Two articles in the April 2024 issue of Academic Psychiatry [1, 2] present the results of the impact of pharmacist-led education on psychiatric trainees. In a study by Vadiei and Smith [1], psychiatry resident and geriatric fellows at two institutions in different states were presented 14 advanced psychopharmacology lectures led by board-certified psychiatric pharmacists (BCPP). The lecture topics covered general principles of antipsychotics; pharmacokinetics/pharmacodynamics; first-generation antipsychotics; second-generation antipsychotics; general principles of mood stabilizers; lithium; anti-epileptics; anxiolytics/hypnotics; stimulants; geriatric psychopharmacology; and treatment of behavioral and psychological symptoms of dementia. Each lecture included at least one type of active learning strategy, such as case-based or game-based learning. All 39 respondents strongly agreed that BCPP-led teaching enhanced their learning of psychopharmacology concepts. In the second study, Khorassani and Espejo [2] provided BCPP-driven naloxone training to 21 psychiatry residents and evaluated their knowledge and comfort prescribing naloxone. About 52% of residents felt knowledgeable and comfortable prescribing naloxone prior to training, and 95% felt knowledgeable and comfortable after training. Authors of both studies were enthusiastic about pharmacist-driven education for psychiatry residents, and some residents in the first study [1] shared their enthusiasm.

While these two reports seem to identify and endorse a new educational resource for teaching psychopharmacology to psychiatry residents, caution is warranted in interpreting the results. First, population samples in both studies were small (39 and 21 subjects). Second, both studies lacked a control group, that is, psychopharmacology education led by non-BCPP educators, which would allow determination of whether the BCPP-led education is viewed and valued differently from other educators, such as psychiatrist-led psychopharmacology education. Nevertheless, these two articles bring attention to a new resource for educating and training psychiatry residents in psychopharmacology.

Collaboration Between Psychiatrists and Clinical Pharmacists in Clinical Settings

Although collaboration between psychiatrists and pharmacists has been ongoing for decades, clinical pharmacy has been underutilized in the area of mental illness [3]. The main areas of collaboration have been traditionally therapeutic drug monitoring, medication care coordination for coexisting conditions, and medication education for family and care providers [3]. In their article on collaboration between child and adolescent psychiatrists and mental health pharmacists, Lu and colleagues [3] outlined many areas where pharmacists can contribute to treatment teams, which included, but were not limited to, screening for drug interactions; advising on optimal/evidence-based dosing; comparing clinically significant differences of formulations of medications; therapeutic drug monitoring; interpreting and applying pharmacogenetic testing; ensuring appropriate laboratory testing and rating scale monitoring; educating psychiatrists, patients, and families about complementary therapeutics; overcoming therapeutic inertia; identifying which medications can be safely and gradually tapered off to reduce side effect burden, cost, and patient confusion; planning for rational deprescribing; and coordinating care with other providers. They also mentioned medication educational groups that can help destigmatize taking medications and provide a forum for family engagement and much-needed patient support and monitoring [3]. Clinical pharmacists can also play an important role in transition of care and medication reconciliation, as they can verify patients’ medication utilization.

Javelot and colleagues [4] also promote the role of clinical pharmacists in the process of medication reconciliation in psychiatry, in psychoeducation and therapeutic patient education to enhance medication adherence, and in therapeutic drug monitoring. They emphasize team-based models of care that “must include pharmacists” [4]. They note that psychiatrists are “aware of recommendations or guideline algorithms, but in some countries it is not always possible to apply them, often because they are incompatible with real-life conditions” [4]. They suggest that a well-educated psychiatric pharmacist can help determine how these guidelines could be adapted to real-life treatment [4].

Two other reports propose further areas of collaboration among pharmacists, psychiatrists, and primary care physicians (PCPs). Mospan and colleagues [5] suggest that community pharmacists can assist in screening for, assessing, and identifying suicidal ideation in collaboration with PCPs and then connecting patients to psychiatric care. They note that many patients have more frequent contacts with their pharmacists than with their PCPs and that patient connection with community pharmacists could be critical in times when their prescribers are not available. Mospan and colleagues [5] acknowledge pharmacists’ lack of comfort, expertise and training in this area and note that Washington is the only state within the USA that has a required suicide training program for pharmacists. In a retrospective analysis of pre- and post-education session questionnaires for patients with chronic pain who are seeking medical cannabis, Parihar and colleagues [6] report that after the session, patients were more likely to report cannabis as having the potential for addiction and harm and less likely to select inhalation as a route of administration. In addition, patients were more likely to choose a lower potency of tetrahydrocannabinol. The authors suggested that either group-based or one-to-one patient education can be used to promote safer use of cannabis for therapeutic purposes and that pharmacists could screen patients for cannabis use and refer them to cannabis education [6].

The potential areas for collaboration between psychiatrists and pharmacists in clinical settings seem to be multiple and appear to lead to improvement in various areas of clinical care, especially in settings where there are high-risk medications or medication combinations or other clinical safety concerns or in rural or underserved settings. In many communities, clinical pharmacists have played an important role in administering and/or ensuring access to long-acting injectable antipsychotics. But what about collaboration in the education of psychiatric trainees? Unfortunately, research is lacking, and there are no additional studies on pharmacist-led education of psychiatric residents that we are aware of beyond the two published in Academic Psychiatry [1, 2].

Pharmacist-Led Education in Psychiatry Residency Training

The pharmacist-led education of psychiatry residents is an interesting idea and a potentially important resource. The health care system is becoming more complicated and difficult to navigate and would benefit from true interdisciplinary collaborations, including education about the role and functioning of each discipline involved in patient care. Pharmacists may serve an important role in the expansion of collaborative care, which is especially important for physicians, in our case psychiatrists, who are the leaders of interdisciplinary mental health care. We have to acknowledge that in most systems, psychiatrists know very little about the work of pharmacists. As there are no further studies on pharmacist-led education in psychiatry and there is no guideline for what pharmacist-led education in psychiatry should be, psychiatrists should become proactive in the delineation of pharmacist-led education. We should define it in collaboration with clinical pharmacists, but collaborative education in this area should be based on the needs of our field. Pharmacist-led education in psychiatry should not replace psychopharmacology education provided by psychiatrists but should complement and enhance it.

Psychiatrists should create a curriculum of pharmacist-led education that addresses some of the ideas presented by Lu and colleagues [3] and others. We may also modify this education based on interesting ideas from studies in other specialties. For instance, in a small study from Australia [7], 17 medical students who received a 1.5-h, case-based tutorial on prescribing presented by a clinical pharmacist were compared to 16 students who did not receive any tutorial 3 weeks after the intervention. The assessment included writing prescriptions for various medications (e.g., controlled substances, combined prescriptions) based on the presented cases and evaluation of common errors (e.g., listing drug strength and formulation). The tutorial group performed significantly better than the non-tutorial group.

In another study [8], first-year, incoming residents from various specialties (e.g., anesthesiology, medicine, family medicine, pathology, and dentistry but not psychiatry) at the University of Tennessee received an eight-question pharmacotherapy pre-test covering a range of pharmacy-based questions during their orientation. This pre-test was followed by a 50-min pharmacotherapy session led by a pharmacist, which covered issues such as insulin management, electrolyte replacement, pain management, the role of a pharmacist in inpatient settings, and various drug information. Following this session, 243 residents were administered the same eight questions as in the pre-test, for example, how many refills can be provided on a class II narcotic such as oxycodone or what to prescribe a patient who is allergic to morphine. This study was conducted during orientation over a 4-year period, from 2016 to 2019. The educational intervention improved resident performance on the post-test by 32%. We are not aware if educating incoming psychiatry residents on common prescribing practices is frequently included in residency orientation. Yet, modified ideas from these two studies could present a useful part of the first-year resident orientation process, possibly led by clinical pharmacists.

What and who should be part of the ideal pharmacist-led curriculum or curricula for psychiatry residents? Psychiatrists should probably utilize clinical pharmacists during orientation to residency that would include training in the mechanics of prescribing (as Mokrzecki et al. [7] noted, prescribing is a core skillset for residents) and a tutorial on common prescribing situations in psychiatry and the role of pharmacists, similar to the orientation described by Hamilton and colleagues [8]. We should also perhaps consider utilizing clinical pharmacists in repeating educational sessions prior to rotations to target common prescribing concerns, such as drug-drug interactions before consultation-liaison psychiatry experiences, emergent side effects that might be seen in an emergency room setting, and pharmacological psychoeducational strategies prior to outpatient work. In addition, residents need to know the various preparations of medications, costs of generics versus brand-name drugs, need for prior authorizations, and what alternatives may be acceptable for patients on Medicaid and Medicare, given limited resources. We typically do not include the costs of medications in our residency education, and pharmacists have a good understanding about the economics of medication management.

These suggestions should not be the limit to pharmacist-led education in psychiatry, however. Psychiatrists should also develop curricula that include the ideas noted but not limited to those mentioned by Lu and colleagues [3]. Examples of these topics include the role of clinical pharmacists/BCPPs; pharmaco-economics; pharmacy benefits; therapeutic drug monitoring; screening for drug interactions and whether they are clinically significant and what to do about them; advising about optimal dosing and use of medication levels; discussing clinically significant differences of medication formulations (e.g., brand name vs. generic, immediate vs. continuous release forms); pharmacokinetics/pharmacodynamics; ordering proper laboratory tests; utilizing rating scales for starting and monitoring certain medications; hel** with rational de-prescribing; providing coordinated, realistic education to patients and caregivers regarding expectations of improvement and side effects, including behavioral ones; use of complementary substances and substances of abuse during medication treatment; cross-titration; enhancing adherence; dealing with cumbersome and not clinically usable algorithms; naloxone training; and pharmacotherapy of special populations, such as children and adolescents, the elderly, and minorities.

In preparing such a curriculum, psychiatrists should be aware of the limitations of clinical pharmacists’ (including BCPPs’) education and their lack of what we consider as clinical experience. Thus, the creation of such a curriculum should not be left to one specialty but truly collaborative, created by both psychiatrists and pharmacists together. Accordingly, a pharmacist should not substitute for a psychiatrist based on convenience (e.g., faculty psychiatrists who feel they are too busy to lecture). Psychiatrists should take active participation in pharmacy-led lectures and put the content into clinical context. Pharmacists could be enlisted to lead teaching in areas usually known better by pharmacists (e.g., pharmacokinetics, pharmacy benefits, and pharmaco-economics). It is also important to note that exposing psychiatry trainees to pharmacists is a valuable part of interdisciplinary learning, including merely hearing the perspective and attitudes of pharmacists with regard to psychiatric disorders and psychiatric patients. Psychiatrists also need to understand the differences in the training of pharmacists and consider which type of training is needed tor teaching in psychiatry programs. The amount of clinical pharmacy training in psychiatry (e.g., seeing patients, especially psychiatric ones, as a pharmacist) may differ between pharmacy programs and fellowships.

Similar to other new areas of psychiatric education, psychiatrists need to decide who should determine the final content of this area of education and whether it should be ultimately determined by individual programs, graduate medical education (GME) offices, or designated institutional officials. GME would likely be the best resource, as this office would be best suited to organize similar pharmacy-led education for all residency programs within its system. Nevertheless, there will be resource-poor programs that may need to share resources via sharing BCPPs within close geographic areas or via virtual communication tools. But even in underserved communities, there can be no compromise in basic standards of care. In resource-poor communities, evidence-based and collaborative video recordings may be vetted by experts and incorporated into pharmacologic education for residents.

Conclusion

Pharmacy-led education of psychiatry residents is an important area that psychiatrists should explore and include in resident education. It would not only strengthen resident education but also help improve patient care. The introduction and implementation of collaborative pharmacist-psychiatric education may be a tall order, as the resources for implementation, namely, BCPPs, may not be available to all residency programs. Nevertheless, given the current complexity of US health care systems, the time has come to seriously consider and evaluate its potential.