Seeing the Patient Behind the Mental Illness

Published on 01 September 2013

Update: Since this story was published, Karadzic has become a regional clinical pharmacy manager in St. Louis overlooking the pharmacies at St. Louis Psychiatric Rehabilitation Center, Metropolitan Psychiatric Center, Hawthorn Children's Hospital and The Psychiatric Stabilization Center on Delmar.

Ismar Karadzic ’10 has treated the president of the United States, who was also a medical doctor. Well, not really. But Karadzic’s patient definitely believed he was both of those things.

And so Karadzic, along with the attending psychiatrist, “consulted” with “Dr. Patient” about the proper course of treatment. When they agreed on the correct drug, the patient took it. A couple of months later, the patient admitted he wasn’t really a doctor…or president, for that matter. Medication and counseling were finally breaking down the patient’s delusions and bringing him back into the real world. Even now, the patient has occasional “breakthrough” delusions, but Karadzic encounters and helps treat such difficult cases on a daily basis.

As he walks the halls of the Southeast Missouri Mental Health Center, a 300-bed psychiatric hospital located in Farmington, Mo., and operated under the auspices of the Missouri Department of Mental Health, Karadzic encounters a huge range of psychiatric patient profiles—from people who are new inpatients to those who have made this facility a virtual home for years at a time.

Some, like the doctor and president, are delusional. A few are paranoid, sure that Karadzic and anyone else they encounter is working against them. Some patients see things that aren’t there. And some seem perfectly fine, until they break with reality and begin talking as if they live on another planet—one that only they can imagine.

Nothing here can be taken at face value. Every case is unique, and many are complex. Medications are intrinsically woven into both short- and long-term care for these individuals. And as pharmacy clinical manager, Karadzic plays a key role on the health care team that manages each patient’s illness.

Practicing psychiatric pharmacy involves a delicate dance of clinical expertise, interpersonal finesse, communication skills, and persistence. Not only are the drugs themselves unique in their potency and potential for side effects and interactions, but the patients who take them are unpredictable and may be resistant to treatment. Off-label uses are not uncommon, and maintaining a firm grasp of pharmacy research and new drug profiles is critical for patient safety. In addition, it is important to be able to think outside the box, delivering medications in doses and formulations that work for each individual patient.

Not only do the drugs need to be delivered in very individualized ways, but they also can sometimes induce or worsen other medical conditions, like high blood pressure or diabetes, leading to the need for additional medications to control those problems. Potential drug interactions are a primary concern, and cost can be another major factor in a patient’s determination regarding whether or not to take a recommended drug. Keeping current on all of these factors is crucial for the psychiatric pharmacist.

A Delicate and Complex Balance

Karadzic’s practice encompasses a range of duties, which is fairly typical for pharmacists who care for psychiatric patients. One important component of his job involves daily rounds with the rest of the interdisciplinary team overseeing each case. Physicians, nurses, social workers, and therapists work together to coordinate patient care. In many ways, the psychiatric setting is one of the most cooperative settings for health care, with each professional providing valuable input and appreciating the contributions of colleagues. “Rounds involve on-site interaction between the team and the patient,” Karadzic says. “Advising on the appropriateness of specific medications and dosages is a very important part of the discussion.”

Karadzic considers his work to be largely educational. Sitting in a small conference room around an oblong table, he faces one to a half-dozen patients suffering from any number of mental illnesses. Some are depressed, some manic, and some psychotic. Without medication, they would all be unable to function in the outside world. Thus, these small-group educational sessions, designed to help individuals understand why they need a particular drug, how it will affect them, how to take it, and why they must follow directions are crucial to creating long-term treatment success.

“Compliance is a big issue,” Karadzic says. “The ultimate goal here is to get patients well enough so that they can leave the hospital and stay out of the inpatient setting. When they feel better and decide it’s time to stop taking their medications because they don’t think they need them anymore, we have problems with return visits. So the trick is to think outside the box and find ways to help the patient feel comfortable about taking the medication.”

Vito Sansone ’77 serves in a similar capacity at SSM St. Joseph Health Center-Wentzville, which includes a 77-bed inpatient psychiatric ward. He earned an MBA following graduation from STLCOP and served as director of pharmacy at St. Anthony’s Medical Center in St. Louis and at the Wentzville facility when it was Crossroads Regional Medical Center, prior to purchase by SSM Healthcare in 2005.

In addition to the type of interprofessional collaboration described by Karadzic, Sansone manages the psychiatric formulary for all behavioral health units at SSM facilities in the St. Louis area. “Because of the cost of many psychiatric drugs, not every hospital can carry them all,” he says. “So we look at which medications have the most evidence-based efficacy and develop an appropriate formulary. Some of the drugs are beginning to go generic, which helps with cost, and we offer a good range of quality medications for our psychiatric patients.”

In working with health care professionals, Sansone says he serves as the “drug information headquarters.” To help behavioral health nurses understand the nuances of psychiatric drugs, Sansone developed special learning modules that are included in nurses’ orientation. The modules provide information on a range of psychiatric drugs from antipsychotics to antidepressants and stimulants used for attention-deficit hyperactivity disorder.

Psychiatrists, too, rely on Sansone for formulary and dosing information. “Psychiatrists have knowledge of psychiatric medicines but aren’t as well versed on other types of medication,” Sansone says. “Since many psychiatric patients are on a slew of other medications, the psychiatrists need to know about potential interactions or other issues,”.

Electronic health record systems, like the one used at SSM St. Joseph Health Center-Wentzville, certainly provide a degree of safety in flagging potential drug interactions, but Sansone notes that every newly admitted patient requires a personalized medication review, sometimes involving calls to their community pharmacists to ensure all listed medications are current and correct. “We need to help make sure that the medicines the patient was taking prior to admission are continued and that any new medications are considered in light of the existing regimen,” he says.

Yet it is the patient interaction that truly makes psychiatric pharmacy unique. For most people, following a doctor’s advice for a chronic condition, such as diabetes or high cholesterol, seems like common sense and is adhered to fairly well. Patients listen to their physicians and, for the most part, take their medicine as prescribed. Psychiatric patients, however, realize that the medications being recommended to them are not necessarily crucial to their physical wellbeing. They weigh the pros and cons of taking medications and often need special counseling to understand the reasons for specific prescriptions and the potential side effects  in relation to the potential benefits.

“There’s a big role for pharmacy but also a human aspect to what I do,” Karadzic says. “We’re always taught to consider the pharmacy standpoint in terms of the drugs, how they work and if they’re appropriate, but it’s through personal interaction that you really start to relate to patients. You see where they’re coming from. You see that the medications with which we’re treating them—and there are a lot—is not an easy decision for them in terms of wanting to take it.”

Sansone notes that it’s important to see the individual behind the disease. “No one wants to have a mental illness,” he says. “People just want to feel better, and they’re counting on their doctors, nurses, and pharmacists to help them lead a normal life.”

Robert Schmitt ’00 has an acute awareness of the need for the pharmacist to “set aside judgement and bias.” He manages four psychiatric facilities administered by the Missouri Department of Mental Health as part of a regional pharmacy team. Two are forensic care centers specially designed for inmates or those being assessed for fitness to stand trial, one specializes in pediatric cases, and another is an acute care psychiatric center.

Although Schmitt has never been attacked or overtly threatened, he is always aware of the possibility. Patients sometimes act out aggressively against staff members. In these cases, medication is often a lynchpin to calming the patient adequately in order to proceed with counseling and further treatment.

“Some of our clients have committed violent crimes, even murder. But we can’t focus on that. We have to set our sights on treatment and restoring individuals to the community,” he says. Still, Schmitt exercises caution, knowing that some of his patients may become agitated and aggressive.

Extreme mental illness may require creative treatment plans, he adds, noting that medications often need to be adjusted over time. Patient history, comorbidities, and careful tracking of patient response to various combinations of medications and therapies all come into play when deciding how to proceed. “Understanding patients is really important,” he says. “Pharmacists are crucial here. Psychiatric pharmaceuticals are a unique subclass of medications, and the potential for drug interactions is certainly a concern.”

Karadzic finds that some patients feel as if they are giving in to the fact that they have a mental illness when they agree to take a psychiatric drug. Admitting their diagnosis to themselves can be difficult, and complying with medication therapy makes it all real.

“In any pharmacy practice, patients choose whether or not to take the medication, so it is a choice-driven process,” he says. “The difficult part of psychiatry is that it can be hard to relate the message of benefits outweighing drawbacks. And that’s why pharmacists play a really crucial role—we’re able to break it down to the human level to get the message across.” For instance, he may have to explain that, “This medicine might make you a little drowsy, but it will also make you feel less depressed, so you can enjoy your grandchildren when they come to visit.”

Another technical challenge to treating the psychiatric population involves the slow efficacy of many psychiatric drugs. Unlike medications for high blood pressure or other medical problems, psychiatric drugs can take weeks or months to create noticeable improvements. Again, Karadzic notes that the pharmacist-patient relationship is crucial to explaining this process and ensuring that the patient complies with the medication dosing even if they’re not seeing any immediate results. Patients who exhibit paranoia are especially challenging in this sense, and the challenge is that medications must begin working to control paranoid symptoms in order to help increase compliance. 

To practice successfully in a psychiatric setting, Karadzic says that listening is a key skill. Many psychiatric patients have been treated for a long time, he notes, and over the years have dealt with a string of physicians, therapists, and other health care professionals. Because of the nature of their illnesses, patients who have been admitted for treatments multiple times often learn what to say and do in order to convince others of their progress. Realizing this potential, teasing out real concerns, and working together to solve them is the crux of the pharmacist-patient relationship.

“We have a big arsenal of medications to draw from,” Karadzic says. “By listening to patients and determining what they are worried about, we can often recommend substitutions that will make them more comfortable with the treatment.” For example, some patients are hesitant to take a pill every day. Instead, Karadzic may recommend a long-acting injection. Expertise in various formulations and strengths of medications is key.

Breaking Through

“Eventually, the patients begin to ask more realistic questions, and you can see they’re getting on board with their therapy,” Karadzic says. “But the process can be frustrating for everyone. We all want to be rewarded with a positive outcome—sooner rather than later. If the patient simply refuses to take a drug, we’re all stuck until we can get through to him or her.”

Sansone agrees that compliance issues are the most time-consuming discussions he has with patients. “Eighty percent of the patients who are admitted here end up as inpatients because they stopped taking their medications at home,” he says. “Maybe they experienced side effects. Maybe the drugs cost too much. Maybe they felt better and thought they didn’t need to continue taking the medicines. We need to figure out the cause. If patients really want to stop taking a medication, we can work with their physicians to wean them off safely or substitute a different type of drug.”

Schmitt finds noncompliance leading to recidivism one of the most frustrating aspects of his practice. “It’s a step backward when we see them return,” he says. “Patients who are delusional may think there’s nothing wrong with them, and that’s a real barrier to compliance.”

Outpatient education offers a different experience, but one that is equally important. As patients “matriculate” to group homes or other outpatient settings, their therapy continues, and medication education is an important component. Pharmacists who have developed relationships with long-term inpatients can follow them in the outpatient setting, helping to ensure that they don’t need additional inpatient treatment.

The world of psychiatric pharmacy also combines with the community pharmacy setting, particularly surrounding the many prescriptions for anti-anxiety and antidepressant medication written by primary care physicians. “Community pharmacists have the opportunity to review patients’ full complement of medications when dispensing prescriptions to help identify any potential problems,” Sansone notes. “They can make the patient aware that some psychiatric medications, like anti-anxiety meds, can cause drowsiness or weight gain.”

Transformative practice

Karadzic became interested in psychiatric pharmacy during a clinical rotation in a psychiatric inpatient setting. “My interest evolved because it takes some time to really understand what this specialty is all about,” he says. “It’s unlike anything else we’re taught to handle. It’s very different in that this patient population is something not many people have exposure to. You have to understand this special subset of patients, and you can only really obtain that by being immersed in it.”

Since graduating, Karadzic has found support and resources through the College of Psychiatric and Neurologic Pharmacists (CPNP) and is pursuing board certification in psychiatric pharmacy. Sansone is board-certified and says the continuing education requirements help him stay on top of the specialty.

“There is a good collegial network through the CPNP,” Karadzic says. E-mail communication, articles about new types of psychopharmaceuticals, information on off-label uses, and an annual conference help psychiatric pharmacists stay current and informed.

Passing on his knowledge to future pharmacists in psychiatric pharmacy also is important. He precepts students on a regular basis. “We cover this material to some extent in school, but it’s just not enough to fully appreciate what psychiatric pharmacy is about,” he says. “I would encourage students with an interest to look into the CPNP and seek out rotations at psychiatric sites.”

Schmitt, too, welcomes students and believes that psychiatric pharmacy should have a central role in the curriculum, especially considering the increasing number of people who take some type of psychiatric medication. He also wants students to know that this specialized aspect of the pharmacy profession may yield some of the greatest rewards.

“We see transformation happen all the time,” he says. “A patient who is unstable and combative may come in. Within a year of starting treatment, that person may be completely different. While not everyone that leaves our care is a success story, we make every attempt to contribute to each patient’s improvement.”

Yet the inside view of psychiatric pharmacy can be shocking and initially unsettling for students. Karadzic eases them into it by starting with less complex patients and gradually introducing students to those with more severe mental illness. “I ask them frequently if they’re comfortable and what they think,” he says. “At first, the students seem to want to appear unfazed, but by the middle of our five weeks together they usually admit that some cases freak them out. It comes with the territory, and they begin to appreciate the complexity of psychiatric illness and treatment.”

Karadzic admits to being somewhat numb to the unique nature of his patient base. “I tell people about some of my cases, and then I realize they’re sitting there with their mouths hanging open. I forget how extreme it all sounds. But that’s what makes it fascinating to me."

This story originially appeared in the Fall, 2013 issue of Script. 

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