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The case for psychotropic stewardship as more youth prescribed medication

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Psychotropic Stewardship

Loren Bonner

Roughly 12% of pediatric patients are prescribed psychotropic medications, with vulnerable populations—such as those in foster care—prescribed these medications at even higher rates.

“With COVID-19, we’ve seen prescribing rates of certain medication classes, like stimulants and antidepressants, go up, too,” said Danielle Stutzman, PharmD, BCPP, a psychiatric pharmacist at Children’s Hospital Colorado and lead author of a paper published September 13, 2023, in the Journal of the American College of Clinical Pharmacy about the role of board-certified psychiatric pharmacists (BCPPs) in child and adolescent psychiatry. “COVID-19 really harmed the pediatric population.”

During the pandemic, the American Academy of Child and Adolescent Psychiatry (AACAP), the American Academy of Pediatrics, and the Children’s Hospital Association declared a national emergency in child and adolescent mental health. The U.S. Surgeon General issued an advisory, too.

An added layer to the crisis is that child and adolescent psychiatrists are in short supply, with a national average of only 14 child and adolescent psychiatrists per 100,000 children, according to AACAP.

But within all the complexity of this, psychotropic stewardship is emerging as a recognized model, with BCPPs playing an essential role in medication management on interdisciplinary psychiatry teams.

“Our goal and our paper, as well as other initiatives, is to encourage psychotropic stewardship as a model in which BCPPs can play a role in medication management on the psychiatric team and a role in mitigating the provider shortage,” said Stutzman.

The ultimate goal of psychotropic stewardship is for every patient with a psychiatric disorder to have their medication therapy reviewed, optimized, and managed by a psychiatric pharmacist as part of a psychotropic stewardship team.

Defining psychotropic stewardship

The American Association of Psychiatric Pharmacists (AAPP) is promoting the expansion of psychiatric pharmacy through the development of psychotropic stewardship programs. In a paper published April 12, 2023, in Mental Health Clinician, researchers define what psychotropic stewardship is—and its purpose.

Similar to antimicrobial stewardship, the authors wrote, psychotropic stewardship promotes the safe and appropriate use of psychotropic medications, minimizes unintended consequences, and improves patient outcomes.

“AAPP envisions every patient with a psychiatric diagnosis will have their medication treatment plan reviewed, optimized, and managed by a psychotropic stewardship team with a psychiatric pharmacist as a co-leader,” researchers wrote.

AAPP and others want psychotropic stewardship to be officially recognized by regulatory agencies as a standard of care for patients who receive a diagnosis of a psychiatric disorder or SUD.

“Like antimicrobial stewardship, [psychotropic stewardship] would allow payment services going forward,” said Robert Haight, PharmD, BCPP, corresponding author of the paper and a clinical pharmacist at Minnesota Department of Human Services.

Lauren Leiby, PharmD, BCPP, a behavioral health patient care pharmacist at Nationwide Children’s Hospital in Columbus, OH, sees the paper by Haight and colleagues as a “call to action.”

Everyday practice

“Stewardship is what I do every day,” said Leiby, who was a coauthor on the recent JACCP paper about the role of BCPPs in child and adolescent psychiatry. “Much like antimicrobial stewardship aims at preventing antibiotic resistance, psychotropic stewardship for youth helps ensure they have positive outcomes in the future if we can optimize medications now.”

Stutzman also recognizes the importance of early intervention for young psychiatric patients. For example, a BCPP pharmacist can help a psychiatrist use clozapine for an adolescent with severe mental illness or early schizophrenia. “That’s a life-changing intervention early on,” said Stutzman.

Specifically, she said she supports the provider to feel comfortable using clozapine—an effective medication, but also one with adverse effects to be aware of. Stutzman will collaborate with the provider on titration of the medication and on the drug monitoring plan.

Other duties include navigating the REMS program and educating the patient and their family. ■

Addressing stimulant shortages

According to the most recent data from CDC, which was released in 2016, 62% of U.S. children diagnosed with ADHD were taking medication for ADHD. This represents 1 out of 20 of all U.S. children.

Danielle Stutzman, PharmD, BCPP, a psychiatric pharmacist at Children’s Hospital Colorado, as well as many other clinicians working in behavioral health, have struggled to get patients their medications because of the ongoing stimulant shortage in the United States.

Stutzman and colleagues created a toolkit for pharmacists and other clinicians, which provides an evidence-based guide for thoughtfully converting from one stimulant product formulation to another.

“We don’t want to tell families they have to go without medication,” said Stutzman.

Visit https://aapp.org/guideline/stimulant to access the toolkit.■

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