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Professional Pharmacy Functions in Community Mental Health Centers*
Professional Pharmacy Functions in Community Mental Health Centers* By William A. Miller and John Corcella
n recent years there has been a trend in mental health to shift care from the large, centralized state institutions to community mental health centers. Most mental health centers have been developed without any plans or provisions for pharmaceutical services except drug distribution. Drug distribution has been provided by physiciandispensing of medications or by giving the patient a prescription order to be dispensed at a community pharmacy of his choice.
I
Mental Health Care-A Review At the turn of the century most patients with mental illnesses were hospitalized in large, isolated state hospitals across the country. The hospitals were isolated in terms of their access to communities and to other people. Most often, individuals having hallucinations and delusions were diagnosed as mentally ill. Frequently they were sent to the hospital for confinement and more or less disappeared from society from that point on. As more was learned about mental illness, the definition was broadened to include neuroses, personality disorders, psychophysiological disorders, alcoholism and drug abuse. In contrast to individuals with psychoses, many of the people with these problems do not necessarily need hospital treatment and do not need to be isolated or removed from society.l In the 1950's the phenothiazines were introduced. They revolutionized the treatment of psychoses and helped make it possible to return many patients with chronic schizophrenia and other psychoses to the community.2 The changes in the definition of mental illness and the availability of psychotropic drugs created a need for a system to provide comprehensive mental health care in the community setting. In the 1960's, Comprehensive Community Mental Health Centers were established in many states to provide this care to the people. Thus, o Adapted from a presentation at the Academy of General Practice of Pharmacy, APhA annual meeting, San Francisco, California, March 29 1971. "
68
the term Comprehensive Community Mental Health Center is used to describe a system of care whereby alternatives to institutional care are developed and placed in the community, close to the people. The centers were developed to make it possible to select from a whole range of services the specific resources which meet individual patient needs, whether they be hospitalization, outpatient treatment, diagnosis and evaluation, group therapy, rehabilitation or other services. One of the most important values of the center, other than its availability to the citizens in the community, is the continuity that a patient can receive from being close to home and family, and the comprehensiveness that can also be provided. In essence then, the community has become the "new horizon" or "new frontier" in mental health care.3 The nationwide community mental health centers program has significantly increased mental health manpower needs. New models for delivering mental health care have been investigated which include the development of an interdisciplinary team and the use of paraprofessionals, mental health technicians and lay personnel in the community. None of these new models have considered fuller utilization of the pharmacist as a member of the mental health team.4-11 Blue Grass East and West Mental Health Centers Blue Grass East and West Mental Health Centers serviced by the Central Kentucky Regional Mental Health-Mental Retardation Board, Inc. were established in 1966 to provide mental health care for patients in 11 counties in Kentucky.12 Currently, the two centers have 5,500 patients divided among the adult and child mental health programs, alcoholic program, drug abuse program, mental retardation program, group therapy and other therapies. An adult mental health-mental retardation program has been established in each of these coun~ ties primarily to provide "outpatient" or "after-care" treatment for patients
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
following discharge from a state hospital or other institution. Drug therapy is one of the important aspects of "after-care" to the mental health patient. A high percentage of the patients seen in the adult clinics are being treated mainly with drug therapy for chronic schizophrenia or other psychoses. The socio-economic background of these patients varies, with about 50 percent being indigent. Prior to the development of mental health centers, mental health aftercare patients returned to one of the state hospitals or other institutions to obtain drugs. However, many of these patients could not afford to purchase their drugs because of the high cost and extended need of psychotropic therapy. Some patients qualified for state medical assistance programs which provided them with a limited number of drugs. If the medical assistance patient required a drug that was not an approved drug, another mechanism had to be used for the patient to obtain medication. This problem was recognized by the Kentucky Department of Mental Health which implemented a program whereby state mental institutions were provided a quantity of drugs to be used on an inpatient and outpatient basis for indigent patients. When mental health centers were developed in Kentucky, the state department of mental health allocated a portion of these drugs to the centers for distribution to outpatients following discharge from state institutions. Initially, the.' centers had no funds or provisions for outpatient pharmacies and pharmacists to dispense drugs to their patients. Medications were dispensed in the clinics by the psychiatrist and nurse. However, this system of drug dispensing proved to be undesirable to all involved because of poor drug control and safety, poor medication records and poor fiscal management. It was also felt that the expertise of the psychiatrist and nurse could be better utilized in performing functions other than drug dispensing. The problem of drug distribution caused the professional staff in the centers to
think about what pharmaceutical services were needed. Philosophically it was felt that the mental health patient should obtain medication in the same manner as any other patient, that is, he should obtain a prescription order for his medication to be dispensed in a community pharmacy. This procedure for obtaining medication would serve as a part of the overall therapy of the patient helping the patient to identify with the community, to re-adjust to his environment and to better relate to other people. The professional staff concluded that a pharmacist was needed as a part of the mental health center team. The pharmacist would be responsible for coordinating a cooperative community pharmacy program for drug dispensing and for developing professional services within the center such as drug histories, drug counseling, drug abuse and drug information services. In July 1970, the center contacted the college of pharmacy at the University of Kentucky for assistance in developing these pharmaceutical services. Pharmaceutical Functions A pharmacist from the clinical pharmacy department of the college was employed 'o n a part-time basis ( 15 hours per week) by the center for the adult mental health clinic program. The clinics are held for half a day three times a week. The pharmacist selected had both the academic and experience background required to function effectively as a part of the mental health center team. The pharmacist's training consisted of doctor of pharmacy coursework-advanced pharmacotherapeutics, drug information services, drug communications, pathophysiology and clinical psychiatry. In addition, the pharmacist had two years experience as a clinical pharmacist at the University of Kentucky Medical Center. One of the objectives of the centers is to effectively utilize all mental health personnel and thereby facilitate a more economic and practical approach fQ patient care. In developing functions for the pharmacist in the adult mental health clinics it was imperative that the pharmacist not simply duplicate the efforts of the psychiatrist, nurse or social worker, but that he take on primary responsibilities in direct patient care which would not be performed by another member of the team. Initially, the pharmacist's functions centered around drug dispensing. After a close working relationship was developed between the pharmacist., psychiatrist and social worker, plans Were made to develop more comprehensive pharmaceutical services. Spe-
William A. Miller, PharmD, is associate director for clinical pharmacy services at the Ohio State University Hospitals in Columbus. Previously he was director of pharmaceutical services at Blue Grass East-West Mental Health Centers in Lexington, Kentucky. A hospital pharmacist from 1963 through 1970, Miller has also taught at the University of Kentucky and at Ohio. At Kentucky, he developed the first decentralized pharmacy program at the university hospital as well as developed and taught the first courses in patient care services and clinical pharmacy, pharmacy clerkship and mental health clerkship. A member of APhA, Miller was active in the Kentucky Pharmaceutical Association.
John Core ella, MD, is director of Team 11, Region 110, of the Mountain Mental Health Services at Methodist Hospital in Pikeville, Kentucky. Previously, Corce/la was director of adult and family services for the Central Kentucky Community Mental Health Center in Lexington. From 1963 to 1969 Corcella served as clinical director oj the Eastern State Hospital in Lexington. He has taught psychiatry at the universities oj Louisville and Kentucky. Having received his doctorate in medicine and surgery from the University of Padua (Italy), Corcella interned at Coney Island Hospital (New York) and served residency at St. Vincent Hospital on Staten Island.
cifically, the pharmacist was charged with developing the following pharmaceutical functions1. To develop and coordinate a cooperative community pharmacy program for drug dispensing to patients under the care of the centers. 2. To dispense medications to those patients who cannot obtain pharmaceutical services through the community pharmacy program because of their financial status. 3. To interview patients and determine the status of their drug therapy program and then to make appropriate recommendations to the physician. The patient's drug therapy program would be reviewed to determinea. Present and past medication (prescription and o-t-c drugs) b. Drug allergies, side effects, incompatibilities, contraindications, adverse drug reactions and toxicities c. Drug therapy effectiveness 4. To maintain a chronological medication profile of drugs prescribed for each patient. 5. To provide drug counseling to patients, to explain therapeutic effects, side effects and potential adverse effects of all drugs given to patients. 6. To assume major responsibility for the after-care of selected patients whose therapeutic plan consists primarily of drug therapy (e.g., chronic schizophrenia, organic brain syndrome). 7. To provide drug information on a consultative basis to the psychiatrist, nurse and social worker. l
Community Pharmacy Cooperative Program Although drug dispensing could have been done in the clinic, it was felt that the patient should receive his medication from a community pharmacy like other patients. In September 1970, community pharmacies in the 11 counties served by Blue Grass
East and West Mental Health Centers were contacted about a communitybased program for the distribution of drugs. Pharmacies were selected and approved by the center pharmacist for participation in this program. Selection was based upon a site visit, chiefly to determine the type of professional practice provided by the pharmacy. The program is now fully implemented. Patients are sent from the center with a prescription order to be dispensed in a community pharmacy. The program works in the following manner (Figure 1, page 70)1. For the patient in normal circumstances, regular prescription forms are used. signed by a center physician and marked to indicate that the patient is a "pay" patient (FC-Full Charge). The participating pharmacist dispenses the prescription order and collects the wholesale cost of the drug plus a professional fee from the patient. 2. For the patient on public assistance, the center physician uses a regular prescription marked to indicate that the patient is on Public Assistance (PA). The participating pharmacist dispenses the prescription and charges in accordance with Public Assistance procedures. 3. For the patient not in categories 1 or 2, whom the center has determined cannot pay anything toward the cost of medication, the prescription order is marked to indicate no wholesale drug charge (NC) to the patient. The participating pharmacist collects a professional fee from the patient but does not charge for the wholesale cost of the medication. 4. On a monthly basis, the participating pharmacist is reimbursed on an "in kind" basis for those medications dispensed in the no charge (NC) category.
Although most patients are given prescription orders for their medicaVol. NS12, No.2, February 1972
69
N2
5285
Comprehensive Care Program of
The Central Ky. Regional Mental Health-Mental Retardation Board, Inc. REGION 15 A aWE CRASS WEST
REGION 15 B BLUE GRASS EAST MENTAL HEALTH CEICTER
MEI'IT~\:~~~H S~EHTER
2~~~~;:~~.
(502) 223.21$2
FOR _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DATE _ __ ADDRESS _ _ _ _ _ __
------_.-- --._FIGURE
1-
Prescription Forms label
_M. l>,
FeD NCO PAD TO BE REFILLED
, Registry No.
0 1 2 3 4 5 6 7 8 9 10
To be reimbUrsed., thIS CO~';~;;Sueet. l.eXiQgton~ Ky.% 4lfIJfJ MRS BusineSS offle~ 201
F
Label
fC O MCO PA O 10 fiE REfiLLED () 1 2 3
4 5 6 1 891il
TO IE R£RLUD 0 1 2 3 4 5 6 1 • 9 11) Il'......;l:__~~.~
FIGURE
Original copy for the community pharmacist; second copy for the community pharmacist to return to the center for no charge (UNC" preand scriptions), third copy for medical record of the patient.
2- Prescription Label COMPREHENSIVE CARE CENTER 201 Mechanic Street Phone 254-3844 Lexington, Ky. 40507
LUCY SMITH
0781
Elavi1 25 mg. TAKE ONE TABLET FOUR TIMES A DAY.
5/21/71 bm Dr. J. Corcel1a tions which are to be taken to a participating community pharmacy, there are a few instances in which drugs are dispensed directly to the patient in the clinic (Figure 2, see above). These situations include1. The patient who is experiencing an acute episode which requires immediate drug therapy. In this instance it is extremely important that someone other than the patient is given the medication and instructed on how to administer it to the patient. 2. The patient who refuses to obtain medication from any other source other than the clinic. 3. The patient who has no available funds and is not under an assistance program which will provide him with needed medication. In this instance samples or regular drugs are provided to the patient at no cost. Not even a professional fee is charged ' to the patient. At the center a technician helps the pharmacist dispense by counting the medications and typing prescription labels. The same technician is also involved in keeping the required records for the cooperative community pharmacy programs. 70
Interviewing and Consultation
The team concept is used in the clinics to provide mental health care. It is not economical or practical for each professional to see every patient who has a clinic appointment. At the beginning of each clinic patients are selected and assigned to either the psychiatrist, social worker or pharmacist depending upon their needs. The policy of the center is that each patient should be seen at least once every three months, and by the psychiatrist at least every three to six months. When the pharmacist or social worker sees a patient he is responsible for assessing the patient's current mental health. This does not make either one of them diagnosticians, but their function here is to observe the patient for changes in basic signs and symptoms. The philosophy of the team is that each professional should have an appreciation and understanding of the basic fundamentals of mental disorders. Each professional should also appreciate and understand what special expertise is contributed by the other team members. The pharmacist's expertise obviously
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
centers around his knowledge of drugs. Although the psychiatrist is well acquainted with psychotropic drugs he often is not familiar with other categories of therapeutic ag~nts.. Since many patients have physlcal lll.nesses in addition to their mental dIsease, often they are being treated with a wide variety of drug agents. Because of the pharmacist's drug knowledge he can-( 1) prevent the simultaneous administration of identical or similar therapeutic agents, (2) prevent clinically significant drug interactions and (3) explain patient rresponses based upon side effects or adverse drug reactions to drugs other than those prescribed by the psychiatrist. The pharmacist interviews and consults with patients whenever (1) patients return to the clinic to obtain more medication, (2) patients are referred to the pharmacist by the social worker or psychiatrist because of a specific drug-related problem and (3) patients are assigned to the pharmacist for after-care follow-up, review and management. Patients Returning for Medication
The pharmacist is the primary professional -responsible for re-evaluating the drug regimen for patients returning to the clini~ solely for the purpose of obtaining more medications. The pharmacist evaluates the patient's present mental status and decides whether there is a need to change or modify the drug regimen. If the patient is stable and no significant behavioral differences are noted since his last appointment, then a prescription renewal is the only thing needed. The pharmacist writes the prescription and has it signed by the psychiatrist. If the patient is not stable or well-controIIed, the pharmacist re-evaluates the drug plan, suggests modifications and refers the patient to the psychiatrist. The pharmacist's judgments and decisions are based upon his evaluation of whether the patient's change is due to an ineffective drug plan or other factors (environment, family, financial, etc.) influencing the patient's condition which require further psychiatric care and diagnostic re-evaluation. Patients Referred for Consultative Services
Patients are referred to the pharmacist by the social worker or psychiatrist because of specific drug-related problems including side effects, adverse drug reactions, suspected drug abuse and inadequate drug history. Often the pharmacist must determine whether the patient is experiencing adverse or side effects from drugs
(e.g., side effect of phenothiazine drugs) (Table I, at right). The pharmacist reviews the patient's medication history and discusses the problem with the patient and then writes a staff note to summarize his findings and make appropriate recommendations to the psychiatrist. The pharmacist is often involved in he counseling of patients about the ilealth hazards of drug abuse. This ,erves to reinforce the psychiatrist's therapeutic plan for patients. The pharmacist also interviews patients when the psychiatrist feels that he does not have an adequate drug history for the patient. After-Care by the Pharmacist
Selected patients are assigned to the pharmacist for after-care follow-up, review and management. The psychiatrist selects patients for the pharmacist to interview with chronic illnesses (e.g., chronic schizophrenia, organic brain syndromes) principally being treated by drug therapy. These patients are those which the psychiatrist believes will not greatly benefit from psychotherapy or other treatment modalities. Thus, their management plan centers around drug therapy. In order to provide after-care, the pharmacist must be skilled in his ability to detect or monitor drug effectiveness. Because there are few obI ject~ve parameters which can be used I to monitor psychotropic drug therapy, the pharmacist must use subjective criteria to evaluate drug response. This subjective evaluation is based on how the patient feels, acts and thinks. The pharmacist is required to be familiar with the most basic signs and symptoms of mental disease (Table lI, at right), and to be able to discuss them with the patient as they relate to drug therapy response. Patient Interview Procedure
Before the patient interview begins, the pharmacist reviews the medical record to familiarize himself with the patient's diagnosis, history over the past several months and the therapeutic management plan. The pharmacist also reviews the information which he has obtained on previous interviews so that he can concern himself with the most pertinent information. The pharmacist, like the physician and social worker, in time becomes familiar with patients. Therefore, it is often not necessary to review the medical record before starting the patient interview. The pharmacist begins the interview by introducing himself as a pharma-
cist and by telling the patient that he is concerned with his drug therapy. During each interview the pharmacist works to develop a rapport with the patient. After several interviews the patient usually develops confidence and trust in the pharmacist and views him as someone genuinely concerned about his drug therapy and his problem as a whole. This type of patient relationship allows the pharmacist to readily assess the effectiveness of drug therapy. The interview generally then proceeds by encouraging the patient to state how he feels, what he has been doing, what he thinks about or what significant events have occurred since his last cliniC appointment. While the patient is talking the pharmacist is listening and carefully observing the patient to determine the appropriateness of his actions and any evidence of change based upon previous signs and symptoms of mental disease. The pharmacist then continues the interview and obtains a drug history (Table lII, below) . The patient is generally asked to tell the pharmacist what medications he is taking, their frequency and the specific schedule being followed. The information obtained is checked against the chronological medication profile (Figure 3, page 72) in the medical record. If there is a discrepancy the pharmacist may
TABLE I
Phenothiazine Side Effects Extrapyramidal disturbances Akathisia Dystonias Parkinson-like syndrome Seizure Autonomic nervous system disturbances Orthostatic hypotension Impotence Anticholinergic effect Blood dyscrasias Photosensitivity Lens and corneal opacities Jaundice
TABLE II
Signs and Symptoms of Mental Disease Anxiety Phobias Obsessions Compulsions Dissocia tions Mental retardation Memory defect Attention span defect Convulsions Hyperactivity Hypoactivity Interpersonal trends Socialization Hallucinations
Intellectual decline Circumstantiality Depression Sleeping pattern changes Appetite changes Weight change Constipation Menstrual change Euphoria Flight of ideas Affect Ambivalence Delusion
TABLE III
Medication History Outline 1. Present Medications a . Medications which the patient is currently taking Identify How long has patient been taking each ? Does he take them according to directions? Does the patient know why he is taking each? b. Other medications which the patient is presently taking for physical illnesses or other fundamental conditions. Ask the same four questions as above 2. Past Medications Try to determine any medications that have been taken for past illnesses. Identify How long did he take these? How long ago did he stop taking them? What directions were followed? For what reason was each medication taken? 3. Allergies and Adverse Reactions a. Has the patient any known allergies? b. Has the patient had any of the typical allergic reactions-skin rash, itching, nausea, vomiting, hypotension, extrapyramidal effects, etc. c. Has the patient had an adverse drug reaction-was a drug ever discontinued because of intolerance? 4. Review of Drug Categories This often uncovers other prescription products that had been forgotten but emphasis should also be placed on o-t-c products: Drugs used for sleep, pain, nerves, eye preps, ear preps, headache, colds, allergies, nasal preps, cough, vitamins, iron preps, hormones, birth control pills, constipation, diarrhea, bowels, heartburn or indigestion, nausea and vomiting, kidney pills, liver pills, fluid pills, any skin preparations, etc. 5. Financial Who pays for medications? Has patient not obtained medications at any time because of financial difficulty ? 6. Instructions Has patient been properly instructed on the use of his medications with regard to proper dosages, potential interactions, side effects, signs of toxicity or adverse reactions?
Vol. NSI2. No. 2. February 1972
71
FIGURE
3
Medication Profile
Record File Index Section 2 EVALUATION-TREATMENT FORMS -0IVIDER
NAME
;-
CARBON COPIES OF REPORTS
I
FILE NO. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
MEDICATION FOLLOW·UP SHEET
L
i
I
.
DATE
MEDICAT!ON
GUANT!TY
DOSAGE
NO. OF GIVEN DRUGS PRESCRIBED REFILLS RX ISSUED BY
r-, I
[
even count the patient's medication to determine the exact quantity of drugs consumed over a given period of time. If the patient has inappropriately taken his medications, the pharmacist will work with the patient to remedy the problem (e.g., lack of understanding, financial or other problems in obtaining medications, drug abuse, etc.). After the interview is completed the pharmacist writes a staff note. (Tables IV and V, at left) and updates the chronological medication profile of the patient. The staff note summarizes the findings of the patient interview, instructions given to the patient and the therapeutic plan. Whenever a medication regimen is altered (e.g., drug discontinued, drug started, dosage schedule change, etc.) the pharmacist confers with the patient to explain thoroughly why drugs have been discontinued, why new drugs have been started, how to take new drugs and, when necessary, what side effects or contraindications apply to new drugs.
Evaluation TABLE IV
Pharmacist's Staff Note
COMPREHENSIVE CARE CENTER Number: 404-11-1230 Name: Miller, John 1/12/71 Present Medications for Schizophrenia, Chronic, Undifferentiated Patient is maintained on: Mellaril100 rng qid Artane 2 mg bid Side Effects Patient does not currently display any phenothiazine side effects. Treatment Patient continues to show no symptoms of a psychotic nature. Therefore, plan to continue medications as stated above. To return in three months.
TABLE V
Pharmacist's Staff Note
COMPREHENSIVE CARE CENTER Number: 402-09-1114 Name: Smith, Lucy 3/2/71 Present Medications for Anxiety Neurosis Triavil4-25 q AM and Noon Tybatran 350 rng q 6 p.m. and hs Allergies and Adverse Reactions No known allergies No known allergic reactions No known adverse drug reactions
Past Medications Darvon Compound-65 PRN pain Quaalude 150 mg hs (sleeping problem) Lasix 40 mg q d (hypertension) Dalmane 30 mg hs (sleeping problem) Oxacholin PRN (gall bladder)
The patient states that she has taken the above listed medications over the past year as prescribed by Dr. Jones. However, we informed Dr. Jones on 1/12/71 of the therapeutic regimen which we are currently using to treat Mrs. Smith. Per our request he has discontinued the Quaalude, Dalmane, and Darvon Compound-65. The patient's hypertension is now being treated solely by dietary means (Lasix discontinued). Mrs. Smith appears to be getting along well emotionally. Patient has had less difficulty with sleeping and depression since her Tybatran dosage was increased from Tybatran 350 mg hs to 350 mg at 6 p.rn. and hs. Patient states that she has had fewer "crying" spells overthe past month. Patient instructed to continue medication regimen as stated above and to return to clinic in one month.
72
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
The most important consideration in evaluating the influence of the pharmacist in the mental health center is his influence upon the delivery ofmental health care. If the pharmacist's functions facilitate a more economic and practical approach to patient care, pharmacists should become required members of the mental health care team. In the Blue Grass East Mental Health Center the number of patients a psychiatrist sees during a clinic has been reduced from 25 to 15 patients. This has been accomplished because the pharmacist sees 10 patients per a four-hour clinic who mainly require drug therapy re-evaluation. These patients were formerly seen by the psychiatrist or social worker during each appointment. This system allows the psychiatrist or social worker to spend more time with those patients who require counseling, psychotherapy or other treatment modalities which the pharmacist is not trained to provide. However, the pharmacist is able to carefully review the drug therapy program for these patients and in this way facilitate better patient care. Thus, the team approach makes it possible for more patients to be treated in an improved fashion. Research needs to be conducted in order to establish the exact influence the pharmacist can have in mental health centers. New models for the delivery of mental health care need to be developed and studied with the pharmacist as an integral part of the team providing care.
Summary Mental health centers have been developed to provide mental health care in the community. Most centers have been established without any plans or provisions for pharmaceutical services except drug distribution. A properly trained pharmacist can, however, provide a variety of pharmaceutical functions as part of the mental health center team which include (1) coordinating a community pharmacy program for drug dispensing to patients, (2) dispensing medications within the center, (3) interviewing patients and determining the status of their drug therapy program and then making appropriate recommendations to the psychiatrist, (4) maintaining a chronological drug profile for each patient, (5) providing drug counseling to patients, (6) assuming major responsibility for the after-care of selected patients whose therapeutic plan consists primarily of drug therapy and (7) providing drug information on a consultative basis to other health professionals. If the pharmacist performs these functions, then he can influence the delivery of mental care because his
Nonprofessional Personnel (continued from page 61)
and final checking of the prescription, several comments are in order. The subjective impression was that the performance of many of these tasks was more by accident than by design. Comments such as "I always do it myself, unless I'm busy," or "If I'm tied up, my girl helps" were frequent. This subjective impression was supported by answers to several questions. Respondents were asked if specific personnel were assigned to specific tasks. Twenty-five percent (nine pharmacies) indicated "No" while 75 percent said "Yes." However, when asked how many people were assigned to these specific tasks, the majority of the remainder (59 percent) indicated that all employees other than the pharmacist had these duties. Efficient management practices indicate that responsibilities and duties of employees should be clearly delineated, and that these should be in writing. Written job descriptions aid both the employee and the employer in controlling the performance of tasks and in delineating responsibilities. Re-
efforts do not duplicate those of the psychiatrist, nurse or social worker but 'rather he takes on primary responsibilities in direct patient care which allow other professionals to be more effective in performing their functions. Mental health centers offer pharmacists a relatively new and unexplored environment for pharmacy practice. Hopefully, in the future more pharmacists will become trained to specialize in this type of community pharmacy practice. • .
References 1. Hargrove, Eugene A., "Medical Care of the Mentally III in North Carolina," Seminar on the Pharmacist's Role in Mental Health, North Carolina Pharmaceutical Association, Chapel Hill, North Carolina (1968)
4. Sifneos, P.E., "The Interdisciplinary TeamAn Educational Experience for Mental Health Professions," Psych. Quart., 43, 123 (1969)
5. Pfeiffer, E., "Multiplying the Hands of the Psychiatrist: The Use of Limited Psychiatric Manpower in a Small College Setting," ]. Am. Coil. Health Assn., 17, 76, (Oct. 1968) . 6. Kubie, L.S., "The Overall Manpower Problem in Mental Health Personnel," ]. Nervous Ment. Dis., 144, 466 (June 1967) 7. Visotsky, H.M., "Modern Approaches to Community Mental Health," Curro Psych. Therap., 10, 203 (1970) 8. Vidaver, R.M., "The Mental Health Technician: Maryland's Design for· a New Health Career," Amer. ]. Psychiat., 125, 1013 (Feb. 1969) 9. Minuchin, S., "The Paraprofessional and the Use of Confrontation· in the Mental Health Field," Am. J. Orthopsych;, 39, 722 (Oct. 1969) . 10. Berlin, LN., "Resistance to Change in Mental Health Professionals," Amer, ]. Orthopsychiat" 39, 109 (Jan. 1969)
2. Prange, Arthur J., "Rational Drug Therapy of Mental Disease," Seminar on the Pharmacist's Role in Mental Health, North Carolina Pharmaceutical Association, Chapel Hill, North Carolina (1968)
11. Levenson, A,I.; Beck, J.C.; Quinn, R., and Putnam, P., "Manpowe.r and 1'raining in Community Mental Health Centers," Hosp. Comm. Psy~h., 20, 85 (March 1969) .
3. Taylor, H. Pat, "New Horizons for Mental Health in North Carolina," Seminar on the Pharmacist's Role in Mental Health, North Carolina Pharmaceutical Association, Chapel Hill, North Carolina (1968)
12. Central Kentucky Regional Mental HealthMental Retardation Board, application for growth grant, Blue Grass East· Mental Health Center, Lexington, Kentucky (1969)
spondents were asked if they had written job descriptions for the personnel employed in the pharmacy. None did. . At the start of the questionnaire pharmacists were asked for the job titles and number of employees in each type of position. At the completion of the questionnaire, an open-ended question, "If the pharmacist has other employees which assist him in performing the various tasks and functions we have discussed, what employees aid him in these tasks (by job title or description)?" was asked. Three pharmacists described this personnel as a "technician." Other titles included "clerk," "secretary," "cashier" and "girl." One of those described as a "technician" was a registered· pharmacy technician from Ireland. The other two were described as having prior experience, highschool education and informal on-the-job training to qualify them for the tasks they performed. Informal on-the-job training was cited by all respondents as a prerequisite for the tasks performed in the prescription department, ten (28 percent) listed prior
experience, and 35 (97 percent) required high school education. Conclusions It is obvious that the pharmacies in this sample utilized nonprofessional assistants in the dispensing process, regardless of the titIeby which such personnel is known. . This research indicates that there are a variety of tasks which nonpharmacists may, and indeed are, performing in the dispensing process within community pharmacies. •
References 1. "Task Force on Prescription Drugs," ~econd Interim Report and Recommendations, Office of the Secretary, U,S. Department {)f Health, Education, and Welfare, Washington, D.C., 58 (Aug, 30, 1968)
2. "Report of the Task Force on Roles of the Practitioner and the Subprofessional in Pharmacy," reprint from JAPhA; NS9, No.8, 11 (Aug, 1969) 3. Ibid., 14-15
4. Ibid., 13 Vol. NS12, No.2, Februa ry 1972
73
n recent years there has been a trend in mental health to shift care from the large, centralized state institutions to community mental health centers. Most mental health centers have been developed without any plans or provisions for pharmaceutical services except drug distribution. Drug distribution has been provided by physiciandispensing of medications or by giving the patient a prescription order to be dispensed at a community pharmacy of his choice.
I
Mental Health Care-A Review At the turn of the century most patients with mental illnesses were hospitalized in large, isolated state hospitals across the country. The hospitals were isolated in terms of their access to communities and to other people. Most often, individuals having hallucinations and delusions were diagnosed as mentally ill. Frequently they were sent to the hospital for confinement and more or less disappeared from society from that point on. As more was learned about mental illness, the definition was broadened to include neuroses, personality disorders, psychophysiological disorders, alcoholism and drug abuse. In contrast to individuals with psychoses, many of the people with these problems do not necessarily need hospital treatment and do not need to be isolated or removed from society.l In the 1950's the phenothiazines were introduced. They revolutionized the treatment of psychoses and helped make it possible to return many patients with chronic schizophrenia and other psychoses to the community.2 The changes in the definition of mental illness and the availability of psychotropic drugs created a need for a system to provide comprehensive mental health care in the community setting. In the 1960's, Comprehensive Community Mental Health Centers were established in many states to provide this care to the people. Thus, o Adapted from a presentation at the Academy of General Practice of Pharmacy, APhA annual meeting, San Francisco, California, March 29 1971. "
68
the term Comprehensive Community Mental Health Center is used to describe a system of care whereby alternatives to institutional care are developed and placed in the community, close to the people. The centers were developed to make it possible to select from a whole range of services the specific resources which meet individual patient needs, whether they be hospitalization, outpatient treatment, diagnosis and evaluation, group therapy, rehabilitation or other services. One of the most important values of the center, other than its availability to the citizens in the community, is the continuity that a patient can receive from being close to home and family, and the comprehensiveness that can also be provided. In essence then, the community has become the "new horizon" or "new frontier" in mental health care.3 The nationwide community mental health centers program has significantly increased mental health manpower needs. New models for delivering mental health care have been investigated which include the development of an interdisciplinary team and the use of paraprofessionals, mental health technicians and lay personnel in the community. None of these new models have considered fuller utilization of the pharmacist as a member of the mental health team.4-11 Blue Grass East and West Mental Health Centers Blue Grass East and West Mental Health Centers serviced by the Central Kentucky Regional Mental Health-Mental Retardation Board, Inc. were established in 1966 to provide mental health care for patients in 11 counties in Kentucky.12 Currently, the two centers have 5,500 patients divided among the adult and child mental health programs, alcoholic program, drug abuse program, mental retardation program, group therapy and other therapies. An adult mental health-mental retardation program has been established in each of these coun~ ties primarily to provide "outpatient" or "after-care" treatment for patients
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
following discharge from a state hospital or other institution. Drug therapy is one of the important aspects of "after-care" to the mental health patient. A high percentage of the patients seen in the adult clinics are being treated mainly with drug therapy for chronic schizophrenia or other psychoses. The socio-economic background of these patients varies, with about 50 percent being indigent. Prior to the development of mental health centers, mental health aftercare patients returned to one of the state hospitals or other institutions to obtain drugs. However, many of these patients could not afford to purchase their drugs because of the high cost and extended need of psychotropic therapy. Some patients qualified for state medical assistance programs which provided them with a limited number of drugs. If the medical assistance patient required a drug that was not an approved drug, another mechanism had to be used for the patient to obtain medication. This problem was recognized by the Kentucky Department of Mental Health which implemented a program whereby state mental institutions were provided a quantity of drugs to be used on an inpatient and outpatient basis for indigent patients. When mental health centers were developed in Kentucky, the state department of mental health allocated a portion of these drugs to the centers for distribution to outpatients following discharge from state institutions. Initially, the.' centers had no funds or provisions for outpatient pharmacies and pharmacists to dispense drugs to their patients. Medications were dispensed in the clinics by the psychiatrist and nurse. However, this system of drug dispensing proved to be undesirable to all involved because of poor drug control and safety, poor medication records and poor fiscal management. It was also felt that the expertise of the psychiatrist and nurse could be better utilized in performing functions other than drug dispensing. The problem of drug distribution caused the professional staff in the centers to
think about what pharmaceutical services were needed. Philosophically it was felt that the mental health patient should obtain medication in the same manner as any other patient, that is, he should obtain a prescription order for his medication to be dispensed in a community pharmacy. This procedure for obtaining medication would serve as a part of the overall therapy of the patient helping the patient to identify with the community, to re-adjust to his environment and to better relate to other people. The professional staff concluded that a pharmacist was needed as a part of the mental health center team. The pharmacist would be responsible for coordinating a cooperative community pharmacy program for drug dispensing and for developing professional services within the center such as drug histories, drug counseling, drug abuse and drug information services. In July 1970, the center contacted the college of pharmacy at the University of Kentucky for assistance in developing these pharmaceutical services. Pharmaceutical Functions A pharmacist from the clinical pharmacy department of the college was employed 'o n a part-time basis ( 15 hours per week) by the center for the adult mental health clinic program. The clinics are held for half a day three times a week. The pharmacist selected had both the academic and experience background required to function effectively as a part of the mental health center team. The pharmacist's training consisted of doctor of pharmacy coursework-advanced pharmacotherapeutics, drug information services, drug communications, pathophysiology and clinical psychiatry. In addition, the pharmacist had two years experience as a clinical pharmacist at the University of Kentucky Medical Center. One of the objectives of the centers is to effectively utilize all mental health personnel and thereby facilitate a more economic and practical approach fQ patient care. In developing functions for the pharmacist in the adult mental health clinics it was imperative that the pharmacist not simply duplicate the efforts of the psychiatrist, nurse or social worker, but that he take on primary responsibilities in direct patient care which would not be performed by another member of the team. Initially, the pharmacist's functions centered around drug dispensing. After a close working relationship was developed between the pharmacist., psychiatrist and social worker, plans Were made to develop more comprehensive pharmaceutical services. Spe-
William A. Miller, PharmD, is associate director for clinical pharmacy services at the Ohio State University Hospitals in Columbus. Previously he was director of pharmaceutical services at Blue Grass East-West Mental Health Centers in Lexington, Kentucky. A hospital pharmacist from 1963 through 1970, Miller has also taught at the University of Kentucky and at Ohio. At Kentucky, he developed the first decentralized pharmacy program at the university hospital as well as developed and taught the first courses in patient care services and clinical pharmacy, pharmacy clerkship and mental health clerkship. A member of APhA, Miller was active in the Kentucky Pharmaceutical Association.
John Core ella, MD, is director of Team 11, Region 110, of the Mountain Mental Health Services at Methodist Hospital in Pikeville, Kentucky. Previously, Corce/la was director of adult and family services for the Central Kentucky Community Mental Health Center in Lexington. From 1963 to 1969 Corcella served as clinical director oj the Eastern State Hospital in Lexington. He has taught psychiatry at the universities oj Louisville and Kentucky. Having received his doctorate in medicine and surgery from the University of Padua (Italy), Corcella interned at Coney Island Hospital (New York) and served residency at St. Vincent Hospital on Staten Island.
cifically, the pharmacist was charged with developing the following pharmaceutical functions1. To develop and coordinate a cooperative community pharmacy program for drug dispensing to patients under the care of the centers. 2. To dispense medications to those patients who cannot obtain pharmaceutical services through the community pharmacy program because of their financial status. 3. To interview patients and determine the status of their drug therapy program and then to make appropriate recommendations to the physician. The patient's drug therapy program would be reviewed to determinea. Present and past medication (prescription and o-t-c drugs) b. Drug allergies, side effects, incompatibilities, contraindications, adverse drug reactions and toxicities c. Drug therapy effectiveness 4. To maintain a chronological medication profile of drugs prescribed for each patient. 5. To provide drug counseling to patients, to explain therapeutic effects, side effects and potential adverse effects of all drugs given to patients. 6. To assume major responsibility for the after-care of selected patients whose therapeutic plan consists primarily of drug therapy (e.g., chronic schizophrenia, organic brain syndrome). 7. To provide drug information on a consultative basis to the psychiatrist, nurse and social worker. l
Community Pharmacy Cooperative Program Although drug dispensing could have been done in the clinic, it was felt that the patient should receive his medication from a community pharmacy like other patients. In September 1970, community pharmacies in the 11 counties served by Blue Grass
East and West Mental Health Centers were contacted about a communitybased program for the distribution of drugs. Pharmacies were selected and approved by the center pharmacist for participation in this program. Selection was based upon a site visit, chiefly to determine the type of professional practice provided by the pharmacy. The program is now fully implemented. Patients are sent from the center with a prescription order to be dispensed in a community pharmacy. The program works in the following manner (Figure 1, page 70)1. For the patient in normal circumstances, regular prescription forms are used. signed by a center physician and marked to indicate that the patient is a "pay" patient (FC-Full Charge). The participating pharmacist dispenses the prescription order and collects the wholesale cost of the drug plus a professional fee from the patient. 2. For the patient on public assistance, the center physician uses a regular prescription marked to indicate that the patient is on Public Assistance (PA). The participating pharmacist dispenses the prescription and charges in accordance with Public Assistance procedures. 3. For the patient not in categories 1 or 2, whom the center has determined cannot pay anything toward the cost of medication, the prescription order is marked to indicate no wholesale drug charge (NC) to the patient. The participating pharmacist collects a professional fee from the patient but does not charge for the wholesale cost of the medication. 4. On a monthly basis, the participating pharmacist is reimbursed on an "in kind" basis for those medications dispensed in the no charge (NC) category.
Although most patients are given prescription orders for their medicaVol. NS12, No.2, February 1972
69
N2
5285
Comprehensive Care Program of
The Central Ky. Regional Mental Health-Mental Retardation Board, Inc. REGION 15 A aWE CRASS WEST
REGION 15 B BLUE GRASS EAST MENTAL HEALTH CEICTER
MEI'IT~\:~~~H S~EHTER
2~~~~;:~~.
(502) 223.21$2
FOR _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DATE _ __ ADDRESS _ _ _ _ _ __
------_.-- --._FIGURE
1-
Prescription Forms label
_M. l>,
FeD NCO PAD TO BE REFILLED
, Registry No.
0 1 2 3 4 5 6 7 8 9 10
To be reimbUrsed., thIS CO~';~;;Sueet. l.eXiQgton~ Ky.% 4lfIJfJ MRS BusineSS offle~ 201
F
Label
fC O MCO PA O 10 fiE REfiLLED () 1 2 3
4 5 6 1 891il
TO IE R£RLUD 0 1 2 3 4 5 6 1 • 9 11) Il'......;l:__~~.~
FIGURE
Original copy for the community pharmacist; second copy for the community pharmacist to return to the center for no charge (UNC" preand scriptions), third copy for medical record of the patient.
2- Prescription Label COMPREHENSIVE CARE CENTER 201 Mechanic Street Phone 254-3844 Lexington, Ky. 40507
LUCY SMITH
0781
Elavi1 25 mg. TAKE ONE TABLET FOUR TIMES A DAY.
5/21/71 bm Dr. J. Corcel1a tions which are to be taken to a participating community pharmacy, there are a few instances in which drugs are dispensed directly to the patient in the clinic (Figure 2, see above). These situations include1. The patient who is experiencing an acute episode which requires immediate drug therapy. In this instance it is extremely important that someone other than the patient is given the medication and instructed on how to administer it to the patient. 2. The patient who refuses to obtain medication from any other source other than the clinic. 3. The patient who has no available funds and is not under an assistance program which will provide him with needed medication. In this instance samples or regular drugs are provided to the patient at no cost. Not even a professional fee is charged ' to the patient. At the center a technician helps the pharmacist dispense by counting the medications and typing prescription labels. The same technician is also involved in keeping the required records for the cooperative community pharmacy programs. 70
Interviewing and Consultation
The team concept is used in the clinics to provide mental health care. It is not economical or practical for each professional to see every patient who has a clinic appointment. At the beginning of each clinic patients are selected and assigned to either the psychiatrist, social worker or pharmacist depending upon their needs. The policy of the center is that each patient should be seen at least once every three months, and by the psychiatrist at least every three to six months. When the pharmacist or social worker sees a patient he is responsible for assessing the patient's current mental health. This does not make either one of them diagnosticians, but their function here is to observe the patient for changes in basic signs and symptoms. The philosophy of the team is that each professional should have an appreciation and understanding of the basic fundamentals of mental disorders. Each professional should also appreciate and understand what special expertise is contributed by the other team members. The pharmacist's expertise obviously
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
centers around his knowledge of drugs. Although the psychiatrist is well acquainted with psychotropic drugs he often is not familiar with other categories of therapeutic ag~nts.. Since many patients have physlcal lll.nesses in addition to their mental dIsease, often they are being treated with a wide variety of drug agents. Because of the pharmacist's drug knowledge he can-( 1) prevent the simultaneous administration of identical or similar therapeutic agents, (2) prevent clinically significant drug interactions and (3) explain patient rresponses based upon side effects or adverse drug reactions to drugs other than those prescribed by the psychiatrist. The pharmacist interviews and consults with patients whenever (1) patients return to the clinic to obtain more medication, (2) patients are referred to the pharmacist by the social worker or psychiatrist because of a specific drug-related problem and (3) patients are assigned to the pharmacist for after-care follow-up, review and management. Patients Returning for Medication
The pharmacist is the primary professional -responsible for re-evaluating the drug regimen for patients returning to the clini~ solely for the purpose of obtaining more medications. The pharmacist evaluates the patient's present mental status and decides whether there is a need to change or modify the drug regimen. If the patient is stable and no significant behavioral differences are noted since his last appointment, then a prescription renewal is the only thing needed. The pharmacist writes the prescription and has it signed by the psychiatrist. If the patient is not stable or well-controIIed, the pharmacist re-evaluates the drug plan, suggests modifications and refers the patient to the psychiatrist. The pharmacist's judgments and decisions are based upon his evaluation of whether the patient's change is due to an ineffective drug plan or other factors (environment, family, financial, etc.) influencing the patient's condition which require further psychiatric care and diagnostic re-evaluation. Patients Referred for Consultative Services
Patients are referred to the pharmacist by the social worker or psychiatrist because of specific drug-related problems including side effects, adverse drug reactions, suspected drug abuse and inadequate drug history. Often the pharmacist must determine whether the patient is experiencing adverse or side effects from drugs
(e.g., side effect of phenothiazine drugs) (Table I, at right). The pharmacist reviews the patient's medication history and discusses the problem with the patient and then writes a staff note to summarize his findings and make appropriate recommendations to the psychiatrist. The pharmacist is often involved in he counseling of patients about the ilealth hazards of drug abuse. This ,erves to reinforce the psychiatrist's therapeutic plan for patients. The pharmacist also interviews patients when the psychiatrist feels that he does not have an adequate drug history for the patient. After-Care by the Pharmacist
Selected patients are assigned to the pharmacist for after-care follow-up, review and management. The psychiatrist selects patients for the pharmacist to interview with chronic illnesses (e.g., chronic schizophrenia, organic brain syndromes) principally being treated by drug therapy. These patients are those which the psychiatrist believes will not greatly benefit from psychotherapy or other treatment modalities. Thus, their management plan centers around drug therapy. In order to provide after-care, the pharmacist must be skilled in his ability to detect or monitor drug effectiveness. Because there are few obI ject~ve parameters which can be used I to monitor psychotropic drug therapy, the pharmacist must use subjective criteria to evaluate drug response. This subjective evaluation is based on how the patient feels, acts and thinks. The pharmacist is required to be familiar with the most basic signs and symptoms of mental disease (Table lI, at right), and to be able to discuss them with the patient as they relate to drug therapy response. Patient Interview Procedure
Before the patient interview begins, the pharmacist reviews the medical record to familiarize himself with the patient's diagnosis, history over the past several months and the therapeutic management plan. The pharmacist also reviews the information which he has obtained on previous interviews so that he can concern himself with the most pertinent information. The pharmacist, like the physician and social worker, in time becomes familiar with patients. Therefore, it is often not necessary to review the medical record before starting the patient interview. The pharmacist begins the interview by introducing himself as a pharma-
cist and by telling the patient that he is concerned with his drug therapy. During each interview the pharmacist works to develop a rapport with the patient. After several interviews the patient usually develops confidence and trust in the pharmacist and views him as someone genuinely concerned about his drug therapy and his problem as a whole. This type of patient relationship allows the pharmacist to readily assess the effectiveness of drug therapy. The interview generally then proceeds by encouraging the patient to state how he feels, what he has been doing, what he thinks about or what significant events have occurred since his last cliniC appointment. While the patient is talking the pharmacist is listening and carefully observing the patient to determine the appropriateness of his actions and any evidence of change based upon previous signs and symptoms of mental disease. The pharmacist then continues the interview and obtains a drug history (Table lII, below) . The patient is generally asked to tell the pharmacist what medications he is taking, their frequency and the specific schedule being followed. The information obtained is checked against the chronological medication profile (Figure 3, page 72) in the medical record. If there is a discrepancy the pharmacist may
TABLE I
Phenothiazine Side Effects Extrapyramidal disturbances Akathisia Dystonias Parkinson-like syndrome Seizure Autonomic nervous system disturbances Orthostatic hypotension Impotence Anticholinergic effect Blood dyscrasias Photosensitivity Lens and corneal opacities Jaundice
TABLE II
Signs and Symptoms of Mental Disease Anxiety Phobias Obsessions Compulsions Dissocia tions Mental retardation Memory defect Attention span defect Convulsions Hyperactivity Hypoactivity Interpersonal trends Socialization Hallucinations
Intellectual decline Circumstantiality Depression Sleeping pattern changes Appetite changes Weight change Constipation Menstrual change Euphoria Flight of ideas Affect Ambivalence Delusion
TABLE III
Medication History Outline 1. Present Medications a . Medications which the patient is currently taking Identify How long has patient been taking each ? Does he take them according to directions? Does the patient know why he is taking each? b. Other medications which the patient is presently taking for physical illnesses or other fundamental conditions. Ask the same four questions as above 2. Past Medications Try to determine any medications that have been taken for past illnesses. Identify How long did he take these? How long ago did he stop taking them? What directions were followed? For what reason was each medication taken? 3. Allergies and Adverse Reactions a. Has the patient any known allergies? b. Has the patient had any of the typical allergic reactions-skin rash, itching, nausea, vomiting, hypotension, extrapyramidal effects, etc. c. Has the patient had an adverse drug reaction-was a drug ever discontinued because of intolerance? 4. Review of Drug Categories This often uncovers other prescription products that had been forgotten but emphasis should also be placed on o-t-c products: Drugs used for sleep, pain, nerves, eye preps, ear preps, headache, colds, allergies, nasal preps, cough, vitamins, iron preps, hormones, birth control pills, constipation, diarrhea, bowels, heartburn or indigestion, nausea and vomiting, kidney pills, liver pills, fluid pills, any skin preparations, etc. 5. Financial Who pays for medications? Has patient not obtained medications at any time because of financial difficulty ? 6. Instructions Has patient been properly instructed on the use of his medications with regard to proper dosages, potential interactions, side effects, signs of toxicity or adverse reactions?
Vol. NSI2. No. 2. February 1972
71
FIGURE
3
Medication Profile
Record File Index Section 2 EVALUATION-TREATMENT FORMS -0IVIDER
NAME
;-
CARBON COPIES OF REPORTS
I
FILE NO. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
MEDICATION FOLLOW·UP SHEET
L
i
I
.
DATE
MEDICAT!ON
GUANT!TY
DOSAGE
NO. OF GIVEN DRUGS PRESCRIBED REFILLS RX ISSUED BY
r-, I
[
even count the patient's medication to determine the exact quantity of drugs consumed over a given period of time. If the patient has inappropriately taken his medications, the pharmacist will work with the patient to remedy the problem (e.g., lack of understanding, financial or other problems in obtaining medications, drug abuse, etc.). After the interview is completed the pharmacist writes a staff note. (Tables IV and V, at left) and updates the chronological medication profile of the patient. The staff note summarizes the findings of the patient interview, instructions given to the patient and the therapeutic plan. Whenever a medication regimen is altered (e.g., drug discontinued, drug started, dosage schedule change, etc.) the pharmacist confers with the patient to explain thoroughly why drugs have been discontinued, why new drugs have been started, how to take new drugs and, when necessary, what side effects or contraindications apply to new drugs.
Evaluation TABLE IV
Pharmacist's Staff Note
COMPREHENSIVE CARE CENTER Number: 404-11-1230 Name: Miller, John 1/12/71 Present Medications for Schizophrenia, Chronic, Undifferentiated Patient is maintained on: Mellaril100 rng qid Artane 2 mg bid Side Effects Patient does not currently display any phenothiazine side effects. Treatment Patient continues to show no symptoms of a psychotic nature. Therefore, plan to continue medications as stated above. To return in three months.
TABLE V
Pharmacist's Staff Note
COMPREHENSIVE CARE CENTER Number: 402-09-1114 Name: Smith, Lucy 3/2/71 Present Medications for Anxiety Neurosis Triavil4-25 q AM and Noon Tybatran 350 rng q 6 p.m. and hs Allergies and Adverse Reactions No known allergies No known allergic reactions No known adverse drug reactions
Past Medications Darvon Compound-65 PRN pain Quaalude 150 mg hs (sleeping problem) Lasix 40 mg q d (hypertension) Dalmane 30 mg hs (sleeping problem) Oxacholin PRN (gall bladder)
The patient states that she has taken the above listed medications over the past year as prescribed by Dr. Jones. However, we informed Dr. Jones on 1/12/71 of the therapeutic regimen which we are currently using to treat Mrs. Smith. Per our request he has discontinued the Quaalude, Dalmane, and Darvon Compound-65. The patient's hypertension is now being treated solely by dietary means (Lasix discontinued). Mrs. Smith appears to be getting along well emotionally. Patient has had less difficulty with sleeping and depression since her Tybatran dosage was increased from Tybatran 350 mg hs to 350 mg at 6 p.rn. and hs. Patient states that she has had fewer "crying" spells overthe past month. Patient instructed to continue medication regimen as stated above and to return to clinic in one month.
72
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
The most important consideration in evaluating the influence of the pharmacist in the mental health center is his influence upon the delivery ofmental health care. If the pharmacist's functions facilitate a more economic and practical approach to patient care, pharmacists should become required members of the mental health care team. In the Blue Grass East Mental Health Center the number of patients a psychiatrist sees during a clinic has been reduced from 25 to 15 patients. This has been accomplished because the pharmacist sees 10 patients per a four-hour clinic who mainly require drug therapy re-evaluation. These patients were formerly seen by the psychiatrist or social worker during each appointment. This system allows the psychiatrist or social worker to spend more time with those patients who require counseling, psychotherapy or other treatment modalities which the pharmacist is not trained to provide. However, the pharmacist is able to carefully review the drug therapy program for these patients and in this way facilitate better patient care. Thus, the team approach makes it possible for more patients to be treated in an improved fashion. Research needs to be conducted in order to establish the exact influence the pharmacist can have in mental health centers. New models for the delivery of mental health care need to be developed and studied with the pharmacist as an integral part of the team providing care.
Summary Mental health centers have been developed to provide mental health care in the community. Most centers have been established without any plans or provisions for pharmaceutical services except drug distribution. A properly trained pharmacist can, however, provide a variety of pharmaceutical functions as part of the mental health center team which include (1) coordinating a community pharmacy program for drug dispensing to patients, (2) dispensing medications within the center, (3) interviewing patients and determining the status of their drug therapy program and then making appropriate recommendations to the psychiatrist, (4) maintaining a chronological drug profile for each patient, (5) providing drug counseling to patients, (6) assuming major responsibility for the after-care of selected patients whose therapeutic plan consists primarily of drug therapy and (7) providing drug information on a consultative basis to other health professionals. If the pharmacist performs these functions, then he can influence the delivery of mental care because his
Nonprofessional Personnel (continued from page 61)
and final checking of the prescription, several comments are in order. The subjective impression was that the performance of many of these tasks was more by accident than by design. Comments such as "I always do it myself, unless I'm busy," or "If I'm tied up, my girl helps" were frequent. This subjective impression was supported by answers to several questions. Respondents were asked if specific personnel were assigned to specific tasks. Twenty-five percent (nine pharmacies) indicated "No" while 75 percent said "Yes." However, when asked how many people were assigned to these specific tasks, the majority of the remainder (59 percent) indicated that all employees other than the pharmacist had these duties. Efficient management practices indicate that responsibilities and duties of employees should be clearly delineated, and that these should be in writing. Written job descriptions aid both the employee and the employer in controlling the performance of tasks and in delineating responsibilities. Re-
efforts do not duplicate those of the psychiatrist, nurse or social worker but 'rather he takes on primary responsibilities in direct patient care which allow other professionals to be more effective in performing their functions. Mental health centers offer pharmacists a relatively new and unexplored environment for pharmacy practice. Hopefully, in the future more pharmacists will become trained to specialize in this type of community pharmacy practice. • .
References 1. Hargrove, Eugene A., "Medical Care of the Mentally III in North Carolina," Seminar on the Pharmacist's Role in Mental Health, North Carolina Pharmaceutical Association, Chapel Hill, North Carolina (1968)
4. Sifneos, P.E., "The Interdisciplinary TeamAn Educational Experience for Mental Health Professions," Psych. Quart., 43, 123 (1969)
5. Pfeiffer, E., "Multiplying the Hands of the Psychiatrist: The Use of Limited Psychiatric Manpower in a Small College Setting," ]. Am. Coil. Health Assn., 17, 76, (Oct. 1968) . 6. Kubie, L.S., "The Overall Manpower Problem in Mental Health Personnel," ]. Nervous Ment. Dis., 144, 466 (June 1967) 7. Visotsky, H.M., "Modern Approaches to Community Mental Health," Curro Psych. Therap., 10, 203 (1970) 8. Vidaver, R.M., "The Mental Health Technician: Maryland's Design for· a New Health Career," Amer. ]. Psychiat., 125, 1013 (Feb. 1969) 9. Minuchin, S., "The Paraprofessional and the Use of Confrontation· in the Mental Health Field," Am. J. Orthopsych;, 39, 722 (Oct. 1969) . 10. Berlin, LN., "Resistance to Change in Mental Health Professionals," Amer, ]. Orthopsychiat" 39, 109 (Jan. 1969)
2. Prange, Arthur J., "Rational Drug Therapy of Mental Disease," Seminar on the Pharmacist's Role in Mental Health, North Carolina Pharmaceutical Association, Chapel Hill, North Carolina (1968)
11. Levenson, A,I.; Beck, J.C.; Quinn, R., and Putnam, P., "Manpowe.r and 1'raining in Community Mental Health Centers," Hosp. Comm. Psy~h., 20, 85 (March 1969) .
3. Taylor, H. Pat, "New Horizons for Mental Health in North Carolina," Seminar on the Pharmacist's Role in Mental Health, North Carolina Pharmaceutical Association, Chapel Hill, North Carolina (1968)
12. Central Kentucky Regional Mental HealthMental Retardation Board, application for growth grant, Blue Grass East· Mental Health Center, Lexington, Kentucky (1969)
spondents were asked if they had written job descriptions for the personnel employed in the pharmacy. None did. . At the start of the questionnaire pharmacists were asked for the job titles and number of employees in each type of position. At the completion of the questionnaire, an open-ended question, "If the pharmacist has other employees which assist him in performing the various tasks and functions we have discussed, what employees aid him in these tasks (by job title or description)?" was asked. Three pharmacists described this personnel as a "technician." Other titles included "clerk," "secretary," "cashier" and "girl." One of those described as a "technician" was a registered· pharmacy technician from Ireland. The other two were described as having prior experience, highschool education and informal on-the-job training to qualify them for the tasks they performed. Informal on-the-job training was cited by all respondents as a prerequisite for the tasks performed in the prescription department, ten (28 percent) listed prior
experience, and 35 (97 percent) required high school education. Conclusions It is obvious that the pharmacies in this sample utilized nonprofessional assistants in the dispensing process, regardless of the titIeby which such personnel is known. . This research indicates that there are a variety of tasks which nonpharmacists may, and indeed are, performing in the dispensing process within community pharmacies. •
References 1. "Task Force on Prescription Drugs," ~econd Interim Report and Recommendations, Office of the Secretary, U,S. Department {)f Health, Education, and Welfare, Washington, D.C., 58 (Aug, 30, 1968)
2. "Report of the Task Force on Roles of the Practitioner and the Subprofessional in Pharmacy," reprint from JAPhA; NS9, No.8, 11 (Aug, 1969) 3. Ibid., 14-15
4. Ibid., 13 Vol. NS12, No.2, Februa ry 1972
73