Q&A: Pharmacist Discusses Unique Challenges in Psychiatric Population

Nina Vadiei, PharmD, BCPP, clinical associate professor in the Division of Pharmacotherapy at University of Texas at Austin College of Pharmacy and a clinical pharmacy specialist in psychiatry at the San Antonio State Hospital, works mostly with forensic patients who have been charged with a crime and have severe mental illness. Despite the many unique challenges she faces with this population, Vadiei said learning from the patients makes it all worth it.

Q&A: Pharmacist Discusses Unique Challenges in Psychiatric Population / NanSan - stock.adobe.com

In a conversation with Drug Topics, Vadiei discussed how her career has unfolded, a program that she worked on that exemplifies the value of pharmacists in patient care, opportunities out there for pharmacists to expand their role, and what harm reduction strategies pharmacists can implement to help patients with substance use disorders.

Drug Topics: What initially drew you to the pharmacy profession?

Nina Vadiei, PharmD, BCPP: I was not totally sure what I wanted to do before college at all. I remember when I got into college, my parents sat me down. They were like, “What do you want to do?” And I was like, I have no idea, which I think is common. Basically, they said, “Well, what do you like?” I identified that I really liked science. I am a people person. I'm very extroverted and I like working with people. I didn't want a job where I would be sitting in an office alone. I wanted to interact with others. I knew that having a sense of purpose and not being bored and mentally challenged was going to be important to me. When I was discussing that with my parents, they were like, “Well, it sounds like healthcare would be a good option.” That's kind of when we started talking about the different possible pathways.

I knew I was really driven and the duration of school wasn't going to be an issue for me. But interestingly, there was this anecdote back when I was at that age of going to college, that pharmacy is a good career for women. Maybe you could work part time, have a good work life balance, and be financially secure. However, I kind of knew deep down that wasn't convincing enough for me. I think what sold me when I was at least prompted to think about pharmacy more than medicine or nursing, was I had a lot of interactions with my local pharmacist. I grew up in Austin, Texas, and I had interacted with my pharmacist a lot because I was a very anxious kid. I think that's what drew me to psychiatry, if I'm being completely honest. I suffered with anxiety growing up and even to this day. I was one of those people who was terrified to take any medication. I was the kind of person who wanted lots of reassurance, had lots of questions. Even with things as simple as birth control, I was too embarrassed to ask with questions with people in the waiting room, My pharmacist was really nice. She would step outside with me and talk to me and answer my questions. I thought it was the coolest thing that I could go see them for free while my mom was grocery shopping.

What really sold it to me was I want to be this accessible person who answers these really important questions about people's health. I don't necessarily have to go wait 45 minutes in a waiting room and be rushed in my appointment. It's ironic, because the pharmacy field is really busy now that I know more about it. But from my perspective, at that time, I thought it was really cool that I could go ask those questions, and how accessible the pharmacist was.

Drug Topics: How has your career unfolded?

Vadiei: I can say it changed a lot. I got into pharmacy school very excited, and I totally thought I was going to go to the retail route because of those experiences from that pharmacist that sold me. I just didn't know about the other career options at the time. When I started pharmacy school, I was working as a pharmacy technician. I really liked it. I enjoyed interacting with people, and I liked the fast paced environment. But then I started going to organizations. I started hearing from speakers in different areas, like hospital, and people with independent practices, clinical specialists. I got excited about basically everything. I got confused, and I thought, “Well, I have experience with retail. I think I should probably find a way to get hospital experience and see if I like it more.” It was hard to find a job back then. I literally would just show up places and ask if they were hiring. I did that at St David's North Austin Medical Center in Austin. I literally just rang the doorbell to the pharmacy, had a good conversation with the manager there, and they were really awesome and worked with me, even though I was a student. They created a nice, flexible, as needed schedule.

I worked as a hospital technician for the next 3 years and I loved it. I thought it fit so well in terms of I was learning therapeutics and stuff in class and there was something about delivering all the medicines in the hospital. I learned so much more about the medicines than I was in the retail environment that was so fast paced. I got to interact with a lot of different healthcare professionals, and I learned that that was really important to me. I liked meeting the nurses and physicians and seeing how the pharmacist interacted with those people. I liked the idea of working in an ICU, there was just so many options. I kind of steered more towards hospital, but then my third year, that's when I started shadowing some specialist pharmacists…They were amazing. They gave me lots of volunteer opportunities, shadowing opportunities. I was like, “Wow. Okay, this is where, I feel like I would be mentally stimulated.” I was actually excited to come home and share the interesting cases and stuff I saw with my partner. I just loved going to see all the interesting things that would come up when I was shadowing those specialists. I kind of knew at that point I wanted to do residency. I was totally set on community, then just hospital and specialty came later. I did my residency, and I loved everything.

It was really hard. I feel like I went through a midlife crisis during the first year when you have to decide what specialty you want to commit to. The one thing I knew is I love acute care. I liked fast paced. I liked challenging consult type work. I was between infectious diseases, critical care and psych. They're all very different. I had some mentors who were like, “How are you going to explain psych versus critical care?” One of them, you're not talking to patients and one of them you're talking to them a lot. I was like, “Well, it's just the challenging nature and the cases and the learning aspect that I enjoyed.” Which is what brought me to academia later. But I just went with my gut. I knew the most important thing by then for me in my job was just how much I would enjoy it. Will it make the time go by fast? I went with what I thought was most fun, and it was psych hands down. I had done it as a student. I did it again as a PGY1 resident. Luckily, that one was right before mid-year, and the time to decide early commitment. There is just nothing more fascinating and interesting. I love listening to the patients and learning from them. I could see myself doing that long term like. I liked the other environments, but I didn't like reading and learning about them as much as I liked psychiatry. I had a lot of personal ties to the field as well. That's how it all unfolded. I tell my mentees a lot now in pharmacy school that you don't need to know what you want to do now. The key thing is getting involved and meeting people so you get exposure to as much as possible, so you at least feel like you were informed when it was time to make a decision.

Drug Topics: Can you talk about some of the rewards and challenges you face in your practice setting?

Vadiei: I kind of hinted at it, but psychiatry, I always tell students that there's never a boring day. It's super interesting. The most rewarding part is truly learning from the patients. I'm very fortunate that in my practice, me and this big interprofessional team all sit and bring the patient to the conference room. They know who we all are. They know what to expect. I see patients every day with them, and I just really enjoy listening to them. I think you have to have a lot of empathy and compassion. I just think there's something to learn from every person, even if they have the same diagnosis. Learning their lived experience, like the traumas they've experienced, the challenges they go through, it makes you a better health care professional to listen to their stories and appreciate them. If you're not seeing patients directly, I think that it's hard to know how to make recommendations about how to optimize their medications without knowing them as a person. That is the most rewarding part, just listening to them, learning from them.

The challenges, though, it's very specific to psychiatry. I will say I think the challenges for pharmacy is a different topic. In psych, unfortunately, a lot of our medicines do not work very well. They have very modest effect sizes. On top of that, they have terrible, terrible side effects. One of the biggest struggles in Psych is getting patients to stay adherent to their medicines. But you know, for me, again, the empathy part, I really understand. There's so many reasons why you wouldn't want to take those medicines because of the side effects and the stigma. On top of that, these patients, they don't oftentimes actually have an understanding of their mental illness or believe it's going on. That's one big barrier to wanting to take your medicine. Number two, they often have a co-occurring substance use disorder. We have very, very limited treatment options for substance use disorders. For some of them, we don't have any, like methamphetamine use disorder and cocaine use disorder. We have patients on my unit who are sneaking contraband into the unit. We find that they snuck a methadone pill from a staff and have very limited ways on how to help treat the co-occurring substance use disorder.

Then some patients are so treatment refractory and severe. We've tried everything, we've exhausted every option, and they're still not getting better. What happens in that situation is rampant polypharmacy. I think that's what hurts my soul most as a psych pharmacist, just seeing some really awful medication regimens. I know after working with the physicians that it's not that the physicians are doing something wrong or they're not educated, it's more that they don't know and there's nothing else to do. They really care about the patient but they're adding and adding and adding. That's why I think pharmacists are valuable. I come in, and my perspective is, I don't think that the risks are outweighing the potential benefits. A lot of it is subjective. What should you do when someone's treatment refractory? I think it's really important to have multiple perspectives in terms of ethics and caring about the patient and their safety. It's a challenging population to work with.

Drug Topics: Can you share something unique about your practice setting, patient population, or a specific program you've implemented that exemplifies the value of pharmacists in patient care?

Vadiei: At San Antonio State Hospital, most of our patients are forensic, and forensic means that they have been charged with a crime, and it's usually been deemed that there's a severe mental illness that has made them unable to stand trial. The patients I work with actually are termed NGRI, and that is not guilty by reason of insanity. It's not the best wording, but these are patients where they did eventually go through the court process, but then there was enough evidence that they were just so severely ill, and that's what caused them to commit the crime. I say this is a unique population, because they're very vulnerable and misunderstood. People hear their charge and their charge follows them for their life, in terms of opportunity and integrating back into the community. It unfortunately traumatizes and defines them. There's a lot of shame around it, and I think it makes it harder for them to ever reintegrate and continue to get the care they need because of the charges that they face.

Some other unique challenges is there's so many patients with severe mental illnesses in jails, there's more than hospitals can accept from the jail. Right now, there's a dire shortage of mental health providers to care for forensic patients who need care. They just aren't getting the care that they need. And consequently, civil patients, which are patients who are not charged with the crime, they're just patients who really need mental health care, they can't get access to hospitals when they're in crisis, because all our beds are being taken up by forensic patients, which is a state priority for state funding reasons. And so, patients without mental health charges, who are also severely mentally ill, are not getting care. Basically, the wording on some advocacy sites is it's that they're waiting to get charged with a crime. They're waiting until things are so bad that they become a danger that's identified in the public, to then get in jail, to then come to the hospital. That's just ridiculous. That shouldn't happen.

But the issue is access to care. Patients with mental illness don't have access to care, and that's not even just severe mental illness, that's just every person with mental illness. There's a huge movement inside pharmacy right now where we're trying to implement what's called psychotropic stewardship programs. The goal is that if we create this standard idea, similar to infectious diseases stewardship programs, that every place that treats mental illness should have a psychiatric pharmacist to oversee care, to optimize treatment and improve safety, that that becomes expected, that we grow this workforce, and that will also help improve access to care. Psych pharmacists in general are very underutilized. We could do so much more. Obviously, there is reimbursement issues, that kind of makes it hard to justify implementing one and so that's why the stewardship programs are one strategy we're trying to use to kind of not mandate but get psych pharmacists into more treatment settings and bridge the care gap. I'm really hoping that we can start a psychotropic stewardship program and try to optimize my services as much as possible for our state hospital.

Drug Topics: In your opinion, what are the biggest opportunities for pharmacists to expand their role in patient care in today's healthcare landscape?

Vadiei: The area of huge growth right now and opportunity is primary care. I will say, I love my practice setting—t's unique, It's cool—but sometimes I have this guilt that I could be doing so much more in the primary care space. A huge area even in psych is called primary care mental health integration. The VA has kind of spearheaded a lot of that. Basically, trying to integrate mental health care into primary care settings where it's such a common issue that's brought up but there's not enough time from primary care providers to address mental health adequately, as well substance use disorders. I think there's just such an opportunity to integrate pharmacists into primary care settings or ambulatory care settings in general, because the shortage of care isn't just psych, it's just global at this point. We are a very underutilized resource to bridge between appointments with the physician. We can be the medication management appointment go-to for patients.

Drug Topics: What harm reduction strategies can pharmacists implement to help patients with substance use disorders?

Vadiei: I'm not working in community, but overall, I would say my passion is just improving access to care and identifying where the biggest needs are. What more do we need to be doing? Something I alluded to earlier is a lot of my patients have co-occurring substance use disorders. I think it's the hardest thing to treat. It's such an area of need right now, that's why I'm passionate about it. In terms of harm reduction strategies, I think the biggest thing is knowing your resources. I just moved to San Antonio a year ago. I'm still learning them, but basically asking, if you are working in a setting with social workers or physicians, people who've been around longer, asking “I want to refer a patient for a safe syringe service exchange program. Where do they go?” Just learning about where patients can be referred for PrEP or drug screening that is done safely. Learning about your resources. For example, we actually have a bi-weekly meeting where all providers in the UT Health Science Center San Antonio region who care for patients with substance use disorders can join and ask other people treating the disorders questions.

I guess the bottom line is just knowing you're not supposed to know everything. It's about learning to ask those questions. An example I can give is we have a patient, and he's been in the hospital, but he has severe substance use disorder. He's the one I alluded to earlier who was sneaking in methadone. That was alarming. I was like, “Well, at what point do we start considering meds for opioid use disorder here in the state hospital setting?” It was this huge controversial thing, because they're supposed to be abstinent in the hospital, but they're not. Patients are sneaking in meds. They're sneaking drugs into the unit. I think that that's a really good example of there's going to be things that come up that you don't know how to address. You have to be an advocate for your patients, and just ask the big questions.

To read more from this series, visit our American Pharmacists Month resource center.

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