were recorded at baseline and for months 1, 3 and 6. Results: Two-hundred six dementia patients prescribed an SSRI after being prescribed an antipsychotic were identified. After reviewing patients for exclusion criteria, 36 subjects were included in the study. Ten patients (27.8%) had their antipsychotic discontinued or stopped taking their antipsychotic by 6 months after SSRI therapy was initiated. One additional patient was able to decrease his dose of the antipsychotic. For these 11 patients that were considered “responders”, 8 (72%) were prescribed citalopram (mean dose = 20mg/day), while 72% of the “non-responders” were prescribed sertraline (p = 0.026). Conclusions: Approximately 28% of patients prescribed antipsychotics for BPSD were able to discontinue therapy at least 6 months after starting an SSRI. Our study found that citalopram was associated with a positive response compared to sertraline.

1. UC San Diego Skaggs School of Pharmacy & Pharmaceutical Sciences; 2. University of California San Diego Department of Psychiatry; 3. VISN 22 Mental Illness Research, Education, and Clinical Center

Abstract Type: Original Research. Background: Bipolar Disorder (BD) patients have regional structural and functional brain abnormalities. This study examined the relationship between use of psychotropic medications, including lithium, and the functional response of select regions of interest during an N-back working memory task. The results of this study have implications for selecting the most beneficial treatment from among common psychotropic medications, as well as dosing regimens where neuroprotective effects are more apparent. Objectives: To examine the relationship between use of psychotropic medications and the corresponding medication load on the functional response of select ROI’s during an N-back working memory task in patients with BDI. Methods: This was a retrospective cross-sectional study with a total of 30 bipolar patients who underwent functional magnetic resonance imaging during an N-back working memory task. The degree of 2-1 back activation during the N-back task was related to history of lithium use (ever vs never) with a univariate general linear model (GLM) with group as a factor and age as a covariate. In addition, current and lifetime medication loads were related to brain response while controlling for age using Pearson partial correlations. Results: All patients with BD were currently taking medication with 63% (19/30) taking mood stabilizers, 53% (16/30) taking antidepressants, 33% (10/30) taking antipsychotics, and 33% (10/30) taking anxiolytics. Of the six regions where each individual’s average 2-1 N-back score was examined, there was a significant difference between those who have ever taken lithium (n = 15) compared to those who have never taken lithium (n = 15) in the activation of the left inferior parietal lobule even after controlling for age (F = 4.52, p = 0.04). Dose of lithium and current and historical medication load across all psychotropics were not significantly related to brain response. Conclusion: Those who ever had lithium in their treatment regimen had more activation in the left inferior parietal lobule compared to those who never used lithium, with a tendency to be slightly faster and more accurate. While there was no relationship between dose of lithium and brain activation in our study, a study with a greater variability in lithium dose is needed to make comparisons to current treatment guidelines.

1. Janssen Scientific Affairs, LLC, Titusville, NJ; 2. In Silico Biosciences, Lexington, MA

Abstract Type: Original Research. Purpose: Clinicians may determine that schizophrenic or schizoaffective patients who are not responding optimally to their current antipsychotic treatment should be switched to paliperidone palmitate once-monthly (PP1M) injectable. Some switching scenarios are reflected in PP1M prescribing information, but the information provided is not exhaustive. Given differences in pharmacokinetic and pharmacological profiles of alternative prior treatments, questions about potential safety and efficacy effects of these scenarios arise. Such questions may be informed by simulation information. Methods: Evaluation of different medication-switching approaches customarily requires clinical trials testing. However, the multiplicity of considerations and the number of patients required to meaningfully address questions related to each concern makes such an approach unachievable. Quantitative systems pharmacology, a mechanism-based and clinically calibrated computer model for schizophrenia, was used to identify optimal switching scenarios from oral antipsychotics or injectable antipsychotics to PP1M. During the transition period from prior treatment to PP1M, both drugs are present in the same patient, leading to pharmacokinetic and, more importantly, pharmacodynamic drug-drug interactions that are based on nonlinear interactions at the level of neuronal circuits. The resulting challenge is to identify risks related to efficacy and side effects that might be expected in patients who are being switched to PP1M. Results: Different scenarios for switching from oral risperidone, haloperidol, olanzapine, aripiprazole, and long-acting injectables (LAIs; haloperidol decanoate and aripiprazole once-monthly) to PP1M have been simulated. Three basic switching approaches were evaluated based on prior knowledge of the patient’s toleration of paliperidone and whether the prior medication was oral or LAI. Simulations demonstrate risk:benefit profiles following switch from oral haloperidol, olanzapine, olanzapine or risperidone and from haloperidol decanoate and aripiprazole LAI to PP1M. The simulated profiles help identify when a nadir of overall efficacy, optimal efficacy, and steady state efficacy and safety might be expected during the transition to PP1M. Conclusions and Future Directions: Quantitative systems pharmacology simulations provide valuable insights into efficacy and side-effect risk:benefit considerations that can help guide clinician observations during switches to PP1M.

1. Marshall B. Ketchum University, College of Pharmacy; 2. Loma Linda University, Department of Neurology

Abstract Type: Original Research. Objective: The aim of this study was to review the published evidence for the efficacy, safety, and dosing practices of droxidopa treatment for symptomatic neurogenic orthostatic hypotension (nOH) in patients with parkinsonism. Background: Symptomatic nOH is a can be disabling disorder defined as a sustained blood pressure reduction on standing. The disorder results from postganglionic, noradrenergic impairment in Parkinson’s disease (PD) or from autonomic dysfunction in multiple system atrophy (MSA). Droxidopa (L-threo-3,4-dihydroxyphenylserine) is currently indicated for the management of symptomatic nOH . Methods: A systematic literature search (PubMed, Cochrane Library, EMBASE) was performed to identify published randomized controlled trials and other comparative clinical studies of droxidopa. Study methodology, patient, and treatment-level data were extracted and summarized using descriptive statistics. Each study underwent quality assessment for bias based on Cochrane metrics. Documentation of inclusion and exclusion processes are presented in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) format. Results: Of 1059 relevant articles identified, 72 were studies and 9 met the inclusion/exclusion and data extraction eligibility criteria. Five of the included studies were randomized controlled trials (RCTs). All RCTs fulfilled criteria for low risk reporting bias. Effective doses ranged between 300 mg to 500 mg tid. Droxidopa was effective in patients with PD and MSA with the majority of studies demonstrating significant benefits measured by reduction in Orthostatic Hypotension Questionnaire (OHQ) composite score and dizziness/lightheadedness score. In 7 of 9 studies, droxidopa was associated with significantly less blood pressure reduction after standing. Reported adverse events included falls, headache, dizziness, fatigue, and nausea. In the majority of studies, occurrence of supine hypertension was similar to placebo. Conclusion: Based on data extracted from 9 RCTs or prospective, open-label studies, a strong evidence base exists to support the use of droxidopa for the treatment nOH in parkinsonism.

1. Marshall B. Ketchum University, College of Pharmacy; 2. Loma Linda University, Department of Neurology

Abstract Type: Original Research. Objective: To conduct a systematic review to evaluate the efficacy, safety, and dosing range of quetiapine for the treatment for hallucinosis / psychosis in patients with PD. Background: Although quetiapine is considered a first-line pharmacological agent for the treatment hallucinosis / psychosis in PD, a systematic literature review of quetiapine for this condition has not been previously published. Methods: A systematic literature search (PubMed, Cochrane Library, and EMBASE) was performed to identify randomized controlled trials and other comparative clinical studies of quetiapine for treatment of hallucinosis / psychosis in PD (published between January 1991 and December 2015). Study methodology, patient- and treatment-level data were independently extracted and then summarized using descriptive statistics. Randomized and nonrandomized studies underwent quality assessment for risk of bias based on Cochrane and TREND metrics, respectively. Documentation of the inclusion and exclusion process is presented in the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) format. Results: 1,126 potentially relevant articles were identified and 7 randomized clinical studies met the inclusion/exclusion and data extraction criteria. Quetiapine doses ranged between 12.5 mg and 300 mg per day. In 4 of 5 placebo-controlled studies, quetiapine failed to significantly improve psychosis; study authors cited high dropout rates and small sample size as limitations for conclusive interpretation of results. In 2 clozapine-comparator controlled studies, quetiapine demonstrated non-inferiority with improvements in Brief Psychiatric Rating Score or Clinical Global Impression of Change. Overall, reported adverse events included dizziness, somnolence, orthostatic hypotension, and sedation. Conclusion: Quetiapine has demonstrated non-inferiority to clozapine for management of hallucinosis / psychosis in patients with PD but has not demonstrated efficacy compared to placebo.

1. The Anne and Henry Zarrow School of Social Work, University of Oklahoma, Tulsa, OK; 2. Clinical Chair, National Health Care for the Homeless, Dean, Indiana University School of Medicine-South Bend; 3. University of Oklahoma College of Pharmacy, Tulsa, OK; 4. School of Community Medicine, University of Oklahoma, Tulsa, OK

Abstract Type: Original Research. Objective: To examine the relationship between Adverse Childhood Experiences (ACEs), illicit drug use, and perceptions of health among homeless adults. The overall goal of this research is to contribute to the development of trauma-informed approaches to address the long-term adverse effects of illicit drug usage for those who have experienced high adverse child experiences. Background: Research has consistently shown that ACEs are associated with poorer physical health. In addition, experiences of abuse are a common antecedent to homelessness, and substance abuse is prevalent among homeless individuals. Methods: A cross-sectional survey design was implemented to measure ACEs, perceptions of health, and illicit drug use among an adult homeless population at a local day center. Researchers administered paper and pencil surveys (N = 207) Participants were offered a piece of fruit and a pen as incentives. Results: One hundred three (103) respondents indicating ‘Caucasian only’, 102 indicating one or more minority ethnicities, and 2 non-respondents; 96 females, 110 males, and 1 non-respondent regarding gender. Results indicate illegal drugs moderate the relationship between greater experiences of ACEs and feelings of poorer health, with bootstrap resampling (N = 5000) performed by SPSS Process indicating that when drug usage is low, there is a significant and robust inverse relationship between ACE scores and perceptions of health, with higher ACEs predicting poorer perceptions of health (b = -.565. 95% BaCI [-1.047, -.083], t = -3.33, p = .02). However, at both the mean and higher levels of illicit drug usage, there is no statistical relationship between ACEs and perceptions of health. The results suggest that illicit drugs ‘buffer’ the relationship between childhood trauma and feeling unhealthy, which may in part explain chronic substance ‘abuse’ among the highly victimized homeless population and the difficulties some trauma survivors have with stopping illicit drug use. Conclusion: These data add important knowledge on the effects of ACEs and the mechanisms of increased illicit drug usage among this cohort and offers information that will help advance the concept of trauma-informed care, particularly as it relates to the way providers view and treat illicit drug use.

All parties are affiliated with Nova Southeastern University, College of Pharmacy

Abstract Type: Original Research. Objective: The purpose of this study is to analyze whether administration of microdoses of lithium have an overall impact on the cognitive performance of patients with mild to moderate Alzheimer’s disease. Background: Lithium is a potent inhibitor of glycogen synthase-kinase-3-alpha/beta which plays a role in the pathogenesis of Alzheimer’s disease, implying that lithium can be used to prevent the progression of dementia for this subset of patients. The amount of studies for this subset is limited and there is no systematic review available on the effectiveness of microdoses of lithium for dementia. Methods: A systematic study was conducted where five different articles were analyzed based on the following criteria: Alzheimer’s patients receiving microdoses of lithium and having measurable cognitive tests from either Mini-Mental State Examination (MMSE) or Assessment-Scale Cognitive (ADAS-cog). The differences in cognitive performance between the baseline and final data for both control and experimental groups were compared. Results: Regarding the MMSE data, three out of the five case studies showed no benefit with lithium (Macdonald, Forlenza and Hampel). Regarding the ADAS-cog data, three of the four case studies showed a benefit on lithium (Hampel, Lehye and Nunes). Conclusion: This review on research articles demonstrated variable results regarding cognitive performance measured by MMSE. However, when comparing the ADAS-cog data, lithium treated patients maintained or improved ADAS-cog scores. Patients with sub-standard microdoses of lithium may improve adherence and perhaps increase sample size in future studies. Additional long-term studies are still needed to support the benefit of microdosed-lithium therapy for dementia.

1. Dr. Georges-L.-Dumont University Hospital Center, Vitalité Health Network, Moncton, NB; 2. Université de Moncton, Department of Mathematics and Statistics, Moncton, NB; 3. Université de Moncton, Department of Chemistry and Biochemistry, Moncton, NB; 4. Dalhousie University, College of Pharmacy, Halifax, NS

Abstract Type: Original Research. Background: Inpatient admissions are the largest contributor to the direct treatment cost of schizophrenia, and long-acting antipsychotic injections (LAI) can improve treatment adherence and delay re-hospitalization. Few studies however have compared paliperidone palmitate (PLAI) with risperidone long-acting injection (RLAI), none focusing on the time until discharge eligibility or relapse in acutely hospitalized patients. Objective: To determine if PLAI decreases the time to hospital discharge eligibility following treatment initiation compared to RLAI, and to compare patients’ time to relapse following discharge. Methods: A retrospective study was conducted using patients admitted to the Dr George-L-Dumont University Hospital Center, and a waiver of consent was obtained from the local ethics board. Patients initiated with PLAI (N = 43) or RLAI (N = 56) during their hospitalization were eligible and stratified to include schizophrenia and other psychotic disorders. Data collected included gender, age, diagnoses, antipsychotic treatment history, commitment status, LAIs received with their administration dates and doses, concomitant scheduled antipsychotic therapy, and time until re-hospitalization and first ER room visit. If documented, discharge eligibility was captured from the patient’s chart; otherwise actual discharge dates were used. Treatment responders were patients discharged while receiving their LAI. Results: 39 RLAI and 32 PLAI patients were included in the final analysis with 72% and 69% under involuntary treatment respectively. Treatment history and co-morbid substance abuse were similar between the groups (P>0.05 and P = 0.636 respectively). Treatment response was 96.9% with PLAI and 89.7% with RLAI (P = 0.370). Concomitant antipsychotic treatment during the first 21 days was 15.8±9.6 mg of olanzapine equivalents (OLE)/day for RLAI and 2.5±4.6 mg OLE/day for PLAI (P<0.001). Patients on PLAI were eligible for discharge 12 days earlier, on average, than those on RLAI (18.5 vs. 30.6 days, P = 0.037). The time until first hospitalization and ER visit were similar for both medications, at least for the first 200 days (P = 0.960 and 0.832 respectively). Conclusions: PLAI may offer a potential economic advantage over RLAI by allowing patients to be discharged earlier. It appears to be similar to RLAI for efficacy in delaying relapse; however, heavy censoring in the PLAI group prevents a definitive conclusion. Longer follow-up studies are needed.

1. Ray Dolby Brain Health Center and California Pacific Medical Center Research Institute, San Francisco, CA. United States; 2. Department of Neurology. Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; 3. Lundbeck LLC, Deerfield, IL, United States; 4. H. Lundbeck A/S, Valby, Denmark

Abstract Type: Encore Presentation. AAGP 2016

1. Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN; 2. Department of Pharmacy Practice, University of Pittsburgh School of Pharmacy, Pittsburgh, PA; 3. Department of Psychiatry and Behavioral Sciences Northwestern University Feinberg School of Medicine, Chicago, IL; 4. Jesse Brown Veteran’s Administration Medical Center, Chicago, IL; 5. Department of Psychiatry, Western Psychiatric Institute and Clinic, Pittsburgh, PA; 6. Department of Psychiatry, University of Chicago, Chicago, IL; 7. Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA; 8. Department of Psychiatry, Harvard Medical School, Boston, MA; 9. Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX

Abstract Type: Encore Presentation. American College of Neuropsychopharmacology Annual Meeting December 9, 2015

1. BDSI, Raleigh, NC; 2. Worldwide Clinical Trials, Austin, TX; 3. University of Delaware, Dept of Chemistry and Biochemistry; 4. Retired (BDSI, Raleigh, NC)

Abstract Type: Encore Presentation. April 2014, American Society of Addition Medicine Annual Meeting

1. Ray Dolby Brain Health Center, California Pacific Medical Center, San Francisco, CA; 2. Pentara Corporation, Salt Lake City, UT; 3. Actavis, Jersey City, NJ, USA, an Allergan affiliate, Jersey City, NJ *Author no longer affiliated with Forest Research Institute (now Actavis), Jersey City, NJ, USA, an Allergan affiliate

Abstract Type: Encore Presentation. AAIC 2015

1. University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA; 2. Takeda Global Research and Development Center, IL USA; 3. H. Lundbeck A/S, Copenhagen, Denmark

Abstract Type: Encore Presentation. Efficacy Meta-analysis with Item Analysis; APA 2015 Encore; Aug 6-9, 2015; Toronto, Canada

1. Takeda Development Center, Americas, Deerfield, IL, USA; 2. University of Miami Miller School of Medicine, Miami, FL, USA; 3. H. Lundbeck A/S, Copenhagen, Denmark

Abstract Type: Encore Presentation. UPSA Responder Analysis, ACNP 2015 Encore; Dec 6-10, 2015; Hollywood, Florida

1. Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ, USA; 2. H. Lundbeck A/S, Valby, Denmark

Abstract Type: Encore Presentation. Each of the abstracts are encores of presentations from the American Society of Clinical Psychiatry annual meeting (22–25 June, 2015, Miami, Florida).

1. Lundbeck LLC, Deerfield, IL, USA; 2. Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ, USA; 3. H. Lundbeck A/S, Valby, Denmark

Abstract Type: Encore Presentation. Each of the abstracts are encores of presentations from the American Society of Clinical Psychiatry annual meeting (22–25 June, 2015, Miami, Florida).

1. Neurocrine Biosciences, Inc; 2. University of South Florida Parkinson’s Disease & Movement Disorder Center; 3. Semel Institute for Neuroscience at UCLA; 4. University Hills Clinical Research

Abstract Type: Encore Presentation. American Academy of Neurology, April 15-21, 2016 in Vancouver, Canada (currently submitted and is pending acceptance)

All parties are affiliated with Regions Hospital

Abstract Type: Encore Presentation. Presented at the Academy of Psychosomatic Medicine 2015 Annual Meeting

All parties affiliated with the Philadelphia College of Osteopathic Medicine - School of Pharmacy

Abstract Type: Encore Presentation. ASHP Midyear Clinical Meeting; December 2015

1. School of Pharmacy, Husson University, Bangor, Maine; 2. College of Pharmacy, University of New England, Portland, Maine; 3. Department of Family Medicine, Maine Medical Center, Portland, Maine; 4. Center for Community and Public Health, University of New England, Portland, Maine

Abstract Type: Encore Presentation. American College of Clinical Pharmacy Global Conference, October 2015, in San Francisco, California

1. Centre for Addiction and Mental Health, Toronto ON, Canada; 2. University of Toronto, Toronto ON, Canada

Abstract Type: Encore Presentation. Originally presented June 18, 2015 at the 77th Annual Meeting of the College on Problems of Drug Dependence

1. Centre for Addiction and Mental Health, Toronto, ON, Canada; 2. University of Toronto, Toronto, ON, Canada

Abstract Type: Encore Presentation. Originally presented June 2014 at the 76th Annual Meeting of the College on Problems of Drug Dependence in San Juan, Puerto Rico.

All parties are affiliated with Magellan Rx Management

Abstract Type: Encore Presentation. AMCP Nexus 2015, Orlando, FL

1. University of California, Department of Psychiatry, San Francisco, CA, USA; 2. Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ, USA; 3. H. Lundbeck A/S, Valby, Denmark

Abstract Type: Encore Presentation. Each of the abstracts are encores of presentations from the American Society of Clinical Psychiatry annual meeting (22–25 June, 2015, Miami, Florida).

1. Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ, USA; 2. H. Lundbeck A/S, Valby, Denmark

Abstract Type: Encore Presentation. Each of the abstracts are encores of presentations from the American Society of Clinical Psychiatry annual meeting (22–25 June, 2015, Miami, Florida).

1. Southern Illinois University Edwardsville, School of Pharmacy; 2. Places for People (PfP), St. Louis, Missouri

Abstract Type: Encore Presentation. December 8, 2015, ASHP Midyear Clinical Meeting, New Orleans, LA

1. University of Oklahoma College of Pharmacy, Tulsa, OK; 2. Department of Psychiatry, School of Community Medicine, Tulsa, OK

Abstract Type: Encore Presentation. ASHP Midyear Clinical Meeting, December 7, 2015, New Orleans, LA.

1. Rutgers University Ernest Mario School of Pharmacy; 2. Monmouth Medical Center, Department of Pharmacy

Abstract Type: Encore Presentation. ASHP Midyear meeting 2015

1. The University of Texas Austin College of Pharmacy, Austin, TX; 2. The University of Texas Dell Medical School, Austin, TX

Abstract Type: Encore Presentation.

1. Nova Southeastern University, College of Pharmacy; 2. Nova Southeastern University, College of Psychology

Abstract Type: Work in Progress. Background: Schizophrenia is a chronic disorder with immense direct and indirect costs. Direct costs arise from treatment of the disease while indirect costs arise from consequences of the disease state. For example, many individuals with schizophrenia tend to act out aggressively. Costs associated with such aggressive events at an inpatient psychiatric facility may include costs accrued from injury to other patients and staff, trips to the emergency department, and increased use of “as needed” (PRN) medications. In addition, non-adherence to antipsychotic treatment has been associated with increased costs. Non-adherence may also lead to an increase in aggressive events in patients with a history of aggression due to lack of adequate therapy. Pharmacoeconomic studies have illustrated cost savings with the use of long-acting injectable (LAI) antipsychotics due to decrease in relapse and hospitalization. However, cost-benefits of utilizing LAIs in long-term inpatient psychiatric facilities remains to be explored. Objectives: To compare costs and benefits associated with the utilization of oral versus LAI antipsychotics in aggressive patients admitted to a long-term inpatient psychiatric facility. Methods: This study is a retrospective, cost-benefit analysis comparing oral antipsychotics to LAIs at a long-term inpatient psychiatric facility. The electronic medical records system and the aggressive events records will be utilized to collect data on patients who have been the aggressors in an aggressive event from January 2013 to December 2015. Patients must have a time period of at least 3 months on a LAI antipsychotic and 2 months on only oral antipsychotics during their admission. Costs for aggressive events will be obtained utilizing 2016 administrative cost records, and costs for medications will be obtained utilizing the 2016 pharmacy acquisition costs. Patients will serve as their own case-control. Average costs associated with aggressive events and medications will be calculated and evaluated for aggressive patients while they are receiving only oral antipsychotics versus LAI antipsychotics. Descriptive statistical analysis will be performed to evaluate the data. Outcomes: Primary outcome measures include average costs per day while patients are receiving oral versus LAI antipsychotics. Secondary outcomes include the number of aggressive events and PRNs utilized while on oral versus LAI antipsychotics.

1. Cincinnati VAMC, Cincinnati, OH; 2. Fort Thomas Cincinnati VA associated facility, Fort Thomas, Kentucky

Abstract Type: Work in Progress. Background: Post-traumatic stress disorder (PTSD) is a chronic psychiatric condition estimated to affect 6.8% of the general United States population. A hallmark symptom of PTSD reported by 70 - 87.2% of veterans is disturbances in sleep related to the intrusion and hyper-arousal symptoms. Disturbances may persist despite the recommended first line PTSD pharmacotherapy treatment. Benzodiazepines (BZD) and non-benzodiazepine receptor agonists (NBrAs) such as zolpidem are prescribed for sleep over long periods of time without established safety data specific to patients with PTSD. The risk of dependency, abuse, and adverse side effects of NBrAs warrant additional studies to establish their relative risks and benefits compared to BZDs in PTSD patients. Objectives: The objectives of this study are to compare the safety and efficacy of zolpidem to BZDs (clonazepam, diazepam, lorazepam, and temazepam) for the treatment of insomnia during the six months post-discharge from the eight week long PTSD residential rehabilitation program (PRRTP) at the Ft. Thomas VA facility in Ft Thomas, KY. Methods: A retrospective chart review of veterans with PTSD who completed eight weeks of the PRRTP at Ft Thomas from 1/1/2009 to 12/31/2013 will be performed. Patients will be divided into two groups based on medication filled during or closely following residential treatment; zolpidem will be in one study group, and temazepam, clonazepam, lorazepam or diazepam will be in the second study group. Baseline demographics, psychiatric and general medical conditions, SSRI/SNRI utilization, and additional sedating hypnotic medication utilization will be collected upon admission to the PRRTP. All cause hospitalizations/ER visits for in the six months following PRRTP discharge, CAPS and PCL scores, and treatment medication fill history will be analyzed. Outcomes: All results reported will be a comparison between the two treatment groups. All cause ER/hospitalizations will be reported as a proportion and mean possession ratios as a percentage over six months post PRRTP discharge. CAPS and PCL scores will be reported as changes from admission score to discharge scores, eight weeks post-discharge, and six months following discharge from PRRTP.

All parties are affiliated with the University of New England, College of Pharmacy

Abstract Type: Work in Progress. Background: Extensive research regarding attitudes of healthcare providers continues to show negative mindsets towards psychiatric patients. Stigma toward mental illness causes patients to feel humiliated and delay or fail to seek treatment. Healthcare providers specifically pose a threat, as patients are less likely to seek or receive appropriate care after a negative experience. Despite the barriers, roughly 20% of top 200 U.S. medications dispensed are psychotropics. High demand for these treatments further demonstrates need for proper training. Currently, healthcare professionals’ lack of education to treat psychiatric patients coupled with the obstacle of their own stigma exemplifies this issue. Objectives: The purpose of this study is to assess if student stigma toward mental illness can be improved by a course focused on treating psychiatric patients and improving stigma. Methods: This quasi-experimental IRB approved study shall evaluate pharmacy students stigma before and after a two-credit elective course aimed at treating mental illness and minimizing associated healthcare barriers. This is the first pharmacy course in the United States known to include an eight-hour certificate-training program for Mental Health First Aid USA from the National Council for Community Behavioral Healthcare and NAMI Maine. Other classes included patients living with mental illness describing their diagnosis and associated stigma endured, an autobiographical book review from a patient with schizophrenia, topic discussions and journal clubs of common psychiatric illnesses, and neurobiology of psychiatric diseases. Data will be compared utilizing Wilcoxon signed rank sum test with statistician level set at α = 0.05. A literature search was conducted to validate previous findings in this area for comparison. Psychosocial aspects surrounding mental illness are not addressed in the required pharmacy curriculum. A secondary outcome shall analyze 2013 data from a previous study comparing data from didactic psychiatry core coursework for pharmacy students (n = 79). Those results will be compared to 2014 elective course results using the Two-sample T-test and Mann-Whitney U test. Outcomes: The OMS-HC completed by 20 students enrolled in the elective served as an informal tool to increase personal awareness of the stigma they carry, but results may additionally demonstrate impact a focused course to improve stigma offers.

All parties are affiliated with the Department of Pharmacy Practice, Nova Southeastern University, Fort Lauderdale, FL

Abstract Type: Work in Progress. Background: Haloperidol decanoate intramuscular injection, intended to be administered monthly, is a treatment option for chronically psychotic patients with non-adherence issues. In order to increase ease of administration, psychiatrists at a long-term inpatient psychiatric facility have been prescribing haloperidol decanoate at half the monthly maximum dose, 200 - 225 mg as a single injection, every two weeks, instead of the monthly maximum dose of 400 - 450 mg given via two separate injections on a single day every four weeks. This study will evaluate whether patients receiving maximum dose haloperidol decanoate exhibit differences in adverse drug reactions and metabolic outcomes with a two-week dosing schedule compared to the recommended monthly dosing schedule. Our previous research has shown no significant difference in clinical efficacy outcomes between the two dosing regimens, therefore choosing the option with the least number of adverse drug reactions may best suit this patient population. Objectives: 1. Document the differences in the adverse drug reactions for patients stabilized on either haloperidol decanoate 200 - 225 mg IM Q2weeks or 400 - 450 mg IM Q4weeks. 2. Evaluate the differences in metabolic outcomes, specifically liver function tests, hemoglobin A1c, total cholesterol, LDL/HDL, and triglycerides between the two dosing regimens. Methods: A retrospective chart review will be conducted evaluating the medical records between 2011 and 2013 of identified patients initiated on haloperidol decanoate 200 – 225 mg IM Q2weeks or 400 – 450 mg IM Q4weeks. Patients will be included if they received at least 5 months of treatment on a stable maximum dose of haloperidol decanoate. Demographic variables (age, gender, race and diagnoses) will be collected. The primary objective is to analyze if there are differences between the reported adverse drug reactions of the two dosing regimens. The secondary objective for this analysis is to compare the differences between the metabolic variables listed and the two treatment regimens. Outcomes: We will report the average number and percentage change for each reaction and metabolic variable and compare them between the haloperidol decanoate two-week and four-week dosing schedules. Results and data analysis will be presented at the 2016 Annual Meeting.

All parties are affiliated with the University of Southern California School of Pharmacy

Abstract Type: Work in Progress. Background: Primary care providers are among the most accessible healthcare professionals and see almost twice as many mental health patients as psychiatrists, making them gatekeepers for depression care. Despite being the second most common chronic disorder in primary care settings and primary care providers prescribing the majority of antidepressants, there remains a high prevalence of unrecognized and misdiagnosed depression. Patient Health Questionnaire Assessments have been shown to be an effective screening tool in the early detection of depression. Health care quality measures, such as the Physician Quality Reporting System (PQRS), call for annual screening and follow-up for depression. While this may increase provider awareness, providers may not have the knowledge or resources to appropriately treat and refer these patients. It is the aim of this study to determine potential gaps in care following positive annual depression screenings. This study will also assess primary care providers’ perception of psychiatric pharmacists’ scope of practice in order to determine potential opportunities for the integration of psychiatric pharmacist services into a primary care setting. Objectives: 1) Evaluate current depression screening, management, and referral process. 2) Identify potential gaps in the management of depression that may be resolved by a psychiatric pharmacist. 3) Assess primary care providers’ perceptions of integrating psychiatric pharmacists into primary care settings. Methods: This is a retrospective chart review of patients ≥ 18 years of age seen at Keck Medical Center of USC primary care clinics in Los Angeles County with a documented annual health screening between January 1, 2015 – December 31, 2015. Demographic variables (age, gender, race), Patient Health Questionnaire scores, as well as psychotropic medications and indications will be collected. The number and percentage of patients screened with Patient Health Questionnaires and interventions (referrals, diagnosis, pharmacotherapy management) made for positive screenings will be reported. Descriptive statistics to evaluate the current process of identifying and managing patients with depression and survey results will be reported. Results: Will be presented Conclusions: Will be presented

All parties are affiliated with the WG (Bill) Hefner Department of Veterans Affairs Medical Center

Abstract Type: Work in Progress. Background: Lurasidone (Latuda) is a newer atypical antipsychotic that is FDA-approved for the treatment of schizophrenia and depressive episodes associated with bipolar-I disorder. The CATIE study, which examined the effectiveness of antipsychotic drugs in patients with chronic schizophrenia, used time-to-discontinuation of study medications as the primary outcome measure because “stopping or changing medication is a frequent occurrence and major problem in the treatment of schizophrenia”. The specific reasons for the discontinuation of treatment comprised the key secondary outcomes. Stopping or changing medications is also a frequent occurrence and major problem in the treatment of bipolar disorder. Determining the rate and reasons for discontinuation of bipolar treatment is of paramount importance in developing effective strategies for facilitating long-term adherence and treatment success. There are currently no published time-to-discontinuation studies examining lurasidone use in the Veteran population. Objective: To examine time-to-discontinuation of lurasidone in Veterans with schizophrenia and bipolar-I disorder and identify reasons for discontinuation. Methods: A random sample of 250 charts will be selected from the population of Veterans who have been prescribed lurasidone at the Hefner VA Medical Center in Salisbury, NC in the past five years. A retrospective chart review will be conducted to determine the average time-to-discontinuation for lurasidone treatment for schizophrenia and bipolar-I disorder. The reasons for discontinuation, if available, will be recorded, analyzed, and reported. Descriptive statistics will be used for data analysis. Results: To be determined Conclusions: To be determined

1. Veterans Affairs Medical Center, Providence, RI; 2. University of Rhode Island College of Pharmacy, Kingston, RI

Abstract Type: Work in Progress. Background: The Veterans Health Administration has an ongoing Opioid Safety Initiative to promote safe prescribing. Combined use of benzodiazepines and opioids results in additive central nervous system effects and increases the risk of respiratory depression. An important goal of this initiative is to “develop new models of mental health and primary care collaboration to manage [co-]prescribing.” Before new models of collaboration can be created, it will first be important to identify and describe current practices. Objectives: The primary objective of this study is to determine whether providers at the Providence Veterans Affairs Medical Center are taking appropriate safety measures when benzodiazepines and opioids are co-prescribed compared to patients on opioids without benzodiazepines. Additional objectives are to describe the characteristics of patients co-prescribed benzodiazepines and opioids and the prescribing habits of providers, as well as to identify if patients have additional safety concerns for their concomitant use. Methods: A retrospective electronic chart review will be performed. All patients currently prescribed both benzodiazepines and opioids with active prescriptions and who have been on these medications concurrently for at least 90 days will be included. For the comparator group, 50 to 100 patients currently prescribed opioids for at least 90 days without benzodiazepines will be included. Patients prescribed opioids for cancer related pain and hospice or palliative care patients will be excluded. In each group, the following data will be collected: age, sex, ethnicity, body mass index, medical conditions, and medications. Additionally, total diazepam equivalents of benzodiazepines and total morphine equivalents of opioids will be calculated. We will determine which was prescribed first, who prescribed each medication, and dose titrations in the last year. To assess whether providers are taking appropriate safety measures, the following data will be collected: naloxone rescue kit prescription, urine drug screen monitoring, state prescription drug monitor program surveillance, documentation of consent for long-term opioids, documentation of safety counseling and indication for medications, documentation of communication between providers, and frequency of appointment visits. Outcomes: Outcomes will include percentage of prescriber compliance to safety measures in each group. Data collection and analysis will be completed and results will be presented.

1. School of Pharmacy, Husson University; 2. College of Pharmacy, University of New England; 3. Department of Neuroscience, Bowdoin College; 4. Department of Pharmacy, Maine Medical Center

Abstract Type: Work in Progress. Background: The prescribing cascade, a phenomenon of treating side effects of medications with other medications, is a growing problem. This practice has the potential to contribute to patient harm via additional adverse effects, drug-drug interactions, reduction in adherence, and additional healthcare costs. Psychotropic side effects, in particular, are often treated with other medications with opposing actions – “antagonistic polypharmacy”. For example, sedative-associated fatigue and/or stimulant-associated insomnia may be treated with a medication from the opposing class. Objectives: The objectives of this study are to evaluate concomitant sedative and stimulant prescribing in the State of Maine and to describe prescribing trends within the subpopulation of patients who receive concomitant sedative and stimulant prescriptions consistently. Consistency will be defined as: concomitant prescriptions for 1) 90 or more days and 50% of the time or greater of either prescription, or 2) greater than 30 days and 75% of the time or greater. With these findings we aim to examine and describe a potential prescribing problem within the State of Maine. By identifying these populations and subgroups, targeted educational interventions can be aimed at providers, pharmacists, and patients, which ultimately increase patient outcomes. Methods: Maine Prescription Monitoring Program records were extracted and de-identified in this Husson University IRB approved study and all stipulations of the Data Use Agreements with the Maine Office of Substance Abuse and Mental Health Services were abided by and adhered to. Patient data includes: a patient unique number, gender, birth year, and county of residence. Prescription information includes: date filled, day supply, quantity dispensed, payment method, prescriber unique number, and pharmacy unique number. Data being analyzed will include the above in patients who have received consistent concomitant sedative and stimulant prescriptions. Outcomes: We will report the characteristics of patients receiving concomitant sedative and stimulant prescriptions for 90 or more days and for 50% of the time or greater of either prescription. We will also analyze prescribing trends within this cohort of patients. Secondary outcomes include characteristics and prescribing trends in patients receiving concomitant sedative and stimulant prescriptions for more than 30 days and for 75% of the time or greater.

1. Buffalo Psychiatric Center, New York State Office of Mental Health; 2. University at Buffalo School of Pharmacy and Pharmaceutical Sciences

Abstract Type: Work in Progress. Background: Behavioral changes can be prompted by a variety of medications, and recent literature has linked HMG-CoA reductase inhibitors (statins) to central nervous system (CNS) adverse effects, such as aggression, agitation, and irritability. Furthermore, lower cholesterol levels, both chronically low and medically lowered, have been attributed to increased irritability, aggression, violence, and similar behavioral disturbances. Lipids are imperative for the function of neurons, specifically in forming neuron cell membranes, the myelin sheath, and nerve synapses. Decreased serum lipids reduce obtainable cholesterol to the neurons, which can lower serotonergic activity by decreasing serotonin receptors on the membrane surface. Alterations to the serotonergic pathway and serotonin availability can cause changes in behavioral control and psychiatric adverse effects. Our study will evaluate if the use of statins increases the incidence of agitation and aggressive outbursts and if cholesterol levels are correlated with these behavioral changes in a psychiatric inpatient population. Objectives: Identify if there is 1.) a relationship between statin use and increased aggression, and 2.) a relationship between cholesterol levels and increased aggression of psychiatric inpatients. Methods: This study was approved by our Institutional Review Board of record (New York State Psychiatric Institute). A patient chart review will be conducted for all inpatients who required a psychiatric emergency code (“Code Green”) between 01 April 2014 through 30 September 2015 for receipt of a statin and most recent lipid panel (total cholesterol, low-density lipoprotein, high-density lipoprotein, and triglycerides). Patients receiving statins and a sample of patients not receiving cholesterol-lowering medications who did not require a code green during this timeframe will also have their charts reviewed for a lipid panel as controls. Patients under 18 years old and who have records of a criminal procedural law will be excluded. Appropriate statistical analysis will be conducted to assess if there is an increased risk of aggression with statin use, and determine if there is a correlation with cholesterol levels and increased aggression. Outcomes: We will report the risk of aggression (measured by Code Green) for patients receiving statin therapy and analyze cholesterol levels for a correlation for increased aggression.

All parties are affiliated with the William S. Middleton Memorial Veterans Hospital

Abstract Type: Work in Progress. Background: Several studies have shown that medications with anticholinergic effects may adversely affect cognitive function. Older people tend to be more sensitive to anticholinergic effects due to decreasing cholinergic neurons or receptors in the brain, a decrease in renal and hepatic removal of medications, and permeability changes in the blood-brain barrier. Medications with anticholinergic effects are used frequently in elderly patients for various health conditions, and the patients using these medications are more likely to be cognitively impaired than those not taking them. Risk of cognitive impairment increases the higher the anticholinergic load a patient has. Because of such data, the Beers criteria discourages use of anticholinergic medications in patients with dementia and cognitive impairment. Despite this, an estimated 20-50% of patients with dementia in the United States take at least one medication with anticholinergic effects. The objective of this study is to estimate the anticholinergic burden in patients diagnosed with dementia and determine if higher anticholinergic burden leads to increased risk of mortality or morbidity or use of health services at the William S. Middleton Veterans Hospital. Objectives: 1. Estimate the anticholinergic burden in patients with diagnosis of dementia. 2. Determine if patients with a higher anticholinergic burden have an increased risk mortality or morbidity or use of health services. Methods: A retrospective chart review will be conducted for 50 patients from a patient list of patients diagnosed with dementia at the William S. Middleton Veterans Affairs Hospital. Randomization will be done by assigning random numbers to each patient and using a computer program to generate a list of random numbers to review. Patients will be excluded if they do not have dementia. Demographic variables, number comorbidities and medications, and severity of dementia will be collected. For objective 1: Anticholinergic Risk Scale will be used to determine anticholinergic burden in patients diagnosed with dementia. For objective 2: regression models will be used to examine if there is a relationship between higher anticholinergic burden and increased risk of mortality or morbidity or use of health services. Outcomes: Final results and conclusions will be presented at the CPNP 2016 Annual Meeting.

1. Hospital Corporation of America; 2. University of Tennessee Health Science Center College of Pharmacy; 3. TriStar Centennial Parthenon Pavilion

Abstract Type: Work in Progress. Background: Antipsychotic polypharmacy (APP) describes the use of more than one antipsychotic medication in a single patient. APP provides limited clinical benefit in the management of most behavioral health conditions, while increasing the risk of adverse effects. While APP may be beneficial in a subset of patients with treatment-resistant schizophrenia, practice guidelines recommend the use of a second scheduled antipsychotic only after multiple trials of a single antipsychotic have proven inadequate, including a trial of clozapine (an agent which has historically demonstrated superior efficacy in patients with treatment resistance). The overuse of APP is addressed by two core performance measures applied by The Joint Commission (TJC) as part of the Hospital-Based Inpatient Psychiatric Services (HBIPS) core measures. Objective: To evaluate the effect of an intensive, collaborative quality improvement initiative on antipsychotic polypharmacy prescribing for patients discharged from inpatient behavioral health facilities. Methods: This retrospective study was approved by the University of Tennessee Health Science Center Institutional Review Board and received no funding. Patients included in the Hospital Corporation of America (HCA) HBIPS sample from five HCA behavioral health facilities will be reviewed. On-site visits to these five facilities were completed as part of an enterprise-wide performance improvement strategy known as Evidence Based Care Measures (EBCM). During the EBCM visits, education pertaining to APP was provided to facility staff which included in-depth discussion regarding indications for APP, accepted justification for APP according to HBIPS-5 criteria, alternatives to APP, and recommended monitoring. Patient groups will be compared before and after the execution of these EBCM site visits, all of which occurred in September and October of 2014. Demographic variables, medication administration data, ICD-9 codes, and hospital admission information will be collected. Outcomes: We will report the number and percent of patients who were discharged on APP and analyze the change in APP prescribing after execution of a quality improvement initiative.

1. Sullivan University College of Pharmacy

Abstract Type: Work in Progress. Background: Clozapine, while an effective antipsychotic medication in the treatment of schizophrenia, possesses the potential to cause several adverse effects, such as neutropenia and agranulocytosis. A Risk Evaluation and Mitigation Strategy (REMS) was established for clozapine in 2008. In late 2015, the Food and Drug Administration updated the REMS for clozapine to include new requirements in order to monitor, prescribe, dispense, and receive the medication. Implementation of this updated REMS occurred in October 2015. Objective: To evaluate the trends in clozapine prescribing practices at a Kentucky state psychiatric hospital before and after the implementation of updated REMS program. Methods: The first portion of this study is a retrospective, observational chart review of patients at an acute care, inpatient, state psychiatric hospital who were prescribed clozapine therapy in the 24 months prior to the implementation of the updated REMS. Adult psychiatric inpatients prescribed and received at least one dose of clozapine are included in the study. Demographic information and data relating to clozapine prescribing, including dosages, frequencies and durations of therapy, and laboratory monitoring, including absolute neutrophil counts, was collected. Additionally, prescribers were educated on the new requirements set by the updated REMS. To assess the comfort level of those prescribing clozapine, a subjective questionnaire was utilized before and after these education sessions. The second portion of the study will be a prospective evaluation of patients at the same facility who are prescribed clozapine in the seven months following the updated REMS implementation. The same demographic, prescription, and laboratory data will be collected on these patients. Outcomes: The information obtained from both portions of the study will be compared to evaluate if there was a change in the prescribing practices of clinicians using clozapine before and after the implementation of the updated REMS. This will be evaluated by comparing the number of patients on clozapine, the maximum daily dose of clozapine, the length of stay of these patients and the duration of clozapine therapy. Data from this study aims to contribute to the general body of knowledge evaluating this new standard of practice implemented by the updated REMS.

1. VA Connecticut Healthcare System, West Haven, CT; 2. Department of Psychiatry, Yale University, New Haven, CT

Abstract Type: Work in Progress. Background: As of January 2015, the Overdose Education and Naloxone Distribution (OEND) program was initiated at VA Connecticut Healthcare System (VACT), which aims to prevent fatal and non-fatal opioid overdoses. While prior studies have investigated provider and patient attitudes regarding naloxone distribution, there have been very few studies to assess patient knowledge after naloxone education. Objective: To evaluate the OEND program and the impact it has on preventing opioid overdose. Methods: In Phase I, researchers are surveying medication providers at VACT in areas of Mental Health, Substance Abuse, and Primary Care. Data is being collected from providers via an anonymous 30-question questionnaire assessing attitudes and knowledge related to prescribing naloxone rescue kits. In Phase II, researchers will be conducting brief, face-to-face, 20-minute interviews with VACT veterans who have been dispensed a naloxone kit by a naloxone-eligible provider working at VACT. These veterans were identified using the OEND dashboard. Patients will be interviewed after OEND program training regarding their attitudes about opioid overdose, behaviors with naloxone rescue kits, recent drug use, and demographic data. Previously published scales and a 30-day Drug Timeline Follow Back will be used to collect data. Outcomes: As this study is still on-going, there are no outcomes at this time. Data will be analyzed to determine if the OEND program has been successful in engaging providers to participate with delivery of adequate education to veterans. Identified areas of weakness will result in modifications to the program to ensure that providers are supported in their prescribing of naloxone and veterans are being properly educated regarding opioid overdose.

1. The University of Texas at Austin, College of Pharmacy, Pharmacotherapy Division; 2. University of Texas Health Science Center San Antonio, School of Medicine, Pharmacotherapy Education and Research Center, and; 3. Texas Department of State Health Services, San Antonio State Hospital, Pharmacy Department

Abstract Type: Work in Progress. Background: First-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs) are commonly prescribed for nonpsychotic psychiatric disorders. A recent study using Medical Expenditure Panel Surveys (MEPS) demonstrated a significant increase in outpatient antipsychotic prescribing for mood disorders between 1996/1997 and 2005/2006. This study aims to extend and expand the analyses of outpatient antipsychotics use to more recent years. Objectives: (1) Determine if there are significant differences in the trends of FGA and SGA outpatient prescribing in different mental disorders from 1996 to 2013; (2) describe the trend of each antipsychotic agent used from 1996 to 2013; (3) describe the demographic changes in the outpatient population with antipsychotic prescription from 1996 to 2013; (4) describe the trends in outpatient antipsychotic expenditure from 1996 to 2003; (5) describe the trend of metabolic syndrome in the outpatient population with antipsychotic prescription from 1996 to 2013. Methods: We performed analyses of nationally representative data from the MEPS from 1996 to 2013. Data were combined in two-year intervals. Trends of prescribing patterns were examined for overall antipsychotics, FGAs, and SGAs in participants with ICD-9-CM codes in schizophrenic disorders, mood disorders, and anxiety disorders. Changes in antipsychotic prescribing patterns were also analyzed by subgroups of sex, age, race, ethnicity, geographic area, income level, and education level. Outpatient expenditures were determined by aggregating prescription costs reported in the prescribed medicines files. Trend of metabolic syndrome was determined by body mass index and ICD-9-CM codes in hypertension, dyslipidemia, and diabetes mellitus. Outcomes: Preliminary results demonstrated a trend of overall antipsychotic use increase from 1.14% to 1.18% in US outpatient population between 2005/2006 and 2012/2013. There were no statistically significant differences in antipsychotic use in participants with mood disorders (Chi-Square = 2.636, P = 0.141) and those with anxiety disorders (Chi-Square = 4.464, P = 0.18). However, there was a statistically significant decrease in antipsychotic use in participants with schizophrenic disorders (Chi-Square = 7.361, P = 0.006) from 88.9% to 77.0%; the decrease was also statistically significant in FGA use from 23.3% to 14.7% (P = 0.002.), but change in SGA use was not statistically significant (P = 0.449.)

1. Center for Behavioral Medicine, Kansas City, MO; 2. University of Missouri- Kansas City School of Pharmacy, Kansas City, MO

Abstract Type: Work in Progress. Background: Evidential recommendations regarding the use of plasma insulin levels in psychiatric patients for the prediction of metabolic complications are nonexistent. Outside the field of psychiatry, a limited body of evidence exists to support the use of plasma insulin levels in general patient populations as a means to predict future metabolic abnormalities. The evaluation of plasma insulin levels in psychiatric patients may provide insight into correlations between elevated plasma insulin levels and future development of metabolic complications. Objectives: The objective of the study is to identify potential correlations between initial plasma insulin level and development of metabolic status changes in forensic psychiatric patients with a length of stay ≥12 weeks. Methods: A convenience based sample size of approximately 87 patients has been identified for this single center, retrospective study conducted at Center for Behavioral Medicine in Kansas City, Missouri. Subjects were selected based on presence of plasma insulin level, duration of stay ≥12 weeks, and presence of at least two laboratory and anthropometric measurements. Information collected to assess the objective will include plasma insulin level, HbA1c, fasting plasma glucose, fasting lipid panel, body mass index, blood pressure, psychotropic agents prescribed, and use of statin, fibrate, oral hypoglycemic medication, and antihypertensive medications. Demographic data including age, sex, race, and diagnoses will be collected as well. Outcomes: Outcomes assessed will include initial plasma insulin level and anthropometric measurements. Changes in blood glucose, HbA1c, fasting plasma glucose, and fasting plasma lipid panel, blood pressure, and body mass index will be assessed. Relationship between the aforementioned parameters, demographic data and medication usage data will be analyzed as well.

All parties are affiliated with Community Care of North Carolina, Raleigh, N.C

Abstract Type: Work in Progress. Background: Community Care of North Carolina (CCNC) is a primary care case management entity connecting Medicaid Beneficiaries with medical homes to advance healthcare delivery, improve healthcare outcomes, and ultimately reduce healthcare costs. In 2014, CCNC created the Community Pharmacy Enhanced Services Network (CPESN), an open network exceeding 250 North Carolina community pharmacies, committed to broadening availability of medication management to the state’s highest-need population via a 3-year grant from the Centers for Medicare and Medicaid Innovations. Community pharmacists are targeted partners since data indicates the highest risk population, most of which who have complex medical and behavioral health (BH) needs, visits a pharmacy more than 35 times/year. The CPESN is evolving into an excellent resource for this population and is shaping CCNC’s BH integration efforts, uniting physical and behavioral health care delivery efforts around the primary care medical home model. Objectives: The CPESN is a collaborative care partnership providing face to face comprehensive medication management and pharmacy care management for Medicaid patients at no additional cost. Program objectives include improving quality of care and patient outcomes related to medication use, enhancing patients’ overall health trajectory, and reducing total healthcare costs. Funding was also granted to explore transforming financial and clinical models of care via support of the innovative service model of the CPESN. CPESN pharmacy core services include medication fill synchronization, adherence monitoring/coaching, compliance packaging, home delivery, comprehensive medication review, care plan development/reinforcement, and clear communication with the patient and provider. Methods: Active integration of participating CPESN community pharmacist activities with the health care team, including primary care physicians, specialty providers such as behavioral health professionals, and the extended care team of the Patient Centered Medical Home are keys to successful program implementation. Behavioral health training resources on motivational interviewing, depression screening and treatment, and mental health first aid training are made available to the CPESN community pharmacy personnel. Outcomes: Claims analysis will provide baseline and quarterly medication adherence rates, emergency department utilization, hospital utilization, and overall healthcare costs for comparison at the patient, pharmacy, and organizational level for program evaluation for the three year duration of the grant.

All parties are affiliated with VA Western New York Healthcare System

Abstract Type: Work in Progress. Background: Opioid use disorder (OUD) is a chronic relapsing illness that poses a major public health concern. More than 11 percent of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans have a diagnosis of substance use disorder, with high rate of prescription opiate use seen in patients with post-traumatic stress disorder. VAWNY has a Buprenorphine Clinic and psychiatric pharmacist-managed OUD Clinic where extended-release naltrexone injection (Vivitrol) is used for OUD treatment. Objectives: 1. Compare relapse rates for Vivitrol (Treatment Group 1) and buprenorphine (Treatment Group 2) patients 2. Compare time to relapse between groups Methods: A retrospective chart review is being performed of Veterans with OUD treated with Vivitrol in the OUD Medication Management Clinic or with buprenorphine in the Buprenorphine Clinic between 7/1/15 and 5/31/16. Data collection is being completed through VAWNY Computerized Patient Record System (CPRS). Logistic regression analysis will be used to evaluate potential relationships between the dependent variable, relapse, and the independent variables (age, sex, ethnicity, mental health diagnosis, current, or history of other substance use, medication compliance, attendance in group or individual therapy, self-reported opiate craving, side effects, hospitalization for treatment of OUD or mental illness, and housing). Kaplan-Meier survival analysis will be used to compare time to relapse between groups. Chi-Square test will be used to compare liver enzyme changes between groups. A nominal alpha (p-value) less than 0.05 will be considered statistically significant. Outcomes: In addition to primary outcomes, we will report summary statistics comparing demographics and independent variables between groups.

All parties are affiliated with the Veterans Affairs Eastern Colorado Health Care System

Abstract Type: Work in Progress. Background: Disease modifying therapies (DMTs) used to treat Multiple Sclerosis (MS) come in oral and injectable formulations. The Department of Veterans Affairs Health System currently treats over 16,000 Veterans with MS. Early recognition and treatment appears to provide the best prognosis for those diagnosed with MS. While there are various subtypes of MS, a majority of patients are diagnosed with relapsing remitting MS (RRMS). Treatment with DMTs requires an individualized approach as prognosis for each patient is highly variable and unpredictable with adverse reactions varying amongst patients. DMTs have been shown to provide benefit in RRMS by delaying disease progression. Patients who do not adhere to their DMT are unlikely to receive the full benefit of treatment. Route of administration is considered to be a factor associated with poorer adherence. Objectives: The primary objective is to describe reasons for discontinuation of DMT or switching to a DMT with a different formulation. The secondary objectives are to describe the length of time the patient was using the DMT and asses if the patient switched to a different formulation or continued the same formulation. Methods: This single-center, retrospective chart review will include Veterans diagnosed with MS and prescribed a DMT between January 1, 2010 and December 1, 2015 in the Veterans Affairs Eastern Colorado Health Care System. The DMTs to be assessed are Glatiramer, Avenox, Rebif, dimethyl fumarate, and fingolimod. Patients diagnosed with forms of MS other than RRMS will be excluded. The following demographic data will be collected: age, gender, and race. MS classification, time of onset of MS symptoms, previous DMT trials, EDSS score, MSFC score, number of lesions on MRI, and number of MS exacerbations and hospitalizations will also be collected. This study is pending Institutional Review Board approval. Outcomes: The number of patients who switched DMT, the number of patients who switched formulation type and reason for switch will be reported.

1. Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center; 2. W.G. Hefner Veterans Affairs Medical Center, Salisbury, NC

Abstract Type: Work in Progress. Background: TBI due to combat and other causes is a major medical concern in the veteran population. TBI can result in cognitive symptoms that can disrupt safe medication use and adherence. TBI patients may benefit from pharmacists providing comprehensive medication management (CMM), which aims to identify, resolve and prevent drug related problems (DRPs). The purpose of this project is to evaluate the impact of CMM on DRPs in patients treated in an outpatient TBI clinic. Objectives: 1) Record the number of drug related problems per encounter and the number resolved one-month post encounter. 2) Apply objective measures to assess if veterans’ drug therapy goals are being met. 3) Determine veterans’ satisfaction with the service. Methods: This is a quality assurance project performed at a single Veteran Affairs (VA) Medical Center. A pharmacy research fellow will provide CMM services to veterans seen in the outpatient TBI clinic from December 2015 to February 2016. Veterans will be offered CMM during routine visits at the discretion of the neuropsychiatrist. The fellow will provide CMM services through face-to-face interactions. The fellow will document the treatment plan within the Computerized Patient Record System (CPRS), provide a written plan for the patient, and offer appropriate follow-up. Obj 1:DRPs will be categorized into 4 main categories: appropriateness, effectiveness, safety, and adherence. Obj 2: The veteran’s goal will be evaluated using objective measures when possible. Obj 3: Veterans’ satisfaction with the service and ways to improve the service will be ascertained by inquiring what the veterans found helpful about the service; what they would change about the service; and if they would recommend the service to other veterans. Descriptive statistics will be used to analyze the data. Interim Results: Interim Results Nineteen patients received the service and three patients have returned to the clinic for follow-up. Timeline for completion: The service will be evaluated through March 2016. The data will be analyzed and a poster will be completed for the College of Psychiatric and Neurologic Pharmacists (CPNP) annual meeting.

1. Austin State Hospital, Austin, TX; 2. The University of Texas at Austin College of Pharmacy, Austin, TX

Abstract Type: Work in Progress. Background: In patients diagnosed with bipolar disorder or schizophrenia, the incidence of non-adherence has been reported to be upwards of 60%. Worsening of disease symptoms as well as increased hospitalizations are the two major results of non-adherence. Multiple strategies are available for improving non-adherence, including long-acting injectable (LAI) formulations of medications. This study will observe whether long-acting formulations of medications are associated with a longer time to readmission at Austin State Hospital. Objectives: 1. To determine whether LAI antipsychotic use is associated with a longer time to readmission when used in those with a history of medication non-adherence. 2. To determine whether LAI antipsychotic initiation decreases one-year readmission rates. 3. To determine if an LAI with longer administration frequency (≥1 month between injections) is associated with a longer time to readmission. 4. To determine if LAIs are associated with a shorter length of stay on readmission. 5. To determine if an atypical LAI is associated with a longer time to readmission when compared to use of a conventional LAI. Methods: The study design is a retrospective evaluation using electronic medical records data from Austin State Hospital from the time period of November 30, 2011 to November 30, 2013. Patients on long-acting injectable antipsychotics will be matched to patients on an “equivalent” oral dose, who have the same number of prior hospital admissions, same psychiatric diagnosis, and similar length of stay. For the primary endpoints, a Kaplan Meier and Cox Proportional Hazards will be used to analyze readmission time, and a Chi-square and Logistic Regression will be used to analyze readmission rates. A Kaplan Meier, Cox Proportional Hazards, T-test, Multivariate Linear Regression, and descriptive statistics will be used to evaluate the secondary endpoints. Outcomes: We will report the differences in time to readmission, one-year readmission rates, and length of stay on readmission for the LAI group compared to the oral antipsychotic group. We will also evaluate whether a longer frequency between LAI injections is associated with a longer time to readmission and whether there are differences between atypical LAIs compared to conventional LAIs with regard to time to readmission.

1. Veterans Affairs San Diego Healthcare System; 2. Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA

Abstract Type: Work in Progress. None Background: Available literature has demonstrated that military training can often be associated with changes in the hypothalamic-pituitary-adrenal axis, consistent with central hypogonadism. Contributing variables include decreased body mass, increased physical activity resulting in energy deficits, sleep deprivation, and psychological stressors. Psychological stressors have been shown to cause transient central hypogonadism, likely secondary to a decrease in hypothalamic gonadotropin releasing hormone, which stimulates testosterone production. Symptoms of hypogonadism can often mimic those present in post-traumatic stress disorder (PTSD) and depression, including fatigue, decreased libido, and poor concentration. We are not aware of any published studies that have evaluated the long-term impact of chronic psychological stressors on testosterone levels. Objectives: 1. Evaluate the impact of PTSD on testosterone levels in male Veterans. 2. Determine if patient-related variables (e.g. combat exposure, opioid use disorder, etc.) are associated with an increased risk for hypogonadism. 3. Evaluate whether untreated low testosterone levels can lead to treatment resistance, as evidenced by increased antidepressant trials. Methods: This retrospective, cross-sectional study reviews computerized records for patients admitted to the VA San Diego’s ASPIRE Center, from February 24, 2014 to January 14, 2016. ASPIRE is a 40-bed residential treatment facility focused on treating Veterans with PTSD returning from the Iraq and Afghanistan wars. Males with a PTSD diagnosis per DSM-5 criteria and at least one documented testosterone level are included in the study. Demographics (e.g. age, past medical history, diagnosis), current treatment modalities (e.g. psychotropic medications, psychotherapy) and objective rating scales (e.g. PCL-C) are being collected to assess for differences amongst Veterans with low testosterone versus those with normal levels. Descriptive and inferential statistics will be applied to address our study objectives. Outcomes: The prevalence of comorbid hypogonadism amongst Veterans with PTSD will be reported. Additionally, patient-related variables that may contribute to the development of hypogonadism will be assessed. Study Implications: An association between PTSD and testosterone levels could explain the presentation of overlapping symptoms that do not improve despite seemingly adequate psychological and pharmacological interventions. Testosterone supplementation could thereby alleviate symptoms such as decreased energy and concentration difficulties in those that qualify for replacement therapy.

1. University of Maryland School of Pharmacy; 2. Maryland Psychiatric Research Center, University of Maryland School of Medicine; 3. University of Virginia; 4. Departments of Medicine and Physiology, University of Maryland School of Medicine

Abstract Type: Work in Progress. Background: Clozapine is the most effective antipsychotic for refractory schizophrenia yet underutilized due to its side effects. Clozapine has high affinity for D4R. Renal dopamine regulates fluid and electrolyte balance and controls ion transport and hence blood pressure. Clozapine raises blood pressure in some patients. Since renal D4Rs are involved with blood pressure regulation, we hypothesize clozapine is directly involved in kidney mediated increases in blood pressure. Objectives: To examine D4R expression in urine derived cells from the kidney in patients prescribed clozapine versus healthy controls. This is the first study to analyze urine D4R expression in clozapine patients. Methods: This is a single treatment group pilot study with a goal of 20 successful subject completions. Under IRB approval, patients 18 to 75 years old and able to give informed consent will be recruited. The treatment group will have a DSM-IV diagnosis of Schizophrenia or Schizoaffective disorder and treated with clozapine for > 2 months (N = 10, 5 normotensive, 5 hypertensive) compared to healthy controls (N = 10) without a diagnosis of mental illness. The analysis of D4R expression in living renal cells collected in a randomly voided urine will be completed at University of Virginia, Department of Pathology. Demographics, blood pressure, pulse, and clozapine dose/level will also be collected. Outcomes: Fifteen participants have been recruited (8 taking clozapine and 7 healthy controls). The mean age is 38.6 years, 9 are male, and 6 are Caucasian. In clozapine patients the mean dose/blood level are 484.38 mg (SD 146.28)/739 ng/mL (SD 411.49). Mean sitting blood pressure in clozapine patients and controls are 120.81 (SD 7.19)/71.69 (SD 6.53) mm Hg and 116.21 (SD 18.49)/71.36 (SD 7.26) mm Hg, respectively (p = 0.411)/(p = 0.90). Mean pulse in clozapine patients and controls are 90.4 (SD 13.06) and 71.5 (SD 7.69) bpm, respectively (p<0.0001). Data from this study could be used in larger studies to help identify if urine derived living cell D4R receptors may be expressed differently in clozapine treated patients to help identify what blood pressure regulatory mechanisms may be implicated. One urine has successfully yielded a number of new nephron specific cell lines as proof of principle.

1. Department of Pharmacy, Veterans Affairs (VA) San Diego Healthcare System, San Diego, CA; 2. Department of Psychiatry, VA San Diego Healthcare System, San Diego, CA

Abstract Type: Work in Progress. Background: Studies have demonstrated that switching patients from oral antipsychotics to paliperidone palmitate (Invega Sustenna^®) improves symptoms of schizophrenia and delays time to relapse. In practice, patients are most commonly switched from oral risperidone to paliperidone long-acting injectable (LAI). There are currently no guidelines for switching patients from oral risperidone to paliperidone LAI. Additionally, the package insert does not recommend bridging with oral antipsychotics, which may result in inadequate serum concentrations in patients on doses of oral risperidone ≥ 4 mg/day. This study will provide important data on strategies for switching patients from oral risperidone to paliperidone LAI and their effects on clinical outcomes (hospitalization, psychiatric emergency clinic visits, adherence) as well as guidance for bridging with oral antipsychotics. Objectives: 1. Determine whether patients with schizophrenia and schizoaffective disorder are optimally dosed on paliperidone LAI when switching from oral risperidone, 2. Evaluate effects of suboptimal dosing of paliperidone LAI on psychiatric hospitalizations, psychiatric emergency clinic visits, and adherence, 3. Develop dosing recommendations for bridging patients on high dose risperidone to paliperidone LAI. Methods: Patients treated at VA San Diego will be included if they are over 18 years old, were diagnosed with schizophrenia or schizoaffective disorder, and were switched from oral risperidone to paliperidone LAI between 1/1/2009 and 10/30/2014. Demographic variables (psychiatric diagnoses, age, gender), medication history, psychiatric hospitalization and emergency clinic visit history, mental health visit history, and medication discontinuation information will be collected through chart review. Outcomes: We will report the difference in rates of psychiatric hospitalization, psychiatric emergency clinic visits, and no-shows to mental health visits one year prior to and after initiation of paliperidone LAI in 1. Patients optimally vs. suboptimally dosed on paliperidone LAI, and 2. Patients switched from high-dose risperidone who were bridged with oral antipsychotics vs. patients not bridged with oral antipsychotics.

1. University at Buffalo School of Pharmacy and Pharmaceutical Sciences; 2. Buffalo Psychiatric Center, New York Office of Mental Health

Abstract Type: Work in Progress. Title: Drug Interaction Review: Evaluation of Concomitant Medications in a Psychiatric Population Background: Drug interactions are avoidable medication events that can endanger the health of patients. Drug interactions occur when a patient takes two or more medications concurrently and, as a consequence, the tolerability, toxicity, or effectiveness of one drug is altered. Both pharmacokinetic interactions, changes in absorption, distribution, metabolism, or excretion of a drug, and pharmacodynamic interactions, when two drugs act at the same time or at interrelated receptors and signaling pathways, attribute to adverse drug reactions. Patients with psychiatric conditions are more apt to a poly-pharmacy drug regimen, and this is especially true for inpatients who are more likely to have a complex medication regimens. Furthermore, psychiatric medications can account for up to 50% of the adverse drug reactions (ADRs) for hospitalized patients with mental illness. Currently, there is limited drug interaction research for patients with psychiatric disorders in an inpatient setting. This study will examine moderate drug interactions in inpatient psychiatric subjects with poly-pharmacy to optimize patient safety. Objectives: 1. Identify the most common agents and potential adverse effects from all moderate drug interactions in our inpatient population 2. Detect any trends of pharmacotherapeutic interactions 3. With our results, educate healthcare providers on the importance of the potential detrimental effects of polypharmacy on patients’ health Methods: This study was approved by our Institutional Review Board of record (New York State Psychiatric Institute). A medication review and analysis will be conducted on inpatient medical records from November 1st-30th in 2009, 2010, and 2011 at the Buffalo Psychiatric Center. Clinical Pharmacology will be used for the drug interaction database, with emphasis on the moderate, level 3, drug interactions. Patients on less than one medication and those who have records of a criminal procedural law will be excluded. Descriptive statistics will be used to assess the demographic information, and appropriate statistics will be conducted to evaluate results. Outcomes: We will report the incidence of all moderate interactions from psychiatric medications and non-psychiatric medications. With these results, we will analyze any trends for possible therapeutic interventions which could improve patient outcomes.

1. UC San Diego Health, San Diego, CA; 2. UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA

Abstract Type: Work in Progress. Background: Acute agitation in the setting of alcohol intoxication is commonly encountered in the Emergency Department (ED). In this setting, expert guidelines recommend haloperidol because the safety profile of risperidone in alcohol-intoxicated patients have not been studied. Objectives: The primary objective was to compare oxygen saturation (O2 Sat) before and after risperidone administration between ED patients presenting with alcohol intoxication and without alcohol intoxication. Secondary objectives were to compare systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and respiratory rate (RR) before and after risperidone administration and the effect of benzodiazepine co-administration and age on vital signs. Methods: This study was a retrospective chart review of patients presenting to the ED with acute agitation receiving oral risperidone between January 1, 2006 and July 31, 2015. Primary and secondary endpoints were compared between two groups: no evidence of alcohol intoxication, EtOH (-) and evidence of alcohol intoxication, EtOH (+). Inclusion criteria were recorded vital signs documented before risperidone administration and within 4 hours afterwards and age ≥18 years old. Patients were excluded if they received opiates or other antipsychotics within 4 hours of risperidone administration. Paired t-test and ANOVA with post-hoc comparisons were used for this subanalysis. Results: In this subanalysis, 134 patients met inclusion criteria, 109 in the EtOH (-) group and 25 in the EtOH (+) group. Drop in O2 Sat was greater in the EtOH (+) group compared to the EtOH (-) group, 1.12 vs. 0.25, respectively (p = 0.058). Ingestion of alcohol, concurrent benzodiazepines and age were not associated with statistically significant decreases in SBP, DBP, HR, or RR. Outcomes: Based on this subanalysis (n = 134), O2 sat drop was greater in patients with alcohol intoxication. With a larger sample size, this study will provide insight into the safety profile of risperidone when used in patients presenting with acute alcohol intoxication for acute agitation. We will be expanding the sample size to approximately 1,000 patients.

All parties are affiliated with the Department of Veterans Affairs Medical Center

Abstract Type: Work in Progress. Background: Despite significant associated adverse effects, benzodiazepines remain frequently prescribed medications in the older adult population. It is recommended by multiple guidelines not to use benzodiazepines in this patient population due to older adults having increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents. In general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures and motor vehicle accidents in older adults. The purpose of this project is to reduce the frequency of benzodiazepine prescribing in older veterans in order to improve patient safety. A plan was created to taper and discontinue the benzodiazepine or to decrease to the lowest possible dose for the identified population of veterans already on benzodiazepines at the VA Sierra Nevada Healthcare System. Objectives: 1. Decrease the number of older veterans receiving benzodiazepines, 2. If unable to discontinue, decrease benzodiazepine to the lowest possible dose, 3. Refer appropriate patients to mental health Methods: This project was reviewed by the Institutional Review Board and was determined to meet the guidelines for a non-research quality improvement project. One hundred and fifteen veterans 75 years of age or older and receiving a benzodiazepine were identified. Veterans appropriate for dose tapering per prescribing provider were reviewed for suitability and contacted to discuss their willingness to discontinue therapy. Phone call attempts are made and discreet messages with a request to contact clinic are left. Veterans with no response after 3 attempts are excluded and corresponding providers are notified. Veterans agreeable to taper are followed by the pharmacy resident in collaboration with the prescribing provider. Veterans asserting the need to continue therapy are offered referral to mental health. Permission is requested from individuals disagreeable to tapering to have a flyer sent with information about benzodiazepines as well as a separate letter with contact information if they decide to taper off in the future. The plan for benzodiazepine tapering is based on current guidance but is tailored for each individual patient. Outcomes: Results will be determined by the success rate of the objectives and will be reported at the CPNP 2016 Annual Conference.

All parties are affiliated with the Department of Veterans Affairs Medical Center

Abstract Type: Work in Progress. Background: Research indicates that strong predictors of psychiatric readmission include non-adherence to medication and to outpatient appointments. The Inpatient to Outpatient Transition Program (IOTP) was recently initiated to help patients with greater than 1 prior admission in the previous year to transition from the acute inpatient to outpatient setting. An initial evaluation is performed to determine the patient’s baseline knowledge. Patients receive education about disease state, medications and importance of follow-up in the outpatient clinic. At discharge, patients are given a tour of the outpatient clinic and 7-day follow-up appointment is made with the psychiatric pharmacy resident. Objective: Determine whether the implemented IOTP resulted in improved compliance to 7-day follow-up appointment and medication adherence. Methods: A retrospective chart review is being performed of Veterans enrolled in the IOTP at the VAWNY Healthcare System between August 1, 2015 and May 31, 2016. Two admission periods will be compared; patients will serve as their own controls. The admission where the patient participated in the IOTP is Period Two. The prior admission is Period One. For the primary endpoint we will compare attendance at the 7-day post-discharge follow-up appointment for Period One and Period Two. Adherence to psychotropic medication will be estimated using the validated Medication Possession Ratio (MPR) equation; changes in MPR for the 90-days following discharge will be compared between Periods One and Two. Logistic regression will be used for multivariate analyses to determine independent variables associated with the primary outcome, attendance at the 7-day follow-up appointment. Independent variables that will be evaluated as potential predictors of the primary outcome include patient demographics, mental illness diagnosis, time since diagnosis of mental health disorder, substance abuse, living situation (residential facility, independent or co-dependent home, homeless), Mental Health Intensive Case Management-MHICM, prescribed psychiatric medications (classes), number of previous hospitalizations within the last 12 months and change in MPR. Significance will be accepted at a p value less than 0.05. Outcomes: In addition to primary outcomes, we will report the number and percent of participants who attended the 7-day follow-up appointment for each group, and summary statistics comparing demographics and independent variables between groups.

1. Regis University School of Pharmacy, Denver, CO; 2. Porter Adventist Hospital, Denver, CO

Abstract Type: Work in Progress. Background: Promoting tobacco cessation in the inpatient psychiatric population has traditionally not been encouraged by psychiatric professionals. Nicotine dependent people with psychiatric diagnoses comprise 7.1% of the United States population and smoke 44% of cigarettes consumed in the nation. It has been shown that people with mental illness have a more difficult time with cessation efforts and are less likely to be presented with cessation resources and guidance. It is well known that major complications of tobacco use include cardiovascular disease, cancer and respiratory disease. It is estimated that tobacco smokers with mental illnesses have a life expectancy 20 years shorter than people without tobacco dependence and mental illness. The investigators of this study believe that promoting tobacco cessation in an inpatient psychiatric setting is necessary to decrease co-morbidities and mortality related to tobacco dependence while providing support in a safe environment with constant surveillance of medical and psychiatric professionals. Objectives: The objective of this study is to determine if inpatient tobacco cessation classes influence the adult psychiatric patients’ readiness to quit using tobacco. Methods: All psychiatric inpatients are screened on admission for tobacco use. Nursing and medical staff ensure nicotine replacement therapy for current tobacco users upon patient request. Participants will be recruited based on prescription nicotine replacement therapy during hospitalization. Participants will be asked to complete a five question pre-survey indicating his or her level of consideration to quit using tobacco products. There are two demographic questions on the pre-survey including amount of cigarettes smoked daily and duration of time that the patient has smoked tobacco. The participant will then attend a 45 minute tobacco cessation class. Immediately following the class the participant will complete a four question post-survey indicating his or her level of consideration to quit using tobacco products. Outcomes: The authors will report the patient’s responses before and after the smoking cessation class in relation to desire to quit, methods of cessation, reason for quitting and likelihood of quitting within 30 days.

1. Husson University, School of Pharmacy; 2. Nova Southeastern University, College of Osteopathic Medicine; 3. Nova Southeastern University, College of Dental Medicine; 4. Nova Southeastern University, College of Pharmacy

Abstract Type: Work in Progress. Purpose: High levels of medication adherence are necessary to prevent the progression of HIV; however, there are several factors which can adversely affect adherence rates in this population. Depression rates among HIV positive patients are higher than in the general population, and could be a potential risk factor for poor adherence to antiretroviral medications. HIV has been shown to be associated with mild cognitive impairment, which could affect medication adherence. While these factors have been studied in HIV positive populations, there is less literature pertaining to the effects on young adults (ages 20 to 29), the group with the highest rates of new HIV diagnosis. The aim of this study is to investigate the correlation between medication adherence rates and depression among young adult patients with HIV. Additional cognitive factors will be assessed for their impact on adherence. Methods: Participants completed depression scales (i.e., Center for Epidemiologic Studies Depression Scale [CESD], Patient Health Questionnaire [PHQ-9]) and cognitive assessments (i.e., Grooved Pegboard test, Trail Making tests A and B). Medication adherence to antiretroviral therapy over a minimum 4 week period was primarily determined using Medication Event Monitoring System (MEMSCaps). Descriptive statistics, independent t-tests, and correlation analysis (i.e., Pearson’s) were used. Results: A total of 12 participants (92% male) with an average age of 27 years have completed the study. Medication adherence was highly correlated with CES-D (r = -.606, n = 12, p = 0.037) and PHQ-9 (r = -.569, n = 12, p = 0.053). Correlation between medication adherence and cognitive tests were as followed: Trail making A (r = -.697, n = 12, p = 0.012), Trail making B (r = .423, n = 12, p = 0.171), Grooved Pegboard-dominant hand (r = -.188, n = 12, p = 0.558), and Grooved Pegboard-non dominant hand (r = -.115, n = 12, p = 0.721). Conclusions and Future Directions: Preliminary results suggest a high correlation between medication adherence and depressive symptoms measured via the CESD and PHQ-9. Additionally, the Trail Making tests, which both take less than five minutes to perform, moderately correlated with medication adherence in this small patient population. Further studies are needed to explore this association.

All parties are affiliated with Salem Veterans Affairs Medical Center

Abstract Type: Work in Progress. Purpose: Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression. With the recent increase in opioid overdose rate, naloxone is available as a rescue injector for patient use. Naloxone can promote safety; however, there are conflicting attitudes regarding provision of a naloxone prescription to opioid users. The hypothesis is that possession of naloxone kit will not impact subsequent opioid use following completion of a 28-day substance abuse residential rehabilitation treatment program (SARRTP). The purpose of the study is to determine if a significant difference exists between patients matched for substance use disorder brief addiction monitoring (BAM) score in a SARRTP who were provided a naloxone take-home rescue kit versus those who were not. Methods: This is a prospective matched cohort study involving patients enrolled in the SARRTP. All patients receiving take-home naloxone rescue kits at the completion of SARRTP will be included in the study. To be included in the study without a prescription of take-home naloxone, the patient must have an active diagnosis of opioid use disorder defined by urine drug screen (UDS). The BAM risk for use subscale score at SARRTP discharge will be used to include those not receiving naloxone to serve as the matching cohort. At follow-up in four weeks post-discharge from SARRTP, patients will be surveyed via telephone regarding relapse, opioid and naloxone usage, and adherence to Aftercare treatment. Patients will be requested to provide their opinion regarding whether naloxone availability is problematic for their opioid use disorder. Results and Conclusion: Results of the study are expected within 3-4 months. Results will be utilized to determine if subsequent opioid use becomes more likely or remains the same when providing naloxone take-home rescue kits in a population of Veterans with a diagnosis of opioid dependence.

1. Saint John Medical Center, Tulsa, Oklahoma; 2. Saint Francis Health System, Tulsa, Oklahoma

Abstract Type: Work in Progress. Background: In the critically ill population, the incidence of mental illness is common. Abrupt discontinuation of psychotropics upon admission can lead to complications including acute destabilization. Psychiatric decompensation in critically ill patients can worsen medical outcomes, decrease adherence to treatment plans, and increase requirements for doses of as needed (PRN) medications, such as benzodiazepines, for agitation or restlessness. Increased usage of benzodiazepines is linked with increased rates of ICU delirium. Therefore, it is crucial to restart home psychotropic medications as soon as possible upon admittance to the hospital Objectives: 1. Evaluate the total number of agitation episodes requiring pharmacotherapy intervention between patient who had restarted home medications in the ICU and those who had not. 2. Evaluate the total usage of PRN benzodiazepines and antipsychotics between patient groups who had restarted home medications in the ICU and those who had not. Methods: Data will be collected retrospectively from November 2014 to October 2015 to evaluate patients admitted to the ICU with a history of mental illness and home psychotropic use who had PRN benzodiazepines or antipsychotics ordered during ICU admission. Patients will be separated from other patients by manual evaluation of patient history and physical notes in charts. Patients with a history of seizures, active substance abuse, detoxification protocols ordered, or on continuous benzodiazepine infusions will be excluded. Charts will be evaluated to discern whether or not a home psychotropic regimen was present. These patients will then be further separated based upon whether or not home psychotropic medications were restarted. One hundred patients will be randomly selected and compared. Outcomes: The number of agitation episodes requiring pharmacotherapy interventions will be documented. The difference in PRN medication use between the two groups will be expressed as total doses given and average daily dose of benzodiazepines in diazepam equivalents and total doses of antipsychotics in chlorpromazine equivalents.

All parties are affiliated with Veterans Affairs Salt Lake City Health Care System

Abstract Type: Work in Progress. Background: Alcohol use disorders affect a large percentage of Americans. It is estimated that 8 million Americans and more than 300,000 Veterans have an alcohol use disorder (AUD). There is need for effective treatment options for AUD to be used. Currently, FDA approved pharmacotherapies for AUD are underutilized. Barriers to utilization include provider perception that medications are poorly to modestly effective, and concerns that patients will be non-adherent. At one Veterans Affairs (VA) Health Care System, both oral and long-acting injectable naltrexone (LAIN) are formulary agents. However, LAIN is restricted to patients for whom adherence is a significant concern, due to considerable differences between LAIN and oral naltrexone in procurement and administration costs. Both formulations have shown efficacy on their own, but to date there are no head-to-head trials comparing LAIN to oral naltrexone. Objectives: To compare: 1) 90 day alcohol-related hospital readmissions in patients receiving LAIN or oral naltrexone for AUD; 2) differences in outpatient clinic and emergency department (ED) visits and 3) medication adherence by medication possession ratio or injection administration visits. Methods: This is a retrospective chart and archived database review. Patients enrolled at a single Veterans Affairs health care system are included if oral naltrexone or LAIN was administered for AUD during a hospitalization or issued as an outpatient prescription from January 1, 2015 through December 31, 2015. Patients will be excluded if they receive additional pharmacotherapy for AUD. Data extracted will include baseline demographics, baseline number of AUD related clinic or ED visits and hospitalizations in the 12 months before naltrexone initiation, naltrexone administration and prescription details, and number of hospital readmissions, clinic, and ED visits in the 6 months following naltrexone initiation. Outcomes: We will report 90 day and 30 day readmission rates, medication adherence, and change in AUD related clinic and ED visits.

1. University of Pittsburgh School of Pharmacy, Pittsburgh, PA; 2. Western Psychiatric Institute and Clinic, Pittsburgh, PA

Abstract Type: Work in Progress. Background: Stigma is defined as “a set of negative and often unfair beliefs that a society or a group of people have about something.” Stigmas are often associated with mental health and are a significant barrier to those seeking effective treatment and recovery from mental illness. All pharmacy students, either personally or professionally, will be in contact with persons diagnosed with mental illness. A study done by Scott Patten et. al. in 2010-2011 entitled Effectiveness of contact-based education for reducing mental illness-related stigma in pharmacy students shows that contact-based interventions are an effective way to reduce stigmas. This intervention is important to all healthcare students, as mental health disorders are seen in the hospital or community. Providing health care professionals with a better understanding of mental health will benefit society as a whole. Objectives: The objectives of eSMILE are to 1) Evaluate the impact of the psychiatry module of the pharmacy curriculum on students’ attitudes towards mental illness 2) Evaluate exposure to psychiatry through didactic and experiential learning and 3) Identify opportunities to increase student exposure to mental illness concepts throughout the curriculum. Methods: Pharmacy students at the University of Pittsburgh will be asked to complete the Opening Minds Scale for Health Care Providers (OMS-HC) to assess their attitudes towards providing care for patients with mental illness. The survey will be sent out through an email to all of the students at the beginning of the spring semester. For third-year professional students (P3), the survey will be repeated at the end of the concentrated psychiatry portion of the Neurology and Psychiatry Therapeutics Module in order to compare the pre- and post-responses. Outcomes: The sample size will include all pharmacy students at the University of Pittsburgh School of Pharmacy. The primary endpoint will be to identify the portion of students who express any degree of stigma toward mental health. The secondary outcome will be to assess whether the current exposure to mental health in the pharmacy curriculum is an effective means of reducing stigma.

All parties are affiliated with Blessing Hospital

Abstract Type: Work in Progress. Purpose: Thromboembolic events are rarely reported in patients admitted to mental health units. However, case reports and epidemiological studies indicate mental health patients are at risk for developing a thromboembolism while in the hospital. Factors such as physical restraint, catatonia, and certain psychotropic medications have been identified as potential risks for thromboembolism. The purpose of this project is to evaluate physician acceptance of a pharmacist-led thromboembolism prophylaxis protocol. Methods: This prospective cohort will examine a pharmacist-led intervention on thromboembolism prevention on an adult mental health unit. Study authors will develop a screening tool to identify patients with an increased risk for developing thromboembolism. Patients will be screened based on weight, age, past medical history, current health status, and specific psychotropic medications. Pharmacists will recommend enoxaparin for patients who meet criteria for thromboembolism prophylaxis. The primary endpoint will be the acceptance rate of pharmacist recommendations for thromboembolism prophylaxis. Secondary endpoints will include incidence of thromboemboli and bleeding events in patients receiving prophylaxis. Descriptive statistics will be used to analyze the data. Interim data analyses will be completed at two months, four months, and six months. Final data analysis will be completed at nine months Results: N/A Conclusions: N/A

1. Eskenazi Health, Indianapolis, IN; 2. Purdue University College of Pharmacy, West Lafayette, IN; 3. Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN

Abstract Type: Work in Progress. This is not an encore presentation. Background: Patients with psychotic illness generally cycle between periods of recovery and acute psychotic episodes. Effective early treatment with antipsychotic medication decreases the risk of relapse. Prevention of relapse after an early or first episode psychosis leads to better patient outcomes and improved likelihood of long-term remission. Not all patients will have consistent adherence to oral antipsychotic medications, limiting the ability of the patient to achieve a significant period of time without relapse. The development of long-acting injectable antipsychotics has provided patients with a treatment option that does not require daily dosing and may improve adherence to drug therapy and effectiveness of treatment. This study will provide new data comparing oral and long-acting injectable antipsychotics with regard to medication adherence and persistence, specifically in individuals with early psychosis. Objectives: 1. Compare adherence and persistence between long-acting injectable and oral antipsychotics, 2. Determine the rate of use of acute care services with both antipsychotic formulations. Methods: PARC patients with a diagnosis of schizophrenia, schizophreniform, schizoaffective disorder, or psychosis NOS, from July 2013 through August 2014, will be included. A one year retrospective analysis of patients’ medical records will include administration route of antipsychotic (PO or IM), prescribed dosing frequency of long-acting injectable, pharmacy refill history, and long-acting injectable administration dates. For objective 1: n and % of patients adherent and persistent with therapy will be reported and compared between groups. Adherence will be defined as ≥80% proportion of days covered using fill quantities of oral medications and administration dates of long-acting injectables. Persistence will be measured by gaps in therapy, defined as a medication refill > 1 day from the expected refill date based on previous fill quantity or a missed injection. For objective 2: the number of times acute care was required while prescribed an oral or long-acting injectable will be reported. Outcomes: We will report adherence, persistence, and rate of use of acute care for patients prescribed any oral or long-acting injectable antipsychotic. Final results will be utilized for future patients with the goal to increase adherence and persistence while preventing relapse and minimizing use of acute care services.

All parties are affiliated with the Department of Veterans Affairs Medical Center

Abstract Type: Work in Progress. Background: Since 2000, the United States has seen a 200% increase in opioid overdose deaths with a 14% increase from 2013 to 2014 alone. This rise has been contributed to both prescription and illicit opioid overdoses, spurring the need for an increased effort to provide naloxone kits to at risk patients. Within the William S. Middleton VA ADTP program, an initiative was developed to have a prescriber available daily to write prescriptions for identified high-risk ADTP Veterans. Objectives: 1. Evaluate changes in naloxone kit prescribing after the start of the on-call ADTP prescriber initiative. 2. Assess naloxone kit prescribing trends. 3. Identify reasons provided for naloxone kit refills. Methods: Data will be gathered from a national dashboard (Overdose Education and Naloxone Distribution (OEND)), local medication evaluation tool (Medication Use Evaluation (MUE) note), and chart reviews. The OEND dashboard identifies Veterans receiving care from a VA who have been issued a naloxone rescue kit within the indicated time period. The MUE note is a medication evaluation tool that is required to be completed prior to prescribing naloxone kits and, when appropriate, prompts providers to indicate the reason for a refill. Chart reviews will be completed for Veterans who have been identified by the OEND dashboard to have received a naloxone kit from the William S. Middleton VA Hospital and associated clinics. Demographic variables risk factors, type of naloxone kit prescriber/clinic issuing kit, and the reason provided for refills will be collected. Data will be reviewed to identify ADTP Veterans who have received naloxone kits from June to August 2015 and compared to those who received a kit from October to December 2015, evaluating for changes in the number of naloxone kits ordered before and after initiation of the on-call prescriber system. Secondarily, naloxone kit prescriptions throughout all clinics within the William S. Middleton VA from December 2014 to December 2015 will be reviewed. This information will be further assessed to determine prescribing trends to identify areas of both high and low kit utilization. Outcomes: Pending at time of abstract submission.

1. Temple University School of Pharmacy Philadelphia, PA; 2. Department of Pharmacy, Barnabas Behavioral Health Center Toms River, NJ

Abstract Type: Work in Progress. Background: Over the last decade, atypical antipsychotics assumed the role of mainstay treatment for patients with schizophrenia due to a more favorable side effect profile. Medication non-adherence is major concern in most patients with mental illnesses and leads to decompensation or frequent re-hospitalization. Long-acting injectable antipsychotics (LAI) were developed in order to counter the issue of medication non-adherence and improve outcomes. Aripiprazole once monthly (AOM) is one of the five atypical antipsychotic LAIs currently available. Aripiprazole has a novel mechanism of action on D2, 5HT-1A, and 5HT-2A receptors and is indicated for schizophrenia. Patients with schizophrenia may benefit from aripiprazole due to its mild side-effect profile and its potential to improve negative symptoms. Patients with mental health illnesses often tend to possess a secondary substance abuse issue and are an increased risk of frequent re-hospitalization. This analysis aims to identify the factors impacting treatment of patients on AOM and provide guidance for health providers in medication selection. Objective: To evaluate the utilization of AOM on re-hospitalization rates and identify possible factors that might indicate positive therapeutic outcome. Methods: A retrospective chart review will be conducted to identify patients who received AOM upon discharge in 2015 at an inpatient mental health hospital in Toms River, NJ. Demographics collected will include age, gender, weight, psychiatric diagnosis, substance abuse history, previous antipsychotic therapies, social support factors, adherence, post-discharge plan, and insurance coverage. Primary outcome will focus on identifying re-hospitalization rates within 30, 90 180, and 360 days after receiving AOM. A student t-test will be conducted to find a difference between the groups. Secondary outcomes will analyze the difference in patient specific characteristics that may impact therapy outcomes. Outcomes: The primary outcome will analyze the utilization of AOM on rehospitalization rates within the local population. Secondary outcomes will assess difference in therapeutic factors to foster improved medication usage.

All parties are affiliated with the WJB Dorn VA Medical Center

Abstract Type: Work in Progress. Background: Benzodiazepines (BZD) are not recommended for the treatment of PTSD due to lack of benefit and potential harm. Patients with a concomitant substance use disorder and/or traumatic brain injury (TBI) may be at greater risk based on limited evidence. Drug interactions with BZD may also increase potential for harm. Previous PTSD studies report 70-91% of patients have difficulty falling or staying asleep and 66% of patients are diagnosed with chronic pain. BZD with sedative hypnotics and/or opioids carry warnings for increased risk of harm and potentially death. Objectives: Evaluate safety outcomes in PTSD subjects with alcohol use disorder and/or TBI receiving a sedative hypnotic and/or an opioid with or without a BZD. Methods: Data will be collected electronically using ICD-9 codes. Study inclusion criteria includes Veterans treated for PTSD at a VA Medical Center between October 1999 and October 2014. BZD subjects must have received BZD monotherapy or BZD concomitantly prescribed with a sedative hypnotic and/or opioid at least twice, with the second fill being no later than 30 days past the eligible refill date. Exclusion criteria includes Veterans not seen by their primary care or mental health provider for a gap of ≥6 months during the study period. Demographics (age, gender, race), Charlson Comorbidity Index scores, and ICD-9 coding for concomitant anxiety, substance use, TBI, and obstructive sleep apnea diagnoses will be collected. Study participants will be matched among the medication groups to control for confounding variables. Demographic and nominal data will be analyzed using a Chi-Square or Fisher’s exact test to estimate odds ratios. Interval and ratio data will be compared using ANOVA among groups. A p-value of <0.05 will be used to determine statistical significance. Data analysis will be completed and results evaluated in February 2016. Outcomes: For the primary outcome we will report rates of all-cause mortality among groups. For the secondary outcomes we will report rates of emergency room visits and rates hospital admissions among groups.

1. Minneapolis Veterans Affairs Health Care System, Minneapolis, MN; 2. University of Minnesota School of Medicine, Minneapolis, MN

Abstract Type: Work in Progress. Background: According to the Center for Disease Control (CDC), abuse of prescription opioids and heroin is an ever-growing epidemic in the United States. As the number of patients abusing these substances has continued to rise, the need for addiction treatment has escalated. Over 300 veterans have received buprenorphine/naloxone treatment for opioid addiction at the MVAHCS since it became available at this VA in 2004. This project seeks to evaluate treatment outcomes in veterans who have received buprenorphine/naloxone therapy at the MVAHCS utilizing the modified Drug Abuse Reporting Program (DARP) criteria. The modified DARP criteria utilizes a four-point scale to rank ten factors thought to influence substance abuse treatment success, including results from urine analyses, functionality at home and work, criminal activity, housing, and social support. Objectives: The primary objectives of this study are to determine if the length of buprenorphine/naloxone therapy increases the likeliness of treatment success, and if treatment success was maintained after treatment discontinuation in those no longer receiving buprenorphine/naloxone therapy. The secondary objective aims to determine if any correlation exists between outcome success and patient participation in group therapy. Methods: A retrospective chart review of patients at the MVAHCS who have received at least six months of buprenorphine/naloxone therapy will be performed. Baseline demographic information will be collected on each patient, including mental health diagnoses, drug(s) of choice, and methadone treatment prior to initiating buprenorphine/naloxone therapy. For patients who are currently receiving therapy, two modified DARP scores will be obtained: 1) At treatment initiation and 2) Current score within the past three months. For veterans who are no longer receiving therapy, three modified DARP scores will be obtained: 1) At treatment initiation, 2) Treatment completion, and 3) Current score within the past three months. An attempt to contact patients who are no longer receiving care at any VA will be made to obtain current information. Those who are unable to be reached will be excluded from the analysis. Outcomes: The results will be presented to assist addiction recovery providers in treatment recommendations for patients receiving buprenorphine/naloxone therapy.

1. Boise Veterans Affairs Medical Center, Boise, ID; 2. Idaho State University College of Pharmacy, Meridian, ID

Abstract Type: Work in Progress. Background: Studies have documented oral antipsychotic polypharmacy that conflicts with practice guidelines. Less discussed is the combination of oral antipsychotics with long-acting antipsychotics (LAI), which are conventionally viewed as monotherapy. The increasing frequency of concurrent use challenges this notion. Existing data regarding concomitant use of LAI and oral antipsychotics does not identify the indications behind the prescribing of both agents. The purpose of this evaluation is to evaluate the prescribing patterns in patients with concurrent use of both long-acting injectable and oral antipsychotics, offering insight into prescribing practices and identifying trends. Objective: 1) Evaluate the prevalence of oral antipsychotic use in population of LAI patients, 2) Describe indications for concurrent usage, and 3) Determine if repeating concordances between specific oral and LAI antipsychotic medications exist. Secondary endpoints will include hospitalizations and emergency department visits of patients included in the evaluation (comparing concurrent LAI and oral antipsychotic use with LAI use alone), total duration of therapy for each treatment, and trends in demographic data by antipsychotic agent. Methods: This medication use evaluation will be a retrospective chart review by design. Inclusion criteria will encompass all patients at the Boise VAMC on long-acting injectable antipsychotic medications as follows: fluphenazine decanoate, haloperidol decanoate, risperidone long-acting injectable, paliperidone palmitate, aripiprazole long-acting injectable, and olanzapine pamoate. Exclusion criteria will remove all patients on concomitant oral and long-acting injectable antipsychotic therapy for less than 60 days. The data collected includes patient age, unique patient identifier (last initial and last 4 of SSN), gender, mental health comorbidities, patient medication history (including antipsychotic, dose, route, duration of therapy, stop and start dates, frequency of injections, any adverse events), hospitalizations and emergency department visits denoting exacerbations, patient diagnosis codes corresponding to antipsychotic therapy, prescriber of the antipsychotic therapy, clinic where prescribed, and any pertinent medical history. The study does not meet criteria for internal review board approval. Outcomes: The data collected from the evaluation will be analyzed and reported using descriptive statistics, relaying any trends or relationships determined from the objectives. Results will be presented to hospital administrators, clinical pharmacists, and medical staff.

All parties are affiliated with the North Florida/South Georgia Veterans Health System, Gainesville, FL

Abstract Type: Work in Progress. Work in progress has not been presented yet Background: Clozapine has been shown to be a very effective agent for patients with refractory schizophrenia, however, its use is often disregarded due to the availability of newer antipsychotics with less monitoring parameters. The 2015 Clozapine-Psychotropic Drug Safety Initiative (PDSI) was implemented nationwide within the Veterans Health Administration due to low clozapine prescribing practices. Local results showed that the North Florida/South Georgia Veterans Health System FY15Q3 prescribing rate of clozapine was 3.2%, which was below the national average of 4%. This appeared unchanged from FY15Q2 indicating a paucity of clozapine prescribing. According to the VHA handbook on Mental Health, “Clozapine prescribing must be available to all veterans who meet criteria after two failed trials of other antipsychotics. The patient’s informed consent, refusal, or contraindication for clozapine treatment must be documented in the medical record.” Objectives: This Continuous Quality Improvement project will determine whether a Pharmacy Clozapine Note intervention is an effective means of increasing clozapine prescribing for individuals who meet pre-specified criteria. Methods: There are currently 518 patients at North Florida/South Georgia VA who meet the VA criteria for clozapine. The patients were identified using the national PDSI dashboard, which identifies individuals diagnosed with schizophrenia who have tried three or more antipsychotics in the past 5 years. A random sample of 100 patients will be selected for chart review. A Pharmacy Clozapine Note will be entered into the patient’s chart in order to notify the patient’s provider whether or not the veteran meets the pre-specified criteria for clozapine prescribing. A second chart review will be conducted for individuals that met the pre-specified criteria, in order to determine if clozapine was initiated based on the Pharmacy Clozapine Note intervention. Outcomes: Descriptive statistics will be utilized to report the percentage of patients who were prescribed clozapine after the formal Pharmacy Clozapine Note intervention. This percentage will be compared to an equal number of patients that did not receive the intervention.

All parties are affiliated with Virginia Commonwealth University Health System

Abstract Type: Work in Progress. Background: Lithium is a mood stabilizer that is U.S. Food and Drug Administration approved for acute mania and maintenance treatment of bipolar disorder. Lithium is also utilized off-label for other indications such as augmentation of major depressive disorder. Lithium has several safety concerns including a narrow therapeutic index, renal dosage adjustments, and many significant drug-drug interactions. Severe toxicity may lead to seizures, renal insufficiency, coma, cardiac dysrhythmias, and death. Medications with a narrow therapeutic index, such as lithium are a common source of medication-related problems. Medication-related problems, many of which may be preventable, can lead to increased emergency department visits, hospital admissions, and increased patient morbidity and mortality. Objectives: The primary objective is to identify any patient specific factors associated with lithium medication-related problems on non-psychiatric inpatient medical units. The secondary objectives are to characterize lithium medication-related problems and describe if any intervention was necessary to resolve the medication-related problem and if an intervention was made. Methods: This is an Institutional Review Board approved, retrospective, electronic medical record review of lithium medication-related problems. Patients who received a dose of lithium or had a lithium level drawn during an inpatient hospitalization at Virginia Commonwealth University Health System from October 1, 2013 to June 30, 2015 were considered for study inclusion. Age less than 6 years, current admission to an inpatient psychiatric unit, pregnant women, and prisoners were excluded. Logistic regression analysis will be utilized to identify any patient specific factors associated with lithium medication-related problems. Patient specific factors evaluated include age, length of stay, medical service, psychiatry consult obtained, congestive heart failure, and greater than six medications received during hospitalization. Descriptive statistics will be utilized for the secondary objectives. Outcomes: Data collection is complete and analysis is currently in process with the results to be presented. Patient specific factors associated with lithium medication-related problems will be reported. The number and types of medication-related problems will be described for each patient as well as if an intervention was necessary and if any intervention was made. Areas of quality improvement and education will be identified.

All parties are affiliated with the Minneapolis Veterans Affairs Health Care System, Minneapolis, MN

Abstract Type: Work in Progress. Background: In the United States the risk of drug-related overdoses linked to opioids has steadily increased over the past two decades to a record high in 2014. An evaluation of the veteran population indicates that approximately half of the deaths associated with opioid overdoses occurred in patients receiving concomitant benzodiazepines. Research has found that implementing a system to down-titrate dose or discontinue benzodiazepines may decrease mortality risk from drug overdose. Objectives: 1) Evaluate benzodiazepine and opioid dose equivalences, prescribing patterns, and negative outcomes in veterans receiving chronic concomitant benzodiazepines and opioid analgesics. 2) Implement interventions to encourage benzodiazepine dose reduction or de-prescribing. 3) Reduce the number of veterans initiated on this medication combination. 4) Provide veterans with education and resources to minimize the risk of drug overdose. Methods: A retrospective chart review of patients at the MVAHCS prescribed concomitant chronic benzodiazepines and opioids was performed. Cancer, hospice, and palliative care patients were excluded. Results were utilized to identify potential risk-mitigating strategies to encourage de-prescribing or safer patient use of this high-risk combination. Our strategy will include a new requirement for a consult system to prospectively evaluate risks/benefits when a benzodiazepine is prescribed in patients also receiving chronic opioids, or when an opioid is prescribed in patients also receiving chronic benzodiazepines. Provider and patient education on risk-mitigating strategies will also be performed and patients will offered naloxone kits as indicated. Outcomes: 450 veterans were identified as currently being prescribed long term concomitant opioids and benzodiazepines; 386 patients were included in the analysis. The median age of those included was 63 years and 94% (n = 362) were male. Primary care prescribed 92% and 46% of opioid and benzodiazepine prescriptions, respectively. Mental health providers were responsible for prescribing 50% of benzodiazepine prescriptions. Results showed that the majority of veterans prescribed this combination are on morphine equivalences of 1-50mg (75%, n = 289) and diazepam equivalences of 1-10mg (54%, n = 210). Results of the impact of interventions and associated outcomes are currently pending and will be presented.

All parties are affiliated with Truman Medical Centers, Kansas City, MO

Abstract Type: Work in Progress. Background: Antipsychotic treatment is the foundation of long-term treatment for schizophrenia, and discontinuation or non-adherence can lead to exacerbation of symptoms and readmission to the hospital. Long-acting antipsychotics provide another option for psychotic patients with poor adherence. This study being conducted to see if patients who receive a long-acting injectable have a shorter length of stay in the hospital and are readmitted with less frequency than those who take oral antipsychotics. Objective: The primary objective of this study is to evaluate patient length of stay and six-month readmission rates of adult patients receiving a long-acting injectable antipsychotic versus an oral antipsychotic in an acute psychiatric care unit. Longer lengths of stay and more frequent readmissions ultimately lead more healthcare spending and so cost of hospitalization will be compared between the two groups. Methods: This study will be a retrospective chart review over a twenty-four month period with the intention to directly compare length of stay and six month readmission rates of patients receiving a long-acting injectable antipsychotic versus an oral antipsychotic. The long-acting injectable group will consist of patients who were admitted to the behavioral health inpatient unit and were started on a long-acting injectable during their inpatient stay and were discharged on a long-acting formulation. This group will include patients who received the long-acting formulation of paliperidone, fluphenazine, haloperidol, aripiprazole or risperidone. The control group will include patients admitted to the behavioral health inpatient unit with acute psychosis and treated with oral antipsychotics. Patients who received a long-acting injectable and who were admitted greater than thirty days strictly due to placement issues, patients given a long-acting injectable in the emergency department but not admitted, and patients 65 years or older will be excluded from the study. The primary objective is to determine if length of stay and readmission rates are shorter and fewer respectively in the long-acting antipsychotic group. Secondary outcomes will include cost of long-acting injectable antipsychotics versus oral antipsychotics and general healthcare costs between the two groups. Outcomes: Research in progress

1. Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey; 2. Henry J. Austin Health Center, Trenton, NJ; 3. PharmD Candidate, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey; 4. Department of Statistics & Biostatistics, Rutgers, The State University of New Jersey

Abstract Type: Work in Progress. Background: It has been estimated that up to 31% of patients with diabetes report depressive symptoms. Patients with diabetes and depression have higher odds of functional disability than those with either condition alone, and this can be a predictor of increased healthcare costs and mortality. Therefore, it is important to screen for depressive symptoms in patients with diabetes. The Patient Health Questionnaire (PHQ-9) is a diagnostic tool which can identify Other Depressive Syndrome (ODS) or Major Depressive Syndrome (MDS), whereby MDS is associated with a higher number of reported depressive symptoms. Pharmacists may use this tool to monitor depressive symptoms in diabetic patients which has the potential to lead to improved management strategies and outcomes. Objectives: To evaluate the impact of adding clinical pharmacists to the standard of care for the management of type 2 diabetes in patients with and without depression. Methods: This study is part of an ongoing prospective, randomized controlled trial focused on the improvement of HbA1C scores in uncontrolled diabetic patients in a Federally Qualified Health Center. Medicaid-eligible patients are enrolled if they have had type 2 diabetes for at least 3 months, a baseline HbA1C of >8%, and are between the ages of 18-74 years old. Enrolled patients are randomized to a control arm in which they receive the standard of care, or an intervention arm in which they also receive care from a clinical pharmacist. Pharmacists provide Medication Therapy Management with a focus on improving HbA1C scores. HbA1C and PHQ-9 results are recorded at baseline and at a 6 month midpoint meeting. Results: Current demographics of the 154 enrolled patients with a HbA1C and PHQ-9 score documented at baseline indicate that 38% report symptoms consistent with ODS or MDS. Mean baseline HbA1C values are 10.3% (SD = 1.6) in the control arm and 10.4% (SD = 1.9) in the intervention arm. Mean baseline PHQ-9 scores are 8.5 (SD = 7.6) in the control arm and 9.4 (SD = 7.5) in the intervention arm, indicating mild depression. Outcomes: Mean HbA1C and PHQ-9 changes from baseline to 6-months will be compared for those with and without depressive syndromes in the control and intervention arms.

1. Eskenazi Health, Indianapolis, IN; 2. Purdue University College of Pharmacy, West Lafayette, IN; 3. Indiana University Center for Aging Research, Regenstrief Institute Inc., Indianapolis, IN

Abstract Type: Work in Progress. Background: Treatment guidelines for the management of schizophrenia discuss initiating a single antipsychotic agent as first line treatment; however, in patients who have partial to no response to initial trials of medications, the next steps in drug selection can vary significantly in different guidelines Treatment resistance is characterized as a suboptimal response to at least two antipsychotic agents at an adequate dose and trial period. Evidence supports the use of clozapine in individuals with treatment resistant schizophrenia; nevertheless, treatment resistance is a commonly used justification for the use of antipsychotic polypharmacy. Studies have shown that antipsychotic polypharmacy is often considered before clozapine in patients that have failed at least one antipsychotic agent. The majority of treatment guidelines discourage antipsychotic polypharmacy due to insufficient supporting evidence; yet this has become common practice. Based on this data, Indiana Medicaid initiated a prior authorization process in March 2014 requiring prescribers to evaluate the use of clozapine prior to approval of antipsychotic polypharmacy. Objectives: To analyze the prescribing trends for clozapine and antipsychotic polypharmacy before and after the implementation of the March 2014 prior authorization. Secondary aims will focus on the frequency of both antipsychotic polypharmacy throughout the defined study period individuals transitioned from antipsychotic polypharmacy to clozapine after the prior authorization launch. Methods: A retrospective review will be conducted in the adult Indiana Medicaid population aged 18 to 64 years with an ICD9 code for psychosis. Participants must have had active Indiana Medicaid enrollment at any time between September 1, 2013 and August 31, 2015. Demographic variables (age, sex, race), number of prescriptions for clozapine, number of prescriptions for concomitant antipsychotic therapy, and type of prescriber will be collected. Descriptive statistics will be used to describe trends in clozapine and antipsychotic polypharmacy prescribing throughout the study period. Outcomes: The number and percent of claims for clozapine, antipsychotic polypharmacy, and transition of individuals from antipsychotic polypharmacy to clozapine before and after implementation of the prior authorization will be reported.

All parties are affiliated with Jesse Brown Veterans Affairs Medical Center, Department of Pharmacy

Abstract Type: Work in Progress. Background: Aripiprazole has become the number one best-selling medication in terms of revenue in the United States. Aripiprazole is a second-generation antipsychotic, which is FDA approved to treat bipolar, schizophrenia or can be an add-on medication for depression. Based on the pharmacokinetic and pharmacodynamic properties of the medication, aripiprazole should be taken once daily. Multiple day dosing can add burden to the patients and increase costs. Pill splitting is also a well-established cost-saving strategy used by health care systems. At Jesse Brown Veterans Affairs Medical Center (JBVAMC), while the majority of patients prescribed aripiprazole take it once daily and split tablets, there still remains a small percentage of patients with multiple day dosing and who are not splitting tablets. Given the high cost of aripiprazole, these patients were targeted for pharmacist interventions as a strategy to save cost while improving patient safety. Objective: The purpose of this study is to examine the efficacy of interventions implemented by the clinical pharmacist in successfully converting prescriptions of aripiprazole to once daily and split tablet dosing. Method: This study will be a retrospective chart review of 150 patients obtained through Computerized Patient Record System (CPRS) at JBVAMC. Descriptive analysis will be used to analyze the primary and secondary endpoints. Outcomes: The primary endpoint is to quantify and compare the change in number of prescriptions successfully converted to split tablets or converted to once daily dosing. The secondary endpoint will quantify and compare costs of aripiprazole before and after implementation of strategies based on individual patient’s medication possession ratio (MPR). In addition, the patient’s chart will be examined for negative outcomes and documentation of provider’s rationale for not converting the patient.

All parties are affiliated with the University of Southern California School of Pharmacy, Los Angeles, CA

Abstract Type: Work in Progress. Background: The alpha-2 adrenergic agonists, clonidine and guanfacine, are considered alternative or adjunctive treatment to stimulants for patients with ADHD. Additionally, alpha-2 adrenergic agonists are used off-label for the treatment of moderate or severe tics, conduct disorder, symptoms of inattention, hyperactivity and irritability in children with ASD, and for symptoms of insomnia in children with ADHD, ASD, anxiety, and mood disorders. While extended release formulations (XR) of guanfacine and clonidine are FDA approved for pediatric ADHD, immediate release (IR) formulations have been used off-label for many years. It has been demonstrated that the alpha-2 adrenergic agonists may be less effective in adolescent patients with ADHD. In one particular study, guanfacine XR showed greater efficacy in 6-12 year old participants compared with 13-17 year old participants. Additionally, lighter patients who received higher weight-adjusted dosages had the most improvement in ADHD-RS-IV total scores. This study aims to evaluate factors associated with efficacy and tolerability of clonidine and guanfacine (XR and IR) in children and adolescents seen for a range of diagnoses in a pediatric psychiatry clinic that serves 240 patients. We hypothesize that clonidine and guanfacine are more effective in lighter, younger children. Objectives: 1) Evaluate the extent and persistence of use of clonidine and guanfacine in a child and adolescent psychiatry clinic. 2) Assess documented clinical efficacy and tolerability of alpha-2 adrenergic agonists for a variety of neuropsychiatric indications. 3) Compare documented efficacy and tolerability based on age, weight, and dosage. Methods: This is a retrospective review, of youth ≤ 18 years of age, receiving at least one prescription for clonidine or guanfacine at LAC+USC Child and Adolescent Psychiatry Clinic from May 1, 2015 through December 31, 2015. Evaluation of medical records was performed by a PGY-2 psychiatric pharmacy resident not involved in treatment decisions during the study period. Outcomes: We will report the number of patients treated with clonidine or guanfacine, their age, weight, diagnoses, dose, duration of treatment and reported therapeutic and/or adverse response according to clinician progress notes in the electronic medical record. Age group, weight, dose, and efficacy and tolerability comparisons will be discussed.

All parties are affiliated with the Department of Pharmacy at West Palm Beach Veterans Affairs Medical Center, West Palm Beach Florida

Abstract Type: Work in Progress. Background: Historically benzodiazepines (BZDs) were the primary posttraumatic stress disorder (PTSD) treatment agents due to their anxiety-reducing properties. However, reports show that there are significant risks associated with BZDs and there is lack of evidence for their effectiveness in the treatment of PTSD. These agents carry risks of abuse, dependence and withdrawal. The most common adverse effects include sedation and sleep apnea. BZDs have been associated with high fall and accident risk especially when combined with opioids and in the elderly. The therapeutic effect of BZDs decreases over time due to development of tolerance; however, the cognitive effects (i.e., BZD-induced neurocognitive disorder) usually persist for issues with attention, memory, and impaired learning. The Veterans Affairs/Department of Defense (VA/DoD) guideline recommends the use of antidepressants, specifically Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) as first line therapy for PTSD. Purpose: To assess current treatment and to implement strategies to minimize new BZDs prescriptions in our Veteran PTSD population in the outpatient psychiatry clinics. Methods: This quality improvement initiative is designed to evaluate the current use of BZDs in the specific outpatient psychiatry clinics at our VA medical center for conformance with the VA/DoD practice guidelines for PTSD. A retrospective review of patient’s Computerized Patient Record System (CPRS) medical records will be evaluated for those patients who received a BZD over a 2 month span for the treatment of PTSD in the outpatient psychiatry clinics from January 1, 2015 to December 31, 2015. Data that will be collected will include patient demographics, primary therapy used for treatment of PTSD, length of therapy of BZD, initiation of taper for a BZD, pertinent comorbidities and completion of previous trials of first line pharmacologic agents. Based on identified trends, the objective is to create a standard operating procedure for utilizing a BZD for the treatment of PTSD at a VA medical center. Additionally, general recommendations for BZD tapering in Veterans with PTSD will be provided.

1. Duquesne University Mylan School of Pharmacy; 2. UPMC Mercy Hospital

Abstract Type: Work in Progress. Background: Gabapentin is an agent that is FDA approved as an adjunct treatment for partial seizures or for post-herpetic neuralgia. Since its introduction, controversy has followed the drug in terms of promotion for off-label use. Some examples of non-FDA approved uses include diabetic peripheral neuropathy, pain syndromes, “hot flashes”, migraine, anxiety, and bipolar disorder. The evidence supporting the off-label use of gabapentin in these disorders has been limited to small studies or case reports. Further, it has been reported both in the literature and anecdotally via “weblogs” that gabapentin has been misused by persons with active or remitted substance use disorders. This work will provide new information regarding the use of gabapentin in a behavioral health population, both FDA approved and off-label, and to determine the rate at which gabapentin is being utilized and/or misused within the mental health population. Objectives: This cross-sectional study concerns itself with determining the rates of gabapentin use prior to admission to a hospital behavioral health unit. The use can be for either FDA approved or off-label uses. A comparison between studied doses and prescribed daily doses will be performed. From this, we hope to determine if a correlation exists between gabapentin administration and co-occurring substance use disorders in a behavioral health population. Methods: Data will be collected on all subjects prescribed gabapentin at the time of admission to a hospital behavioral health unit during a one-year period. Other collected data will include: age, gender, race, total daily gabapentin dose, renal function, psychiatric diagnoses, medical diagnoses, history of substance misuse disorder, the need for medical detoxification on admission, detoxification protocols utilized, urine drug screen results and the reason for gabapentin use. Outcomes: The data collected will be analyzed for the rate at which gabapentin is being used for an FDA approved indication compared to “off-label” use. We will also determine if a correlation exists between gabapentin use and co-morbid substance use disorders. Lastly, we will determine the percentage of patients taking gabapentin compared to the total number of behavioral health admissions to determine the prevalence of gabapentin use in the mental health population.

1. School of Pharmacy, University of Waterloo; 2. Epilepsy Waterloo-Wellington

Abstract Type: Work in Progress. Background: Epilepsy is a prevalent neurological condition, affecting 0.3 - 1% of North Americans. Although both males and females are affected, women face gender-specific challenges with epilepsy and antiepileptic drugs (AEDs). These include hormonally influenced seizures and seizure patterns, interactions between AEDs and oral contraceptives that decrease the latter’s effectiveness, changes in AED pharmacokinetics during pregnancy, increased risk of osteoporosis from AEDs, and increased risk of teratogenicity in offspring if taken during pregnancy. It is imperative that women with epilepsy (WWE) be able to make informed decisions about the treatment of their condition. Community pharmacists are among the most accessible of healthcare professionals as well as experts in medication management, thus are in an ideal position to counsel WWE about safe and effective use of their AEDs. Objectives: 1. To better understand the expectations and needs that WWE have of their community pharmacists. 2. To develop medication education interventions tailored to WWE to be delivered by community pharmacists. Methods: Eligible WWE (18 years or older currently being treated with AEDs) are being recruited to participate in focus-group sessions and one-to-one interviews to better understand their needs, expectations and experiences. Focus group sessions, with four to six participants per group, and one-to-one interviews will be held until point of data saturation is reached. Participants complete a pre-session survey to capture demographics, epilepsy-related medical history, medication history and their interactions with community pharmacists, and a post-session survey to determine satisfaction with the focus groups and interview process. Transcribed notes from focus group sessions and one-to-one interviews are analyzed through constant comparison analysis to identify themes related to the research objectives. Outcomes: Preliminary analysis indicates WWE struggle to find appropriate and satisfactory information. WWE expect their community pharmacist to be a reliable, approachable, and timely source of information on AEDs, in particular, drug interactions (e.g. oral contraceptives, natural health products), side effects, teratogenicity, as well as appropriate pre-conception measures, pregnancy and breast-feeding, safety measures and affordable alternatives. WWE also expressed a need for privacy, repetitive counseling on important information, especially among adolescents, and collaborative care effort by community pharmacists.

All parties are affiliated with VA Salt Lake City Healthcare System

Abstract Type: Work in Progress. Background: Prescription opioid overdose is an epidemic in the United States, unintentional overdose deaths increased by 125% between 1999 and 2007. Veterans have a two-fold greater risk of death from opioid overdose than the general population. Recent studies suggest that the previously published risk factors for opioid overdose may not predict all overdose events. There is pharmacogenomic variability in opioid metabolism. Hydrocodone, tramadol, and oxycodone, present in two-thirds of overdoses, are metabolized through CYP 2D6 to highly potent active metabolites. Approximately 3-5% of Caucasians have an ultra-rapid CYP 2D6 phenotype which might result in greater production of these highly potent opioid metabolites. CYP 2D6 phenotype in individuals who experience an opioid overdose is unknown. Objectives: The purpose of this study is to determine the CYP 2D6 genotype and phenotype of veterans who have experienced opioid overdose. Methods: Veterans who have survived an opioid overdose (patients) and those who have similar clinical characteristics and medications but who have not experienced opioid overdose (controls) will be recruited. Following informed consent, a sample of blood will be collected and send to the reference lab to be evaluated for CYP 2D6 phenotype. Charts will be reviewed for opioid and other medication prescription data, medical conditions, age, gender, race and ethnicity. A questionnaire will be administered to gather pertinent information not available in the patient’s electronic chart. Descriptive statistics will determine the percentage of patients and controls with various CYP 2D6 phenotype. Outcomes: Differences in the prevalence of CYP 2D6 ultra-rapid phenotype between patients and controls will be reported. The results may ultimately contribute to safer opioid prescribing practices and decrease prescription opioid overdose.

All parties are affiliated with Summa Health System

Abstract Type: Work in Progress. Background: Neuroleptic malignant syndrome (NMS) is a rare condition characterized by hyperthermia, “lead pipe” muscle rigidity, mental status change and autonomic dysfunction. NMS is an adverse reaction from antipsychotic medications. Previous studies have identified that high potency, first generation antipsychotics have a higher risk of NMS compared to others. Antipsychotics via parenteral routes, higher titration rates and total dose of drug administered also confer a higher risk. Additional risk factors include; alcohol and substance abuse, previous brain injury, mental retardation and dementia. Recent attention has been paid to rapid dose escalation of antipsychotics as a potential risk factor with mixed results to date. Objectives: 1) To determine how many patients were diagnosed with NMS at Summa Health System from 2008-2015. 2) To evaluate if patients diagnosed with NMS have or were exposed to identifiable risk factors. 3) To determine if there is some aspect of care provided at Summa Health System that may be related to NMS development. Methods: A retrospective chart analysis of patients who were diagnosed with NMS at Summa Health System will be performed. Demographic data, clinical features of NMS, antipsychotic agent, number of scheduled and as needed antipsychotics, route of administration, antipsychotic naive, antipsychotic dose stability, escalation or de-escalation, Richmond Agitation Sedation Scale (RASS), use of delirium order set, length of stay, other psychotropic medications, NMS treatment and death data points will be collected. Patients with NMS will be identified through Summa Health System MEDMARX adverse drug reporting database, computerized physician order entry (CPOE), drug utilization review of dantrolene and chart review. Diagnosis will be based on a triad of fever, rigidity and rhabdomyolysis with or without delirium with use of an anti-dopaminergic agent. Inclusion criteria include: patients ≥ 18 years old and documented diagnosis of NMS. Exclusion criteria include: patients < 18 years old, pregnancy, patients who developed NMS from agents other than antipsychotics and patients with confounding diagnoses. Outcomes: The primary outcome is the proportion of NMS cases related to antipsychotic dose escalation. The secondary outcomes include identifying other pharmacologic risk factors for NMS specifically quantified antipsychotic exposure, polypharmacy and route of administration.

1. Southern Arizona VA Health Care System; 2. Biomedical Research and Education Foundation of Southern Arizona

Abstract Type: Work in Progress. Background: Posttraumatic stress disorder (PTSD) management guidelines discourage the use of benzodiazepines, citing a lack of core symptom improvement and a risk of patient harm. In the combat veteran population in particular, benzodiazepines have been classified as being relatively contraindicated due to the high prevalence of comorbid substance use disorders. Guidelines also urge clinicians to weigh the risks and benefits of using opioids given increased risk of abuse and decreased overall functioning. Yet these medications are frequently prescribed for symptomatic relief of PTSD and comorbid chronic pain. Objective: This retrospective cohort study will evaluate hospitalization risk in veterans who have been newly prescribed first-line therapies (serotonin selective reuptake inhibitors [SSRIs] or serotonin and norepinephrine reuptake inhibitors [SNRIs]) for PTSD compared to those also taking benzodiazepines and/or opioids. Methods: The records of all veterans diagnosed with and treated for PTSD at the Southern Arizona Veterans Affairs Health Care System (SAVAHCS) who were newly prescribed either an SSRI or SNRI between November 1, 2010 (immediately following the release of the 2010 Veterans Affairs/Department of Defense PTSD practice guidelines) and August 1, 2013 will be evaluated. Data collected will include number of unique hospitalizations, time to first hospitalization, and demographic information (gender, age, cormorbid mental health disorders, comorbid substance use disorders, comorbid insomnia, comorbid pain, and concomitant psychotropic medications). Using Weibull proportional hazard regression models, unadjusted and adjusted hazard ratios will be reported. Outcomes: The primary outcome will be overall 2-year risk of hospitalizations between patients prescribed SSRI/SNRI monotherapy, concurrent SSRI/SNRI and benzodiazepine therapy, concurrent SSRI/SNRI and opioid therapy, and concurrent SSRI/SNRI, benzodiazepine, and opioid therapy. Index date will be determined as the first date of SSRI/SNRI prescription in the monotherapy group or the first date of therapy overlap in the concurrent therapy groups. Secondary outcomes will include risk of mental health hospitalizations and risk of medical hospitalizations.

All parties are affiliated with Veterans Affairs Loma Linda Healthcare System (VALLHCS)

Abstract Type: Work in Progress. Background: Poor medication adherence is an on-going challenge for clinicians and is considered as one of the contributing factors for long-term dysfunction in patients with psychiatric illnesses that may result in relapses and hospitalizations. The creation of long-acting injectable antipsychotics (LAI APs) was made to theoretically combat this medication issue. However, the current body of evidence supporting better medication adherence with LAI APs use over oral APs is conflicting and varies depending on the study design. Observational studies have been suggested to show better medication adherence than randomized clinical trials. A previous systemic review sought to identify the baseline characteristics of the ideal patient profile for initiating a LAI AP, but the results were inconclusive due to inconsistent documentations between studies. The authors, however, strongly urged for more observational studies identifying the ideal patient’s baseline demographic and clinical characteristics for successfully initiating and maintaining a LAI AP. Objectives: 1. Evaluate patient clinical and demographic characteristics before initiating on a LAI AP, 2. Compare psychiatric and safety outcomes and cost of medication-related expenses before and after initiating a LAI AP Methods: This is a retrospective chart review of veterans who received one of the selected LAI APs—haloperidol decanoate, fluphenazine decanoate, risperdone, monthly paliperidone palmitate, and aripiprazole monohydrate—at VALLHCS during a two-year study period. The primary endpoints of this study are to evaluate patients’ baseline demographic including age, gender, ethnicity, body mass index, housing status, presence of a caregiver, and travel distance, and clinical characteristics including history of psychotropic use, psychiatric history and hospitalization, mental status, and relevant diagnosis. The secondary endpoints are the comparison of psychiatric and safety outcomes, as well as direct-medication related costs pre- and post-initiation of a LAI AP. Outcomes: We will report patients’ most influential baseline demographic and clinical characteristics that led to the successful initiation and continuation of a LAI AP, which may in turn maintain psychiatric stability and prevent hospitalizations. This report may help guide clinicians in selecting the most suitable candidate for starting a LAI AP in the future.

1. Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey; 2. Henry J. Austin Health Center

Abstract Type: Work in Progress. Background: Integrated behavioral health care (IBHC) strives to deliver patient-centered care through a systematic, cost-effective approach via collaboration among primary care providers (PCPs) and behavioral health clinicians. Henry J. Austin Health Center (HJAHC), a Federally Qualified Health Center in New Jersey, has adopted such a model. One of the challenges posed by IBHC is defining the role of PCPs regarding management of psychotropic medications. Targeted education provided by clinical pharmacists may provide PCPs with the knowledge necessary to appropriately manage psychotropic medications, result in a successful IBHC program, and promote integration of pharmacists into new clinical settings. Objectives: 1. Identify PCP concerns regarding outpatient management of psychiatric conditions, 2. Evaluate the impact of pharmacist-led seminars on knowledge of psychotropic medications, 3. Evaluate the impact of educational seminars on prescribing practices and requested pharmacy consultations. Methods: Over the course of four months, educational seminars covering three distinct topics were presented to members of the interdisciplinary team at HJAHC. Topics included Antidepressants, Anxiolytics, and Agents for Alcohol Use Disorders. Regardless of prescribing authority, all staff members we invited to attend. Attendees were asked to complete a pretest and posttest at the time of the presentation. Scores will be calculated as per a predefined rubric in which questions are of equal weight. Questions left unanswered will be scored as incorrect. To assess impact on prescribing practices, all prescribers who were in attendance will be invited to participate in a post-seminar survey to be completed no sooner than eight months after the presentations. All drug information requests documented by the pharmacy team during the three months prior, four months during, and three months following the presentations will be retrospectively reviewed to determine total number of requests and proportion concerning one or more psychiatric condition. Regardless of seminar attendance, all HJAHC prescribers will be invited to participate in a survey evaluating attitudes regarding outpatient treatment of psychiatric conditions, including medication management. Outcomes: The impact of clinical pharmacist-led seminars on psychotropic medication knowledge and management in an outpatient IBHC model will be reported.

All parties are affiliated with the University of Texas at Austin and the Seton Healthcare Family in Austin, Texas

Abstract Type: Work in Progress. Background: Acute agitation/aggression events are prevalent on the inpatient psychiatric unit and are an important treatment target. Pharmacologic management using antipsychotics and benzodiazepines for as needed (PRN) or emergent use may be considered as treatment options. This practice may cause medication overuse and unnecessary adverse effects due to differences in nurses’ opinions regarding the need for medications. Studies have shown up to 41% of nursing documentation didn’t explain why medications were administered or doesn’t provide adequate description on how the patient was agitated. A workgroup in our hospital was established to pilot the use of the Modified Overt Aggression Scale (MOAS), a validated rating scale, during emergency medication administration on two adult units to determine how use of the scale impacts treatment optimization. Building upon the workgroup’s pilot, the primary purpose of this project is to assess if there is an improvement over time in nursing documentation of both PRN and emergency medications administered for all agitation/aggression incidences as a carryover effect after the implementation of the MOAS. Objectives: 1. Review changes in the quality of documentation on medication administration for agitation/aggression 2. Compare differences in documentation between intervention group (2 adult units using MOAS) and control group (2 adult units not using MOAS) 3. Changes in MOAS scores before and after administration of medications Methods: Charts of approximately 200 incidences of agitation/aggression will be reviewed over a four-month period to assess the quality of nursing documentation. Demographic variables (age, gender, race, diagnoses), medication regimen, and medications used for agitation/aggression incidences will be collected. PRN and emergency medications will be ordered and administered per usual care. Objective 1: review nursing documentation to determine if enough information is provided to retrospectively complete the MOAS. Objective 2: compare the differences in number of retrospectively completed MOAS for each group. Objective 3: include actual MOAS scores per agitation/aggression incidence. Outcomes: Authors will report on data collected throughout the 4-month implementation period of the MOAS on the adult inpatient psychiatric units to determine a progression of changes in nursing documentation throughout time. This project was reviewed by IRB and deemed to be quality improvement.

1. Department of Pharmacy, VA Northern California Health Care System, Mather, CA; 2. Department of Primary Care, VA Northern California Health Care System, Mather, CA

Abstract Type: Work in Progress. Background: Overdoses of prescription opioids have more than tripled in the past 20 years. Veterans are twice as likely to die from accidental overdose as the non-Veteran population. The Veterans Health Administration Opioid Safety Initiative was developed to improve safe and effective chronic pain management. In addition, VA launched an opioid overdose education and naloxone distribution program. Objectives: Evaluate the outcomes of a group appointment led by pharmacy and primary care practitioners for high risk patients emphasizing safety concerns of opioid use and providing training and distribution of naloxone kits. Methods: Patient demographic and clinical data will be collected via electronic medical record review. All patients receiving chronic treatment with opioids for chronic non-malignant pain on a daily dose of greater than or equal to 120 mg morphine equivalents will be identified using the VA integrated service network medication safety dashboard. Letters will be mailed to patients inviting them and a caregiver to the group appointment. Patients can accept, decline or request an alternate appointment time. Attendance data will be collected. Following the educational presentation on opioid safety and naloxone kit training, patients will complete a questionnaire and be offered a naloxone kit. Reponses to the questionnaire will be recorded regarding their understanding of opioid safety, interest and willingness to decrease opioid or benzodiazepine dose, interest in receiving a naloxone kit, and understanding of naloxone kit use. The information obtained will be used to improve the group appointment process for high-risk patients. Outcomes: We will report the number of participants on high doses of opioid medications that were in attendance for a group appointment; will analyze knowledge and preferences of patients based on reposes on survey questions.

All parties are affiliated with the Department of Pharmacy, Medical University of South Carolina Institute of Psychiatry, Charleston, SC

Abstract Type: Work in Progress. Background: Preventing hospital readmission is an organizational goal of most health care systems in the United States. Previous research at our inpatient psychiatric hospital revealed medications as the primary contributing factor in 16% of 30-day psychiatric readmissions. Further research into discharge medication delivery for indigent patients demonstrated a 22% decrease in 30-day psychiatric readmissions when a 30-day supply of medications was provided at discharge. Over the past 5 years, our hospital has streamlined a process to offer discharge medication delivery for all adult psychiatric patients regardless of prescription insurance benefits. We sought to determine whether discharge medication delivery to adult psychiatric patients would impact 30-day readmission. Objectives: 1) Determine whether discharge medication delivery is associated with a difference in the 30-day readmission rate compared to patients who did not have discharge medications delivered. 2) Determine the financial impact of discharge medication delivery. Methods: All adult patients discharged between October 1, 2015 and December 31, 3015 were included with 30-day readmission data collected until January 30, 2016. A report of discharge medication deliveries, available from the electronic medical record was used to identify patients and prescription details (agent, dose, quantity, insurance coverage). Demographics, prescription funding, cost of medications, number of medications per discharge, and service will be examined. Outcomes: From October 1, 2015 through December 31, 2015 there were 369 discharge prescriptions filled and delivered from our outpatient pharmacy for 106 encounters (18% of adult discharges). On average 3 prescriptions were delivered per encounter (range 1-11). Trazodone was the most commonly filled product with 27 prescriptions; however most individual medications were only filled twice and included both psychiatric and non-psychiatric agents. We will be compare and report 30-day readmission rates between medication delivery and medication non-delivery groups. Further we will compare rates between funded and unfunded patients to determine if the service has differential benefits between those two groups.

All parties are affiliated with the Department of Pharmacy from the Miami Veterans Affairs Healthcare System, Miami, FL

Abstract Type: Work in Progress. Background: The Acetylcholinesterase Inhibitors (AChEIs) and memantine are approved by the FDA to slow cognitive decline in patients with dementia. The magnitude and clinical significance of these medications on the improvement of symptoms continues to be debated. Furthermore, it has been found that these medications are often prescribed inappropriately, increasing medication-associated costs, risk for side effects, and drug interactions. For memantine and AChEIs, the Veteran Affairs Healthcare System (VAHS) provides clinical guidance to improve quality of care and promote cost-effective drug prescribing through outlining their criteria for use (CFU) in the treatment of dementia. Despite these measures, physician-prescribing patterns vary from these recommendations. In addition, studies have shown that older patients and patients with dementia are frequently prescribed potentially inappropriate medications (PIMs), which can lead to adverse drug events such as falls, drug interactions, and hospitalizations. At the Miami VAHS a pharmacist clinical intervention (CI) template was created and used since July 2015. The note was drafted to reflect the CFU and has been used by mental health (MH) pharmacists to standardize documentation of review for processed prescriptions for dementia medications. Objectives: This quality improvement project (QIP) aims to: (1) evaluate MH pharmacists CI at ensuring appropriate use of dementia medications, (2) analyze the impact of these CIs on physician-prescribing patterns, (3) evaluate the most common PIMs, (4) develop an order set that provides guidance on the appropriate use of these medications and improve the quality of prescribing practices. Methods: CIs completed from July to December 2015 will be reviewed to determine the number of patients who met CFU, type of interventions, acceptance rate of pharmacist recommendations, and reasons for not accepting the recommendations. The second part of this QIP is to evaluate the impact of CIs (post-CI period) on the number of dementia prescriptions as compared to the previous 6 months (pre-CI period). Using the 2012 Beers Criteria for patients with “dementia and cognitive impairment” as a guide, the use of PIMs will be evaluated. Finally, the CFU and these results will be used to design a pharmacy medication order set to guide physicians in ordering AChEIs and memantine.

1. Nova Southeastern University, College of Pharmacy; 2. Husson University, School of Pharmacy; 3. Nova Southeastern University, College of Osteopathic Medicine; 4. Nova Southeastern University, College of Dental Medicine

Abstract Type: Work in Progress. Purpose: One of the fastest growing populations of HIV+ persons are older adults and rates are likely to increase dramatically. As patients with HIV age, they may experience neurocognitive disorders which can impair memory, behavior, and motor function. This poses new challenges since they may also develop chronic conditions further impairing memory (e.g., type 2 diabetes [T2D], depression). While previous studies show T2D or depression may affect medication adherence, a lack of data exist in older adults with HIV. As persons with HIV age, adherence to antiretroviral therapy may be affected and tests assessing cognitive impairment may be useful in identifying those at risk for non-adherence. Therefore, the purpose of this pilot study is to assess if chronic conditions affect cognitive function in older adults with HIV. Additionally, the association between these factors and medication adherence will be explored Methods: Participants with HIV and 65 years of age or older were recruited after IRB approval. The CLOX 1 and 2, Trail Making tests-parts A and B, and the Grooved Pegboard test were used to assess cognition. Center for Epidemiologic Studies Depression Scale (CESD) was used to assess depressive symptoms. Medication adherence over a minimum 4 week period was primarily determined by using Medication Event Monitoring System (MEMSCaps). Descriptive statistics, independent t-tests, and correlation (i.e, Pearson’s) analysis were used. Results: To date 23 participants completed the study. Participants were mostly male (87%), non-Hispanic White (74%), and ranged from 65 - 76years old (M = 69.6). Greater depressive symptoms were significantly correlated with greater impairment in Grooved Pegboard-non dominant hand (r = .44, n = 23 p<0.05). CESD was not correlated with Trail Making or CLOX tests. Moreover, T2D or depressive symptoms were not associated with medication adherence. Conclusions and Future Directions: Greater depressive symptoms appear to be correlated with greater impairment of fine motor tasks in older HIV+ adults. The majority of participants with T2D were controlled (i.e., HgA1c <6.5%) which may explain why there was no association with cognitive impairment or medication adherence. As a result, further studies may be needed to evaluate if cognitive impairment affects medication adherence in uncontrolled T2D HIV+ older adults.

1. Pharmacy Department, South Texas Veterans Health Care System (STVHCS), San Antonio, TX; 2. Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX; 3. Pharmacotherapy Education & Research Center, School of Medicine, UTHSCSA, San Antonio, TX; 4. Division of Community Recovery, Research and Training, Department of Psychiatry, UTHSCSA, San Antonio, TX

Abstract Type: Work in Progress. Background: The demand for mental health (MH) services, particularly providers with prescribing privileges, has increased in recent years as more veterans have been diagnosed with – and sought care for – one or more MH conditions. At the South Texas Veterans Health Care System (STVHCS), electronic consults (e-consults) may be submitted by healthcare providers to the MH Clinical Pharmacy Specialists (CPSs) for medication review and recommendations regarding initiation, continuation, cessation, or adjustment of psychotropic medications for MH conditions. These consults target less severe conditions that may be managed in primary care (PC) to maintain patients in PC and reserve psychiatry and visits with MH prescribers for patients with more severe conditions requiring more intensive management. Pharmacists have been shown to improve outcomes and access to care in PC settings such as diabetes and hypertension through medication therapy management, but there remains limited data on the impact of pharmacists in MH settings. Objectives: 1. Compare the number of submitted consults with the number of accepted and implemented recommendations from initiation of the e-consult service (May 2014) through December 2015; 2. Analyze the number of submitted consults and implemented recommendations with the number of patients successfully managed and maintained in the PC setting from consult response to December 31, 2015; 3. Report the apparent efficacy of the e-consult service and MH CPS recommendations, and provide recommendations for improving the service or changing the way the service is advertised and utilized by healthcare providers. Methods: Information is collected through a retrospective chart review of STVHCS veterans. The study population includes any patient with a “PharmD MH Cons E-consult” note placed in their chart from May 2014 through December 2015. Patients’ MH diagnosis (-es) will be recorded for analyses. Patients will be evaluated over time with respect to implementation of CPS recommendations and subsequent maintenance in the PC setting. Objectives: The results of this study may be used to validate the need for and importance of MH CPSs in successful management of MH conditions in the PC setting and provide opportunities for improvement of the e-consult service if deficient areas are found in this review.

All parties are affiliated with the VA Tennessee Valley Healthcare System

Abstract Type: Work in Progress. Background: Safe and effective patient healthcare requires teamwork and collaboration of various health and social care professionals. Healthcare delivery has shifted the focus from traditional, unidisciplinary models of treatment towards an integrated, multidisciplinary model to help reduce overall costs, enhance communication, and improve patient healthcare outcomes. An area of limited study is the evaluation of patient healthcare outcomes in a trainee-led interprofessional team in the outpatient mental health setting. This study will evaluate the mental health outcomes associated with a resident-run Behavioral Health Interdisciplinary Program (BHIP) clinic at a VA Medical Center. Objectives: The primary objective will seek to evaluate mental health response and remission rates of BHIP patients, utilizing objective self-assessment measures. Secondary outcomes will analyze the change in assessment scores from baseline to most recent assessment. Assessment measures may include, but are not limited to, the BAI, PCL, and PHQ-9. Furthermore, secondary objectives will assess change in the number of psychotropic medications prescribed, the number of psychiatric related emergency room visits, and the number of acute psychiatric admissions, as well as the difference in “no-show” rates in the BHIP clinic compared to Psychiatry Ambulatory Care Services (PACS) appointments. Methods: This is a single-center, longitudinal, retrospective, chart-review, and survey study at a VA Medical Center. Participants must be currently enrolled in the BHIP clinic for > 3 months with a documented intake appointment and at least one medication follow-up and individual therapy visit. The study dates of review include October 2013-April 1, 2016. A baseline assessment measurement was provided during initial intake visits; corresponding measurements were obtained at subsequent follow-up appointments as appropriate. The VA Computerized Patient Record System (CPRS) will be used to continue data collection. Outcomes: Preliminary results yielded 31 patients who met criteria for the primary endpoint. Remission or response was achieved in ≥ 50% of patients diagnosed with depressive disorder, PTSD/unspecified trauma, or anxiety disorder. Only 8% of patients with a pre-BHIP psychiatric admission had similar admissions during enrollment in the clinic. The number of psychotropic medications prescribed was reduced in 34% of patients. Results of ongoing data collection will be reported.

All parties are affiliated with Avera McKennan Hospital & University Health Center

Abstract Type: Work in Progress. Background: Patients with a serious mental illness typically have higher mortality rates which may be a result of multiple co-morbid chronic medical illnesses. Consequently, these patients have complicated medication regimens, history of noncompliance, and lack of consistent follow up. There have been few studies evaluating the role of a clinical pharmacist in a psychiatric ambulatory care setting, but most have shown positive outcomes. Patients within these studies, on average, had a decrease in the number and dosage of psychiatric medications, increase in cost savings, and significant improvements in the safe and effective use of antipsychotics and antidepressants. While these preliminary studies show a positive impact of the pharmacist in an ambulatory setting, more research is needed to prove the numerous benefits of pharmacists in this role. Objectives: 1. Develop and measure the impact of a pharmacist in an outpatient psychiatric clinic. 2. Justify the funding of a full time employee (FTE) pharmacist position in an outpatient psychiatric clinic. Methods: All patients who are admitted to Avera Behavioral Health Center to adult inpatient units from October 19th, 2015 through February 19th, 2016 will be evaluated by a pharmacist upon admission and discharge to determine if patients are considered “high risk” for readmission. For those who qualify at discharge, the pharmacist will meet with patients to coordinate scheduling a follow up appointment with a pharmacist within 7 days. The clinic pharmacist will perform medication reconciliation to determine compliance, complete diagnostic assessments, review adverse effects, answer questions the patient may have, and ensure the patient is aware of their follow up appointments. The visit summary will be reported to the psychiatrists to ensure continuity in care via patient’s electronic medical record. Per our collaborative practice agreement the psychiatrist will be contacted during the clinic visit if deemed necessary. Outcomes: We will report the number and percent of patients who refused, were excluded, or agreed to the pharmacist clinic. We will also report the number and percent of patients who attended their scheduled appointment, pharmacist interventions, readmission rates for all candidates, and cost savings using the hospital’s intervention reporting system.

All parties are affiliated with the Veterans Affairs Palo Alto Health Care System (VAPAHCS)

Abstract Type: Work in Progress. Background: The dangers of co-administration of opioid pain relievers (OPRs) and benzodiazepines (BZDs) are well documented. Additive effects of OPRs and BZDs increase the risk of falls, respiratory depression and death. According to Centers for Disease Control data, OPRs and BZDs make up the majority of the medications involved in prescription drug-related overdose and are often used concomitantly. A similar pattern has been identified in studies involving Veterans. The Veterans Health Administration implemented the Opioid Safety Initiative aimed at improving patient safety surrounding OPRs. In an effort to achieve a BZD and OPR co-prescribing goal of < 13% set by Veterans Integrated Service Network 21, VAPAHCS implemented a prior authorization pharmacy consult, which mandates adjudication for co-prescribing. The results generated from this study will provide information about the effectiveness of a pharmacy prior authorization consult on co-prescribing and patient safety outcomes. Objectives: 1. Assess the effect of the consult on co-prescribing, 2. Assess the effect of the consult on hospitalizations and ER visits due to overdose, 3. Describe the actions taken by prescribers in the setting of disapproved consults, 4. Assess patient characteristics associated with co-prescribing and the frequency of co-prescribing without a consult. Methods: This was a single-center, retrospective chart review at VAPAHCS. Patients were included in the analyses if they were treated in the outpatient setting, were > 18 years of age, and co-prescribed a BZD and OPR. Microsoft^® Structured Query Language server database queries were used to extract data. Microsoft^® Access and Excel were utilized to organize, query and analyze the extracted data. Objectives 1 and 2 will be reported as percentage change, before and after implementation of the consult. Descriptive statistics will be utilized for objectives 3 and 4. Outcomes: The effect of the prior authorization pharmacy consult on co-prescribing of OPRs and BZDs, and patient safety will be presented.

All parties are affiliated with the Chillicothe VA Medical Center

Abstract Type: Work in Progress. Background: Alexander, et al conducted a study in veterans with post-traumatic stress disorder (PTSD) which demonstrated that less than 40% of veterans newly initiated on prazosin in 2010 continued the drug for 1 year.¹ This study also showed that less than 20% of veterans received the minimum recommended daily dose (6mg) per Veterans Affairs/ Department of Defense (VA/DoD) PTSD guidelines.¹ Subsequently, a medication review at the Chillicothe VA Medical Center confirmed that the majority (90.2%) of outpatient prazosin prescriptions for nightmares associated with PTSD are below the VA/DoD PTSD guideline minimum recommended efficacious dose. The average dose of prazosin was 3mg at bedtime. The opportunity for psychiatric pharmacists to improve patient care in this area is significant. Objectives: 1. Implement pharmacist-run prazosin titration clinic at the Chillicothe VA. 2. Evaluate number and percentage of veterans meeting the VA/DoD guideline minimum recommended daily dose or maximally tolerated dose of prazosin after one year of clinic operation. Methods: This pharmacist-run prazosin titration clinic will utilize a standardized titration schedule, adapted from Raskind, et al, to reach a target state of 30% of veterans on the VA/DOD guideline minimum recommended daily dose or maximally tolerated dose of prazosin.² Well-established telehealth services at the Chillicothe VA will be used to monitor blood pressure and heart rate. Additionally, clinic implementation requires approval from the Chief of Staff, Pharmacy and Therapeutics Committee, and Medical Status Executive Committee. Outcomes: We will report the number and percentage of patients meeting the VA/DoD guideline minimum recommended daily dose or maximally tolerated dose of prazosin during the first year of clinic operation to determine the relevance of the pharmacist-run prazosin titration clinic. Completion: Implementation of clinic anticipated March 2016- April 2016; evaluation of clinic outcomes anticipated 2017

¹Alexander B, Lund B, Benardy N, et al. Early discontinuation and suboptimal dosing of prazosin: a potential missed opportunity for veterans with posttraumatic stress disorder. J Clin Psychiatry. 2015;76(5):e639-e644.

²Raskind MA, Peterson K, Williams T, et al. A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and Afghanistan. Am J Psychiatry. 2013; 170(9):1003-1010.

All parties are affiliated with the Clement J. Zablocki VA Medical Center

Abstract Type: Work in Progress. Background: Transitions of care are vulnerable to medication errors. One in eight patients have been found to experience an adverse drug event when discharged from the hospital to the home setting; of those that led to disability, nearly 50% were preventable. Commonly, psychotropic medications are implicated in adverse drug events leading to hospital admission. The mental health patient population is particularly susceptible to adverse drug events due to the barriers imposed by their psychiatric illness, such as decreased ability to care for themselves and medication non-adherence, juxtaposed with complex medication regimens. Evidence has clearly indicated that when pharmacists are involved in transitions of care, readmissions are prevented, the quality of the discharge process is improved, and the number of preventable adverse drug events is decreased. Objectives: 1. Implement a pilot, pharmacist-led discharge counseling service on an acute, inpatient psychiatric unit 2. Reduce medication–related errors during the discharge process 3. Assess healthcare provider satisfaction with the pilot discharge counseling service Methods: Current policies and procedures for pharmacist-led discharge counseling on the medical acute care units of the Zablocki VA Medical Center were used as a guideline for the pilot service on the acute inpatient psychiatric unit. Pharmacists and pharmacy trainees provided medication discharge counseling from August 31, 2015 through October 31, 2015. Patients were excluded from receiving the service if they left against medical advice, refused the service, were discharged to a residential treatment program, or were discharged to a facility where medications are not self-managed. The following data was collected and will be analyzed using descriptive statistics: demographic variables (age, gender, race), number of new medications prescribed upon discharge, number of medications filled upon discharge, number and type of pharmacist interventions made, and time spent on the counseling process. A five-question survey assessing healthcare provider satisfaction with the pilot program was conducted at the end of the eight-week period. This retrospective study was exempt from IRB approval due to its designation as a quality improvement project. Outcomes: The number and types of pharmacist interventions made will be reported along with the results of the provider satisfaction survey.

1. Captain James A. Lovell Federal Health Care Center, Department of Veteran Affairs Medical Center; 2. Rosalind Franklin University of Medicine and Science, College of Pharmacy

Abstract Type: Work in Progress. Background: In the United States alone, 2.7 million people have chronic hepatitis C virus (HCV) infection. Among those individuals, the highest prevalence, close to 75%, are those born between 1945-1965, making the “baby boomer” generation the most commonly infected. Multiple studies have shown the veteran population, as well as a mental health population, to be at higher risk, as this specific cohort of individuals have a higher rate of potential exposure. The large majority of infected individuals are unaware of their diagnosis as acute HCV presentation is rare, which poses a risk for further transmission of HCV to others. With the emergence of highly effective direct acting antiviral therapy, identifying infected individuals is imperative in order to treat and prevent further transmission. This study will provide important information regarding the incidence of HCV infection among veteran baby boomers with mental health disorders. Objective: The purpose of this study is to identify the incidence of HCV in a veteran mental health patient population among baby boomers. Methods: This study is a retrospective chart review to analyze the incidence of a mental health diagnosis in HCV infected individuals among baby boomers. The study group will consist of veterans with a positive hepatitis C diagnosis, born between 1945 to 1965. Further stratification will occur based on mental health diagnosis, defined by either depression, bipolar depression, schizophrenia, post-traumatic stress disorder, anxiety, substance abuse, attention-deficit hyperactivity disorder, or personality disorder. The primary outcome will be assessed using the student’s t-test. Further stratification of data will be compared and statistical differences will be analyzed using chi-square test or Fisher’s exact test, based on sample size. Outcomes: The primary objective of this project is to analyze the incidence of a mental health diagnosis in HCV infected individuals among baby boomers. The secondary objective will be a sub-group analysis of types of mental health disorders that are more likely to test positive with a specific focus on substance abuse history.

1. University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences; 2. Kaiser Permanente Colorado; 3. Colorado Biostatistics Consortium, Colorado School of Public Health; 4. University of Colorado School of Medicine

Abstract Type: Work in Progress. Background: Major depressive disorder (MDD) affects approximately one-third of primary care patients, yet remains under diagnosed and under treated. Reasons for poor treatment outcomes are likely multi-factorial. One factor which remains under characterized in primary care is stigma. Stigma is commonly divided into two subtypes: perceived public stigma (PPS), when an individual believes the public discriminates against the individual and self-stigma (SS), the internalization of PPS resulting in devaluing and shame-filled thoughts. This study will provide information about the prevalence of SS and PPS and examine their relationship to depression remission in a MDD cohort cared for by a pharmacist-led collaborative care model (CCM) within primary care. Objectives: The objectives of this study are to 1) characterize stigma (prevalence and subtype) in a primary care population with MDD (patient health questionnaire (PHQ)-9>9); 2) determine the association between baseline stigma and depression remission (PHQ-9<5); and 3) assess the change in stigma (by subtype) over time. Methods: The study population includes patients with MDD (baseline PHQ-9 > 9) from two University-based primary care clinics whose depression is managed by a pharmacist-led CCM. SS and PPS will be measured at baseline (during first clinic visit with the pharmacist) using a validated questionnaire and again at one year. Informed consent will be obtained. The questionnaire consists of fourteen four-point Likert scale questions assessing SS and PPS. Depression remission (PHQ-9< 5) will be assessed based on PHQ-9 scores after the acute phase of treatment (12-16 weeks) and at one year. General linear regression will be used to evaluate the associations between baseline and one year SS and PPS scores, and to identify characteristics associated with improvement. Logistic regression will be used to evaluate the associations between baseline SS and PPS and depression remission, adjusting for covariates and confounders (e.g. age, gender, baseline PHQ-9, modified Charlson co-morbidity score, antidepressant treatment history, concurrent psychotherapy, socioeconomic status) as appropriate. Outcomes: We will report average baseline SS and PPS subscale scores, the association between baseline SS and PPS score and depression remission, and mean change in PPS and SS from baseline to one year.

1. Feik School of Pharmacy, University of the Incarnate Word; 2. South Texas Veterans Healthcare System; 3. University of Texas Health Science Center at San Antonio

Abstract Type: Work in Progress. Background: Individuals who are transgender or gender nonconforming frequently experience discrimination, even within the modern-day healthcare system. While many health challenges disproportionately impact transgender communities, a lack of culturally competent and knowledgeable providers is a major contributor to this significant health disparity.¹ To date, evaluations of transgender healthcare topic incorporation into pharmacy school curricula are very limited. Given recent policy developments which have served to increase access to care for transgender individuals, the need for competent pharmacy providers who can deliver compassionate, quality care is high. Objective: Assess the impact of an interactive lecture reviewing a transgender healthcare topic on pharmacy students’ knowledge, confidence and attitudes. Methods: Third-year pharmacy students will attend a 1-hour, interactive, didactic lecture reviewing the pharmacotherapy of Gender Dysphoria (GD). Lecture content will be developed using evidence-based guidelines, and reviewed by content experts (psychologist, PharmD, MD). Students will be given access to an optional, electronic pre- and post-survey 1-week prior to and following the lecture. Demographic and survey questions were developed using available published literature, the Attitudes Toward Transgender Individuals (ATTI) scale,² and modified for discipline-specific outcomes. Survey questions will aim to measure: 1. attitudes toward individuals who are transgender, 2. confidence in providing pharmacotherapeutic care to patients undergoing feminization or masculinization treatment, and 3. knowledge regarding both healthcare disparities among transgender individuals and evidence-based treatment for GD. Outcomes: Pre- and post-survey data will be linked through computer software, and de-identified by a neutral third party. Changes in pre- and post-survey questionnaire scores will be evaluated for significance. Demographic data will be evaluated in aggregate for trends in relation to changes in survey scores. Data collection will be completed 01/31/2016.

¹Grant JM, et al. National Transgender Discrimination Survey Report on Health and Healthcare. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Taskforce; 2010. Web site. http://transequality.org/PDFs/NTDSReportonHealth_final.pdf. Accessed August 26, 2015.

²Walch SE, Sakkaphat NT, Francisco J, et al. The attitudes toward transgendered individuals scale: psychometric properties. Arch Sex Behav. 2012;41:1283-1291.

All parties are affiliated with the University of Waterloo School of Pharmacy

Abstract Type: Work in Progress. Background: Individuals with epilepsy are at an increased risk of fracture compared to those without, in part due to decreased bone mineral density related to treatment with anti-epileptic drugs (AEDs). Adults over the age of 50 and, in particular, women are at increased risk. Established strategies to improve bone health in the general population include physical activity and adequate vitamin D and calcium supplementation. A previous study, conducted in a younger population with a mean age of 42 years, demonstrated that only 24% of patients with epilepsy reported adequate intake of calcium and vitamin D, 28% adequate exercise and 50% adequate sun exposure. The Canadian Community Health Survey (CCHS) is an annual nationwide survey that includes a component with questions related to sun exposure, physical activity and dietary choices. In 2011, participants were asked questions specifically related to epilepsy. Data from the CCHS will be used to investigate and compare lifestyle decisions made by adults aged 50 years and over with epilepsy to those without. Objectives: 1. To compare the amount of sun exposure and physical activity as well as dietary choices based on calcium content or osteoporosis concern in Canadian adults aged 50 years with epilepsy to those without; 2. To investigate differences in these behaviours based on gender, age and if AEDs are being taken. Methods: This study is a secondary analysis of data from the CCHS 2011. The CCHS 2011 was a cross-sectional survey administered during the months of January – December to 65,000 Canadians. Data for 54 items of the survey will be abstracted. These items refer to age, gender, physical activity, sun exposure, dietary choices, ambulatory status, injuries, fractures, epilepsy status, severity of epilepsy, and current AED use. Outcomes: ANOVA will be used to compare physical activity, sun exposure and dietary choices between those with and without epilepsy. Regression modeling will be used to investigate relationships between physical activity, sun exposure, dietary choices, use of AEDs, fractures, age and gender. Other self-reported conditions will be controlled for.

All parties are affiliated with Western Psychiatric Institute and Clinic of UPMC

Abstract Type: Work in Progress. Background: Psychosis-spectrum disorders, including schizophrenia, are complex illnesses requiring long-term treatment with pharmacotherapy. Non-adherence to oral antipsychotic medications can be a barrier for patients with a psychosis-related illness, and even partial adherence can lead to a relapse in symptoms requiring hospital readmission as well as increasing health-care associated costs. In addition to an increase in health-care associated costs, repeated relapses are also associated with neurotoxic effects on the brain, possibly leading to an increase in impairment throughout the course of the disease. Long-acting injectable antipsychotics (LAIAs) were developed to help prevent this cycle by removing the need for patients to take their antipsychotic medication daily. Current treatment guidelines support the use of this class of medication; however, they lack consistent evidence proving their superiority over their oral counterparts. LAIA use can be controversial at times due to this paucity of evidence and their high cost. Hypothesis: We hypothesize that initiating an LAIA medication in patients with a psychosis-spectrum disorder will have a significant impact on both healthcare associated costs as well as patient outcomes by improving medication adherence and outpatient follow-up. Methods: We will perform a retrospective chart review of the associated patients for all new-start LAIA pharmacy consults during the time period of July 1, 2013 to June 30, 2014 at Western Psychiatric Institute and Clinic of UPMC in order to compare patient data for the 12 month period before LAIA initiation and for a 12 month period after. Data will be collected in order to evaluate the patients’ adherence to the injectable medication, number of missed outpatient appointments, emergency room visits, crisis visits, hospital readmission rates, and number of days hospitalized. This data will only be included if it is an encounter associated with behavioral health. A cost per service will also be evaluated for the unplanned acute healthcare associated costs which include emergency room visits, crisis services, and inpatient hospitalizations. Outcomes: We predict that in the 12 months after starting an LAIA, there will be an increase in outpatient follow-up and a decrease in overall healthcare usage compared to the 12 month period prior to initiation.

1. Community Health Network, Indianapolis, IN; 2. Butler University College of Pharmacy and Health Sciences, Indianapolis, IN

Abstract Type: Work in Progress. Background: Readmission into an inpatient psychiatric facility has been proposed as one indicator of the quality of inpatient psychiatric services. The Hospital Readmission Reduction Program (HRRP) penalizes hospitals for 30-day readmissions of Medicare patients after initial hospitalizations for selected conditions. Currently, psychiatric hospitals are exempt from HRRP, but it is unknown if psychiatric diagnoses will be included in future years. As a result, hospitals are focusing on reducing 30-day readmissions when possible. While there are a number of studies published on factors affecting readmission into an inpatient psychiatric facility, few studies have been published specifically on 30-day readmission rates in patients with schizophrenia and related disorders. Objectives: 1. To determine which medication factors are associated with reduced risk of readmission within 30 days of discharge and 2. Describe the trends and prescribing patterns of medications for patients with schizophrenia and related disorders at Community Health Network. Methods: A retrospective, observational chart review study will be performed. Inpatients admitted to the Behavioral Health Pavilion between September 1, 2013 and August 31, 2015 with a diagnosis of schizophrenia and related disorders (ICD-9 codes 295.00-295.95) and an inpatient readmission within 30 days of discharge will be identified by social work report. Subjects will be matched to a control group with a diagnosis of schizophrenia and related disorders without an inpatient readmission within 30 days of discharge. The discharge medications from the original admission will be reviewed and the regimens between the two groups will be compared. Collected data will include: patient demographics, length of stay, diagnosis code, comorbid psychiatric diagnosis codes, readmission post discharge day, and medications at discharge. Medication information collected will include name, dose, dosage form, classification, and total number of antipsychotics. Outcomes: The medication factors that are associated with a reduced risk of readmission within 30 days of discharge will be reported.

All parties are affiliated with Purdue University, College of Pharmacy

Abstract Type: Work in Progress. Background: Members of CPNP Purdue have previously conducted a literature review examining stigma towards those with mental illness, and deficiencies in research were observed regarding the perceptions of college-aged individuals, particularly the perceptions of pharmacy students. This study will address this gap in knowledge, as well as assess the effectiveness of Mental Health First Aid (MHFA) training in combating stigma in both pharmacy and other university students. MHFA is an interactive certification course that provides an overview of mental illness and fosters an understanding of potential impacts of such illnesses. Methods: Twenty-five pharmacy students of any professional year, as well as 25 students of any major outside the College of Pharmacy at Purdue University, will be recruited to attend an eight-hour, MHFA session provided by Mental Health America of Tippecanoe County. The Social Distance Scale and Attitudes to Mental Illness Questions will be utilized to assess the impact of the MHFA. Students will complete the question prior to and after completing the educational session. Pharmacy students not participating in the intervention will be asked to voluntarily complete instruments and serve as a comparison group. Evaluation Strategy / Outcome Measure(s): Assessment of stigma will be conducted through the utilization of the Social Distance Scale as well as the Attitudes to Mental Illness Questionnaire (AMIQ). Both scales use vignettes. The Social Distance Scale is comprised of seven questions that utilize a five-point Likert scale as well as one question in which participants are asked to identify what, if anything, is wrong with the patient. The AMIQ is eight questions in length and uses a four-point Likert scale. Descriptive statistics will be performed for all measures. Dependent upon the data, nonparametric and parametric statistics will be used for the comparisons. Students’ pre and post responses from the educational session will be compared to evaluate the overall impact of the program. In order to assess whether student major influences the impact of the training, pharmacy students completing MHFA training will be compared to non-pharmacy students completing the training. Lastly, pharmacy students not completing the training will be compared to pharmacy students completing the training.

All parties are affiliated with the Department of Veterans Affairs Medical Center

Abstract Type: Work in Progress. Background: At a Veterans Affairs Medical Center (VAMC) the Mental Health Intensive Case Management (MHICM) program cares for Veterans who are high risk for suicide, need intensive health care due to frequent hospitalizations/high risk status, and in some situations require home health visits. This program allows the Veterans to maintain themselves in the community as much as possible. The goal is to shift the focus of care from emergency departments and inpatient facilities to outpatient clinic services. The multi-disciplinary team provides support to the Veteran based on individual needs; a healthcare provider sees patients at least twice weekly. Services offered can range from assistance with food shopping, to medication management, to enrollment in vocational services. While many patients will remain enrolled in MHICM long-term, some patients are able to improve their functional skills and become stable enough for discharge from MHICM. Purpose: The purpose of this project is to evaluate the role of a clinical pharmacy specialist in the MHICM program model at a VAMC. Methods: A pharmacy resident will conduct chart reviews on patients deemed high risk, defined as: four or more psychotropic medications or patients residing in an assisted living facility (ALF). This will be done in order to provide the MHICM patient and team with the following services: 1) medication optimization for the patient, 2) pharmacological recommendations for the MHICM team, and 3) creating a streamlined medication reconciliation process for those patients in ALFs to decrease the amount of medication errors. The end process will result in creating a VA standard operation procedure (SOP) that will be provided to the ALFs. During the patient chart reviews and ALF reviews, the following information will be gathered: 1) number and type of pharmacotherapy recommendations made by the resident, 2) number and type of pharmacotherapy recommendations accepted by the psychiatrist, 3) number of medication errors (e.g. medication duplication, incorrect dose), and 4) adverse drug reaction reporting. Once the data has been collected, descriptive statistics will be used for analysis. Results: Pending Conclusions: Pending

1. Lipscomb University College of Pharmacy; 2. Vanderbilt Psychiatric Hospital

Abstract Type: Work in Progress. Background: According to R.P. Bright’s article in Current Psychiatry, suicide among resident physicians account for 26 percent of all physician fatalities, which is higher than the national average of 11 percent for the same age group. The higher incidence rate could stem from unrecognized or under treated depression among physicians. Despite the evidence of increased depression among medical residents, there is lacking research assessing depression amid pharmacy residents. The purpose of this study is to look specifically at pharmacy residents across several teaching institutions to recognize underlying precursors to clinical depression that may warrant further assessment. Objectives: The primary objectives of this study are to identify the incidence self-reported depression among pharmacy residents in Tennessee and assess resident self-awareness of signs and symptoms of depression. The secondary objective of this study is to assess residents’ knowledge of available mental health benefit resources. Methods: A survey was generated and administered via the survey software, REDCap™ The survey was distributed to the pharmacy residency program directors across Tennessee with potentially 120 residents participating in the survey. The goal is to have 40 residents complete the survey. The following demographic data will be collected: age, gender, discipline, area of practice, and year in residency. Using questions modeled after the Major Depression Inventory (MDI) and Patient Health Questionnaire (PHQ9), subjects will be asked to identify any personal signs or symptoms of underlying depression. The survey will also assess residents’ knowledge of mental health resources available to them through their residency program and community resources. All data will be recorded without identifiers and maintained confidentially. The researcher will observe any emerging trends of depression and offer mental health education to interested residency programs that participated in the study. Outcomes: The percentage of residents who self-reported depression and the percentage of residents who indicated signs and symptoms of depression will be reported. The percentage of residents who were unaware of available mental health benefit resources and who desired more information regarding these resources will also be reported. This survey and its results will help raise mental health awareness in the field of pharmacy.

1. East Tennessee State University, Bill Gatton College of Pharmacy, Department of Pharmacy Practice; 2. East Tennessee State University, College of Arts and Sciences, Department of Sociology & Anthropology

Abstract Type: Work in Progress. Background: Psychiatric disorders are among major public health concerns. The large number of psychotropic medications and high incidence of concomitant physical illnesses have resulted in complex medication regimens and an elevated potential for drug interactions, adverse effects, and poor medication adherence. Particularly, in rural health centers with limited access to psychiatrists, patient care remains suboptimal because primary-care providers may not feel comfortable in providing psychiatric medications consults beyond uncomplicated mental illnesses. Board-certified psychiatric pharmacists are considered experts in providing mental health services including comprehensive medication management and coordination of multidisciplinary treatments. Although such services are increasingly gaining acceptance among healthcare teams, their value still awaits systematic evaluation from patients’ perspectives. Objective: The specific aim of the study is to examine perspectives of patients regarding mental healthcare services received from a psychiatric pharmacist in comparison with those from other healthcare providers (e.g., nurse practitioners). Methods: We will conduct a survey and focus groups in patients from a Federally-Qualified Health Center (FQHC) located in Johnson City, TN. The eligibility criteria are: 1) adult patients that received at least one psychiatric consultation and a follow-up visit with a psychiatric pharmacist or a nurse practitioner during 2016-17, and 2) patients diagnosed with at least one psychiatric disorder and are receiving at least one psychiatric medication. Participating patients will complete the survey in the waiting area before their regularly scheduled appointment. Other patients will participate in one of three focus groups (n = 12/group). The survey and focus group meetings will include questions on medication adherence, perceived competence of providers, ease of working with providers, and overall patient satisfaction. We estimate that 300 patients (approximately 150 patients each that received care from a psychiatric pharmacist or another provider) will complete the survey. Approval will be obtained from the East Tennessee State University Institutional Review Board. Outcomes: For survey data, Mann-Whitney U tests will be conducted to compare composite section scores between healthcare providers. Focus group data will be transcribed and analyzed thematically. The outcomes will provide useful information on patients’ perspectives regarding mental healthcare services provided by psychiatric pharmacists in comparison with other providers at a FQHC.

1. PharmD Student, College of Pharmacy, Purdue University, West Lafayette, IN; 2. Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN; 3. Department of Pharmacy and Midtown Community Mental Health Center, Eskenazi Health, Indianapolis, IN

Abstract Type: Work in Progress. Background: Some second-generation antipsychotics (SGA) are currently approved for use in children and adolescents with schizophrenia, bipolar I disorder with manic or mixed symptoms, and irritability with autism spectrum disorder, and are often used off-label in clinical practice to treat aggression and attention deficit hyperactivity disorder. These drugs have been shown to be efficacious in indicated disease states, however, they are associated with high levels of cardiac and metabolic adverse effects, including weight gain, obesity, impaired glucose tolerance, hyperprolactinemia, dyslipidemia, and hypertension. Currently, there are no specific clinical guidelines for metabolic monitoring in this patient population, but it is imperative to monitor for these adverse effects in children and adolescents to prevent long-term morbidity and mortality associated with these comorbid conditions. Objectives: (1) Evaluate the clinical literature regarding the rate and outcomes of metabolic monitoring in children and adolescents; (2) Develop a metabolic monitoring guideline for the Indiana Department of Child Services Psychotropic Consultation Program using the data collected from the literature review; (3) Design a future study regarding metabolic monitoring for children and adolescent members of Indiana Medicaid who are taking second-generation antipsychotics Methods: Relevant manuscripts were identified using a PubMed search (2005 to present) of English-language literature. Keywords used were atypical or second-generation antipsychotics, children, adolescents, pediatric, metabolic effects, and monitoring. Identified literature will be evaluated and presented for relevance and inclusion in metabolic monitoring review and proposed monitoring guideline. Outcomes: The goal of this literature review is to describe the current state of metabolic monitoring in this population, as well as the rates of adverse effects (specifically metabolic effects and hyperprolactinemia). We will use this review to develop a monitoring guideline that we will use when evaluating prescribers of these medications in a future study.

1. Eskenazi Health, Indianapolis, IN; 2. Purdue University, College of Pharmacy, West Lafayette, IN

Abstract Type: Work in Progress. Background: For patients with schizophrenia spectrum disorders, antipsychotic medications are essential to reduce positive symptoms and improve psychosocial functioning. Unfortunately, these agents carry a lifetime metabolic syndrome risk, underscoring the importance of close monitoring to promptly address metabolic abnormalities. Some studies involving first-episode psychosis patients hypothesize that this drug-naïve population already has elevated metabolic syndrome risk before initiating any clinical interventions. Available research specifically pertaining to metabolic monitoring and subsequent treatment in the setting of early psychosis with antipsychotic use is growing yet still scarce. This retrospective study will evaluate effectiveness of a protocol that targets weight, lipids, blood glucose, and blood pressure of patients followed at the Prevention and Recovery Center for Early Psychosis (PARC), an outpatient mental health clinic guiding the care of individuals in the early stages of psychotic disorders. Objectives: 1. Characterize monitoring for metabolic abnormalities for PARC patients according to an established clinic protocol focusing on weight, blood pressure, and metabolic labs, 2. Describe metabolic monitoring frequency, referral to primary care and programs focusing on weight loss and healthy dietary habits, and medication prescribing in response to abnormal labs as appropriate. Methods: A retrospective chart review will be performed for patients seen for at least one visit at PARC between July 1, 2013, and June 30, 2015, in Indianapolis, Indiana. Subjects will include patients that are at least 18 years old, have lab results provided by Eskenazi Health or from an outside provider documented in their electronic medical record, and have one of the following diagnoses: schizophrenia, schizoaffective disorder, schizophreniform disorder, or psychosis not otherwise specified. Data will be collected on demographics; medications prescribed, specifically antipsychotics and those used to treat metabolic abnormalities; baseline weight, blood pressure, HgbA1c, and LDL direct or lipid profile; and referral status to a primary care provider or other health care services. Descriptive statistics will be used for both objectives; other statistical tests may be used for subgroup analyses. Outcomes: We will report the number and percent of subjects monitored appropriately according to a clinic protocol as a function of demographics, medication use, vital signs, lab values, and referral status.

1. VA Salt Lake City Health Care System; 2. Orlando VA Medical Center * Corresponding Author

Abstract Type: Work in Progress. Background: Opioid overdose is a public health crisis and veterans are over-represented among overdose deaths. For each fatality, there are >10 non-fatal overdoses. History of overdose significantly elevates risk for another overdose. Little is known if medical management or prescribing patterns change following a non-fatal overdose. Objectives: 1) To detect if/when opioids are prescribed following a non-fatal overdose in a sample of veterans 2) To compare name and dose of opioid prescribed before and after a non-fatal overdose 3) To detect if/when subsequent opioid overdose occurs following a non-fatal overdose 4) To describe the incidence/cause of death during the period following a non-fatal overdose Methods: A retrospective, open chart review of veterans treated for an opioid overdose at the George E. Wahlen VA Medical Center was performed. The patients reviewed were included in a previously approved study of patients who experienced a non-fatal opioid overdose between January 1, 2009 and January 1, 2012. The 80 veterans who were included in the present study averaged 60 years of age, none had documented history of opioid use disorder but 41% had documented history of non-opioid substance use disorder. Data were extracted following their first overdose event after January 1, 2009 and continued through January 1, 2016. These data included number of days until an opioid was prescribed again, name and dose of prescribed opioid, type of clinic generating prescription for both the original and post-event opioid, days until another overdose event occurred, and incidence and cause of death during the follow-up period (if deceased during review period). The following criteria were used to identify opioid overdose events: documentation in emergency department or admission notes of ‘overdose’ or respiratory depression resulting in prescription of a full dose of i.m., i.v., or intranasal naloxone. Outcomes: We will report: 1) number of days until an opioid was prescribed, 2) name of prescribed opioid, 3) dose of prescribed opioid, 4) type of clinic generating both original and post-event opioid prescription, 5) days until another overdose event, and 6) incidence and cause of death during the follow-up period.

All parties are affiliated with the University of Findlay College of Pharmacy, Findlay, OH

Abstract Type: Work in Progress. Background: Medication adherence and compliance with scheduled office visits are critical issues in maintaining the well-being of individuals with mental illness, particularly those suffering from schizophrenia. Coupled with that is ensuring that clients are on adequate doses of medication to control their symptoms to allow them to more actively participate in the management of their illness. Current research focuses on comparing oral vs. long acting injectable (LAI) antipsychotics to determine which therapy is more effective. While LAIs offer our clients the benefit of not having to remember to take their oral medications on a daily basis, just as with oral medications it is critical that both groups of clients comply with their scheduled office visits to ensure that they are not off their medication for any prolonged period of time and at risk for relapse. Objectives: The objectives of this study are: 1) To assess comparative dosing of oral vs. LAIs based on published equivalent doses; and 2) To determine whether adherence with outpatient clinic visits differs between clients prescribed oral vs. LAI antipsychotics. Our hypothesis is that clients receiving LAIs will be on lower comparative doses and will have better compliance rates with scheduled outpatient clinic visits. Methods: Clients receiving antipsychotic drug treatment will be identified from the clinic’s electronic medical records and divided into two groups, those receiving oral antipsychotic therapy and those receiving LAI antipsychotic therapy. Data will be recorded on clients’ diagnosis, antipsychotic drug, drug dosage and number of scheduled and missed clinic visits. Outcomes: The data will be analyzed to determine what specific antipsychotics were prescribed, what average daily dosages were prescribed for oral antipsychotics and what average doses were administered per dosage interval for LAIs, how those doses compare with the recommended doses for those antipsychotics and how the average antipsychotic doses compare when converted to published dose equivalents. Compliance with clinic visits will be assessed by comparing documented scheduled clinic visits vs. clinic visits actually attended by the patient for both the oral vs. LAI antipsychotic groups.

All parties are affiliated with the New Mexico Veterans Affairs Health Care System, Albuquerque, NM

Abstract Type: Work in Progress. Background: Patients with schizophrenia are prone to psychotic relapse. The most common causes of relapse include poor adherence or discontinuation of antipsychotic therapy. Long-acting injectable (LAI) antipsychotics have been developed as a way to improve adherence and reduce relapse. Studies suggest that LAIs improve patient outcomes leading to improved functioning and quality of life; however, they remain largely underutilized. A better understanding of the potential benefits of LAIs, and in whom LAIs benefit the most, may guide long-term medication management and encourage use of this valuable treatment option. This study aims to determine differences in patient characteristics, clinical outcomes, and annual healthcare costs of LAI antipsychotic treatment versus standard oral antipsychotic treatment within a VA Health Care System. Objectives: 1. Determine characteristics of Veterans receiving LAI antipsychotics versus oral antipsychotics. 2. Determine the difference in number of psychiatric hospitalizations, length of hospitalization stays, number of ER visits, and number of walk-in visits to the outpatient psychiatry consultation clinic for Veterans receiving LAI antipsychotics versus oral antipsychotics. 3. Evaluate the cost-effectiveness of LAI antipsychotic treatment versus oral antipsychotic treatment. Methods: This will be a single-center, retrospective chart review and pilot study of Veterans receiving treatment at the New Mexico Veterans Affairs Health Care System (NMVAHCS). The target population will include adult patients (≥18 years) with a diagnosis of schizophrenia or schizoaffective disorder and who received outpatient care through the Psychiatry Primary Care Clinics (PPCC) at the NMVAHCS during the timeframe of August 1st 2015 through February 1st 2016. The intervention group will consist of a random sample of patients who were receiving LAI injections through the outpatient Long-Acting Neuroleptic Clinic (LANC). The comparison group will include a random sample of patients receiving oral antipsychotics. Descriptive statistics will be generated, and group differences will be analyzed using the χ2-test for categorical data and two-sided t-test for continuous variables. Outcomes: We will report the differences in patient characteristics (demographics, psychiatric histories, and medical histories), hospitalization events, and estimated annual health care costs between the two groups.

All parties are affiliated with the Iowa City Veterans Affairs Health Care System

Abstract Type: Work in Progress. Purpose: Prazosin is a selective postsynaptic α-1 antagonist that has demonstrated efficacy for the treatment of PTSD-related symptoms and nightmares in randomized control trials. A recent national VA study found that < 40% of veterans persisted on prazosin for greater than one year and < 20% of veterans reached the minimum VA/DoD guideline recommended dose of 6 mg/day. The reasons why prazosin is discontinued early and suboptimally dosed in the veteran population remain unclear. The purpose of this study is to describe current prescribing practices of prazosin in veterans at the Iowa City VA Health Care System (ICVAHCS) to better delineate existing clinical barriers to persistence on prazosin therapy. Objectives: 1. Determine the percentage of patients persisting on prazosin therapy at one year 2. Identify reasons for prazosin discontinuation 3. Describe adverse effects experienced with prazosin 4. Evaluate dosing of prazosin for PTSD in clinical practice Methods: This retrospective descriptive study will utilize electronic ICVAHCS medical records. Eligible adult veterans initiating prazosin for the treatment of PTSD between July 1, 2010 to December 31, 2013 will be included. Prazosin initiation will require a history of no prazosin use within the prior 365 days. Patients with no VA follow-up within 180 days of starting prazosin will be excluded. Chart reviews will be conducted for the 365 days following prazosin initiation to determine the duration of prazosin persistence based on prescription refill history and provider notes, as well as the reason for discontinuation among those who fail to persist for the full year. Baseline characteristics including comorbid psychiatric diagnoses, psychotropic medications, diagnosis of hypertension, and diagnosis of benign prostatic hyperplasia will be recorded. Prazosin dosages, reported adverse effects, and documented effectiveness of therapy will be recorded. Outcomes: We will report the frequency of patients persisting on prazosin therapy at 1-year. The documented effectiveness, dosage achieved, rates of adverse effects, and reasons for discontinuation will also be reported and summarized. Study findings will help optimize treatment provided to veterans in a pharmacist-managed prazosin titration clinic.

1. South Texas Veterans Health Care System; 2. University of Texas Health Science Center San Antonio; 3. The University of Texas at Austin; 4. Veteran Affairs Central Iowa System

Abstract Type: Work in Progress. Background: The risks of metabolic complications when using second-generation antipsychotics (SGA) are significant compared to the general population. Current guidelines recommend monitoring weight at baseline, week 4, 8, and 12, and then every 3 months thereafter. The waist circumference, blood pressure, fasting glucose/ A1c, and fasting lipids should be measured at baseline, week 12, and then annually thereafter. Currently, the South Texas Veterans Health Care System (STVHCS) policy states that the prescribing physician should monitor their patients that are on SGA’s; however, compliance to the recommended guidelines is low. Objectives: 1. Increase the adherence to recommended monitoring of SGA’s to improve patient safety 2. Identify and establish a system to assist providers in monitoring 3. Educate mental health providers regarding established processes to assist with metabolic monitoring Methods: This pilot program is provided to veterans at the Frank Tejeda Campus at the STVHCS from September 2015 to May 2016. Patients who require metabolic monitoring follow-up are identified using Datamart, an online portal that stores prescribing information within the healthcare system. On average, 25 patients are reviewed weekly. Up to 4 hours/week is dedicated to face-to-face visits for those who are due for baseline, 3 month, and annual labs/vitals. For those who are due for monthly or quarterly weights, a telephone follow-up appointment is conducted to document their weight. If clinically indicated and appropriate, medication recommendations are provided to the primary mental health prescriber or primary care physician, and consults to nutrition and weight management programs may also be entered. Outcomes: The authors will report the number of patients who were appropriately monitored while on a SGA after enrolling in the metabolic monitoring clinic. The number of consults entered to nutrition and weight management services will be tracked. Additionally, the number of recommendations provided and accepted will be reported. Cost savings secondary to interventions made will be calculated using the TheraDoc© system. A survey will be administered to mental health prescribers to assess satisfaction with the metabolic services and newly established procedures.

All parties are affiliated with Clara Maass Medical Center, Belleville, NJ

Abstract Type: Work in Progress. Background: In the inpatient psychiatric setting, PRN or “as needed” administration of psychotropic medications is an important tool for addressing acute behavioral disturbances. Nursing documentation describing patient behavior and why medication administration was needed is of particular importance. This documentation helps to provide a more complete clinical picture for physicians and other staff when determining if current therapy is adequate or requires adjustment. Appropriate documentation also provides evidence to justify PRN psychotropic administration to ensure that misuse of these medications is not taking place. Providing education to nursing staff not only aids in improving documentation practices but also allows for more informed clinical decision making based on patient presentation and medication options. Objectives: 1. Evaluate nursing documentation practices regarding PRN psychotropic administration prior to providing staff education, 2. Assess the impact of a pharmacist-delivered nursing education session on documentation practices, 3. Determine what effect, if any, this education has on the overall use of PRN medications Methods: All instances of PRN psychotropic administration between February 1 and April 30, 2015 will be evaluated to determine if documentation regarding the administration is present and if that documentation provides evidence to justify the administration. A nursing education session will be conducted prior to February 1, 2016 which will discuss the use of PRN psychotropic medications and documentation of administration of these medications. All instances of PRN psychotropic administration between February 1 and April 30 2016 will then be evaluated to determine the impact of the pharmacist-delivered education session. Outcomes: The results from the evaluation of both the 2015 and 2016 time periods will be reported to determine if documentation of PRN psychotropic administration has changed following the education session. Statistics will also be presented to determine any changes in the overall use of PRN psychotropic medications.

All parties are affiliated with the Yale-New Haven Hospital Department of Pharmacy, New Haven, CT

Abstract Type: Work in Progress. Background: Medication related errors occur in over 1.5 million patients each year. Many of these errors could be prevented with accurate medication histories and medication reconciliation across transitions of care. The World Health Organization and Joint Commission agree that medication reconciliation is key to preventing medication errors. In 2005, Joint Commission added a National Patient Safety Goal focused on medication reconciliation. At Yale-New Haven Hospital (YNHH), medication reconciliation technicians obtain medication histories for patients with high-risk disease states, such as COPD, CHF and pneumonia. However, patients with psychiatric disorders are at high risk for hospital re-admission as well. Furthermore, the acuity of psychiatric symptoms at admission may prohibit providers from obtaining an accurate medication history. This quality improvement study aims to identify opportunities for pharmacists to optimize the medication reconciliation process in an inpatient psychiatric population. Objectives: 1. Quantify the impact of pharmacist interventions on medication reconciliation in psychiatric patients, 2. Maintain accurate and up to date medication profiles for psychiatric patients throughout all transitions of care, 3. Identify error-prone steps in the medication reconciliation process, 4. Evaluate the need for additional pharmacy employees in the behavioral health service line. Methods: Participants will be recruited from four psychiatry units at YNHH (adult, dual diagnosis, young adult, and geriatric). Patients who meet one or more of the following criteria will be eligible for study inclusion: first admission to YNHH, re-admission within 3 months of hospital discharge and/or ≥8 home medications. The pharmacist will obtain a comprehensive medication history and compare it to the current inpatient list. Identified discrepancies will be documented in the medical record and the treatment team will be notified and provided with any relevant clinical pharmacotherapy recommendations. The pharmacist will also perform discharge medication reconciliation. Patient demographics, primary psychiatric diagnosis, comorbid conditions, date of recent hospital stay (if applicable), and the number of medications originally on the medication list will be collected. Outcomes: We will report the medications involved, number, and type of discrepancies identified in the medication history and reconciliation processes. Intervention data will be quantified and classified and the associated pharmacy resource requirements will be captured.

1. School of Pharmacy, University of Waterloo; 2. Center for Family Medicine Family Health Team; 3. Department of Family Medicine, Michael G DeGroote School of Medicine, McMaster University

Abstract Type: Work in Progress. Background: The prevalence of Alzheimer’s disease and related dementias is increasing dramatically worldwide. Management of dementia presents many challenges due to multiple comorbidities, contribution of inappropriate medications to cognitive dysfunction, polypharmacy and dementia-related medication adherence issues. Pharmacists are in a valuable position to assess and optimize the complex pharmacotherapeutic regimens for patients with cognitive impairment or dementia. Optimizing medication management may significantly reduce worsening of cognitive impairment, improve control of vascular risk factors, increase medication adherence, and help to reduce caregiver burden. However, there is a paucity of literature describing the activities performed by pharmacists when providing care to persons with cognitive impairment. Objectives: The primary objective of this study is to classify pharmacist activities and interventions performed in an interdisciplinary primary care memory clinic (PCMC). The secondary objective is to develop frameworks or tools to guide medication reviews and assessments by other PCMC teams. Methods: This study is designed as a retrospective review of medical records of all patients assessed at one PCMC from January 2010 to December 2015. The following data will be collected and analyzed: demographics, clinical measurements, social history, past medical history, current medical problems, allergies, date and type of diagnoses of dementia-related conditions, history of recent falls, cognitive testing scores, list of current medications, pharmacist activities performed, medication related problems identified, pharmacist recommendation(s), and acceptance of pharmacist recommendation(s) by patients and physicians. Pharmacist activities will be categorized, coded, and quantified. Outcomes: The primary outcomes assessed will be types of pharmacist activities performed, such as assessment of patient’s medication management skills, adherence to medications, medications that can impair cognition or function, medications for vascular risk factor control as well as MRPs. We will also report on cognitive testing scores, medications, MRPs, and changes in medications over time.

All parties are affiliated with the Department of Veterans Affairs Eastern Colorado Healthcare System (VA ECHCS), Denver VA Medical Center (Denver VAMC)

Abstract Type: Work in Progress. Background: A shortage of psychiatric providers has resulted in mental health patients with unmet needs. While this has been largely recognized as an ongoing matter, healthcare systems must also adapt to transient, short-term fluctuations in provider availability, effecting accessibility to care. One such transient fluctuation arises from provider turnover, which can have a substantial effect on patients and put unneeded stress on institutional services such as the Psychiatric Emergency Services (PES). Opportunities exist for psychiatric pharmacists to provide interim care while patients are between providers. Objectives: 1. Quantify and describe the number of pharmacist interventions in the specified time period. 2. Compare the number of PES visits before and after implementation of the clinic. 3. Describe the types of interventions psychiatric pharmacists performed. Methods: This study is a single center, retrospective, cohort study of patients without an assigned outpatient Mental Health provider receiving care at the Denver VAMC between the dates of October 01, 2015 and January 31, 2016. Baseline characteristics (age, gender, psychiatric diagnoses, psychiatric medications), number and types of pharmacist interventions, number of PES visits, and descriptions of each intervention will be collected. Outcomes: We will report and describe the number and types of interventions as a function of demographic characteristics and assignment status at the time of the interview. We will also report adjustments in dosage, frequency, and use for all medication related interventions.

1. Captain James A. Lovell Federal Health Care Center, North Chicago, IL; 2. Rosalind Franklin University School of Medicine and Science, School of Pharmacy, North Chicago, IL; 3. Syracuse Veterans Affairs Medical Center, Syracuse, NY

Abstract Type: Work in Progress. Background: Attention deficit/hyperactivity disorder (ADHD) is one of the most common psychological disorders presenting in children, but the study, diagnosis, and treatment of adult ADHD is rising. Two most recent estimates of the prevalence of ADHD in adults residing in the United States fall at 2.9 and 4.4%. Evidence suggests the prevalence of adult ADHD may be higher in the Veterans Affairs population. Adult ADHD may be more prevalent in undomiciled veterans and veterans with posttraumatic stress disorder, traumatic brain injury, substance use disorder, anxiety disorders, and depressive disorders. This pilot study will provide data for the Veterans Affairs population by surveying the prevalence of adult ADHD-like presentation in outpatient clinics, rather than in veterans with specific disease states. Objectives: 1. Determine the prevalence of ADHD-like presentation in outpatient clinics of Captain James A. Lovell Federal Health Care Center (FHCC), 2. Identify correlates between ADHD symptoms and participants’ demographic information, service connection, military history, family history, service utilization, and history of common mood disorders, anxiety disorders, certain medical conditions, substance use disorders, and pharmacological treatment for ADHD. Methods: Participants will be recruited from outpatient clinics at FHCC. The target enrollment is 290 participants. Inclusion criteria are veterans, age 18-45 years, who can read and understand English, enrolled in FHCC outpatient clinics, and who are cognitively intact. Subjects will be excluded if they are not veterans, cannot both read and understand English, are acutely medically ill, or display current intoxication, altered mental status, or acute psychosis. Participants will complete the ADHD Self-Report Scale (ASRS) v1.1 Symptom Checklist-Expanded, which results in a positive or negative screen for ADHD. A retrospective chart review will obtain secondary outcome measures. For objective 1: n and % of subjects with ADHD-like presentation will be reported. For objective 2: descriptive statistics will be used to report correlation of ADHD symptoms with secondary outcome measures. Outcomes: Pending.

1. School of Pharmacy, Husson University, Bangor ME; 2. Unum Portland ME; 3. School of Medicine, Tufts University, Boston MA; 4. Maine Medical Center, Portland ME; 5. Department of Psychology & Neuroscience, Bowdoin College, Brunswick ME

Abstract Type: Work in Progress. Background: Anxiety is common in the general population with an estimated prevalence rate of 14%. Among students, 2.9% of undergraduates and 3.8% of graduate students screen positively for generalized anxiety. While some anxiety can be beneficial to students, manifesting as motivation to study and complete assignments, persistently high levels of anxiety may negatively impact the student’s ability to focus, concentrate, and keep up with course and program workload. Stigma associated with a diagnosis of anxiety may reduce the likelihood of students to seeking help, impeding proper screening and treatment. Objectives: The main objective is to describe the overall prevalence of potentially undiagnosed anxiety among students enrolled in professional healthcare programs in Maine. Secondary objectives include comparing and contrasting the prevalence of anxiety between students in various program types and between year-of-schooling subgroups. Our goals are to increase awareness of anxiety in healthcare programs and to identify, quantify, and describe the proportion of students with potentially undiagnosed anxiety in our study population. Methods: Participants must be 18 years or older and enrolled as full time students in their 1st, 2nd, 3rd, or 4th years of either the pharmacy, nursing, or physical therapy programs at Husson University or University of New England. Participants will complete an anonymous survey consisting of four demographic questions (gender, university, program type, and year-of-schooling), followed by the validated 20-item Zung Self-Rated Anxiety Scale (ZSAS) and three additional questions asking about general diagnosis, treatment, and receipt of counseling services for a history of or ongoing anxiety disorder. For each item of the ZSAS, participants will be asked to rate themselves on a Likert Scale of 1-4. Scores are defined as follows; <45, no anxiety; 45-59, mild-moderate anxiety; 60-74, marked-severe anxiety, and >74, extreme anxiety. Outcomes: We will report the number and percentage of students with potentially undiagnosed anxiety and analyze the prevalence and severity of anxiety amongst the study subpopulations to increase awareness of anxiety amongst students enrolled in competitive healthcare programs. We hope to identify subpopulations for targeted interventions, such as formal screening or educational sessions aimed at reducing bias around seeking professional help.

All parties are affiliated with the Department of Pharmacy, Medical University of South Carolina, Charleston, SC

Abstract Type: Work in Progress. Background: Health literacy requires patients to interpret documents, read, write, speak and listen to important healthcare information. Health literacy is determined by patients understanding basic information in order to make health decisions. Low health literacy is associated with poor health outcomes, and interventions designed at targeting issues of health literacy have improved rates of ED visits and hospitalizations. The Medical University of South Carolina Institute of Psychiatry (IOP), admits patients in the high risk populations mentioned above; however, it is unclear if our patients would benefit from specific interventions targeted at health literacy. Ultimately, results of this study could lead to interventions to improve health literacy and subsequent outcomes. Objectives: Classify the perception of patients’ own health literacy who are admitted to an inpatient psychiatric hospital 2. Identify disparities between provider perception of health literacy and patient perception of their own health literacy Methods: An anonymous electronic survey will be provided to the medical residents, psychiatrists, nurse practitioners, and social workers through RedCapTM to assess providers’ perception of patients’ health literacy. An anonymous paper health literacy survey will be provided to randomly selected adult IOP patients. Within the survey, demographic questions will be asked to help identify patients in some of the high risk groups as well as questions that have been found to be effective in identifying health literacy inadequacies in patients. Preliminary Outcomes: A total of 48 responses were received for the provider survey. Most of the responses were received from either attending or resident psychiatrists with half of providers in practice for 1 to 5 years. Most providers believe patients often need someone to help them read hospital materials, can sometimes fill out medical forms themselves, and often have problems learning about their own conditions because of difficulty understanding written information. To date, 37 patients have been randomly selected to participate in the survey with 11 completing the survey for a 30% response rate.

1. Nova Southeastern University, College of Pharmacy; 2. Nova Southeastern University; College of Psychology

Abstract Type: Work in Progress. Purpose: Nova Southeastern University (NSU) Interdisciplinary Fall Prevention Clinic consists of healthcare providers working together to assess patients with a history of falls to determine contributing risk factors. Psychiatric conditions (e.g., depression, anxiety) have been associated with a risk of falls. However, data are limited in exploring whether the association is related to the disease (e.g., depression vs. anxiety), its severity, or the medications used to treat such disorders. Therefore, the aim of this preliminary pilot study is to identify psychiatric factors (e.g., diseases, psychotropics used) associated with an increased risk of falls. Method: After IRB approval, retrospective data between 2011-2015 were collected. Cognitive impairment, depression, and anxiety symptoms were rated by the use of Montreal Cognitive Assessment (MoCA), Geriatric Depression Scale – Short Form (GDS-SF), and Geriatric Anxiety Inventory (GAI), respectively. Descriptive statistics, independent t-tests, and correlation (i.e., Pearson’s) analysis were used. Results: Thus far, data from forty patients have been evaluated. Seventy percent of patients were female with an average age of 76.6 years (+/- 8.1). The calculated average number of falls per patient is 1.95 (+/-1.57). Forty-five percent of patients reported clinically significant levels of depressive symptoms and, of those, 61% also reported clinically significant levels of anxiety. Overall, thirty-five percent reported clinically significant levels of anxiety symptoms and were taking a benzodiazepine. Antidepressant use was not associated with number of falls; however, greater number of falls were associated with benzodiazepine use in the treatment of those reporting higher anxiety symptoms (p = 0.04). There were no correlations between number of falls and MoCA, GDS, and GAI scores. Conclusions and Future Directions: In a limited sample size, it appears most patients seen in the clinic had approximately two falls within the last year prior to the appointment. While the degree of psychiatric symptoms did not demonstrate correlations with falls, it appears benzodiazepine use contributed to greater fall risk. Further exploration is needed to determine if psychotropic medications and specific doses may have contributed to adverse events leading to an increased risk for falls.

All parties are affiliated with the Department of Veterans Affairs, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia

Abstract Type: Work in Progress. Background: The growing need of mental health services continues to highlight the importance of increased access-to-care and mental health recovery as a major goal in delivering optimal care for our Veterans. The PTSD program has provided excellent care for patients, offering various therapies to address their trauma provided by psychologists and social workers through both individual and group psychotherapy. Pharmacists have been an integral part in improving access-to-care by providing adjunctive medication management as a consultation service for this patient population, but there are no pharmacy services embedded within the PTSD curriculum as a standard of care. The aim of this study is to assess the specific roles pharmacists play in promoting health and medication literacy to our Veterans as part of their PTSD recovery. Objectives: 1. Evaluate patient understanding of the clinical utilization of medications for the treatment of PTSD, 2. Evaluate patient perception of medication adherence and engagement in pharmacotherapy, 3. Evaluate patient satisfaction of medication education provided by pharmacists within a PTSD group setting. Methods: Participants will be recruited voluntarily from patients enrolled in the two most highly utilized groups offered within PTSD clinic – Recovery Group and Seeking Safety Group. The class will be divided into three 30-minutes sessions, including an “Introductory Class”, a “Core Class”, and a “Wrap-up Class”. These three additional classes will be conducted during week 1, week 6, and week 12, of their PTSD group using standardized curriculum. Each participant will be asked to complete a survey pertaining to patient-satisfaction of the class itself, and understanding and perception of medication utilization and medication adherence. These surveys will be completed at the beginning of the first class and at the end of the wrap-up session. Outcomes: The authors will report the demographics of the participants. We will also report the results of the satisfaction surveys of the class, the number of participants with change and the percent change in perception of medication utilization and adherence. Conclusion: The authors anticipate that this class will increase patient understanding of medication therapy for PTSD treatment and clarify the role pharmacists play in PTSD recovery.

All parties are affiliated with Chillicothe Veterans Affairs Medical Center

Abstract Type: Work in Progress. Background: The Chillicothe VA serves veterans from Ohio, Kentucky, and West Virginia, where the rates of opioid abuse are some of the highest in the nation. Prior to the implementation of a symptom-triggered opiate withdrawal protocol, there was no standardized process in place to treat veterans undergoing opioid withdrawal at the Chillicothe VAMC. The initiation of a symptom-triggered opioid withdrawal protocol was intended to offer evidence based medical treatment to veterans in the hopes of decreasing length of hospital stay and increasing the number of veterans seeking outpatient rehabilitation treatment. Retrospective chart reviews will be analyzed to detect differences in clinical outcomes before and after the implementation of a symptom-triggered opiate withdrawal protocol at the Chillicothe VAMC with specific focus on patients who received buprenorphine/naloxone. Objectives: The primary objective of the study is to investigate differences in the number of hospital admission days for opiate detoxification before and after implementation of the symptom-triggered opiate withdrawal protocol in patients who received buprenorphine/naloxone. Additional objectives are to detect the difference in Substance Abuse Program retention (start and completion), to investigate the number of patients who received maintenance therapy with buprenorphine/naloxone, and to identify the number of patients who remained sober for 3 months following opiate detoxification. Methods: The proposed study is a retrospective cohort study. A list of all patients who have received buprenorphine/naloxone via the opiate withdrawal protocol will be provided along with a list of patients who underwent opiate detoxification prior to the implementation of the opiate withdrawal protocol. Thirty patients prior to implementation and 30 patients who received buprenorphine/naloxone is the estimated sample size needed to meet power. Computerized Patient Record System (CPRS) will be used to determine the clinical outcomes as well as demographic information. Student’s t test and Fisher’s exact test will be conducted to assess for statistical significance. Outcomes: We will report the process of developing a symptom-triggered opiate withdrawal protocol at the Chillicothe VAMC, along with the clinical outcomes for veterans who received buprenorphine/naloxone for detoxification.

All parties are affiliated with the Veterans Affairs Texas Valley Coastal Bend Healthcare System, Harlingen, TX

Abstract Type: Work in Progress. Background: Antipsychotic agents are FDA indicated and proven to be effective for treatment of schizophrenia, schizoaffective disorder, bipolar disorder, and as an adjunct for major depressive disorder. Since their emergence, atypical agents have been utilized over conventional agents due to more favorable side effects and improved adherence. Furthermore, they are increasing in use for many disease states as off-label indications. Veterans Affairs applies a careful selection and review process that relies on evidence-based guidelines and clinical trials prior to placement of agents within the formulary. Veteran Integrated Service Network (VISN) oversees prescribers’ requests for non-formulary or restricted medications. A restricted drug request (RDR) for antipsychotic agents was implemented in 2011 in order to reduce adverse outcomes and promote the safe application of agents for therapy. Through the RDR process, prescriptions for antipsychotics were identified as meeting criteria for use or an alternative which was in line with evidence-based guidelines was suggested. As a result, the RDR process has reduced the percentage of total prescriptions by 0.3% while promoting safety and quality of care outcomes. This retrospective review encompasses one of the regular evaluations of outcomes from RDR of atypical antipsychotics to ensure best practices. Objectives: Evaluate the tolerability and safety outcomes of individuals with a RDR for an atypical agent to establish efficacy and quality of care. Methods: Retrospective chart review of veterans evaluated at VA Texas Valley Coastal Bend who had a RDR for an atypical agent. Data from 276 chart reviews were obtained by pulling health-factors tied to a RDR placed January 2014-December 2014. Veterans were included if a RDR was placed during 2014 and excluded if medical history was inaccessible through electronic records. Chart review encompasses prior psychiatric history leading to RDR placement in 2014 and follow up through January 2016. Outcomes: The primary outcome is patient safety, as defined by the incidence of hospitalizations and change in suicide risk level on assessment. Secondary outcomes include drug tolerability as measured by adherence and the incidence of adverse events, including metabolic changes, falls, extrapyramidal symptoms, or any other side effect leading to discontinuation of the agent.

All parties are affiliated with Virginia Garcia Memorial Health Center and Pacific University School of Pharmacy, Hillsboro, OR

Abstract Type: Work in Progress. Background: Previous studies have shown a bidirectional link between depression and diabetes describing how patients with diabetes are more likely to be depressed and how patients with depression are more likely to have diabetes. This study attempts to correlate HbA1c scores and PHQ9 scores to observe any association between the two. Are people with elevated PHQ9 scores more likely to have elevated HbA1c scores? Should patients with elevated HbA1c scores be screened for depression routinely? Objectives: 1. To determine if patients with uncontrolled depression (PHQ9 scores 10 or higher) are more likely to have poor control of their diabetes (higher HbA1c scores) than patients without uncontrolled depression (PHQ9 scores less than 10). 2. To compare HbA1c values in patients in each category of depression, based on PHQ2 or PHQ9 scores. Methods: This is a retrospective study looking at patients with Type 2 Diabetes who have routinely seen providers at any of the five Virginia Garcia clinics over the last three years. Data will be collected from patients who have been seen at least twice in three years, and who have at least one PHQ9 score within 3 months of an HbA1c. Patients will be placed in groups based on their PHQ9 scores to correlate with depression scale criteria (none, minimal, mild, moderate, moderately severe, and severe depression). If PHQ9 scores are unavailable, then a PHQ2 negative result may be used to determine no depression. The average HbA1c of all patients in each depression group will be calculated, and any differences will be analyzed. This study has been submitted for approval to the Pacific University Investigational Review Board (IRB). Outcomes: We will report number of participants in each depression category based on PHQ2 or PHQ9 scores and correlate the average HbA1c of all participants in each category. Categories include: PHQ2 negative or PHQ9 0 = No depression, PHQ9 1-4 = minimal depression, PHQ9 5-9 = mild depression, PHQ9 10-14 = moderate depression, PHQ9 15-19 = moderately severe depression, and PHQ9 ≥ 20 = severe depression.

1. School of Pharmacy, North Dakota State University, Fargo, ND; 2. Department of Sociology, North Dakota State University, Fargo, ND

Abstract Type: Work in Progress. Background: Self-stigma is a perceived condition that deviates from what someone would consider normal and is linked with attributes that would produce a negative image, spoiling one’s identity. In patients with depressive disorders, stigma has been associated with poor quality of life (QOL), decreased antidepressant adherence, and social isolation which could lead to restricted social networks, lower income, and unemployment. Photovoice is a method that encourages participants to use a camera to capture their experiences that can be shared to others to enable communication, education, and advocacy. Photovoice methodology has been employed with mental illness sufferers, which has uncovered themes of misunderstanding, invisibility, and inability to control their disease, which are also common themes of stigma. Objectives: The primary objective of this study is to highlight the stigmatized experience to educate others about the self-stigma felt by antidepressant users. The researchers also intend to determine whether medication related self-stigma is emphasized by participants and how self-stigma influences the use of antidepressants. Methods: The researchers will perform a secondary analysis of an initial study that used Photovoice to explore the medication experience of participants that had self-reported using a psychiatric medication. In three cohorts, 17 (n = 5;8;4) total antidepressant users, were given a disposable camera and a journal and were asked to document their medication experience. The researchers are currently analyzing participants’ journal entries and photo interview transcriptions. Line-by-line coding of stigma mentions by the participants will be done according to the definitions and structure of self-stigma as specified in the Self-Stigma Depression Scale (SSDS). Self-stigma codes and descriptions will then be tallied and grouped according to themes. Outcomes: Resultant themes and descriptions will characterize how stigma associated with antidepressants affects the medication experience of antidepressant users. Through this study, the aim is to decrease stigma through a visual educational piece depicting self-stigma to raise awareness and educate others.

All parties are affiliated with the Eastern Colorado Department of Veterans Affairs, Denver, CO

Abstract Type: Work in Progress. Background: One-third to one-half of patients with schizophrenia remain actively ill despite pharmacological treatment. The American Psychiatric Association guidelines do not address dual antipsychotic therapy and the NICE guidelines only consider dual antipsychotic therapy appropriate during a cross titration period. Despite this guidance, up to 50% of patients with schizophrenia are placed on dual antipsychotic therapy at some point in their care. Addressing this difference between current guidelines and clinical practice may improve outcomes. Additional studies are important because antipsychotics are associated with significant risks including cardiometabolic side effects. Additionally, antipsychotic agents place financial strain on the patient and the institution. This study will provide important data in regards to the safety of antipsychotic polypharmacy. Objectives: 1. Evaluate the prevalence of side effects in the antipsychotic polypharmacy group compared to the antipsychotic monotherapy group. 2. Evaluate the differences in hospitalizations, mortality, anticholinergic prescriptions and abnormal involuntary movement scale scores in the antipsychotic polypharmacy and monotherapy group. Methods: This is a retrospective chart review, with a target enrollment of 300 patients. Participants will be analyzed from January 1, 2010 through December 1, 2015. The patients must have received antipsychotic polypharmacy or monotherapy for at least 90 days. The average dosing equivalent will be calculated for each antipsychotic regimen using the international consensus study of antipsychotic dosing tables. Outcomes: The primary endpoint of this study is to evaluate the prevalence of side effects between the polypharmacy and monotherapy groups. This will be determined through recorded blood pressure, weight/BMI, hemoglobin A1C, and total cholesterol/triglycerides after at least 90 days of therapy. These values will be compared to the pre-therapy values and a percentage change during therapy will be calculated. Secondary outcomes will include hospitalizations, mortality, anticholinergic prescriptions during antipsychotic therapy and AIMS.

1. Department of Pharmacy Services, UC Health-University of Cincinnati Medical Center; 2. University of Cincinnati

Abstract Type: Work in Progress. Background: Mental status changes secondary to neurological events occurring in the post-liver transplant period have been well described in the literature, occurring at rates between 9% and 40%. Elevated incidence of mental status changes in the liver transplant population has previously been attributed to surgical complexity, metabolic disturbances, previous hepatic encephalopathy, and neurotoxicity secondary to calcineurin inhibitor administration. Although these changes are not well defined and remain highly unpredictable, the associated increase in morbidity and mortality in this patient population has been well established. Improved and timely characterization of mental status alterations such as PTSD, depression, anxiety, delirium, acute psychosis, and suicidality through the development of a validated screening tool would allow optimization of medication therapy and improved global management of the liver transplant population. Objectives: The primary objective is to optimize the screening and characterization of mental status changes including PTSD, depression, anxiety, delirium, acute psychosis, and suicidality in the liver transplant recipient occurring during the post-liver transplant hospital admission period. Secondary objectives include determining the frequency of mental status changes and their associated risk factors. Methods: This prospective, single-center study will enroll liver transplant recipients admitted to the transplant service at the University of Cincinnati Medical Center. Patients will be enrolled consecutively from the time of approval with a goal to enroll 30 subjects in a projected 4-6 month enrollment period. Informed consent will be obtained before initiation of any study procedures. The screening tool will be administered at specified time points according to the study schedule. Subsequent follow-up screenings will be conducted three days after initial screening and then every seven days until discharge. The screening tool will primarily screen for depression, PTSD, anxiety, and suicidality by combining elements of pre-existing, validated screening methods. Symptoms of delirium and psychosis will be captured through CAM/RASS scores and electronic medical record documentation. Additional information will be collected following discharge through retrospective chart review to determine secondary endpoints. Descriptive statistics will be utilized to assess specific aims. Results: Data will be collected beginning in January 2016. Conclusion: Results will be interpreted and presented at the Great Lakes Pharmacy Resident Conference.

1. Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA; 2. Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA, USA

Abstract Type: Work in Progress. Introduction: Fibromyalgia (FM) is a chronic pain disorder associated with various symptoms including fatigue, muscle stiffness, sleep disturbance, depression, anxiety, and cognitive disturbance. FM patients have reported experiencing distrust, doubt, non-acceptance, rejection, frustration and stigmatization from family, health care providers, work-places, and other social environments. The term invalidation has been used to refer to the “discounting” and “lack of understanding” that patients receive from their personal, professional and social environments due to invisible symptoms. Studies in the past have compared invalidation in FM patients to that in rheumatoid arthritis, osteoarthritis, gout, systemic lupus erythematosus, and other such inflammatory and rheumatic disorders. These conditions, however, are often well-accepted by the medical fraternity and society due to the relative ease in identification, diagnosis and treatment. Contrarily, most symptoms associated with FM are invisible. Therefore, the goal of this study is to compare FM to another similarly invisible pain disorder. Migraine is one such chronic pain condition similar to FM in that both disorders are associated with central sensitization and hyperalgesia. According to the best knowledge of the researchers, no studies have compared invalidation in FM and migraine. Objectives: The aim of this study is to identify and differentiate experiences of invalidation between two groups of people with chronic pain with inherently invisible symptoms: FM and migraine. Methods: The current study is a cross-sectional web-based survey administered via Qualtrics© software (Provo, Utah). The survey includes closed and open-ended questions and the use of standardized instruments/measures. The instruments included in the survey are: Illness Invalidation Inventory, Patient Health Questionnaire, Pain Impact Questionnaire, American College of Rheumatology updated diagnostic criterion, ID Migraine Screener. An open-ended question was utilized to collect information on patient experiences with their respective disorders. Outcomes: Reported outcomes will include statistical comparisons of the following between fibromyalgia and migraine patients: 1) invalidation scores, 2) mood disorders, and 3) impact of pain and its severity. A content analysis of open-ended comments will also be conducted to identify and compare patient experiences and to direct future research in the area of “invalidation” and stigma associated with these two disorders.

1. UNC Eshelman School of Pharmacy; 2. UNC Medical Center Department of Pharmacy

Abstract Type: Work in Progress. Background: While often unintentional, stigma associated with mental health remains prevalent amongst healthcare professionals and is implicated in treatment disparities between patients who present with mental disorders and those who do not. It has been demonstrated that many members of the healthcare team exhibit stigma, including pharmacists who may find themselves unable to counsel or monitor such patients effectively. Pharmacy students have also been previously described as prone to stigma and discomfort interacting with patients with mental disorders. This is a descriptive study in educational research that uses an online questionnaire to assess student involvement in activities focused on mental health awareness, stigma associated with mental illness, and student interest in future opportunities in psychiatric pharmacy. The study seeks to describe the effect of various exposures to mental illness on stigma in pharmacy students. Objective: Evaluate the extent that participation in student organizations focused on mental health influences attitudes and perceptions towards patients suffering from mental illness. The impact of various programs and activities on students’ plans to pursue additional educational opportunities in psychiatric pharmacy will also be assessed. Methods: Data collection has been implemented as an anonymous, voluntary survey open to all student CPNP chapters for the 2015-2016 academic year. Demographic information including race, gender, year in pharmacy school, political orientation, and CPNP involvement will be collected as well as information on mental health stigma and interest in future psychiatric pharmacy opportunities. Sections of the survey instrument on stigma were an adaptation of previously validated instruments assessing stigmatizing beliefs using various validated scales (e.g. Opening Minds Scale and Social Distance Scale). The survey was generated using an online survey tool and disseminated electronically via a CPNP student listserv by a designated third-party, non-faculty, CPNP National personnel on behalf of the investigators. Additionally, consent is obtained through a consent form at the beginning of the survey. All data collected through this study is being collected anonymously and without identifying information. Data collection is currently ongoing. Outcomes: Attitudes towards mental illness and interest in psychiatric pharmacy will be reported against level of involvement of the study population in mental health-related activities.

All parties are affiliated with Denver Health Medical Center, Denver, CO

Abstract Type: Work in Progress. Background: Measuring the quality of health care is becoming increasingly important as pay-for-performance reimbursement becomes more common; the Department of Health and Human Services has announced it will tie 50% of Medicare payments to quality outcomes by the end of 2018. While quality measures have been well-studied in other areas of healthcare, psychiatric quality measures, especially for inpatient facilities, have not been identified at the same rate. For example, when the Centers for Medicare and Medicaid Services recently proposed 130 new quality measures, only two were specified as measures for inpatient psychiatric facilities, and neither addressed medication use. To keep pace with the transformation of health care toward patient value, and to maximize revenue in a pay-for-performance system, psychiatry needs an evidenced-based set of quality metrics around the use of psychiatric medications. To address this, a multistep project was initiated to develop measures which characterize high quality patient care on inpatient psychiatric units. First, a literature search was conducted to identify common problems related to medication use in inpatient psychiatric settings. Second, quality metrics were proposed based on this literature. Third, inpatient psychiatrists will be surveyed to assess their opinion of the proposed quality metrics. Once implemented, the metrics will be evaluated to assess utility. In this initial step, results of the psychiatrist survey regarding the proposed quality metrics will be reported. These opinions will subsequently be incorporated into decisions on which metrics to implement and evaluate at Denver Health Medical Center. Objective: The goal of this quality improvement project is to evaluate psychiatrists’ opinions of the proposed measures with regard to their feasibility and utility in inpatient psychiatric settings. Methods: An electronic survey will be used to evaluate the proposed metrics. All psychiatrists at Denver Health Medical Center will be eligible to fill out the survey and invited to participate, excluding those that work solely in an outpatient setting. The survey will include rating scales and options for free text responses for each metric. Once collected, descriptive statistics will be used to analyze the data. Outcomes: Data collection and analysis are pending.

1. University of Pittsburgh School of Pharmacy, Pittsburgh, PA; 2. Western Psychiatric Institute and Clinic of UPMC, Pittsburgh, PA

Abstract Type: Work in Progress. Background: Long acting injectable antipsychotics (LAIAs) have been shown to increase medication adherence and reduce inpatient admission rates when compared to oral antipsychotic agents. While studies have shown demographic differences in LAIA prescribing patterns, evidence regarding the effect of demographic differences on medication adherence and admission rates is lacking. This study will attempt to identify demographic factors that impact LAIA prescribing, adherence and clinical outcomes as measured by inpatient admissions. Objectives: This study will assess LAIA prescribing patterns, adherence and clinical outcomes in an outpatient psychiatric population. Methods: Participants will include approximately 300 outpatients of Western Psychiatric Institute & Clinic (WPIC) in Pittsburgh, Pennsylvania receiving LAIAs for schizophrenia or schizoaffective disorder during Fiscal Year 2015 (FY15). Demographic, clinical and financial information will be collected from the electronic medical record and pharmacy computer systems including: race, gender, age, LAIA prescribed, administration dates, inpatient admissions, duration of stay and copayment or cost of LAIA. Adherence rates for each individual will be calculated using Medication Possession Ratios. Regression analysis will be used to determine whether relationships exist between demographic factors, adherence and clinical outcomes. Outcomes: Prescribing patterns, adherence rates and clinical outcomes will be evaluated in the context of demographic factors to inform implementation of targeted LAIA adherence interventions and clinical recommendations to ensure optimal treatment outcomes in this vulnerable patient population. Current demographic data collected is as follows: 58% male and 42% female, mean age 46.2 years, and a racial breakdown of 66.7% African American, 32.7% Caucasian, and 0.6% Asian.

All parties are affiliated with Magellan Rx Management, Scottsdale, AZ, United States

Abstract Type: Work in Progress. Background: Non-adherence rates in schizophrenia are estimated at 50%. This often leads to hospitalizations and worsened clinical outcomes for patients. Long acting injectable antipsychotics (LAIs) are an option for patients with non-adherence. LAIs are underutilized due to possible barriers including utilization management criteria and administration requirements. Barriers to prescribers may be the prior authorizations that these medications often require in Medicaid health plans. A pilot program for a community mental health center (CMHC) was created to allow open access to LAIs. Intervention was conducted to educate affected prescribers. This pilot study will provide information regarding the impact prior authorizations (PA) have on the prescribing of LAIs. It is imperative to understand any barriers to prescribing LAIs, as they have been shown to improve adherence and have the potential to decrease hospitalizations. Objective: 1. Evaluate if there will be increased utilization with the removal of the PA process for LAIs 2. Evaluate if there is a change in hospitalizations, medication adherence, office visits, and emergency room visits Methods: Included in the pilot program will be 14 psychiatrists that treat patients at a CMHC in a state Medicaid plan. Included will be adult patients with a diagnosis of schizophrenia, schizoaffective, and bipolar disorder who have a history of non-adherence defined as seven days or greater past the refill date. Education will be provided to the prescribers on the correct use and dosing of second generation injectable antipsychotics. Prescriptions for those medications will not have to undergo prior authorization criteria before being dispensed in order to facilitate their use. Outcomes: We will analyze pre and post intervention medication paid claim counts for second generation LAIs by prescriber. Secondary outcomes analyzed will be hospitalization rates, number of office and emergency room visits, and medication adherence rates for the LAIs prescribed.

All parties are affiliated with the Central Texas Veterans Health Care System

Abstract Type: Work in Progress. Background: Current guidelines recommend the use of long-acting injectable (LAI) antipsychotics in patients with schizophrenia or schizophrenia type disorders with poor adherence to oral antipsychotics. Previous studies reviewing medical claims information have shown that 40-60% of patients on LAI continue to receive concurrent prescriptions for oral antipsychotics despite the lack of evidence for efficacy or safety. These studies do not however address whether or not patients continued to use both oral and LAI antipsychotics outside of the recommended oral overlap period or whether there are significant differences in dosing between patients receiving monotherapy or dual therapy. Objectives: The primary objective of this study is to review the use of oral antipsychotic agents in conjunction with LAI second generation antipsychotics (SGA) to determine if a dosing disparity exists between veterans receiving LAI SGA as monotherapy and those receiving both LAI SGA and oral antipsychotics. Secondary objectives include identifying the frequency of concurrent use of LAI SGA and oral antipsychotics beyond the recommended oral overlap period, and the average duration of concurrent use of LAI SGA and oral antipsychotics beyond the recommended oral overlap period. Methods: This is a retrospective chart review of veterans receiving an outpatient prescription for a LAI SGA between January 1, 2013 and August 31, 2015. Subjects will be included if they received a LAI SGA as an outpatient for the treatment of schizophrenia or schizoaffective disorder. LAI SGA included in this project include risperidone, paliperidone palmitate, and aripiprazole. Subjects will be excluded if they received a LAI SGA for an indication other than schizophrenia or schizoaffective disorder or received antipsychotic medications from non-designated facility while receiving LAI SGA therapy. Subjects will be assigned to two groups, those receiving LAI SGA monotherapy (LAI-only) and those receiving both LAI SGAs and oral antipsychotics (LAI+oral). Outcomes: A student t-test or Wilcox rank-sum will be used to compare the average LAI SGA dose between groups. Frequency of second outcomes and baseline characteristics will be presented using description statistics.

All parties are affiliated with Alameda County Behavioral Health Care Services

Abstract Type: Work in Progress. Background: The value of shared decision making (SDM) has been increasingly recognized in the literature and supported by several states’ legislation, but remains an underutilized service in behavioral health. Previous literature supports that medication focused SDM-decision support tools facilitate the SDM experience and supplement the prescribers’ information while ultimately improving the quality of care. Specific to behavioral health, antidepressant cards were well received by providers and improved client knowledge, satisfaction and comfort with their treatment decisions; in turn, these improvements have a positive impact on treatment alliance. However, there is little information available about prescribers’ perceptions and attitudes on the value of decision making tools for other psychotropic medications. In 2014, Alameda County Behavioral Health Care Services (ACBHCS) developed the first known antipsychotic cards to facilitate provider initiated SDM practices to manage antipsychotic medications for clients 16-24 years of age. The goal of this quality improvement project is to identify how the use of antipsychotic cards can be optimized to benefit all ACBHCS clients. Objectives: Specific aims include: 1) to estimate the frequency of antipsychotic card use with ACBHCS clients, 2) to evaluate the prescribers’ perspectives and attitudes regarding the utility of antipsychotic cards as a decision support tool, and 3) to identify patient related factors that favor prescriber initiated SDM using the antipsychotic cards. Methods: Participants in this study are identified from the ACBHCS prescriber network. Full time and part time prescribers in the network are eligible for inclusion. Eligible prescribers will be electronically administered an anonymous survey and a Likert scale utilized to assess perceptions and attitudes involving specific aim 2. The demographic data, including credentials, years of practice, and primary population served (e.g. child system of care, older adult system of care), will be used to stratify data and compare results using descriptive statistics. Outcomes: With this study, information regarding the use of antipsychotic cards for SDM, including the prescribers’ perspectives and attitudes, contributes knowledge about the optimal use of antipsychotic cards as a decision support tool. Additionally, the results will assist in directing efforts in the development of decision making tools for other psychotropic medications.

All parties are affiliated with the Lexington VA Medical Center, Department of Veterans Affairs

Abstract Type: Work in Progress. Background: Prazosin has been shown to be a beneficial medication for some patients to decrease the frequency and severity of nightmares associated with PTSD. It can be rapidly titrated and is generally well tolerated. In practice, however, the titration of this medication is often prolonged due to several reasons including limitations in health-system resources and a hesitancy to provide patients with standardized titration schedules. A delay in reaching a therapeutic dose of prazosin may negatively affect response rates. The intention of this clinic is to provide a viable, safe, and efficient way in which to more rapidly utilize the benefits of prazosin in day-to-day practice. Objectives: 1. Evaluate time to therapeutic dose of prazosin. 2. Compare average dose of prazosin for patients completing this clinic to patients not enrolled. 3. Assess change in severity of nightmares from initiation in clinic to achievement of therapeutic dose. Methods: Patients will be recruited from the Lexington VA Medical Center in Lexington, KY. Patients will be naive to prazosin, and identified by mental health clinic prescribers for placement. There will be a target enrollment of 16 patients and the length of stay in clinic will be dependent on patient specific responses. De-identified demographic variables including age, race, and gender, initial nightmare associated CAPS (B1, B2) and PCL-5 score (2) will be collected. Initial telephone appointments will be 30 minutes in duration where an overview to prazosin therapy and clinic requirements will be discussed. Subsequent telephone appointments will be 15 minutes and will include medication adjustments, an evaluation of patient tolerance in regards to potential adverse effects, and symptom response in regards to nightmares. Student t-test will be used to evaluate outcomes one and two; chi-squared test will be used to evaluate outcome three. This pilot program is viewed as a quality improvement project and is IRB exempt. Outcomes: We will record and report the average length of clinic enrollment, the average dose of prazosin at discharge, change in nightmare associated CAPS score (B1, B2), and change in nightmare associated PCL-5 score (2).

All parties are affiliated with the Department of Pharmacy, Medical University of South Carolina, Charleston, SC

Abstract Type: Work in Progress. Background: There appears to be a lack of documentation regarding pro re nata (PRN) medication administration among studies assessing the use of PRN medications in psychiatric hospitals. At the Medical University of South Carolina Institute of Psychiatry (IOP), there is no specific policy regarding requirements for nursing documentation when administering PRN medications. Implementation of a PRN documentation protocol may be beneficial to ensure PRN medications are administered for the intended indication and efficacy is documented. Objectives: 1) Assess the existing documentation process at the time of administering select PRN medications at an inpatient psychiatric hospital. 2) Identify ways that this process can be improved and standardize nursing documentation for all PRN psychotropic medications. Methods: A report was obtained from the electronic medical record (EMR) detailing all PRN administrations of chlorpromazine, diphenhydramine, haloperidol, hydroxyzine, and lorazepam given to patients on adult units at the IOP from July 1, 2015 through September 30, 2015. Data collected included: patient demographics, administration specifics (dose, route, and frequency), and medication administration record (MAR) comments. A random sample of administrations was accessed through the EMR to further assess documentation outside of the MAR and to assess whether medications were administered appropriately (i.e. for the documented indication). A brief survey will be provided to all nurses to gather their current understanding of the requirements for PRN documentation. Preliminary Outcomes: There were a total of 5031 PRN medications administered during the study period, with MAR comments on 1432 (28%) of administrations. Out of the 503 sampled PRN administrations, 256 (51%) had either MAR comments or progress notes documented. Of the 256 PRN administrations that had documentation, 50 (20%) had both a MAR comment and progress note. Based on the documentation, almost half (45%) of the administrations were appropriate. Additionally, 10% of the sampled administrations had an outcome documented and 5% had non-pharmacological interventions documented. The most commonly administered medication was hydroxyzine. Data to be analyzed includes administration patterns according to patient demographics and patient units. Results of the survey will help determine how to incorporate existing perceptions of PRN documentation and any implementations for improvement in the process.

All parties are affiliated with Touro University California College of Pharmacy

Abstract Type: Work in Progress. Background: Vegetarian dietary patterns have been shown to decrease the risk of numerous medical conditions, including cardiovascular disease, diabetes, and cancer, and to lower all-cause mortality. Although the relationship between vegetarian diets and physical health has been established, the association between vegetarianism and mental health remains unclear. Previous studies used more homogenous samples that were not representative of the general U.S. population. Objectives: The present study aims to identify the potential risk factors for depression in a representative sample of the U.S. population and to investigate the relationship between a vegetarian dietary pattern and depression. Methods: A retrospective, cross-sectional analysis will be performed, examining U.S. adults aged 20 years or older who participated in the National Health and Nutrition Examination Survey (NHANES) from 2005-2012. NHANES is a publicly available database maintained by the Centers for Disease Control and Prevention (CDC) that uses a probability sampling design to select participants who represent the non-institutionalized civilian U.S. population. Dietary information within NHANES is obtained through two 24-hour dietary recall interviews. Vegetarian dietary pattern will be characterized by participants who did not report eating any meat, poultry, or fish on either interview day. Depressive symptoms in NHANES are assessed through the Patient Health Questionnaire-9 (PHQ-9). A PHQ-9 score ≥ 10, indicating moderate to severe depression, will be considered clinically significant depression. Multivariate logistic regression will be employed with depression as the outcome variable and vegetarian status as the predictor. Three logistic regression models will be used. The first model will account for demographic characteristics only, including age, gender, and race/ethnicity as covariates. The second model will include demographic factors as well as socioeconomic factors, such as marital status, education level, income, and health insurance. The third model will include demographic and socioeconomic factors along with clinical characteristics, including smoking status, body mass index, hypertension, cardiovascular disease, diabetes, cancer, and sleep disorders. Preliminary Results: From 2005-2012, 22,692 adults aged 20 years or older participated in NHANES with 16,817 adults completing both dietary recall interviews and the PHQ-9 component of the survey. 553 vegetarians and 16,264 non-vegetarians were identified to be included in the analysis.

All parties are affiliated with the Salt Lake City VA Health Care System

Abstract Type: Work in Progress. Background: Unintentional overdose death due to prescription opioid medications is an increasing problem. Naloxone kits are a highly effective treatment for reversing overdose due to opioid medications. At the Salt Lake City VA Health Care System (VA SLCHCS), several programs have been implemented to increase naloxone kit utilization in both mental health and primary care to Veterans susceptible for an overdose. Many Veterans within the VA SLCHCs receive the majority of their care from Community Based Outpatient Clinics (CBOCs) and are not targeted in the programs implemented within primary care and mental health. Objectives: In order to evaluate the impact of a direct-to-patient educational brochure on veteran interest in receiving a naloxone prescription, this study aims to: 1) measure the proportion of Veterans receiving the brochure who contact a pharmacy resident to express interest in naloxone kit receipt, 2) tally reasons stated by veterans for their interest in receiving naloxone, and 3) determine relevant factors common in the response group. It is expected that observations of these three measures will provide insight into the effectiveness of the direct-to-patient brochure in fostering veteran interest in naloxone receipt or reducing use of a potentially harmful medication, as well as which Veterans respond best to the brochure. Methods: Participants will be identified by use of a currently available data collection report, filtered for the desired inclusion criteria (prescribed opioid at >/=100 mg daily morphine equivalents and/or concomitant benzodiazepine prescription and receive primary care at a VA SLCHCS CBOC). The educational brochure will provide information about how to receive a naloxone kit and/or what to do if the patient is interested in lowering the dose of their opioid medication. Following Veteran receipt of the naloxone brochure, data will be collected and responses will be reviewed. As the study is observational, data will be presented using descriptive statistics. Outcomes: The proportion of Veterans receiving the brochure who contact a pharmacy resident to express interest in a naloxone kit with be recorded. Reasons for obtaining a naloxone kit and common factors of Veterans interested in kits will also be reported.

All parties are affiliated with University of Waterloo School of Pharmacy

Abstract Type: Work in Progress. Background: Anti-epileptic drugs (AEDs) have been associated with decreased bone health in individuals with epilepsy, particularly a decrease in bone mineral density. The prevailing theory is that AEDs decrease biologically active vitamin D. Vitamin D deficiency has been observed in patients with epilepsy using AEDs. Supplementing with vitamin D is a potential strategy to counteract this effect. However, the majority of epilepsy treatment guidelines do not explicitly recommend vitamin D supplementation. Moreover, there is evidence that the vitamin D doses that are typically prescribed are too low to have a beneficial effect on bone. Objectives: To conduct a comprehensive systematic review of the literature to investigate the effect of vitamin D supplementation on bone health in adults with epilepsy. Methods: Medline, EMBASE, Scopus, Cochrane Trials, International Pharmaceutical Abstracts, Health Canada Clinical Trials, Clinical Trials.gov, EU Clinical Trials and Google were searched using specific terms including but not limited to epilepsy, bone and vitamin D. Inclusion criteria for studies include adult participants ≥ 18 years old with a diagnosis of epilepsy, a vitamin D treatment arm and bone health measurement. Articles pertaining to other medical conditions and vitamin D treatment for outcomes outside of bone health will be excluded. Full-text articles will be accessed for all articles meeting the criteria. Two members of the team will independently review the titles, abstracts, and full-text articles to determine eligibility as well as to extract outcomes. Any disagreements will be resolved by team discussions. Methodological quality of the included studies will be critically appraised independently by two team members using the Cochrane Collaboration’s tool for randomized studies and the Newcastle Ottawa Scale for non-randomized studies. Outcomes: Bone health measurements (bone mineral density, bone mineral content, bone mass), serum calcium, vitamin D, and parathyroid concentrations, and fractures will be compared between intervention arms and pre and post intervention where data is available.

All parties are affiliated with the Edward Hines, Jr. VA Hospital, Hines, Illinois

Abstract Type: Innovative Practices. Background: Clozapine is the most effective antipsychotic medication available for treatment resistant schizophrenia (TRS). Clozapine has also been found effective in patients with schizophrenia who have developed antipsychotic resistance, suicidal or assaultive behavior, substance abuse, or non-adherence. Some clinicians may be uncomfortable with prescribing clozapine due to its large array of serious adverse effects and/or lack of experience. Purpose: This study was designed to investigate the relationship between physicians’ knowledge of clozapine before and after an educational in-service training. Primary objectives include recognizing physician attitudes regarding clozapine prescribing, identifying prescribing barriers and knowledge gaps and determining whether further education is necessary and/or methods of standardizing prescribing practices are warranted. Methods: A modified one-group pretest-posttest quasi-experimental design was used to fulfill the aim of the study. Participating psychiatrists attended an intensive educational in-service on clozapine conducted by the investigators at the Edward Hines, Jr. VA Hospital. Pre- and post- in-service tests were matched using a “code word” to ensure participant confidentiality. A 13-item clozapine preference and attitude questionnaire (CPAQ) was developed to assess preferences and attitudes towards prescribing clozapine on a 5-point Likert scale. (1) =Strongly Disagree at all to (5) = Strongly Agree for these 13 items. Concerns regarding clozapine were assessed open endingly by asking providers to rate, in order of priority, the three most problematic issues with clozapine. A 19-item clozapine clinical knowledge questionnaire (CCKQ) was developed to measure physicians’ knowledge before-and-after in-service. The core knowledge testing questions were conceptually split into five domains (considerations before starting clozapine; monitoring requirements; interactions with clozapine; therapy optimization; adverse events and side effect management). Knowledge mean gains were calculated using t-tests to compare the mean percentage of correct responses. Chi-square McNemar analyses were be conducted for identified change in the follow-up test. All statistical analyses will be performed using STATA, Version 13 for Windows. Results/Conclusions: To be presented at the CPNP 2016 annual meeting.

1. Akron General Medical Center, Department of Pharmacy; 2. Northeast Ohio Medical University, College of Pharmacy; 3. Northeast Ohio Medical University, College of Medicine Department of Psychiatry; 4. Northeast Ohio Medical University, College of Medicine Department of Family and Community Medicine

Abstract Type: Innovative Practices. Background: Patients with severe and persistent mental illness (SPMI) die an estimated 25 years earlier than the general population. An interdisciplinary case conference was developed using a fictional case involving a patient with schizophrenia who develops elements of the metabolic syndrome. The purpose of the activity is to provide students with an interprofessional opportunity to explore caring for patients with SPMI. Description of Innovative Service: Four faculty instructors jointly conduct a 1.5 hour session, 8 times per year, at a community mental health clinic. Medicine, pharmacy, nursing, and social work students, representing four colleges from three universities, are divided into interprofessional groups of 7-8 students. A patient case and pre-session readings are distributed prior to the session. Following a brief didactic lecture, each group develops a care plan specific to the case and describes how each profession contributes to the patient’s care. Each group presents their work during the class discussion. The session ends with a tour of the facility which has successfully integrated care across disciplines. Impact on Patient Care/Institution: During the 2014-2015 academic year, nearly 300 students attended one of the 8 sessions. A total of 215 evaluations were completed. Students evaluated the session on a scale of 1 (strongly disagree) to 4 (strongly agree). The majority of students strongly agreed with each of the session objectives: describe conditions that lead to premature mortality in patients with SPMI (n = 159), explain the rationale for using various classes of medications to treat SPMI (n = 130), identify the adverse metabolic effects of these medications (n = 173), and describe why interprofessional teams are important for providing primary care to patients with SPMI (n = 165). Themes from narrative comments suggest students gained an understanding of the complexity associated with treating patients with SPMI and an appreciation of the value of interprofessional care in this setting. Conclusion: Patients with SPMI suffer from premature mortality. An interdisciplinary case conference was developed to expose students to interprofessional care of patients with SPMI. Students evaluated the session favorably. This may provide an example for other institutions interested in expanding interprofessional student experiences to mental health.

1. Peach State Health Plan, Atlanta, Georgia; 2. Philadelphia College of Osteopathic Medicine School of Pharmacy, Suwanee, Georgia; 3. Mercer University College of Pharmacy, Atlanta, GA

Abstract Type: Innovative Practices. Background: According to a report by the Centers for Disease Control (CDC), Medicaid patients less than the age of 65 have a higher prevalence of smoking compared to the general population, 30.1% compared to 18.1% respectively.3 Cigarette smoking is one of the greatest drivers of adverse health outcomes and costs for state Medicaid programs. As a result opportunities exist for clinical pharmacist and technicians to provide evidence base approaches to smoking cessation for this population. Description of Innovative Service: This pilot program is a telephonic service taking place at Peach State Health Plan within the pharmacy department to Medicaid members. Services are provided by a board certified psychiatric pharmacist and 6 pharmacy coordinators that are trained pharmacy technicians. Pharmacy coordinators provided an initial outreach to members with asthma and nicotine dependence, asking and advising them to quit. The clinical pharmacist upon referral from coordinator conducted member consultations including behavioral modification, pharmacotherapy recommendations, and prescriber outreach for prescriptions. Impact on Patient Care: For seven months in 2015, our pharmacy coordinators had 457 identified asthma and nicotine dependent members to outreach. Of those 457 members 175(38%) were successfully outreached by our pharmacy coordinators. Afterwards a total of 63 (36%) members were referred to the clinical pharmacist. Of the 63 members referred to the clinical pharmacist, 30 (48%) members received consultation and interventions. Of the 30 members the clinical pharmacist consulted with, 19 (63%) had some sort of psychiatric diagnosis. As a result of the clinical pharmacist intervention 27 (90%) members had prescription claims for a smoking cessation pharmacotherapy product. Pharmacy staff and the health plan have responded favorably to this outreach program which involved this collaborative effort of the entire pharmacy team. Conclusion: Smoking cessation is an important factor in improving health outcomes for a variety of health conditions for Medicaid members.5, 6 This smoking cessation outreach program proved that clinical pharmacists and pharmacy technicians can play a significant role in providing smoking cessation in the managed care setting.

All parties are affiliated with William S. Middleton Memorial Veterans Hospital

Abstract Type: Innovative Practices. Background: Insomnia is a condition with widespread impact including economic costs and increased risk for psychiatric illness (Shepardson et al). Research suggests that Veterans report insomnia at a higher rate than the general population, making adequate treatment within the Veterans Administration (VA) a priority. Cognitive behavioral therapy for insomnia (CBTI) is the behavioral intervention with the best supporting evidence and is being promoted within the VA (Shepardson et al). However, many Veterans are still being treated with hypnotics, which can pose long term risks. A study done by Zavesicka et al demonstrated that tapering hypnotics during CBTI could lead to improvement in sleep as opposed to worsening. To further apply this model of care among Veterans, a pilot treatment group involving CBTI in combination with a medication tapering component was evaluated. Group Structure and Description: Veterans treated within the mental health clinic at the Rockford VA outpatient clinic with active zolpidem prescriptions were offered group participation. Exclusion criteria included active substance use disorders, unstable mental or physical health, shift work, bipolar disorder diagnosis, seizure history, and presence of a high risk flag. The group consisted of 7 sessions which were approximately 90 minutes each. The structure of the group included typical CBTI content along with medication education, information on risks and benefits of tapering hypnotics and individualized taper plans provided by a pharmacist. Outcomes and Impact: Three Veterans participated in the pilot group. All three Veterans had improvement in sleep efficiency between session 2 and 7. Two of the three Veterans were able to successfully discontinue zolpidem. Combining a front-line treatment, like CBTI, with an opportunity for Veterans to explore medication tapering could be a safe and efficient way to improve insomnia treatment. Conclusions: Although this pilot group was small, 66% of patients were able to discontinue their hypnotic medication and all saw improvements in sleep efficiency. Future directions will involve increasing the number of Veterans participating, including Veterans on a variety of hypnotic agents, and further integrating Motivational Interviewing and psychoeducation to address rebound insomnia and psychological dependence in support of Veterans successfully changing hypnotic use.

Author affiliated with the Department of Veterans Affairs Medical Center

Abstract Type: Innovative Practices. Background: Depression Care Management (DCM) is an evidence-based approach to improving depression outcomes in the primary care setting by assessing and monitoring a patient’s depression symptoms, identifying barriers to treatment, and encouraging treatment adherence. Although there is considerable evidence for its effectiveness in a variety of primary care settings, patients in specialty mental health clinics are often treated without the same level of monitoring. Research indicates that rates of suicidal ideation and attempts are increased in treatment periods following antidepressant starts, making additional monitoring during this time particularly important. Therefore, DCM was implemented in the outpatient Mental Health Clinic (MHC) at the William S. Middleton Memorial Veterans Hospital with a goal to improve depression outcomes. Description of Innovative Service: DCM was implemented with a select number of providers with a goal to implement it on a larger scale pending pilot results. All patients complete a baseline PHQ9 prior to their visit to assess severity of depression symptoms. The visit, including evaluation and treatment planning, proceeds as usual. Patients who are prescribed a new antidepressant, or have their dosage increased, may be enrolled in DCM. They are then contacted by a nurse or pharmacist via telephone in two weeks to monitor depression symptoms, medication side effects, and compliance. Any concerning side effects and dosage adjustment recommendations are alerted to the prescriber. Subsequent follow-up calls are made at two to four week intervals until the patient is considered stable or until their next appointment. Impact on Patient Care: Systematic reviews of DCM programs in the primary care setting have found statistically significant improvements in patients’ depression symptoms, treatment satisfaction, and medication adherence. DCM has been successfully implemented in the Primary Care-Mental Health Integration (PC-MHI) clinic at the William S. Middleton Memorial Veterans Hospital and has resulted in improvement in PHQ9 scores over time. We anticipate similar results with DCM in the MHC. Conclusion: The implementation of DCM in the outpatient MHC provides patients with more frequent follow-up and improved medication monitoring. Rates of suicidal ideation and attempts are increased in periods following antidepressant starts, making this a particularly important time for monitoring.

All parties are affiliated with the Edward Hines, Jr. VA Hospital, Hines, Illinois

Abstract Type: Innovative Practices. Background: Mental health clinical pharmacy specialists (MHCPS) have been involved in mental health care settings for over 40 years. Prior data have demonstrated that pharmacists can prevent medication errors, minimize adverse effects, decrease the cost of therapy, and improve outcomes related to patient care. Edward Hines, Jr. VA Hospital, located 12 miles west of downtown Chicago offers primary, extended and specialty care and serves as a tertiary care referral center to over 56,000 veterans annually. Recent development of the PGY-2 Psychiatric Pharmacy Residency Program has provided our facility unique opportunities to optimize patient care and establish new clinical pharmacy services on the acute psychiatric inpatient unit. Purpose: The purpose of this study is to evaluate the impact of specialized, clinical pharmacy services in a VA medical center, acute-care, psychiatric inpatient unit, to quantify clinical and economic outcomes, and assess perceived value of clinical pharmacy services by psychiatric clinical staff. Methods: This study was conducted at the Edward Hines, Jr. VA Hospital acute psychiatric inpatient unit (2S) from May 11, 2015 to October 30, 2015. Primary objectives were to identify and characterize activities most likely to impact patient care and quantify associated clinical and economic outcomes. All clinical interventions were documented electronically using a standardized intervention tracking tool and involved both written and verbal interactions with healthcare professionals, patients, and caregivers. To ensure uniform documentation, all clinical pharmacy activities captured included date category and description of pharmacy intervention, perceived clinical benefit, acceptance of intervention, impact factor (probability that harm may have occurred without intervention), evaluable outcome, and psychotropic drug safety initiative (PDSI) measures. To determine perceived value of clinical pharmacy services, an anonymous 10-item post-service satisfaction survey was developed via SurveyMonkey^® to assess the attitudes and perceptions of all clinical staff on the acute psychiatric inpatient unit. Descriptive statistics were used to analyze common intervention categories, perceived clinical benefit, evaluable outcomes, potential cost avoidance, and attitudes and perceptions of clinical staff. Intervention driven cost avoidance was determined by using published cost estimates for interventions performed by clinical pharmacists. Results/Conclusions: To be presented at the CPNP 2016 annual meeting.

1. Eskenazi Health, Indianapolis, IN; 2. Butler University College of Pharmacy and Health Sciences, Indianapolis, IN

Abstract Type: Innovative Practices. Background: In 2013, more than 16,000 people died from opioid abuse in the United States. Due to the dangers relapse poses to patients recovering from opioid addiction, it is important that they have access to naloxone, which could prevent an overdose-related hospital admission or death. Methadone is often used in opioid replacement programs to deter heroin and prescription opioid use, in patients with opioid use disorder. However, methadone’s unpredictable pharmacokinetics and multiple drug interactions increase the risk for opioid overdose leading to respiratory depression, coma, and death. Naloxone is the opioid antagonist of choice for overdose reversal. Intravenous naloxone is the preferred route of administration. However, with the increase risk of blood borne pathogens and difficult administration, this route is infrequently used in non-hospital settings. A solution has been the increased utilization of intranasal naloxone. Intranasal naloxone administration is easily used by trained individuals to provide overdose symptom reversal. The alarming number of opioid overdose deaths has caused legislation to expand access to intranasal naloxone. The purpose of this prospective study is to train current methadone narcotic treatment program patients and their designees about appropriate use of intranasal naloxone and subsequently provide access to the medication. Methods: Our Opioid Overdose and Naloxone Dispensing (OEND) training sessions will take place at the treatment facility and address the risks and symptoms of opioid overdose and appropriate intranasal naloxone administration technique. Immediately thereafter, the participant can choose to receive intranasal naloxone via a pharmacist-initiated e-prescription to an outpatient pharmacy within our health system. Compliance will be assessed by reviewing the pharmacy dispensing records for participants who opted to pick up their prescription. Secondary endpoints will be to analyze the participant training experience and knowledge using pre- and post-surveys around the OEND session. Additionally, a review of emergency department records will be conducted for admissions with a primary diagnosis of opioid overdose, in those patients who participated in the OEND sessions. Outcomes: Our study will support the use of pharmacist-driven OEND throughout Eskenazi Health, a safety net healthcare system, and provide validation of the necessary educational tools for individuals to prevent opioid overdose deaths.

All parties are affiliated with the Long-Acting Therapy (LAT) Clinic, Memorial Healthcare System

Abstract Type: Innovative Practices. Background: People with serious mental illness (SMI) suffer from a chronic disease process, marked by alternating periods of full or partial remission and frequent relapses of symptoms. It is estimated 80% of patients with SMI will relapse within five years of diagnosis, primarily due to poor adherence to oral antipsychotic medication. Medication non-compliance results in decompensation and increased healthcare expenditures through frequent hospital and emergency department admissions. Long-acting antipsychotic injections (LAAIs) are an effective way to promote medication adherence. Patients on LAAIs have decreased hospitalization rates, reduced healthcare resource utilization rates, and better treatment outcomes over patients on oral antipsychotic medications. Description of Practice: The Long-Acting Therapy (LAT) Clinic is a hospital outpatient clinic providing administration and medication coordination services for patients on LAAIs. Programmatic, clinical and operational oversight of the clinic is managed by a psychopharmacologist working through a collaborative practice agreement with community-based prescribers. In addition to medication administration, LAT Clinic monitors metabolic parameters to reduce patients’ risk of developing metabolic syndrome and improve adherence to treatment through an evidence-based assessment of medication related side effects. The Clinic coordinates patient care through close communication with the patient’s primary prescriber, insurance carriers, community resources and supportive family members. Impact on Patient Care: By providing integrated care to people with SMI on LAAIs, LAT Clinic is improving the overall health of the patients it serves. LAT Clinic has reduced the number of rehospitalizations and effectively linked its patients with ongoing medical care. The Clinic serves all patients regardless of insurance status and routinely utilize patient medication assistance programs to reduce medication cost burden. Since its inception in May 2015, LAT Clinic has served over 60 unduplicated patients. In the last 8 months, the LAT clinic has increased its average number of patient encounters from one to seven per week. Conclusion: LAT Clinic provides accessible, integrated care for patients with SMI, with a focus on evidence-based monitoring of metabolic issues, treatment compliance, side effects and medication interactions. The continuing growth of LAT Clinic demonstrates the effectiveness of a pharmacy-driven clinic which improves patient care for people with SMI.

Author affiliated with Monmouth Medical Center, Long Branch, NJ and Ernest Mario School of Pharmacy, Rutgers University

Abstract Type: Innovative Practices. Background: The Integrated Health Home (IHH) is a wellness program that provides behavioral health and physical health services for patients with a serious mental illness. Patients in the IHH program are managed by a multidisciplinary team that includes nurse practitioners, social workers and community health workers. A psychiatric pharmacist was also integrated into the multidisciplinary team as of July 2015. Description of Innovative Service: The psychiatric pharmacist provides many services to patients in the IHH program. Pharmacy consultations, telephone calls and home visits are some of the key services provided by the pharmacist. Comprehensive pharmacy consultations are provided to patients upon admission into the IHH program. Pharmacy consultations are also provided to patients when requested by the treatment team. Pharmacy consultations include reconciling medications, providing medication education and counseling information as well as assessments of medication regimen, medication adherence and adverse effects. Pharmacy consultations also allow patients the opportunity to have their medication related questions answered by the pharmacist. The pharmacist also conducts patient home visits to setup pillboxes when requested by the treatment team. Wellness telephone calls are also made to patients on a regular basis by the pharmacist. Additional services provided to patients include enrolling patients in assistance programs, smoking cessation education, sleep hygiene education and nonprescription medication education. Patient care services provided by the psychiatric pharmacist are documented in the electronic medical record. Impact on Patient Care: The IHH program currently has 157 patients. In a 6 month time period (July 2015-Dec 2015) the psychiatric pharmacist provided patient care services for 146 patients. Pharmacy consultations were provided to 136 of 157 patients. Home visits were provided for 28 patients. Of which twelve patients received multiple home visits. Pillbox setup services were provided to 18 patients. Eight of these patients received pillbox setups on a weekly basis. The pharmacist also placed 96 wellness telephone calls. Conclusion: As a valuable member of a multidisciplinary team, psychiatric pharmacists are able to provide and expand substantial services to patients in the IHH program.

1. Centre for Addiction and Mental Health, Toronto, Ontario, Canada; 2. University of Toronto, Department of Psychiatry; 3. University of Toronto, Lawrence S. Bloomberg Faculty of Nursing; 4. University of Toronto, Department of Family and Community Medicine; 5. University of Toronto, Leslie Dan Faculty of Pharmacy

Abstract Type: Innovative Practices. Background/Rationale: In 2012 the Centre for Addiction and Mental Health (CAMH) conducted an inter-professional failure mode and effects analysis (FMEA) to assess monitoring of inpatients on clozapine. Risks identified included patients: 1) receiving clozapine before being enrolled in the manufacturer’s clozapine program, 2) receiving clozapine without sufficient monitoring of adverse effects (e.g., agranulocytosis, myocarditis, constipation), 3) receiving overly aggressive dose titrations causing side effects, leading to premature discontinuation of the drug, and 4) having their clozapine trial cancelled, or dose decreased to below an effective dose, due to the lab’s ‘normal’ maximum clozapine plasma level set too low. Description of the Innovative Service: CAMH implemented an electronic health record in 2014. This was seen as an ideal opportunity to automatize safeguards to reduce the risk of all of the above events: 1) A rule was built so that a doctor is alerted if a patient is not enrolled in the manufacturer’s clozapine program. Doctors are also prompted to use the clozapine order sets, 2) Clozapine pre-treatment and initiation order sets containing: a pre-checked, mandatory, cycling CBC order, baseline and weekly C-Reactive Protein and troponin for 4 weeks (for myocarditis monitoring), a pre-checked order for nurses to monitor bowel function daily, and clozapine-specific bowel care medication orders, 3) A safe dose titration for ‘new starts’, and 4) A toxic level warning was removed from clozapine plasma concentration results. Impact on Patient Care/Institution: It is expected that these computerized safeguards reduce the risk of important adverse events associated with clozapine. As well, it is hoped that patients are less likely to have clozapine prematurely discontinued now that the lab’s toxicity warning has been removed and a standardized, conservative dose titration has been implemented. Conclusion: A FMEA analysis helped this hospital identify error-prone steps in the clinical monitoring of clozapine. The electronic health record was designed to incorporate error prevention strategies to address these identified risks, to improve the safe and effective use of clozapine.

All parties are affiliated with the Chillicothe Veterans Affairs Medical Center

Abstract Type: Innovative Practices. Background: Opiate abuse and dependence has become an increasing healthcare issue within the United States, specifically with its veterans, in recent years. At the Chillicothe VAMC, there is a 3-week residential Substance Abuse Treatment Program (SATP) and a maintenance Suboxone (buprenorphine/naloxone) Clinic. As opiate withdrawal is not life-threatening, not all patients experiencing opiate withdrawal require an inpatient admission; however, it is thought that patients who are provided assistance with opiate detoxification are more likely to continue onto substance abuse programming and maintenance treatment for opiate abuse disorder. Description of Innovative Service: The Clinical Opiate Withdrawal Scale (COWS) is a validated tool used to assess the severity of opiate withdrawal. A symptom-triggered opiate withdrawal protocol was developed by two PGY-1 pharmacy residents, a Clinical Pharmacy Specialist in Psychiatry, and an addictionologist. The protocol utilizes the COWS assessment and has two pharmacotherapy options, clonidine or buprenorphine/naloxone, in addition to other as-needed symptom medications, that can be given based on the COWS score. Following facility approval of this protocol, nursing and provider education was provided by the pharmacy residents and the protocol was then implemented on the acute medical and acute psychiatry units in May 2015. Impact on Patient Care: To determine the impact of the symptom-triggered opiate withdrawal protocol with clonidine following its implementation, several clinical outcomes will be evaluated comparing patients treated for opiate withdrawal prior to and after protocol implementation. The primary outcome to be evaluated will be the total number of hospital admission days. Secondary outcomes to be evaluated include the average daily dose of clonidine for opiate detoxification, SATP retention rate, the number of patients who received maintenance treatment with buprenorphine/naloxone, and the number of patients who remained sober for 3 months following opiate detoxification. Conclusion: Following analysis of the above listed outcomes, we will report the results and determine if the previously implemented symptom-triggered opiate withdrawal protocol, specifically with clonidine, resulted in superior detoxification related outcomes compared to patients who underwent opiate withdrawal at the Chillicothe VAMC prior to the implementation of this protocol.

All parties are affiliated with Wilkes University

Abstract Type: Innovative Practices. Background: In the United States, 44 million and 20 million adults suffer from a mental illness or a substance use disorder, respectively. Education regarding these illnesses in pharmacy school focuses in pharmacotherapeutics with minimal discussion regarding psychotherapies or psychosocial impacts. Counseling skills taught in pharmacy school do not prepare students to interact with emotional patients. As future pharmacists, students will be interacting with this patient population in most practice settings and would benefit from more emphasis on these topics in order to form more therapeutic relationships with patients. Description of innovative practices: These activities were incorporated into an elective class consisting of 29 fourth and fifth year pharmacy students. During two classes an hour and a half in duration, students participated in improvisational exercises used to improve focus, identify emotions, and react positively to negative circumstances. Students were led through an active discussion regarding cognitive behavioral therapy (CBT), watched a shortened CBT session, and were led through a mindfulness session. Students then reflected on their experience in class. Students also attended a local Narcotics Anonymous (NA) meeting. Students then reflected on their experiences in class and at the meeting. Impact on patient care: As indicated in reflections, students felt more confident in their ability to handle emotional patients and indicated areas where they could use the techniques learned in their current internships. They also indicated feeling like they can “connect” more with mental health patients after learning about different therapies. Reflections were overwhelmingly positive for the NA meeting. Students saw this as an “eye opening” experience and had a new found appreciation for substance use disorders as an illness. Conclusion: Patients with mental health and substance use disorders are a large population in the United States and there is a high likelihood that pharmacists interact with these patients on a daily basis. Providing students with the education needed to react appropriately to emotions, understand other treatments, and appreciate the psychosocial impact can enhance the treatment of mental health patients and improve the patient-pharmacist relationship.

All parties are affiliated with the South Texas VA Health Care System

Abstract Type: Innovative Practices. Background: Primary care physicians are often tasked with the longitudinal care of patients with alcohol problems.¹ However, a 2012 report by the National Center on Addiction and Substance Abuse concluded that “only a small fraction of individuals receive interventions consistent with scientific knowledge about what works.”² The authors went on to question if this failure to bring practice in line with evidence could be considered medical malpractice. In 2015, the VA selected sites, including the South Texas Veterans Health Care System, the Alcohol Dependence Pharmacotherapy and Treatment in Primary Care (ADaPT-PC) initiative in order to increase prescriber familiarity with alcohol dependence medications and prescribing rates of these medications. One barrier to initiating patients on these medications in the primary care setting is concern about the necessary ongoing medication management. This report describes the implementation of a shared medical appointment developed to improve access, assist in medication management, and provide alcohol psychoeducation in a group setting in support of efforts to increase utilization of these under-prescribed medications. Description of the Service: Patients were referred from primary care physicians and identified via a report of active prescriptions for acamprosate, naltrexone, and topiramate prescribed by primary care physicians. Indications for the medications were verified via chart review. They were then invited to attend a shared medical appointment facilitated by pharmacists and psychologists, where they received both medication management as well as alcohol use psychoeducation. Services facilitated by the pharmacist included medication education, side effect monitoring, addressing compliance issues, monitoring drinking rates, and lab draws as appropriate. Impact on Patient Care: Authors will be measuring refill rates as a marker of medication compliance, alcohol use and craving as reported by patients, and prescriber perception of the usefulness of the program. Results pending. Conclusion: Pending.

¹Fiellin DA, Reid MC, O’Connor PG. New therapies for alcohol problems: application to primary care. Am J Med. 2000;108(3):227-237.

²The National Center on Addiction and Substance Abuse. Addiction Medicine: Closing the Gap between Science and Practice. 2012.

Author affiliated with the University of Illinois Hospital & Health Sciences System

Abstract Type: Innovative Practices. Background: Smoking was frequently observed among individuals with psychiatric diagnosis per literature and clinical setting observation. Face-to-face counseling demonstrates lowest reach and intervention with low efficacy. Support group approach is used to attract patients to sessions. Description of Innovation Service: The Smoking Cessation Support Group was initiated by a clinical pharmacist covering mood-anxiety and psychosis outpatient clinics to support patients interested in quitting smoking. This group runs twice a month for an hour and is open to all patients in the Psychiatric Outpatient Clinic. • The support group setting promotes a patient-friendly environment for better participation. • These sessions offer information on drug therapies in aiding smoking cessation, a smoking cessation resource center, and information about the challenges and benefits of abstinence. • All persons at various readiness stages for smoking cessation are encouraged to participate. • Flyers for each session are placed in psychiatric resident mailboxes monthly. • Email reminders are issued monthly to all psychiatry providers. • Flyers are posted in the patient waiting room and check-in area. • This program offers two group sessions monthly free of charge. • After each session, patients are offered an opportunity to meet with the pharmacist to begin use of pharmacologic products to aid in cessation; the patient’s provider is notified. • Patients learn about smoking cession through five stages: Pre-contemplation, contemplation, preparation, action, and maintenance; they complete self-assessment questionnaires to discover at which stage they stand. Impact on patient care: The program’s goal is to motivate smokers to quit smoking and sustain long-term cessation. Most patients attending the program are not prepared to take action on smoking cessation; they attend as recommended by their psychiatrist or are interested in how to cope with cessation. Patient participation and readiness stages are documented in patients’ charts; progress notes are forwarded to providers. Conclusion: The group struggles with low turnout; attendees lose interest or are not ready for cessation; patient recruitment is a challenge for this program. As the pharmacist plays a vital role in this setting, patients may demonstrate improved treatment satisfaction and greater acceptance with this continuity of care.

1. Mayo Clinic Medical Center, Department of Pharmacy; 2. College of Medicine, Mayo Clinic; 3. Mayo Clinic Medical Center, Department of Nursing, Psychiatry

Abstract Type: Innovative Practices. Background: Frequently there is a need in hospital and ambulatory care settings to destroy medications no longer taken by patients when considered a safety risk to the patient. The hospital pharmacy department is often left with the role of storing and disposal of patients’ own medications (POMs) when brought into the hospital by the patient. Procedures related to this process can be time consuming, incur costs related to destruction, and increase diversion risk of controlled substances. Description and Impact: A commercially available, drug deactivation pouch was piloted in a hospital based outpatient, pain rehabilitation program due to high volumes of patient controlled substances necessitating destruction. The Pain Rehabilitation Center (PRC) is a 3 week program with primary goals of improving functioning and quality of life along with discontinuation of opioids and selected other medications. In the pilot, following the tapering of medications, the nurse assists the patient in destruction of the discontinued medication using the charcoal-based deactivation pouch. Each (6x10 inch) pouch holds approximately 90 tablets, 360mL liquid or 12 patches. Once mixed with water in the pouch, the medications are neutralized and can be disposed of in the general trash, without concerns to the environment. Over the course of a 6 month pilot, PRC patients used nearly 200 pouches to destroy their own discontinued medications. Cost for the pouch is approximately $2.70 each. Although this pilot only spanned 6 months in 2015, a reduction of over 50% was seen in the number of bags of POMS taken to the incinerator for destruction between 2014 (552 bags) and 2015 (283 bags). Conclusions: Based on the results of the pilot, the institutional policy will be updated with the new process implemented hospital wide, including the psychiatric units. When patients refuse to dispose of medications that involve a perceived safety risk, security will be contacted and the medication confiscated, and taken to the government public disposal deposit. These policy changes will result in improved public safety, regulatory compliance, cost reduction and significant improvement in resource allocation for the pharmacy department with the elimination of a labor intensive storage and destruction process.

1. University of Oklahoma College of Pharmacy, Tulsa, OK; 2. Crisis Care Center, Family and Children’s Services, Tulsa, OK

Abstract Type: Therapeutic Case Report. Background: Dextromethorphan (DXM) is an over-the-counter product used for cough suppression. At supratherapeutic doses, DXM produces a dissociative state similar to that of phencyclidine (PCP). Structural similarities between DXM and the PCP metabolite 4-phenyl-4-piperidino-cyclohexanol have been reported as one explanation for cross-reactivity/false-positive results with some marketed PCP immunoassays. Abuse of both drugs presents with similar durations: DXM ranges from 6 hours to longer in cases of extremely high doses. With PCP, the effects can last 4-8 hours with additional effects lasting up to 48 hours. The use of mass spectrometry as a confirmatory analysis is recommended to differentiate the between substances. Complete Patient-History: A 30 year old Caucasian male with a history of DXM-containing cough syrup abuse was admitted to inpatient status due to agitation and psychosis. During the intake process, the patient admitted drinking approximately 944 milliliters of cough syrup, containing an estimated 2832 milligrams of DXM, on the day prior to admission. He has a history of agitation resulting from cough syrup use. The patient’s urine drug screen (UDS) on this admission was positive for PCP; however, the patient fervently denied use of anything other than cough syrup. He tested positive for PCP during previous admissions, during all of which the patient insisted the only thing he had taken was cough syrup. His legal guardian also denied knowledge of any other substances of abuse. Review of Literature: Literature retrieval was accessed through OVID, Web of Science, Google Scholar, and PubMed (1975-November 2015). Reports of false positive urine drug screens or related effects were reviewed using the search terms dextromethorphan, PCP, psychosis, phencyclidine, abuse, effects, pharmacokinetics, serotonin syndrome, and chlorpheniramine. Conclusion: This case represents the need for a comprehensive medication history, including the use of over-the-counter medications with the potential for psychiatric effects. Practitioners should be aware of the clinical presentation, onset, and duration of effects when treating patients who exhibit signs and symptoms fitting with DXM abuse or toxicity with secondary confirmation in cases of positive results.

1. University of Oklahoma College of Pharmacy, Tulsa, OK; 2. Crisis Care Center, Family and Children’s Services, Tulsa, OK

Abstract Type: Therapeutic Case Report. Background: Brief psychotic disorder is characterized by a sudden onset of psychotic symptoms (delusions, hallucinations, and disorganized speech) and a duration ranging from 1 day to less than 1 month with a return to baseline following the episode. No prodromal period is present; these features may develop within 2 weeks. Caffeine-induced psychosis, on the other hand, is characterized by the presence of autonomic symptoms consistent with stimulant use and paranoia. Complete Patient-History: A 43-year-old Caucasian female presented to a psychiatric urgent care unit due to increased psychosis with reports of auditory hallucinations almost constantly, visual hallucinations (seeing large words), and a sensation of feeling knives in her hands. Due to the severity of the psychotic symptoms, she developed suicidal ideation. The patient’s treatment providers reported significant insomnia, recent poor diet with a ten pound weight loss documented over the preceding month, and an excessive amount of caffeinated soda intake. Approximately 96 hours prior to admission, the patient purchased 4 cases [96 cans, each 12 ounces] of caffeine-containing cola. Each can contained 69 milligrams (mg) of caffeine. Twenty-four hours prior to admission, 2 cans were unconsumed. The patient endorsed the cola as her sole source of calories for this period. It is estimated that the patient consumed in excess of 6,900 mg of caffeine. Use of the Naranjo ADR Probability Scale indicated a probable relationship (7 of 13) between the adverse effect of high caffeine usage and the development of psychosis in this patient. Review of Literature: Literature retrieval was accessed through Ovid, Google Scholar, MEDLINE, and PubMed (1965-October 2015). Reports of caffeine-related psychosis were reviewed. Included in the review were the use of energy drinks and caffeine tablets. Conclusion: In this patient, high caffeine intake for a sustained period of time was associated with the onset of psychotic symptoms consistent with hallmark features of delusions, hallucinations, and disorganized speech. Clinicians are encouraged to explore dietary habits and preferences, the use of caffeine, and food intake when evaluating patients presenting with signs and symptoms of psychosis. The half-life of caffeine and autonomic symptoms may be differential diagnostic considerations.

Author affiliated with Lipscomb University College of Pharmacy

Abstract Type: Therapeutic Case Report. Background: Anti-NMDA receptor encephalitis is a neurologic disorder formally recognized in medicine in 2007. It is most common in women with paraneoplastic tumors and presents with prodromal symptoms that mimic flu-like symptoms. This typically progresses into psychiatric symptoms within two weeks. The disorder transitions into a period of severe autonomic instability, including seizures and hypoventilation. Patient-History: A 30 year-old, African American female presents with rapid, disorganized speech, grandiosity and hyper-religiosity x one week. Past medical history included asthma, stress incontinence and polycystic ovarian syndrome. The patient had no psychiatric history but a family history positive for mood disorders. While in the ED, the patient became combative and received haloperidone and diphenhydramine. Upon transfer to the psychiatric hospital, the patient was scheduled olanzapine once daily. Six days later, the patient reportedly had a seizure. Her vital signs were stable afterward, though she remained confused. This episode was not attributed to olanzapine. Over the next eight days, the patient remained agitated, delusional and manic, with periodic confusion and catatonic-like movements. The patient was tested for anti-NMDA receptor antibodies and paraneoplastic auto-antibodies, testing positive and negative respectively. Olanzapine was stopped due to worsening of catatonic symptoms and she was transferred to the medical center where she was treated for possible neuroleptic malignant syndrome. Over the course of the next few months, the patient continued to experience seizures and was treated with depakote, IVIG and solumedrol without significant improvement. The patient was then treated with rituximab and methotrexate every three months for one year in addition to 33 ECT treatments. One year after the initial presentation, the patient was near her baseline behavior. Review of Literature: A PubMed search was performed using the search terms “anti-NMDA receptor encephalitis bipolar” and “anti-NMDA receptor encephalitis bipolar” yielding 13 results. There are three reported patient cases with similar presentations to this patient case. While anti-NMDA receptor encephalitis is now a recognized neurologic disorder, its presentation mimics that of many psychiatric disorders. Conclusion: Literature regarding anti-NMDA receptor encephalitis suggests early detection and treatment are valuable for better patient outcomes. This case demonstrates that treatment can be complex.

1. Center for Behavioral Medicine; 2. Northwest Missouri Psychiatric Rehabilitation Center

Abstract Type: Therapeutic Case Report. Background: Neutropenia is defined as an absolute neutrophil count (ANC) less than 1.5 x 10⁹/L. Common causes of neutropenia include hematologic malignancy, aplastic anemia, congenital causes, and medications, among others. First and second generation antipsychotic medications have been linked to neutropenia. Patient History: The patient is a 55 year old black male with past medical history significant for schizophrenia, antisocial personality disorder, and neutropenia. During his four year hospitalization at two state hospitals, he received risperidone, haloperidol, olanzapine, aripiprazole, and fluphenazine, with some medications being trialed more than once. When dose increases were initiated with each medication the ANC value would subsequently decrease. The patient was seen by hematology/oncology and medical causes of neutropenia were ruled out. They recommended monitoring complete blood count with differential regularly and continuing antipsychotic medication until ANC decreased to 0.5 x 10⁹/L. While receiving haloperidol 5 mg daily a drop in ANC to 0.36 x 10⁹/L was observed leading to haloperidol discontinuation and initiation of lurasidone 40 mg daily with dinner. Lurasidone remained at 40 mg for seven weeks with ANC values ranging from 0.592 to 1.31 x 10⁹/L during this time. The dose was then increased to 80 mg daily with dinner and no clinically significant drop was noted in ANC value (0.86 and 0.9 x 10⁹/L). After eight weeks, lurasidone was increased to 120 mg daily with dinner which has been successfully continued for over four months with ANC values ranging from 0.7 to 1.19 x 10⁹/L. Review of Literature: A MEDLINE/PubMed search revealed no published case reports of lurasidone-induced neutropenia or reported maintenance of ANC values with lurasidone. Conclusion: This case report describes repeated decreases in ANC values with first and second generation antipsychotics necessitating discontinuation of the agents causing failure to treat psychotic symptoms. This case demonstrates successful initiation and dose increases of lurasidone without impacting ANC values and appears to be the first reported case of such success. While other first and second generation antipsychotic medications have reported cases of neutropenia it is possible that lurasidone may pose a reduced risk for this adverse effect.

1. School of Community Medicine, Department of Psychiatry, University of Oklahoma, Tulsa, OK; 2. University of Oklahoma College of Pharmacy, Tulsa, OK

Abstract Type: Therapeutic Case Report. Background: Lithium augmentation of antipsychotics is used for some affective disorders. Frequently reported medication-related adverse drug effects include fine hand tremor, nausea, headache, and endocrine dysfunctions. Cardiovascular effects, such as reversible T-wave flattening and electrocardiogram inversions, have been reported with therapeutic doses. Additional effects are arrhythmias and bradycardia. Complete Patient-History: A 30-year-old African American man, diagnosed with schizoaffective disorder, cannabis abuse, and nicotine dependence, presented to clinic reporting dizziness, lightheadedness, nausea, and eating very little for weeks in response to delusional ideation. Vitals were blood pressure of 105/64 and heart rate (HR) of 46 beats per minute (bpm). His medication regimen included total daily oral doses of benztropine 2 mg, divalproex extended release 1000 mg, fluphenazine 15 mg, gabapentin 300 mg, and lithium carbonate 600 mg. Fluphenazine decanoate 50 mg was given intramuscularly every 2 weeks. Prior to initiation of lithium and over a 5 month pre-treatment period, HR readings ranged from 60-91 bpm, averaging 75 bpm. Over the 5 month period after initiation, HR readings ranged from 50-66 bpm, averaging 58 bpm. At clinic, the patient presented with a HR of 46, recent anorexia, lightheadedness, dizziness, and nausea; emergency medical services were called. Although they recommended emergency transport to the hospital, the patient refused treatment and/or laboratory studies. The physician discontinued lithium due to suspected lithium-induced bradycardia and possible lithium toxicity secondary to presumed dehydration. After discontinuation, the patient’s HR increased to 60 bpm within 24 hours; symptoms of dizziness, lightheadedness, and nausea improved. Use of the Naranjo ADR Probability Scale indicated a probable relationship (7 of 12) between the adverse effect of bradycardia and lithium use. Review of Literature: Literature retrieval was accessed through OVID, Google Scholar, MEDLINE, and PubMed (1965-July 2015). Reports of bradycardia secondary to lithium use and lithium toxicity with cardiovascular effects were reviewed. Conclusion: In our patient, symptomatic bradycardia resolved following discontinuation of lithium. Rechallenge was not attempted. Primary care providers may not be fully aware of the presentation and potential severity of this medication-related effect. Clinicians are encouraged to counsel patients about the possibility of bradycardia and follow-up with patients regularly for monitoring.

All parties are affiliated with the University of Georgia College of Pharmacy, Athens, Georgia

Abstract Type: Therapeutic Case Report. Objective: A unique case report to demonstrate addiction in a pharmacist through the use of buprenorphine/naloxone film for the self-prescribed treatment of migraine headaches. Case Summary: A 35 year old female hospital pharmacist is admitted to treatment for opioid use disorder for using buprenorphine/ naloxone film to self-medicate her migraine headaches. After daily use of sublingual buprenorphine/naloxone, and several failed attempts to discontinue use, the pharmacist was admitted to a partial hospitalization treatment program. She was prescribed sumatriptan subcutaneous injection for her migraines while maintaining buprenorphine/naloxone abstinence. Upon completion, the pharmacist transitioned to the aftercare program where she maintains sobriety and uses her story to help aid in other patients’ recoveries at the treatment center. Discussion: Addiction and substance abuse affect a substantial number of healthcare professionals. Pharmacists are particularly vulnerable to prescription drug misuse and addiction as a result of their direct access and vast pharmacologic knowledge. . This case is a story of rehabilitation and recovery of a pharmacist who has a desire to return to the practice of pharmacy through the use of effective pharmacological and behavioral interventions. Review of Literature: MEDLINE and GALILEO searches revealed no published case reports of Buprenorphine/Naloxone addiction. Cases may be underreported, leading to a lack of existing data. Conclusion: In conclusion, the patient in this case successfully completed six weeks of outpatient treatment in summer of 2010. After being discharged from primary treatment, the patient transitioned to the aftercare program where she participated in mirror imaging - a method where the patient played the role of counselor to combat the shame and embarrassment of overcoming addiction. The patient reported that mirror imaging served as reminder of where she used to be and saw similarities in others’ experiences, thus prompting her to provide insight and advice to current patients. She contributed to group therapy sessions as if she was still a patient and was cognizant of modeling behavior that set a reachable example for other patients. She hoped that soon she would have her license reinstated and returned to the practice of pharmacy.

All parties are affiliated with Regions Hospital

Abstract Type: Therapeutic Case Report. Background: Considerable attention is given to the potential cardio- and cerebrovascular risks associated with antipsychotics. Less attention and study is given to antipsychotic associated dysphagia, which results in aspiration, pneumonia, and even death. Patient History: A is a 47 year old female with schizophrenia, who was treated with clozapine. She experienced an out of hospital cardiac arrest following food aspiration and subsequently expired. B is a 20 year old male with schizophrenia, who is treated with clozapine, haloperidol, and lithium. He experienced a choking episode as an inpatient, but cleared his airway without assistance. He reported that clozapine caused difficulty swallowing and described choking episodes while eating. C is a 54 year old male with schizoaffective disorder, who is treated with clozapine, haloperidol, and valproic acid. As an inpatient, he experienced recurrent aspiration events leading to pneumonia, necessitating antibiotic treatment on three separate occasions. Review of Literature: We performed a systematic review of dysphagia, sialorrhea, and choking as they relate to patients with mental illness or antipsychotic treatment. Patients taking antipsychotics appear to have an increased prevalence of dysphagia when compared to the general population. Additionally, asphyxiation death due to food aspiration is substantially higher in this population. Proposed mechanisms for this correlation include: tardive dyskinesia, extrapyramidal and anticholinergic side effects, behavioral aspects of the primary illness, and other neurologic disorders. Clozapine-associated sialorrhea also appears to be a strong risk factor. Discussion: Although we are not able to directly link antipsychotic use to the choking episodes described here, the life-threatening experiences of our patients and the systematic review is concerning. Dysphagia therapy and interventions are common in post-stroke care and we believe that research is warranted to determine if these or other interventions may be beneficial in reducing morbidity and mortality amongst patients treated with antipsychotics. Conclusion: There appears to be a worrisome correlation between choking or dysphagia and the use of antipsychotics, especially clozapine. We propose that clinicians who prescribe antipsychotics routinely question patients about dysphagia, near-misses with high-risk foods, or choking while sleeping. In doing so, more formal testing with subsequent education and intervention may be warranted.

All parties are affiliated with the Captain James A Lovell Federal Health Care Center

Abstract Type: Therapeutic Case Report. Background: Many publications have noted that increases in dopamine, specifically in the mesolimbic area of the brain, can produce psychotic symptoms. Venlafaxine, a first line medication for depression, inhibits the reuptake of both serotonin and norepinephrine, as well as increases the amount of dopamine. Phentermine/topiramate (Qsymia), specifically the phentermine component, exhibits its function by blocking the dopamine transporter and the norepinephrine transporter, similar to amphetamine. Patient History: RR is a 40 year old Hispanic female with a past medical history significant for major depressive disorder, post-traumatic stress disorder, anxiety, irritable bowel syndrome and migraines. RR was started on venlafaxine 75 mg extended release by mouth once daily for approximately one month for depression prior to admission. Prior to the initiation of venlafaxine, RR was started on phentermine/topiramate for weight loss. RR presented to the outpatient clinic as her husband noticed a change in mood. RR reported attempting to cut her wrists and was admitted to the inpatient psychiatry unit. Additionally, she reported having delusional thinking such as being an assassin for the military. The patient previously tried venlafaxine years ago and denied any psychosis related to the medication, as well as when phentermine/topiramate was the only medication she was taking. RR was treated with lurasidone 40 mg by mouth daily and psychosis resolved. Review of literature: A PubMed searched revealed no current literature or case reports on psychosis induced by the combination of venlafaxine and phentermine/topiramate. Individual cases reports of psychosis in patients on venlafaxine alone and the phentermine component of phentermine/topiramate alone have been reported. Conclusion: This case report demonstrates psychosis induced by the combination of venlafaxine and phentermine/topiramate.

1. University of Oklahoma College of Pharmacy, Tulsa, OK; 2. School of Community Medicine, Department of Family Medicine & Bedlam-L Clinic, University of Oklahoma, Tulsa, OK

Abstract Type: Therapeutic Case Report. Background: Prescription medication sharing (PS) is a problem that has received relatively little attention. A recent literature review on the prevalence of sharing revealed rates ranged from 5% to 52%. Even if the shared medication is theoretically appropriate for the condition, self-medicating via PS may result in incorrect usage (wrong dose or interval), resulting in a poor therapeutic response. This may create doubts about effectiveness and potential nonadherence if the same medication, or class, is prescribed correctly. Undocumented use may also be associated with adverse effects. Complete Patient-History: A 56-year-old male diagnosed with diabetes mellitus, type 2 (T2DM), hypertension, and dyslipidemia was seen in an initial diabetes management visit by a PharmD, Certified Diabetes Educator. His current medication list included insulin (glargine and glulisine), pravastatin, bisoprolol/hydrochlorothiazide, and amlodipine. The patient was started on the insulin 2 months prior to the visit due to a glycated hemoglobin (A1c) increase from 9.3% to 13.9% (goal: <7.0%) over the previous 5-months. A comprehensive medication history was obtained that included current medication use, adherence, over-the-counter agents, and any other nondisclosed medications substances. At that time, the patient disclosed he had been taking his friend’s quetiapine 200 mg regularly at bedtime for several years due to difficulty falling asleep. The patient had not disclosed the quetiapine use to his physicians “because no one asked.” The patient was educated on the risks of taking medications not prescribed to him in addition to blood glucose self-monitoring, and insulin injection techniques. On follow-up 4 months later, his A1c had decreased to 9.3% (4.6% decrease) since the initial T2DM management visit. The patient denied taking any quetiapine since that visit. Review of Literature: Literature retrieval was accessed through OVID, Google Scholar, MEDLINE, and PubMed (1965-July 2015). Search terms included adverse event, adverse reaction, consequences prescription sharing, drug history, and sharing prescription medication. Conclusion: Clinicians should exercise great intentionality and thoroughness in communication with patients to help elucidate PS. Increased awareness of the prevalence of prescription sharing helps create a more accurate medical record. We recommend inquiring about PS as part of the medication history at every visit.

All parties are affiliated with the North Florida/South Georgia Veterans Health System

Abstract Type: Therapeutic Case Report. Background: Drug-induced parkinsonism (DIP) is defined as the appearance of parkinsonism on treatment with pharmaceutical agents. Symptoms typically manifest within a few days with 90% of cases emerging within 3 months. PET studies have shown that blockade of 75-80% of postsynaptic D2 receptors results in parkinsonism motor features. Conversely, drugs with no significant D2 affinity also produce DIP, indicating that dopamine receptor blockade is not the sole mechanism. Patient-History: The patient is a 68 year old white male with a past medical history significant for bipolar I vs cyclothymic disorder, hypertension, hyperlipidemia, allergic rhinitis, and coronary artery disease. Patient denies the use of alcohol, tobacco, or illicit substances and is currently homeless. Patient presents with pressured speech, flight of ideas, distractibility, delusional ideation, loose associations, and disorganized thinking. He was admitted and started on risperidone 0.25mg and titrated to a max dose of 8mg with periods of noncompliance. During this time benztropine 0.5mg once daily was started for possible parkinsonism symptoms. Due to a subclinical response patient was cross-tapered from risperidone to olanzapine, divalproex was started, and benztropine was discontinued. The patient was then given paliperidone 234mg long-acting injection (LAI) and a second loading dose of 156mg one week later. The patients cognitive status subsequently declined and he developed a shuffled gait, slowed movements & speech, hypophonia, and hypomimia. All neuroleptics were discontinued and the patient was transferred to medicine. He was intermittently treated with diphenhydramine, benztropine, and carbidopa/levodopa until he developed a severe allergy to benztropine. Patient was then treated with carbidopa/levodopa and amantadine. Despite treatment, patient required G-tube placement and botulinum toxin injections for cervical dystonia. Presently, the patient is immobile with unintelligible speech, incontinence, rigidity, and dystonia. Review of Literature: A PubMed search revealed no published case reports of debilitating paliperidone-LAI induced parkinsonism. Literature suggests the loading dose of paliperidone-LAI does not lead to higher rates of EPS compared to oral paliperidone. Conclusion: In our case report, a causal and temporal relationship was observed between the initiation of paliperidone-LAI and the development of parkinsonism. Practitioners should be cognizant of potential long-term reactions when using this medication.

All parties are affiliated with Husson University School of Pharmacy and Acadia Hospital

Abstract Type: Therapeutic Case Report. Background: Valproate induced hyperammonemia without hepatic impairment is a known effect of valproate. Mild elevations of ammonia can occur in 16-52% of patients and can occur at any time during treatment. Elevations usually resolve with a single dose of carglumic acid. The cause of the elevation is not well understood. Hyperammonemia induced encephalopathy however in the absence of hepatotoxicity is rare, with existing evidence almost exclusively consisting of case reports. Complete Patient History: An 11-year-old male with a past medical history significant for reactive attachment disorder, suspected autism spectrum disorder, and suspected post traumatic stress disorder was admitted following escalation of aggressive behavior at his group home. He was initiated on Depakote to address persistent aggressive behavior and violent outbursts and was quickly titrated to 1250mg total daily dose. Follow up labs after one week showed hyperammonemia at 91 µmol/L, VPA level of 116 and normal LFTs. At that time, the patient appeared fully alert, showing no signs of toxicity or encephalopathy. A same day re-draw of the ammonia came back at 154 µmol/L. Depakote was held for 24 hrs. And lactulose ordered to treat hyperammonemia. Ammonia levels returned to normal. Due to persistent behavioral outbursts, which worsened significantly following Depakote discontinuation, Depakote was restarted. Within 24 hours of restarting the Depakote, patient showed signs of toxicity including vomiting, lethargy and confusion. The patient was transferred to the emergency department where Depakote was discontinued and the symptoms of confusion, vomiting, and sedation resolved within 24 hours and did not reoccur. Review of Literature: A PubMed literature search yielded primarily case reports with majority in adult patients, and a smaller body of evidence in pediatric patient with epilepsy of valproate associated hyperammonemia encephalopathy. One article in particular called for more routine ammonia monitoring due to growing concern over risks associated with valproate-induced hyperammonemia. This case report would be an important addition to the growing body of literature for this topic. Conclusion: An 11-year old male was given Depakote, subsequently developed symptomatic hyperammonemia in the absence of liver dysfunction, and the hyperammonemia and associated symptoms resolved upon discontinuation of Depakote.

1. Wingate University School of Pharmacy; 2. Park Ridge Health; 3. Mission Hospital Pharmacy Department

Abstract Type: Therapeutic Case Report. Background: Major Depressive Disorder (MDD), and Hypothyroidism symptomatically overlap (lethargy, fatigue, mood fluctuations, and cognitive changes), and in some patients may occur concurrently. Hypothyroidism is a deficiency of thyroid hormone and the mainstay of treatment according to AACE/ATA is Levothyroxine (L-T4) monotherapy. Utilizing dual levothyroxine plus liothyronine (L-T3) has become a common practice for patients diagnosed with concomitant depression and hypothyroidism, but is this evidence based medicine or merely anecdotal? Patient History: The patient, a 75 year old Caucasian female, presented with weakness anorexia, depression, and fatigue, beginning 12 weeks prior, and gradually worsening with recent onset of SI. Her PHM includes: MDD, anxiety, cognitive disorder, diabetes, fibromyalgia, hypothyroidism, and hyperlipidemia with unknown diagnosis dates. Home medications include: desvenlafaxine 100 mg daily, levothyroxine 50mcg daily, metformin 500mg daily, multivitamin daily, pantoprazole 40mg daily, potassium 20mEq daily. Pertinent vitals and labs include BG: 166-280, K: 4.1, eCrCl 87, T3: 1.1pg/mL, THS: 2.68mIU/L, T4f: 1.3mcg/dL, A1C: 7.0. The patient was started on mirtazapine 15mg HS, and changed from desvenlafaxine to venlafaxine. Liothyronine 5mg was added on day three, but increased to 7.5mg on day seven. The patient remained withdrawn, depressed, suicidal, and isolative until the eighth day of inpatient treatment, when she told a nurse she felt that treatment changes were helping. The patient remained on dual Levothyroxine and Liothyronine and was discharged with planed outpatient endocrinology follow-up. Literature Review: The STAR*D trial revealed that L-T3 is a reasonable option for antidepressant augmentation in depressed patients who did not reach remission with previous treatments, but STAR*D did not evaluate L-T4. Animal models and human studies have shown that 3,5,3′-triiodothyronine (T3) influences the potency of serotonin and catecholamine. Evaluating the most recent biological research on thyroid metabolism and neuronal signaling may help account for the conflicting results and help guide treatment recommendations in the future. Conclusion: Providers are quick to add on Liothyronine in patients with underlying hypothyroidism already treated with levothyroxine. This patient case and literature review evaluates the current evidence comparing reported clinical improvement with combination L-T3/L-T4 therapies versus L-T4 monotherapy.

Abbreviations: American Association of Clinical Endocrinologists/American Thyroid Association (AACE/ATA)

1. University of Florida Health Jacksonville, Jacksonville, FL; 2. University of Oklahoma College of Pharmacy, Tulsa, OK

Abstract Type: Therapeutic Case Report. Background: Seizures are a potential consequence of a traumatic brain injury (TBI). It has been reported that between 5-7% of patients hospitalized with a TBI experience at least one post-trauma. Additional damage may include hypoxia and increased intracranial pressure. To help mediate the potential for additional brain injury, an anticonvulsant may be initiated. Valproic acid, which is highly protein bound, may be one prophylactic choice. Concomitant medication competing for binding sites may decrease valproic acid levels. Complete Patient-History: A 72-year old male presented through the emergency department following surgery for a right acetabular fracture. The patient was subsequently admitted. Past medical history included seizures, hypertension, atrial fibrillation, TBI with subdural, malnutrition, and moderate obesity. At the time of admission, the patient was prescribed valproic acid and had been seizure-free for 3 years. Wound cultures were obtained and infectious disease consult recommended ertapenem, which is also highly protein bound. Three days after ertapenem initiation, the patient’s valproic acid level was 14.2 mcg/mL, no level at admission had been obtained to compare it to. Valproic acid was increased to 1000 mg orally twice daily. Two days after the dose increase, the patient had three witnessed seizures. A neurology consult recommended lacosamide. The antibiotic was changed to piperacillin/tazobactam. No further seizures were documented. The Naranjo Probability Scale was applied and indicated a probable relationship (6 of 12) relationship between ertapenem initiation and use of valproic acid. Review of Literature: Literature retrieval was accessed through OVID, Google Scholar, MEDLINE, and PubMed (1965-August 2015). Reports on the use of carbapenem antibiotics and valproic acid were identified and reviewed. Conclusion: In this patient, the addition of erapenem was associated with the onset of new seizure activity. Primary care providers and other healthcare providers in both inpatient and outpatient settings may encounter TBI patients requiring antibiotic therapy. Clinicians are encouraged to consider the potential for interactions and monitor closely to determine if adverse effects are experienced, particularly if the individual agents are highly protein-bound or compete for metabolic pathways.

All parties are affiliated with Mayo Clinic, Rochester, Minnesota

Abstract Type: Therapeutic Case Report. Background: There are a growing number of cases reporting severe or fatal outcomes associated clozapine-associated gastrointestinal hypomotility (CIGH). Risk factors for severe CIGH included higher dose/serum level, febrile illness, concomitant anticholinergic medications, and metabolic inhibitors of clozapine. Reported is a fatal case of clozapine-associated CIGH. Complete Patient History: A 58-year-old male with a history of hypertension and schizophrenia was transferred from a psychiatric facility after 2 days of worsening abdominal pain and distention. His medications included clozapine 500mg, quetiapine 1200mg, diphenhydramine 150mg and atenolol 100mg daily. On admission he was in severe pain, with absent bowel sounds, shortness of breath, hypotension, and fever. This progressed to shock and respiratory failure requiring multiple vasoactive agents and mechanical ventilation. Respiratory failure was likely secondary to aspiration pneumonitis as feculent material was suctioned from the endotracheal tube. Computed tomography revealed marked distention of the large bowel with fecal impaction attributed to constipation and adynamic ileus. The patient was taken to the operating room for exploratory laparotomy where he underwent a total colectomy with end ileostomy. The final postoperative diagnosis was toxic megacolon with abdominal compartment syndrome. Following the development of renal failure, ischemic hepatitis, and disseminated intravascular coagulopathy the patient expired 4 days after admission. Review of Literature: The estimated incidence of life-threatening CIGH is 3 cases per 1000 patients exposed, with an estimated mortality rate of 27.5%. Other reports have noted mortality associated with CIGH is at least 3 times greater than with agranulocytosis. Multiple of mechanisms likely contribute to CIGH including the clozapine’s anticholinergic and 5-HT3 receptor antagonism properties as well as a patient’s lifestyle. When mild to moderate CIGH is identified, attempts at lifestyle modification or reducing polypharmacy should be made in addition to initiating an adequate bowel regimen. There are no guidelines for managing CIGH but in clinical practice multiple agents may be required. Use of a senna-docusate may be instituted. Other agents that have been suggested include polyethylene glycol, lubiprostone, lactulose, and orlistat. Conclusion: Clinicians must routinely monitor patients’ bowel function during clozapine therapy due to the morbidity and mortality associated with CIGH.

All parties affiliated with Husson University School of Pharmacy and Acadia Hospital

Abstract Type: Therapeutic Case Report. Background: Risperidone and aripiprazole are FDA indicated to treat autism associated irritability in pediatric patients. Other second-generation antipsychotics have also been studied with mixed results. Far less evidence exists for first generation antipsychotics, and for patients with co-morbid mental health diagnoses. Complete Patient History: An 11-year-old male with a past medical history significant for reactive attachment disorder, suspected autism spectrum disorder, and suspected post traumatic stress disorder was admitted following escalation of aggressive behavior at his group home. The patient was admitted taking low dose risperidone. Risperidone was quickly titrated to 5mg in divided doses with no effect. Quetiapine and olanzapine were also trialed at appropriate therapeutic doses with minimal effect on aggression and irritability. The patient continued to have severe behavioral outbursts resulting in multiple psychiatric emergencies, restraints and injuries to unit staff. Following failure with second-generation agents, the patient was trialed on fluphenazine and haloperidol. Patient had an allergic response to fluphenazine and haloperidol was ineffective. At this point genetic testing was obtained which was only significant for ultra rapid metabolism at CYP1A2 enzyme system. Chlorpromazine was initiated following positive response from prn dosing during psychiatric emergency. Patient had partial response at therapeutic doses and the dose was titrated up to 1000mg due to persistent aggressive outbursts and absence of adverse effects. Patient became over sedated and the dose was decreased to 700mg daily. After over a month in an acute psychiatric hospital patient stabilized with significant improvement in aggressive behaviors and was able to be discharged back to his group home. Review of Literature: A PubMed literature search yielded an extensive body of evidence for antipsychotic use in autism spectrum disorder. The majority of the evidence focused on second-generation antipsychotics with virtually no evidence for chlorpromazine use in autism spectrum disorder. A substantial body of evidence exists to support chlorpromazine use in adult patients with persistent aggression associated with other diagnoses. Conclusion: The successful use of chlorpromazine in this pediatric patient may indicate the need to revisit this older agent for use in severe treatment resistant aggression associated with autism.

1. Saint. John Medical Center; 2. Saint Francis Health System

Abstract Type: Therapeutic Case Report. Background: Aripiprazole is a second-generation antipsychotic approved in the United States as an oral tablet in 2002 and as a long acting injectable in 2013. At this time, none of the atypical antipsychotics in any formulation are indicated for use in eating disorder patient. Case reports and studies throughout the literature suggest these medications may have a potential role in the management of these patients. Patient History: The patient is an 18 year-old female diagnosed with restricting type anorexia nervosa (AN). The patient has a past psychiatric history positive for previous treatment of AN, depressive mood symptoms, and obsessive compulsive disorder. Attempts to treat symptoms of distress associated with therapy utilizing selective serotonin reuptake inhibitor (SSRI) therapy failed due to tolerability. The patient was then started on oral and intramuscular immediate release aripiprazole. To increase adherence, the patient was moved to a long-acting aripiprazole injection. The patient was started on a long acting aripiprazole injection 300mg intramuscularly once per month. The recommended starting dose of 400mg was decreased due to severe malnourishment and very low BMI. Patient exhibited fewer behavioral issues and episodes of extreme agitation following 3 injections. Patient continues to report a decrease in obsessive thoughts, as well a reduction in her urges to restrict caloric intake and exercise. Literature Review: A MEDLINE search revealed no published case reports for the use of long-acting aripiprazole for the treatment of psychiatric symptoms in an eating disorder patient. Minimal data does exist for the use of oral antipsychotics in this population. As there are no current guidelines for treating psychiatric symptoms in patients with anorexia nervosa, limited data is available for potential treatment options. Conclusion: At this time, no long-acting antipsychotics are indicated for the treatment of psychiatric symptoms or behavioral disturbances related to AN. Based on the positive outcomes seen in this patient, long-acting aripiprazole injections may be a potential option for improving outcomes in AN patients.

1. Pharmacy department, Maisonneuve-Rosemont Hospital. Faculty of Pharmacy, University of Montreal; 2. Nephrology division, Maisonneuve-Rosemont Hospital. Department of medicine, University of Montréal

Abstract Type: Therapeutic Case Report. Background and Review of Literature: Rhabdomyolysis is a syndrome due to muscle injury that can be direct (by trauma of muscle) or indirect. The death of the muscle fibers and the release of their contents into the bloodstream can result to renal failure and rarely, to death. A MEDLINE search revealed a few published case reports of venlafaxine-induced rhabdomyolysis, most of them in the context of an overdose or serotonin syndrome. This is, to our knowledge, the second case of rhabdomyolysis described in a patient taking a low dose. Patient History: A 30 year-old female, in good health except for generalized anxiety disorder (GAD), had been taking venlafaxine XR 37,5 mg once daily for six years, and an oral contraceptive containing ethinyl estradiol 30 mcg and desogestrel 150 mcg once daily for 15 years. The patient’s social history was noncontributory. She tried stopping venlafaxine for 6 months, and then she restarted at 37.5 mg once daily, functioning much better on this medication. One month later, venlafaxine was increased to 75 mg daily. Three weeks after the increase, she went swimming for 25 minutes at a moderate pace. An hour later, she started having intense pain on the arm and shoulder with hematuria. Her body temperature reached 38°C. She presented herself to the emergency department and analysis revealed creatinine kinase (CK): 100 879 U/L, AST 781 U/L, ALT 172 U/L, and blood and proteins (3 g/L) in her urine. She was admitted to the hospital and she recovered completely without acute renal failure with IV hydration and withdrawal of venlafaxine. EMG and acylcarnitines plasmatic dosages were normal. A final diagnosis was made of rhabdomyolysis due to venlafaxine, triggered by exercise. The only other contributing factor found was subclinical hypothyroidism. She was discharged with mirtazapine for her GAD without any muscular side effect. Conclusion: A temporal relationship was observed between the increase of the dose of venlafaxine and the rhabdomyolysis, and no other cause could explain its severity. Although rare, clinicians must be aware of this side effect, as it can be fatal if not recognized rapidly.

1. Department of Pharmacy, Barnabas Behavioral Health Center, Toms River, NJ; 2. Clinical Assistant Professor of Pharmacy Practice, Fairleigh Dickinson University, Florham Park, NJ; 3. Department of Pharmacy, Community Medical Center, Toms River, NJ

Abstract Type: Therapeutic Case Report. Background: Neuroleptic malignant syndrome (NMS) is an idiosyncratic and a potentially fatal complication of antipsychotic use. NMS can be characterized by hyperthermia, autonomic dysfunction, muscle rigidity, and altered mental status. Delayed treatment can result in rhabdomyolysis, arrhythmias, venous thromboembolism, and organ failure. Early management is crucial in patient prognosis, however due to its rare incidence, only anecdotal evidence and expert opinion provide guidance for treatment options. Patient-History: The patient is a 51-year-old Caucasian female who presented to the emergency department after a potential overdose. Past medical history was significant for depression, bipolar disorder, anxiety, and previous suicide attempt. Patient was admitted for observation when she experienced a tonic-clonic seizure and postictal confusion. During this hospitalization, the patient was diagnosed with benzodiazepine and barbiturate withdrawal delirium requiring one-to-one supervision. Over the next 36-hour time period, she received 2.5mg oral risperidone, 10mg oral haloperidol, 5mg IM haloperidol, and 5mg IV-push lorazepam. A “rapid response” was called 1-hour post IM haloperidol administration, the patient appeared disoriented, diaphoretic, and displayed signs of muscle rigidity. Further work-up revealed hypertension, tachycardia, tachypnea, pyrexia, elevated creatinine phosphokinase, hypernatremia, and leukocytosis suggesting a possible NMS diagnosis. The patient was admitted to the ICU and started on bromocriptine 2.5mg every 8-hours and IV lorazepam drip titrated to 5mg/hr. One dose of intravenous dantrolene was administered due to a lack of improvement in muscle rigidity and fever. The patient continued on bromocriptine and lorazepam for five days. On day six, the patient was transferred to an inpatient mental health facility. Review of Literature: A MEDLINE search identified thirteen case reports of NMS management between 2000 and 2015. Inclusion criteria consisted of articles published in English language, an established NMS diagnosis, and utilization of both bromocriptine and dantrolene in adult patients. Majority of cases responded to the regimen and improvement was noted; however, there was one case of non-response. Conclusion: Our case report demonstrated a positive effect of a single dantrolene dose along with bromocriptine and lorazepam in resolving NMS symptoms. Literature analysis identified similar successful case reports, however most differentiated in severity of presentation, demographics, and duration of treatment.

All parties are affiliated with Virginia Commonwealth University Health System

Abstract Type: Therapeutic Case Report. Background: Gender dysphoria is defined as a marked incongruence between one’s experienced gender and assigned sex at birth that causes significant distress. It may be present in children but often disappears prior to puberty. Gender dysphoria is more likely to persist into adulthood when present in adolescents, with ages 10 to 13 years being the crucial period for long-term gender identity development. Patients with gender dysphoria may have a greater incidence of psychiatric comorbidities which may be socially induced. Internalizing comorbidities such as anxiety and depression are more common than externalizing comorbidities. Patient History: A 13-year-old transgender male admitted due to worsening depression and suicidal ideation related to ongoing family strain. He began his gender transition 10 months prior to admission. He was continued on ethinyl estradiol-norethindrone daily for suppression of menses. His discharge diagnosis included major depressive disorder, social anxiety disorder, and gender dysphoria by history. A 16-year-old transgender male admitted due to worsening depressive episodes with suicidal ideation since school restarted. The patient initiated his gender transition two years ago and testosterone therapy nine months prior to admission. He was maintained on testosterone 50 mg subcutaneously once weekly. He wore a compression garment around others and hoped to have top surgery in the future. His discharge diagnosis included unspecified bipolar disorder, unspecified anxiety disorder, and gender dysphoria. A 17-year-old transgender female admitted due to suicidal ideation and self-harm. She began her gender transition two years prior to admission. She was continued on spironolactone 50 mg twice daily and expressed the desire to ultimately have gender reassignment surgery. Her discharge diagnosis included unspecified depressive disorder, unspecified anxiety disorder, and gender dysphoria. Two additional cases will be presented, but the patients were not on pharmacotherapy related to their gender transition. Review of Literature: A PubMed search revealed one case report of gender dysphoria in a 14-year-old girl with autism. No case reports regarding psychiatric admission for transgender adolescents with comorbid anxiety, depression, or suicidal ideation were identified. Conclusion: Anxiety, depression, and suicidal ideation are common comorbidities leading to psychiatric hospitalization of adolescent transgender patients in various stages of gender transition.

All parties are affiliated with the South Texas Veteran Affairs Health Care System

Abstract Type: Therapeutic Case Report. Background: Opioid overdose-related morbidity and mortality remain one of the most pressing public health crises. Overdose education and naloxone dispensing (OEND) have emerged as an effective initiative for mitigating overdose deaths. This case highlights areas of patient education essential to optimizing treatment outcome when utilizing a naloxone reversal kit Patient-history: Patient is a 46-year-old Caucasian male with a past medical history significant for opioid use disorder, alcohol use disorder, stimulant use disorder, sedative-hypnotic use disorder, and post-traumatic stress disorder. During his first admission to the substance abuse residential treatment program (DOM-SA), the patient received an intranasal naloxone kit after OEND training. Five months later, the patient reached out to his providers for a new naloxone kit, at which time the original’s disposition was explored. The patient recounted how he was telephoned to pick up an unconscious friend (and fellow Veteran) from a non-residential location. Upon arrival, the patient recognized opioid products near his friend and immediately performed the sternal rub. After no response, he administered one dose of 2mg/2ml naloxone intranasally with the supplied nasal atomizer and luer-lock syringe. He reasoned against performing rescue breathing due to the chaotic environment and instead kept track of his friend’s pulse and respirations. After his friend regained consciousness, the patient briefly discussed aftercare at a medical facility, but readily acquiesced to his friend’s request to be driven home. To the patient’s knowledge, the friend fully recovered. When reviewing his actions with providers, the patient admitted to forgetting naloxone’s short duration of action and the risk of re-overdose, acknowledging that he should have forcibly taken his friend for prolonged aftercare. When given a choice between receiving another intranasal kit or the auto-injector, the patient chose the latter. Review of literature: A Pubmed search located one other case report of successful naloxone reversal of opioid overdose in the Veteran population, which involved fentanyl sold as heroin. Conclusion: In our case report, a Veteran successfully used his naloxone kit to reverse a suspected opioid overdose in another Veteran, but also took incomplete aftercare steps. This experience may influence content changes for future OEND training.

1. University of Oklahoma College of Pharmacy, Tulsa, OK; 2. School of Community Medicine, Department of Psychiatry, University of Oklahoma, Tulsa, OK

Abstract Type: Therapeutic Case Report. Background: Extrapyramidal symptoms (EPS) are drug-induced movement disorders. The severity of these effects may lead to antipsychotic (AP) discontinuation. The most common cause is attributed to high potency first generation antipsychotic (FGA) dopamine D2 receptor antagonism. Second generation antipsychotics (SGAs) have lower D2 receptor affinity or higher serotonin 5-HT2A receptor affinity and lower reported rates of EPS. Loxapine, a FGA, demonstrates similarities to the SGA clozapine: extremely strong binding affinity for dopamine D4 and serotonin 5-HT2 receptors allowing for additional D2 receptor blockade while maintaining 5-HT2A antagonism and avoiding EPS. Complete Patient-History: A 44-year-old Caucasian male diagnosed with schizoaffective disorder, bipolar type, presented to the emergency department complaining of severe EPS. Physical symptoms of akathisia (rapid/repetitive marching-type leg movements, jerking arm motions, shoulder tics, hand tremors) interfered with work (involuntary motor activity increased), becoming noticeable to colleagues and customers, negatively impacting task completion, appropriate job performance interactions, and quality of life (eating, drinking). The medication regimen included paliperidone 234 mg long-acting injection (LAI) every 4 weeks (4 months prior, baseline AIMS = 0) and total daily oral doses of paliperidone 6mg, benztropine 2mg, and propranolol long-acting 80mg. In clinic two months after LAI initiation, AIMS = 6. A clonazepam trial was unsuccessful and sedating. The patient was labile and indicated consideration of medication discontinuation due to these effects. His lifetime treatment included multiple trials of FGAs, SGAs, and mood stabilizers but never a trial of loxapine. Paliperidone LAI was discontinued and loxapine (10 mg mornings, 20 mg at bedtime) initiated. On follow-up 2 months later, the patient was back to baseline (AIMS = 0) and stable mood. The Naranjo Probability Scale was applied and indicated a probable reaction (7 of 12). Review of Literature: Literature retrieval was accessed through OVID, Google Scholar, MEDLINE, and PubMed (1965-December 2015). Reports of akathisia or related effects were reviewed. Conclusions: EPS remains a clinically important concern. The incidence and severity differs amongst APs. Use of loxapine successfully resolved EPS in this patient. It was theorized similarities to clozapine contributed. Clinicians were encouraged to consider the structural–activity relationship and receptor affinity when selecting agents, particularly when addressing medication-related adverse effects.

All parties are affiliated with Virginia Commonwealth University Health, Richmond, Virginia

Abstract Type: Therapeutic Case Report. Background: Electroconvulsive therapy (ECT) is an effective, but controversial treatment option for severe depression and schizophrenia. ECT is associated with side effects, such as cognitive impairment and increased cardiac risks, and variable documented effectiveness. ECT may be a treatment option in severe cases or after failure of two or more pharmacotherapy trials. Patient History: A 17-year-old African-American female with a past psychiatric history significant for schizoaffective disorder, depressive type and anxiety disorder with multiple psychiatric admissions and two suicide attempts by overdose on medication presented with increased depression and worsening auditory hallucinations. Her past medical history includes obesity and type 2 diabetes mellitus. The patient’s social history was noncontributory. The patient has been managed on multiple psychotropic medications in the past including sertraline, fluoxetine, aripiprazole, risperidone, quetiapine, and divalproex sodium. The patient’s current medication regimen consists of lurasidone 80 mg daily, citalopram 40 mg daily, and lamotrigine 100 mg daily. During her eighth hospitalization at our institution, the decision was made to initiate ECT to reduce the patient’s psychotic symptoms and improve mood stabilization. The patient tolerated all treatments with minimal short term memory loss and occasional headaches. Following twelve index ECT treatments, no auditory hallucinations and suicidal ideations were endorsed and mood was improved. The patient’s response was also evaluated by the Montogmery-Asberg Depression Rating Scale (MADRS). The patient had a MADRS score of 28 prior to the start of therapy. This was reduced to a score of 10 prior to her receiving the final ECT treatment. At this time, it was recommended that the patient not receive maintenance treatments of ECT. Review of Literature: A MEDLINE search revealed no published case reports of the use of electroconvulsive therapy to treat refractory schizoaffective disorder in a pediatric patient. Conclusion: In this case report, the use of electroconvulsive therapy in a pediatric patient with treatment refractory schizoaffective disorder resulted in improvement in the patient’s psychotic and depressive symptoms with minimal adverse effects. Electroconvulsive therapy may be considered as a treatment option in addition to pharmacotherapy in treatment refractory schizoaffective disorder in pediatric patients.

Author affiliated with the White River Junction VA Medical Center, White River Junction Vermont

Abstract Type: Therapeutic Case Report. Background: Akathisia is one type of extrapyramidal symptom (EPS) that manifests as a need to be constantly moving and is often accompanied by observed movements of the legs. Akathisia can be distressing to patients and has been linked to an increase in suicidal behavior. Akathisia is a potential side effect of dopamine-blocking agents, such as antipsychotics, as and antidepressants, such as selective serotonin reuptake inhibitors. If the offending agent cannot be removed, the treatment of akathisia includes propranolol and benzodiazepines. Clozapine is an atypical antipsychotic with a relatively low risk of EPS, especially akathisia. This case describes a patient who had been maintained on clozapine for 2.5 years when the first signs of akathisia began to manifest. Her symptoms were successfully treated with high dose propranolol. Complete Patient History: CM is a 37 year old female veteran with depression, PTSD and borderline personality disorder who suffers with auditory hallucinations and chronic suicidality. She tried and failed antipsychotics, mood stabilizers and antidepressants and has required multiple psychiatric hospitalizations. Clozapine was started to target the treatment-resistant auditory hallucinations and chronic suicidality. CM was maintained on clozapine 200mg/d for 2.5 years when she reported feeling “restless” and “uncomfortable under my own skin”. Leg movements and rocking motions were notable. CM noted that she rocks to calm herself, but the internal feeling of restlessness was new. Her medications included propranolol LA 120mg/d for hypertension, anxiety and migraine prevention, clozapine 200mg/d and temazepam 30mg/d as needed for insomnia. Given her presenting symptoms, akathisia was highly suspected, but was not objectively tested. Temazepam did not alleviate her symptoms. Propranolol was titrated up to 200mg/d with no reported side effects. CM noted that her restlessness decreased significantly. Her leg movements and rocking motions were no longer visible. Review of Literature: A literature search of clozapine-induced akathisia generated three case reports. The case reports describe patients with acute akathisia, acute nocturnal akathisia and tardive nocturnal akathisia related to clozapine. Conclusion: Clozapine may cause acute or tardive akathisia. It is rare, but possible. Propranolol is an appropriate treatment option for akathisia and higher than recommended doses may be required.