Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .
Pharmacists are not new to mental healthcare but Ray Love, psychiatric pharmacist and past president of the College of Psychiatric and Neurologic Pharmacists, says they’re underutilized. “Within pharmacy, we can serve a whole array of clinical roles in patient care settings,” he said. As behavioral healthcare demands increase and the workforce continues to plummet, Love believes psychiatric pharmacists can help address these shortages.
In recent years, the pandemic has pushed community pharmacists into the spotlight, with those working at retail pharmacies like Walgreens and CVS administering vaccines and long-acting injectables like antipsychotic medications and naltrexone for substance use disorders. “Community pharmacists were the unsung heroes of Covid — they did all the vaccinations in assisted living and nursing homes and then administered them in the community,” he said. The moment was a culmination of years long efforts for pharmacists to be able to immunize people.
Since 1994, there’s been a slow progression of legislation that, state by state, has allowed pharmacists to give people flu shots and, later, other vaccines. But not until recently have pharmacists been permitted to administer other injectable drugs.
When people think of pharmacists, they often think of those who work in community drugstores, but Love points out that pharmacists are woven throughout healthcare settings. He recently went to the emergency room; one of the first people he met with was the pharmacist. “In addition to having general pharmacy training, they’d also done a residency and were board certified,” he said, adding that all specialized pharmacists must go through similar rigor. According to the American Journal of Pharmaceutical Education, psychiatric clinical pharmacy dates back to the ‘60s, with the U.S. Public Health Service creating a 2-year residency in 1973.
Today, there are multiple psychiatric pharmacy residencies; many are within the United States Department of Veterans Affairs, while others are affiliated with academic medical centers. Most psychiatric pharmacists work in hospital or ambulatory care settings, including community mental health centers and VA clinics, but Love says this can vary by state and region. “Psychiatric pharmacists are also part of federally qualified health center teams in many states,” he said.
In many states, pharmacists can obtain prescriptive authority, which allows them to prescribe medications and order lab tests for patients. In other states, the role is more limited, with clinical care pharmacists acting in an advisory capacity. When Love worked in Maryland’s state hospital system, he was integral to the treatment team and counseled patients on their medication. “I was often involved in the person’s transition back to their doctor or a clinic in the community,” he said, noting that the role sometimes involved tapering medication and follow-up lab monitoring.
Over the past four years, he’s witnessed the scope of what community pharmacists do expand. That’s no coincidence. Like in other areas of healthcare, the Covid pandemic resulted in rapid changes in pharmacy, including policy related to the administration of long-acting injectables. Before Covid, these medications — taken every two weeks to six months depending on the drug and formulation — were often administered at urgent care centers or travel medicine clinics. However, during the pandemic, these settings were limited, either by surges in demand or because they closed. “As places switched to telemedicine, patients couldn’t get their medications,” he said, adding that community pharmacies were among the few remaining open and accessible settings.
“Community pharmacists had been giving immunization injections for a long time but then [during Covid] there was a push to get laws passed so they could administer long-acting injectables for mental health patients,” said Love.
The National Center for Health Workforce Analysis at the Health and Human Services Department has projected that by 2036, there will be shortages throughout the behavioral health workforce, including addiction counselors, psychiatrists, psychologists, social workers, school counselors and psychiatric physician assistants. The center predicts that some of the shortages, like that of addiction and mental health counselors, will be in the hundreds of thousands.
As experts in medication management, psychiatric pharmacists, says Love, are optimally situated to join treatment teams and help alleviate workforce shortage pressure points. “That includes administration and monitoring of medication,” he said. “As a society, we’re pretty good at starting people on medication but not great at monitoring its effects.”
Collaborative drug therapy management, where a psychiatric pharmacist partners with a provider to manage the drug therapy of one or more patients, most often occurs in a mental health center or clinic. In Maryland, psychiatric pharmacists in a mental health clinic helped manage substance use disorder patients who were on buprenorphine, a medication to treat opioid use disorders. “They took care of drug therapy, but they weren’t doing that in isolation,” said Love. “They were working with the physician in the clinic, keeping them informed and making referrals when needed.”
As behavioral health care continuums expand nationwide, Love suggests leaders use the collaborative model and incorporate psychiatric pharmacists in crisis and respite care, helping support people who need somewhere to go to make changes to their medication. “When you start on medications like clozapine, there’s a titration that needs to take place,” he said.
Love says pharmacists are well suited to manage enrollment and monitoring of medications that fall under REMS, the Food and Drug Administration’s risk evaluation and mitigation strategies program, classification. “In some psychiatric hospitals, pharmacists manage the paperwork — reporting and monitoring — that has to do with the REMS program, helping free up prescribers’ time.” Among active REMS are brexanolone, used to treat postpartum depression; opioid analgesics like buprenorphine; and clozapine and olanzapine, both antipsychotics.
Psychiatric pharmacists can monitor and make medication adjustments within clinical and crisis settings and in the transition of care. They’re often experts in specialized areas like pharmacogenomics, how genes affect a person’s response to medication, and pharmacokinetics, how the body interacts with medication. “Certain genes might predict certain adverse effects or that a person might not metabolize a drug well,” said Love. “We can also look at how drug blood levels change over time, whether someone is in the therapeutic blood level range, and how best to adjust dosing.”
He notes that while there are providers with this expertise, adding psychiatric pharmacists to the treatment team to address these specific issues “helps take it off someone else’s plate.” “That’s just another role we can play in addition to direct patient care management and education,” he said.
As workforce shortages rise, Love believes psychiatric pharmacists can help. “We’re skilled in behavioral health medications and are complementary team members,” he said.
