After finding out about the RxPharmacist Graduate Transitions Program through my school advisor, I had a strong interest in joining the program. I definitely thought it was too good to be true, to earn income while studying for your boards, but it has truly been a mutually beneficial experience! With a fellowship position already in place, I wanted to join the summer internship to enhance my work experiences and further build my skillset before beginning my fellowship in July. The program is very unique in that it specifically caters to graduating fourth year students and gives them an opportunity to edit or create MPJE/NAPLEX material of the student’s interest. Since I attended pharmacy school in Florida, I had no experience with the Massachusetts MPJE material, but I wanted to be licensed in the state for my fellowship. After editing the Massachusetts guide, I found the whole experience to be very effective and helpful in learning the material. I feel very prepared to take my MPJE exam and pass on the first time easily.
The RxPharmacist Graduate Transitions Program is very flexible and really cares about the success of the intern. I was able to create my own schedule and work on my own time. Throughout the program, I have learned valuable skills through the workshops offered on topics such as LinkedIn and writing effective cover letters through RxPharmacist’s, “How to get a Job Series” program that all interns get free access to. I have also expanded on my previous writing experiences that I know will be very beneficial to my career in the pharmaceutical industry. Another perk of the program is being matched with a mentor to support you through your projects and help you further your professional development. I enjoyed my sessions with my mentor and being connected with other professionals within the pharmaceutical industry. I cannot recommend this program enough, you need to definitely apply!
I stumbled upon RxPharmacist from a dear friend of mine who kindly forwarded the email she received about their internship programs over to me. I remember taking a quick glance out of confusion then rereading everything as it sounded too good to be true! It turns out I was right, it WAS too good to be true! RxPharmacist has a noble mission of not only helping pharmacy students pass their boards, but also earn some cash in the process. On top of everything, there are optional sessions for career growth, mentorship, and interviewing tips. For me, this was a once in a lifetime opportunity that helped me answer some of my own dilemmas and pursue my true passion. Questions such as should I pursue a regular pharmacist job out of graduation, or can I be able to strive for an entry level position in the pharmaceutical or medical writing industry? After all, the skills you gain here will take you as far as you let them. This internship program by RxPharmacist is designed to help each one of us [the interns] establish a solid foundation that will set us apart in today’s competitive workforce.
My favorite part about this internship is the flexibility you are given when it comes to balancing your schedule. This is beneficial as I felt that I needed to practice having more of a “work-life balance” and there was no better way of doing so than with a fully remote work environment. RxPharmacist has been doing 100% remote work since 2016! For anyone seeking a non-traditional pharmacy role, this is the way to go as it may help some people realize if this path is even right for them and discover what they truly want out of a job and their life. This is why I highly recommend this internship for anyone seeking to challenge themselves, help future pharmacists, and gain new skills in a relatively short amount of time. Reflecting on my experience, I have learned more about my work and learning styles, as well my inspirations. I am more driven than ever to achieve my goals thanks to this exclusive experience I shared with my mentors and fellow interns. I hope that anyone out there who feels lost or unsure of what the future holds for them after pharmacy school explores this unique opportunity to experience it for themselves.
I am a 2022 graduate of Florida Agricultural and Mechanical University College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health. In the summer following my graduation, I will begin a post-doctoral fellowship in Public Affairs and Patient Advocacy with Sanofi in conjunction with the Rutgers Pharmaceutical Industry Fellowship program. My main ambitions are becoming a leader patient advocacy that makes the healthcare a space more comfortable for patients to navigate.
Although I didn’t know what to expect, I stumbled upon the RxPharmacist internship program and applied to work on creation of a NC MPJE guide as my post-graduate fellowship program will be in North Carolina. The graduate transition program at RxPharmacist, LLC is an amazing opportunity for new pharmacy graduates looking for guidance in taking the first step in their career. I was paired with a mentor, and we talked about my goals and how to achieve them. I was also able to learn a new skill in health care writing that will surely be invaluable as a move forward. The team here is passionate about ensuring that each intern has tools for success they need in the future.
I would highly recommend their program to graduating pharmacy students especially if you want a career in medical writing, business, or other non-traditional pathways in pharmacy.
I was first introduced to RxPharmacist in my first year of pharmacy school when I had little idea of what I wanted to do when graduation came. As the first person in my family to pursue a professional health care degree, I was searching for a mentor and spent much of my first few months of school exploring as many paths through pharmacy as I possibly could. When I was presented with an opportunity through RxPharmacist for mentorship and an opportunity to make connections in the world of pharmacy, I was beyond ecstatic. Beyond that, I was given the chance to help to build the online platform for a company that valued students like myself, and to learn from people who were truly working to make a difference for recent graduates. I was tasked with translating written guides into the online learning modules on the website. I remember spending hours sitting quietly in my room watching YouTube videos about programming because everything was so new to me. But for those three years, I was a sponge, soaking up as much information as I could about career paths, life advice, and even the eventual licensure exams I had to take, and I had support from that RxPharmacist team every step of the way.
When it came time for fourth year rotations, I was ready. I felt like I had so many new networking skills under my belt, and I was so excited about the people I was about to meet. The mentor I met through RxPharmacist ended up being my primary mentor throughout school. She listened to what I was looking for in a wholistic life and career, and introduced me to people in fields that I was interested in. During my fourth year, I was finally able to actually experience what these possible careers would be like for myself. I ended up falling in love with the Indian Health Service and made so many connections because I had training on the kinds of research I needed to do to connect with people as I met them! It is truly incredible how small pharmacy is, and how few degrees of separation there are between you and the person who has your dream job.
Now, I am about to start a PGY1 with Cherokee Indian Hospital in North Carolina, and I was finally able to help create an MPJE guide of my own! I am so thankful for the opportunities that have shaped who I am today and that have helped to guide me here. During my first year at RxPharmacist, I wrote a blog post about the value of an internship and about how an internship worthy of your time is one that truly values YOU. Now, four years later, I am simply so excited to give back to new graduates because of how much this internship has given me.
-Madeline W., 2019-2022 RxPharmacist Graduate Intern
The World Health Organizationestimates that approximately 5.0% of the world’s population suffers from depression.1 Depression is highly complex and arises from biological, environmental, and social factors. Although depression can happen at any age, the usual onset occurs during early adulthood. Sometimes, it is even common for depression to affect an individual in late adulthood as well.2 The PHQ-9 (Patient Health Questionnaire) is a widely used diagnostic tool for depression and can be accessed on the my HealthyVet VA website.
Depression is often diagnosed by psychiatrists, licensed therapists, or psychologists and is dependent on certain criteria. Depression must be present for at least twoweeks consecutively, and a patient must have five or more of these symptoms2:
Loss of interest or pleasure in daily activities (must be present for depression diagnosis)
Feelings of sadness, hopelessness, or emptiness (must be present for depression diagnosis)
Increased or decreased appetite
Increased or decreased sleeping patterns
Decreased or slowed thinking, speaking, or movement
Feelings of constant guilt and worthlessness
Difficulty thinking or making decisions
Feelings of tiredness or energy loss
Frequent thoughts of suicide with or without a plan
These symptoms may occur every day or most of the day and must cause an individual lots of distress or interference of daily functioning. A depression diagnosis should not be attributed to the following:
substance use disorders,
adverse effects of other medications,
manic or hypomanic episodes, or other mental disorders such as schizophrenia, delusional disorder, or schizophreniform disorder.2
Depression can be brought about due to certain life events (loss of employment, financial loss) and tragedies (serious illness, loss of a loved one). Sometimes, there is no clear reason for what causes someone to develop depression. Depression may be transient or lifelong and it is important to discuss treatment options with providers as therapy is unique to each individual.
The usual side effects of antidepressants are diarrhea, constipation, sexual dysfunction, fatigue, and sleep disturbances. It is also very important to note that antidepressants carry a black box warning for increased thoughts of suicidality in children, adolescents, and young adults. Common treatments for depression at listed below. For a complete list of specific FDA-approved medications for depression, visit the FDA website.
Novel Treatments for Depression: A Breakthrough in Psychopharmacology
Recently, psychedelicshave been making headlines in the mental health world and so far, many signs are telling us they might be here to stay. As many as two-thirds of patients will not initially respond to an antidepressant, and there is increasing evidence to show that psychedelics may provide the answer that most clinicians have been searching for. In a recent United States survey, many Americans showed their support for the use of psychedelics if they were proven to be more effective than the standard treatment for mental disorders.4
The first psychedelic approved for treatment-resistant depression was esketamine(Spravato). Esketamine is an S-enantiomer of ketamine and an NMDA (N-methyl-D-aspartate) receptor antagonist. Granted FDA approval in 2019, esketamine’s efficacy and safety were evaluated in three parallel-group studies. All three studies looked at the Montgomery–Åsberg Depression Rating Scale (MADRS) scores. The MADRS is scored from 0 to 60 (scores on the higher end show more depressive symptoms). Patients in these studies received a new antidepressant at the start of the trial (for ethical purposes) and either placebo or esketamine treatment.
Results demonstrated that there was a significant reduction in MADRS scores compared to patients’ normal baseline readings.5 Because of esketamine’s potential for abuse, the FDA conducted a withdrawal study before a new drug application was sent out for submission.
Esketamine also has a REMS (Risk Evaluation and Mitigation Strategy) program for patient understanding of how benefits may outweigh risks.
Psilocybin
Another psychedelic treatment that is currently garnering attention for treatment-resistant depression is psilocybin. Compass Pathways, a mental healthcare company, recently completed a phase 2 double-blind, randomized controlled trial with favorable results.
The investigators of the trial compared the efficacy of psilocybin (COMP360) at 25mg, 10mg, and 1mg in 233 patients who randomly received these doses along with psychological support. Results using MADRS scores as the primary endpoint indicated that the majority of patients showed response or remission after receiving the 25mg dose by the third week.6 In addition, patients who were taking the 25mg dose were able to maintain their response at the end of the third month.6 Phase 3 is set to begin in mid 2022.7
MDMA
MDMA (3,4-methylenedioxymethamphetamine) is a derivative of amphetamine and has gained some traction for the treatment of post-traumatic stress disorder (PTSD) in phase 3 trials. For the indication of depression, MDMA shows signs of having its place in therapy.
In a systematic review of various psychedelics used for patients with terminal illnesses, preliminary open-label results revealed a significant reduction in depression in patients taking MDMA. Although the sample size was relatively small with 13 patients receiving 125mg – 187.5mg of MDMA and 5 patients receiving placebo, depressive symptoms in patients were greatly diminished, even up to one year later.8 Other observational studies have also presented positive outcomes with MDMA reducing major depressive episodes.9 Overall, more clinical trials must be conducted to get a clearer picture of how MDMA plays a role in depression therapy.
Depression can affect the lives of many but there are lots of treatments out there that can help. From the standard treatments of SSRIs to newly approved psychedelics like esketamine, there is hope in getting better and feeling better. As we look to the future with several breakthroughs in research, it is possible that one day depression might become less and less prevalent. With psychedelics constantly on the rise in the mental health world, these treatments may become the new standard of care for patients. Until these novel treatments become the norm, it is important for healthcare workers everywhere provide quality and compassion care to those suffering from depression.
Dr. Joseph Suarez, Pharm.D. is a Medical Writer at RxPharmacist, LLC who resides in San Antonio, Texas. His interests are in psychopharmacology, psychotherapy, and reconciling healthcare disparities. Dr. Suarez is seeking opportunities to utilize his incredible medical writing talents. If you are looking to hire, you may contact Dr. Suarez via LinkedIn.
Kim J, Farchione T, Potter A, Chen Q, Temple R. Esketamine for treatment-resistant depression — first FDA-approved antidepressant in a new class. New England Journal of Medicine. 2019;381(1):1-4. doi:10.1056/nejmp1903305
Compass Pathways announces positive topline results from groundbreaking phase iib trial of investigational COMP360 psilocybin therapy for treatment-resistant depression. Compass Pathways. https://compasspathways.com/positive-topline-results/. Published November 9, 2021. Accessed February 25, 2022.
Schimmel N, Breeksema JJ, Smith-Apeldoorn SY, Veraart J, van den Brink W, Schoevers RA. Psychedelics for the treatment of depression, anxiety, and existential distress in patients with a terminal illness: A systematic review. Psychopharmacology. 2021;239(1):15-33. doi:10.1007/s00213-021-06027-y
Jones GM, Nock MK. Lifetime use of MDMA/ecstasy and psilocybin is associated with reduced odds of major depressive episodes. Journal of Psychopharmacology. 2022;36(1):57-65. doi:10.1177/02698811211066714
Current Trends During the COVID-19 Pandemic and the Pharmacist’s Perspective
The COVID-19 pandemic has affected everyone at some point. From job displacement to the loss of a loved one, COVID-19 has definitely changed the way we function in society. As some states are adopting to relax COVID-19 masking policies, the pandemic that began two years ago is not over yet. The CDC estimates that over 930,000 people in the United States have died from COVID-19.1 As we approach the unfortunate million number milestone, there are an estimated 130,000 weekly cases of COVID-19 as of February 2022.1
Some challenges that we have seen during these trying times have been especially taxing for healthcare professionals. Surges in COVID-19 hospital admissions, medical staff shortages, and usually long hours behind the pharmacy counter have left some providers with a sense of mental burnout. As a result, the “great resignation” has led numerous people to jump ship from their current jobs in search of finding that work-life balance that many once had prior to the pandemic. Some retail pharmacists are even moving to nontraditional careers such as remote opportunities amid the shortages of help and reduction of pharmacy store hours.2,3,4 Some common stressors pharmacists face are listed in the chart below.
Common COVID-19 Stressors Pharmacists Experience5
Facing Uncertainty
Staffing Issues
Increased Workload
PPE Shortages
Updated/Changing Guidelines
Family Health Concerns
Lack of Role Clarity
Threat to Professional Identity
PPE = Personal Protective Equipment
On the other hand, roles for pharmacists, pharmacy students, and pharmacy staff have greatly expanded throughout the COVID-19 pandemic, creating a kind of incentive for pharmacists to provide vital and necessary patient care.6 Some examples of these role expansions have been:
Creating community pharmacies that serve as COVID-19 testing sites
Permitting emergency pharmacist authority for pharmacist refilling (in some states)
Allowing pharmacy student volunteering while under pharmacist supervision
Granting pharmacy technicians the rights to administer vaccines, conducting remote data entry tasks, and taking new orders (in some states)
Image: unsplash.com
The Pharmacist’s Role Concerning Vaccinations, Home Testing Kits, and Personal Protective Equipment
The general public who visit the pharmacy may have several questions or reservations concerning COVID-19 vaccines. We’ve all seen and heard the vast amounts of misinformation regarding vaccines out there on social media, and it is important for pharmacists to intervene and educate patients about certain misconceptions. The public may ask these questions for themselves, for their family members, or for their own children. Some common COVID-19 vaccination concerns are outlined below. For more information regarding frequently asked vaccination questions, please refer to the CDC website.
In recent news, Pfizer-BioNTech (Comirnaty®) and Moderna (Spikevax) COVID-19 vaccines have been approved by the FDA for the prevention of COVID-19 and authorized for emergency use.7,8 The Janssen (Johnson & Johnson) COVID-19 vaccine, however, does not yet have FDA approval but is authorized for emergency use.9
Each vaccine has different criteria (e.g., age, booster eligibility) for patients. If a patient is receiving their COVID-19 vaccination for the first time, it would be wise to go over the vaccination schedule with them to ensure proper follow up. So far, most individuals qualify for the normal vaccination series and a booster (See chart below). Currently, the push for a second booster is reserved for individuals who are severely immunocompromised per CDC updates.
In early 2022, the Biden-Harris Administration began the initiative to provide millions of Americans with free at-home COVID tests and N95 masks. This decision came after massive surges in COVID-19 cases and when the Centers for Disease Control’s updated its guidance on N95 masks, noting that these masks offer “the highest level of protection.”10
In pharmacies today, people are eligible for free at-home COVID-19 testing kits with or without insurance plans. Everyone is now able to claim at least 4 at-home tests per household. Pharmacists can direct the general public to this government website for free orders. Kits usually arrive in about 7 to 12 days and is delivered by the United States Postal Service. For information on N95 mask availability, individuals are advised to contact their local grocery stores, pharmacies or community centers.
The Pharmacists Role in Advocating Mental Health
From day to day, pharmacists might be overwhelmed and preoccupied with consults, phone calls, medication reconciliations, issues with prior authorizations, or medication transfers to say the least. Understandably so, this makes sense since there are so many tasks to do in a short amount of time. Even though a great deal of work is handled behind the scenes, it is important to recognize situations where patients or even coworkers might need certain help, especially when it comes to mental health.
Incidences of depression have unfortunately been on the rise during the pandemic. In a longitudinal study that followed groups of U.S adults 18 years and older from March-April of 2020 and March-April 2021, depression in representative samples showed an increasing trend.11 In this study, the 2020 March-April cohort reported 27.8% depressive symptoms (95% CI: 24.9, 30.9) while the 2021 March-April cohort reported 32.8% depressive symptoms (95% CI: 29.1, 36.8). Reasons for the recent increases in depression have been attributed to life stressors such as socioeconomic status and job loss.11
depressed mood or loss in interest in things that are pleasurable
concentration disturbances
energy loss
psychomotor agitation or slowing
If the pharmacist has reason to believe that an individual might be suffering from depression, they can offer suggestions or recommendations to assist others. Mental health stigma is still very much widespread and negative societal beliefs may prevent others from seeking any help at all. It is always important however, to approach mental health discussions with a welcoming, yet careful manner to open up conversations that might be uncomfortable at first. Referring someone to a provider, therapist, or counselor is a great start. For more resources, visit the National Institute of Mental Health website.
Common resources utilized for immediate intervention are the following:
Pharmacists everywhere can do their part to help those who need it the most during the COVID-19 pandemic. For pharmacists who have stayed diligent in providing continued, exceptional healthcare during the pandemic, their role in helping patients has never been more crucial. Even though time constraints during the pandemic may be the biggest barrier in helping patients throughout the day, pharmacists can still exercise their judgements in helping patients who may need that extra care. Although we may not know what changes to expect during this pandemic, we can certainly adapt to provide exceptional healthcare to everyone.
Dr. Joseph Suarez, Pharm.D. is a Medical Writer at RxPharmacist, LLC who resides in San Antonio, Texas. His interests are in psychopharmacology, psychotherapy, and reconciling healthcare disparities. Dr. Suarez is seeking opportunities to utilize his incredible medical writing talents. If you are looking to hire, you may contact Dr. Suarez via LinkedIn.
Langran C, Mantzourani E, Hughes L, Hall K, Willis S. “I’m at breaking point”; exploring pharmacists’ resilience, coping and burnout during the covid-19 pandemic. Exploratory Research in Clinical and Social Pharmacy. 2022;5:100104. doi:10.1016/j.rcsop.2022.100104
Merks P, Jakubowska M, Drelich E, et al. The legal extension of the role of pharmacists in light of the COVID-19 Global Pandemic. Research in Social and Administrative Pharmacy. 2021;17(1):1807-1812. doi:10.1016/j.sapharm.2020.05.033
Comirnaty® [package insert] Pfizer Inc., New York, NY. 2021.
Spikevax [package insert] Moderna US, Inc. Cambridge, MA, 2022.
Janssen. [package insert] Janssen Biotech, Inc. A Janssen Pharmaceutical Company of Johnson & Johnson Horsham, USA, PA. 2021.
Ettman CK, Cohen GH, Abdalla SM, et al. Persistent depressive symptoms during COVID-19: A national, population-representative, Longitudinal Study of U.S. adults. The Lancet Regional Health – Americas. 2021;5:1-12. doi:10.1016/j.lana.2021.100091
History and Overview of Long-acting Injectable Antipsychotics
Long-acting injectable (LAI) antipsychotics are commonly indicated for schizophrenia. Schizophrenia is characterized by positive, negative, and cognitive symptoms.1
Schizophrenia Symptoms
Positive Symptoms
Negative Symptoms
Cognitive Symptoms
Hallucinations, Delusions, Disorganized thinking
Anhedonia, Alogia, Affect flattening, Avolition
Attention and memory impairment, Diminished executive functioning
The first LAI was introduced in 1966 with proven applicability and convenience for patients and healthcare providers alike.2 Before the turn of the century, many healthcare professionals such as psychiatrists and psychologists directly treated patients with schizophrenia and other similar mental illnesses in hospital settings.2
It wasn’t until the latter part of the 20th century where outpatient services vastly grew. With expansions in psychiatric healthcare, there was strong acknowledgement of the problem of nonadherence of antipsychotic medications prescribed in the long term. The recognition of the use and need of LAIs definitely demonstrated good patient outcomes despite early side effect profiles with first-generation antipsychotics (e.g., tardive dyskinesia, extrapyramidal symptoms). Subsequently, second-generation LAIs were then introduced in 2003, but also presented with its own side effect profiles in direct comparison to oral agents (e.g., QTc prolongation, sedation, weight gain).3 Choosing the right LAI for the right patient can be challenging when there are many factors to consider, but it is always important to have your patient’s best interest in mind.
Image: unsplash.com
The Issue of Adherence
Long-acting injectable antipsychotics are largely prescribed for combating the issue nonadherence. LAIs are highly effective in preventing relapse of schizophrenia; however, there are numerous barriers that often prevent patients from staying on their appropriate LAI regimens. The common reasons for nonadherence of LAIs can be attributed to4:
stigma
serious adverse events
patient mistrust with healthcare professionals
lack of medical resources
patient denial of diagnosis
regimen issues
Most often than not, patients are nonadherent because their symptoms might simply “resolve” or “go away.” While on oral medication, patients might take their pills when their symptoms come back and these gaps in therapy might not be the best course of treatment patients. LAIs, however, fix this issue as patients are more likely to be adherent. This is mostly in part to longer dosing intervals and the elimination of oral overlap in some LAIs. Since the medication is slowly delivered over the course of weeks to months, it is likely that the patient will be more willing to continue therapy in the convenient setting of an outpatient clinic.
As always, it is important to discuss with patents the risks and benefits of LAIs. An informed patient will have the tools for better decision making in the long run. A summary of long-acting injectable antipsychotics is outlined below.5,6
Medication
LAI Generation
Injection Schedule
Haloperidol Decanoate Haldol
First generation
Every monthNo PO overlap if loading dose is given
Fluphenazine Decanoate Prolixin
First generation
Every 2 to 3 weeksNo PO overlap
Risperidone Risperdal Consta
Second generation
Every 2 weeksPO overlap given 3 weeks after first injection
Paliperidone Palmitate Invega Hafyera
Second generation
Every 6 months; No PO overlap*
Paliperidone Palmitate Invega Sustenna
Second generation
Every month; No PO overlap
Paliperidone Palmitate Invega Trinza
Second generation
Every 3 months; No PO overlap
Olanzapine Pamoate Zyprexa Relprevv
Second generation
Every 2 weeks or every 4 weeks; No PO overlap
Aripiprazole Monohydrate Abilify Maintena
Second generation
Every month; PO overlap given 2 weeks
Aripiprazole Lauroxil Aristada
Second generation
Every 1 to 2 months; PO overlap given 21 days after first injection
* = Invega Hafyera (approved in 2021 for twice a year administration) is safely administered to patients who have been taking either Invega Sustenna or Invega Trinza. Oral paliperidone is needed when there is incomplete administration between doses. See package insert for more information.
Image: unsplash.com
Long-acting Injectable Antipsychotics: First Generation vs Second Generation
The side effect profiles of first and second generation LAIs are unique to their respective classes. For example, First generation LAIs can cause more extrapyramidal symptoms (e.g., akathisia) than second generation LAIs. In addition, second generation antipsychotics can cause undesirable side effects such as metabolic issues (weight gain and hyperlipidemia), sedation, and hyperprolactinemia.5
Selection is everything. Second generation LAIs such as paliperidone and risperidone are known to have higher incidences of hyperprolactinemia than aripiprazole.3 With all things considered, depending on the patient’s comorbid conditions and specific risk factors (heart disease, sleep disturbances), certain LAIs may be given priority over others.
Clinical research has shown that even though second-generation LAIs are fairly tolerable given their side effect profiles, differences in patient relapse outcomes are pretty much favorable just like their first generation counterparts.3 The ACLAIMS trial was a pivotal randomized controlled trial that examined the relapse differences in patients with schizophrenia who were administered either haloperidol decanoate or paliperidone palmitate. The primary outcome of efficacy failure in both groups was not statistically significant (HR = 0.98; 95% CI = 0.65-1.47).7 Given these clinical outcomes, LAI therapy is guided by patient factors rather than a certain medication.
Image: Unsplash.com
Other Considerations for Long-acting Injectable Antipsychotics
Some patients may have other conditions or diagnoses that might be a cause for concern. In any case, a comprehensive medication history is needed for the appropriate LAI treatment. The following considerations may be evaluated on a case-by-case basis8,9:
Patient Considerations for Long-acting Injectable Antipsychotics
Pregnancy
Pregnant patients may safely take an LAI unless: There is a known contraindication There is a rational reason for discontinuation
Pregnant patients may benefit from taking an LAI if: There is a history of nonadherence There is a history of many hospitalizations There is a history illicit drug use There are unresolved symptoms during postpartum term
Differential Diagnosis
Patients are candidates for LAIs if they also have these diagnoses: Bipolar disorder* Schizoaffective disorder†
* = Certain LAIs are indicated for the maintenance treatment of bipolar I disorder. See individual package inserts for appropriate indications. † = Schizoaffective disorder includes schizophrenia symptoms and can overlap with either bipolar or depressive type manifestations.
After selecting the right treatment for the right patient, long-acting injectable antipsychotics can be quite effective in treating patients with schizophrenia. The data out there is consistent with positive results with both LAI generation formulations. Despite these outcomes, adherence remains a widespread problem.3 Healthcare professionals should always advocate for their patients while reinforcing the advantages of therapy. With collaborative efforts, we will eventually see a step in the right direction.
Dr. Joseph Suarez, Pharm.D. is a Medical Writer at RxPharmacist, LLC who resides in San Antonio, Texas. His interests are in psychopharmacology, psychotherapy, and reconciling healthcare disparities. Dr. Suarez is seeking opportunities to utilize his incredible medical writing talents. If you are looking to hire, you may contact Dr. Suarez via LinkedIn.
References:
American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5). Washington, DC: APA, 2013.
Johnson DAW. Historical perspective on antipsychotic long-acting injections. The British Journal of Psychiatry . 2009;195:s7-s12. doi: 10.1192/bjp.195.52.s7
Correll CU, Lauriello J. Using long-acting injectable antipsychotics to enhance the potential for recovery in Schizophrenia. The Journal of Clinical Psychiatry. 2020;81(4):1-8. doi:10.4088/jcp.ms19053ah5c
Crimson ML, Smith T, Buckley PF. Schizophrenia. In: Pharmacotherapy: A Pathophysiologic Approach. 11th ed. New York: McGraw Hill Medical; 2020.
Invega Hafyera. [package insert]. Janssen Pharmaceuticals, Inc. Titusville, NJ. 2021.
McEvoy JP, Byerly M, Hamer RM, et al. Effectiveness of paliperidone palmitate vs haloperidol decanoate for maintenance treatment of schizophrenia. JAMA. 2014;311(19):1978. doi:10.1001/jama.2014.4310
Reinstein SA, Cosgrove J, Malekshahi T, Deligiannidis KM. Long-acting injectable antipsychotic use during pregnancy. The Journal of Clinical Psychiatry. 2020;81(6):1-3. doi:10.4088/jcp.20ac13597
Pacchiarotti I, Tiihonen J, Kotzalidis GD, et al. Long-acting injectable antipsychotics (LAIS) for maintenance treatment of bipolar and schizoaffective disorders: A systematic review. European Neuropsychopharmacology. 2019;29(4):457-470. doi:10.1016/j.euroneuro.2019.02.003
All images in this article pulled from: unsplash.com
PTSD Overview
Post-traumatic stress disorder (PTSD) is a type of anxiety disorder that is more common than you might think. It is estimated that at least 60% of men and 50% of women will go through some sort of traumatic experience in their lifetime.1 Also, the one-year prevalence of PTSD in the United States is approximately 3.5 to 4.7 percent.2 PSTD has long been associated with the terms “shell shock,” “post-Vietnam syndrome,” and “combat fatigue” in veterans for years; however, PTSD can occur in all populations regardless of age, gender, race, or socioeconomic status.3 There are many treatments available for PTSD that have been proven effective and in recent years, there have also been innovative yet experimental approaches to treating PTSD.
In summary, PTSD occurs after a traumatic experience (e.g., car collision, sexual assault, witnessing a death, developing a serious medical illness) and can manifest in different ways months to years after the trauma has passed. Although every case of PTSD is unique, many people will experience hallmark symptoms or manifestations such as intrusion, hyperarousal, avoidance,and distortions in thinking. These symptoms must be present for at least a month and cause marked distress that impairs the person’s quality of life.3
PTSD Symptoms/Manifestations3
Term
Definition
Examples
Intrusion
Unwanted and intrusive thoughts associated with trauma. This is also known as “re-living” the traumatic experience and can occur with constant flashbacks or nightmares. Certain noises, sights, and smells of a similar manner in which the trauma occurred can trigger strong, spontaneous emotions.
A retired veteran wakes up from a recurring nightmare about an airstrike that occurred 30 years agoA woman has an instant flashback of a robbery that happened a year ago while hearing popping of balloons in a department store
Hyperarousal
The state of being irritable, easily shaken, hypervigilant, self-destructive, distracted, or unreasonably aggressive after a traumatic experience occurs.
A young man becomes overprotective of his 5-year-old daughter around dogs after a he suffered a vicious dog attack last month A woman flinches when people hug her during get-togethers after a close family friend sexually assaulted her years ago
Avoidance
Evading or going out of one’s way to avoid situations, places, discussions, activities, or objects that serve as triggers of past trauma.
A man takes a shortcut on his way to work to avoid the construction site where he crashed into another car during a busy intersectionA girl avoids rollercoasters when she goes to amusements parks after her friend was ejected next to her on a ride with faulty safety equipment
Distortions in Thinking
Irrational, distorted, or negative thinking in one’s behavior, feelings or thoughts after experiencing trauma. This can lead to beliefs that oneself or other people are “untrustworthy” or “bad.” Sometimes there is also thinking that oneself or other people do not deserve happiness or the right to lead a normal life.
A woman holds anger directed at all of her doctors after learning her primary care physician misdiagnosed her serious heart condition that caused a delay treatmentA man cuts off all communication with his friends and family after he was robbed at knifepoint while walking to the bus stop two years ago
As always, it is important that proper diagnosis from either a psychiatrist, physician assistant, nurse practitioner, or licensed therapist is confirmed before any treatments are started. Related conditions that can highly mimic PTSD are the following3:
social anxiety disorder
panic disorder
agoraphobia
separation anxiety disorder
social anxiety disorder,
acute stress disorder,
disinhibited social engagement disorder, adjustment disorder
reactive attachment disorder (in children)
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Current Evidenced-based Treatments for PTSD
There are a wide array of treatments for PTSD that are backed by evidence-based science. PTSD patients can choose nonpharmacological, pharmacological, or a combination of both. At times patients can be hesitant to try a new medication and might want to explore other approaches first. Since patient situations and circumstances vary, the provider and patient will come up with a plan for the best course of treatment. Nonpharmacological treatments for PTSD psychotherapies involve cognitive behavioral therapy (CBT). The types of CBT that are promoted by the American Psychological Association (APA) guidelines and the Veterans Health Administration and Department of Defense (VA/DoD) guidelines are4,5:
Cognitive Processing Therapy(CPT) – A type of PTSD therapy that focuses on changing internal thoughts and feelings in order to eliminate current and future negative thoughts and actions. CPT encourages the patient to rationalize or “make sense” of the traumatic experience, and how it has changed their perceptions either about themselves or others around them. CPT is typically 12 sessions (once weekly) and the patient will learn tools to help them come to terms with their trauma and how to cope with everyday life.6
Prolonged Exposure (PE) – A type of PTSD therapy that involves “rechallenging” or gradual repeated exposure to a situation, place, or activity that was once the source of trauma for the patient. PET helps the patient to incorporate “emotional processing” to slowly process the events related to the trauma that was not processed initially. To help guide this process, in vivo and imagined exposure are incorporated into therapy. In vivo exposure encourages patients to go back to the event, situation, or activity to accomplish a sense of desensitization of the trauma. Imagined exposure helps patients with confronting thoughts, memories and feeling surrounding the traumatic experience.6
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Another psychotherapy treatment for PTSD is Eye Movement Desensitization Reprocessing (EMDR). This involves the patient recalling the trauma and examining the patient’s current emotional state. The patient moves their eyes from side to side during the session and the patient slowly incorporates positive thoughts when the traumatic thoughts subside.6
The APA and the VA/DoD have recommended CPT and PE after extensive systematic and meta-analysis of these evidenced-based treatments.7 It is important to note that the APA guidelines on PTSD are for treating all individuals, while the VA/DoD guidelines are recommendations for providers working for the VA or the DoD.7 Currently the APA guidelines suggests the use of EMDR, however the level of evidence is conditional.4 It is unclear at this time if the level of evidence will be changed to “strong” in the not-too-distant future. This contrasts with the VA/DoD’s strong recommendation for use in patients with PTSD.5 Even though EMDR needs additional exploration to address some limitations (cultural differences, diverse clinical settings), EMDR is still widely used in patients with PTSD.7
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Pharmacotherapy
Currently, only four medications are recommended for the treatment of PTSD: sertraline, paroxetine, fluoxetine, and venlafaxine. While only sertraline and paroxetine are FDA approved for the treatment of PTSD, the APA and the VA/DoD recommend all the aforementioned medications for use.4,5
Medication Recommendations for PTSD4,5,8
Medication/Class
Indication
FDA Approval
APA Recommendations
VA/DoD Recommendations
Sertraline (SSRI)
PTSD
Yes
Conditional*
GRADE A†
Paroxetine (SSRI)
PTSD
Yes
Conditional
GRADE A
Fluoxetine (SSRI)
PTSD (off-label)
No
Conditional
GRADE A
Venlafaxine SNRI)
PTSD (off-label)
No
Conditional
GRADE A
SSRI = Selective Serotonin Reuptake Inhibitor, SNRI = Serotonin-Norepinephrine Reuptake Inhibitor, * = Conditional recommendation indicates good outcomes, but evidence may not be robust (risks vs benefits may vary from patient to patient), † = The GRADE system examines four domains for strength recommendation: Outcomes (morbidity, mortality, quality of life), Evidence Quality (randomized controlled trials, meta-analysis), Patient Preferences (risks vs benefits for patients, certain beliefs or perspectives in approach to therapy) and Other Implications (resources and/or cost-effectiveness)
In patients with PTSD, the VA/DoD suggests the usage of trazodone (GRADE B evidence for adjunctive treatment) for sleep disturbances and prazosin (GRADE B evidence for adjunctive treatment) for nightmares. Currently, the APA does not have current recommendations for these medications two medications.4,5
As far as benzodiazepines are concerned, the APA does not make mention of any usage of this medication class in their guidelines. The VA/DoD however, strongly recommends (GRADE D) against the usage of benzodiazepines, citing insufficient evidence and adverse side effect profiles5,9
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The Future of PTSD Treatments: Psychedelics
Recently, the use of psychedelic medications has been gaining worldwide attention. In 2019, esketamine, a dissociative hallucinogenic therapy, was approved by the FDA for treatment-resistant depression.10 Other psychedelics such as psilocybin and 3,4-methylenedioxymethamphetamine (MDMA) have also followed suit for future FDA approval.
In 2021, psilocybin was granted FDA breakthrough therapy designation for depression after a phase 2, randomized, double-blind, placebo controlled trial.11 This trial compared baseline depression scale scores in those taking either escitalopram or psilocybin.12 Results showed little difference in the change in scores (2 points difference between both groups) but did implicate some promise for future use. Experts claim that psilocybin will likely gain FDA approval for depression in a couple of years.13 In the PTSD realm, the jury is still out on whether or not psilocybin has its own unique place in therapy.
Similarly, MDMA was granted FDA breakthrough therapy designation for the treatment of PTSD first in 2017 after a phase 2 trial, and more notably in 2021 after a phase 3, randomized, double-blind, placebo controlled trial.14,15The 2021 phase 3 trial compared the remission rates of PTSD in those taking either MDMA or placebo. After 18 weeks, two-thirds (67%) of the participants taking MDMA demonstrated complete remission of PTSD as opposed to the 32% taking placebo.10 Even though head-to-head studies are needed to demonstrate superiority (sertraline vs MDMA), so far, this novel treatment is making strides on its own.15 FDA approval for the use of MDMA in patients with PTSD could be coming as soon as 2023.13
Possible uses of psilocybin and MDMA does come with its own disadvantages. Both medications do carry the potential for abuse, just like their predecessor esketamine. Another thing to consider is the limitations of the setting in which these psychedelics are taken. In other words, it is highly unlikely that both these medications will be administered in a place other than a controlled environment like a licensed facility.
Whether we want to accept it or not, psychedelics might be here to stay for the long haul. What was once viewed by many as dangerous, mind-altering drugs are now seen with gradual acceptance for the future in treating many mental illnesses including PTSD.
About the Author
Dr. Joseph Suarez, Pharm.D. is a Medical Writer at RxPharmacist, LLC who resides in San Antonio, Texas. His interests are in psychopharmacology, psychotherapy, and reconciling healthcare disparities. Dr. Suarez is seeking opportunities to utilize his incredible medical writing talents. If you are looking to hire, you may contact Dr. Suarez via LinkedIn.
Clinical Practice Guideline for the Treatment of PTSD. American Psychological Association. https://www.apa.org/ptsd-guideline/ptsd.pdf. Published February 24, 2017. Accessed February 1, 2022.
Watkins LE, Sprang KR, Rothbaum BO. Treating PTSD: A review of evidence-based psychotherapy interventions. Frontiers in Behavioral Neuroscience. 2018;12(258).doi:10.3389/fnbeh.2018.00258
Medications for PTSD. American Psychological Association. https://www.apa.org/ptsdguideline/treatments/medications. Published May 2017. Accessed February 1, 2022.
Carhart-Harris R, Giribaldi B, Watts R, et al. Trial of psilocybin versus escitalopram for depression. New England Journal of Medicine. 2021;384(15):1402-1411. doi:10.1056/nejmoa2032994
Expert: MDMA is very likely to be FDA-approved for PTSD by the end of 2023. Pharmacy Times. https://www.pharmacytimes.com/view/expert-mdma-is-very-likely-to-be-fda-approved-for-ptsd-by-the-end-of-2023. Published November 7, 2021. Accessed February 1, 2022.
Feduccia AA, Jerome L, Yazar-Klosinski B, Emerson A, Mithoefer MC, Doblin R. Breakthrough for trauma treatment: Safety and efficacy of MDMA-assisted psychotherapy compared to Paroxetine and Sertraline. Frontiers in Psychiatry. 2019;10.doi:10.3389/fpsyt.2019.00650
Mitchell J, Harrison C, Lilienstein A, Bogenschutz M. MDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study. Nature Medicine. 2021;27:1025-1033. doi:https://doi.org/10.1038/s41591-021-01336-3
Many of my peers may agree that we are often pushed and pulled in multiple directions during our education. Encouraged to find our place, we stress on discovering where we best fit in the field of pharmacy. We tend to try to tailor our interests based on the discussions with alumni, interactions with mentors, or academic experiences. However, this is still not enough. We may not immediately enjoy our first experience after earning our long-desired degree. We may regret it. Or we may feel lost if we don’t get the position we thought we’d always hoped for. Or we may feel overwhelmed because we couldn’t choose what we wanted to do. This is where I found myself after graduation. I’m sure I am not the only one who has or will be here too.
Instead of asking “what do I do now”, I changed my thinking into “what CAN I do now”. I reminded myself that I have a world of opportunities to dip into all of my interests. An area that I only had some exposure in was non-traditional pharmacy areas such as medical writing. Hence, I began exploring the roles I could have in this area by asking my classmates who had fellowships or went straight into the workforce, having phone and video calls with professionals with years of experience, and researching what they entailed. I had the pleasure to learn about RxPharmacist from a fellow peer who was an intern with the company right after we graduated. As someone who enjoys creating educational materials and staying updated on healthcare topics, medical writing seemed fitting for me and led me to apply for RxPharmacist. When I was welcomed into the company as an intern, I was happy to find a place where I could improve my proficiency in editing, quality checking, writing, and researching. Moreover, I feel lucky to have a boss and supervisor who has given me guidance in this relatively unknown area of pharmacy and motivates me to never settle for anything less than what is best for me. My mentor and preceptor were a pillar of support who I could share all my goals and obstacles with. They were instrumental in pushing me forward in my career and remain as valuable individuals that I am grateful for knowing. It is thanks to RxPharmacist that I could fully invest in all the interests that I’ve always wanted to.
Denzel Washington once wrote, “Show me a successful individual and I’ll show you someone who had real positive influences in his or her life. I don’t care what you do for a living — if you do it well I’m sure there was someone cheering you on or showing the way. A mentor.” [1]
Washington’s words ring true not only for himself but for everyone. It doesn’t matter if someone is an intern, contractor, associate, or director as a true mentor will always be invaluable to their development both professionally and personally throughout their career.
RxPharmacist strives to help young professionals thrive through tailored mentorship which provides ample opportunity to paint a unique portfolio of accomplishments in their own image and color. This kind of experience is invaluable in not only helping develop those hard and soft skills, but has the additional benefit of sharpening them further into evolving and channeling a person’s unique self if they are already further along in their professional journey.
RxPharmacist’s stellar mentorship model has benefited professionals in all walks of life. Interns are offered a wealth of support which include 1:1 mentoring, professional networking and hands-on projects which emphasize the healthy balance of teamwork and independent initiative needed to really shine in a typical workplace. Likewise, employees are consistently encouraged to try new things and venture outside their comfort zone to further refine and grow their abilities. It is not an understatement to say the bright, adventurous, and nurturing culture at RxPharmacist is the pinnacle of its success and family-like spirit.
Anyone can develop their career anywhere, but it is the dedication and commitment of the RxPharmacist model to both personal and professional growth which sets it apart from other opportunities. At RxPharmacist, curiosity is not punished but eagerly rewarded and creativity is not pushed aside but highly embraced. There is a clear value and framework for inclusion at RxPharmacist which empowers and supports employees from all backgrounds to have a real sense of belonging and support. To earn one’s stripes is no simple feat, but with the right support and mentorship it can be just the beginning to a highly remarkable journey ahead.
Here at RxPharmacist we are always eager to welcome new interns and employees to our team, feel free to apply by submitting your information through our website.
Bibliography
1. Washington D. The Mentors He’ll Never Forget. Guideposts. https://www.guideposts.org/better-living/positive-living/the-mentors-hell-never-forget. Published 2007. Accessed January 26, 2022.
