VA Pharmacists Find Niche in Mental Health Services

Pharmacists at the Department of Veterans Affairs (VA) who specialize in mental health disorders say their greatest rewards come from knowing they have helped patients improve their lives.

“I have the best job in the world,” said Cynthia A. Gutierrez, clinical pharmacy specialist (CPS) and Associate Chief of Clinical Pharmacy Programs at the South Texas Veterans Health Care System in San Antonio.

Gutierrez practices at an outpatient specialty clinic for veterans with serious mental illnesses, including psychotic disorders, bipolar disorder, severe posttraumatic stress disorder (PTSD), and major depression.

“I like working with this population, just because I think they are so underserved and misunderstood,” Gutierrez said. “It’s just very, very rewarding.”

She recalled one patient she met soon after she started working at the clinic in 2003 — a veteran with major depressive disorder with psychotic features. She said he came to his appointments but was “essentially mute” during the sessions.

“I would see him every month, every 6 weeks. I tried to get him into psychotherapy and of course he didn’t really want to talk. Psychotherapy doesn’t work if you’re not willing to talk,” she said.

Her biggest worry was that the veteran might harm himself.

Over time, she said, he started to open up and was found to have PTSD, for which he received treatment. He became an active participant in his care and even researched ways to manage his nightmares and cognitive distortions.

“Now he’s much more able to function. He’s taking on projects, working on his car. And he’s happier. He’ll come in and he’ll talk and he’ll tell stories,” Gutierrez said. “It’s hard to believe that he’s the same person.”

One of the most memorable patients for Elayne D. Ansara, CPS for the behavioral health interdisciplinary program at Richard L. Roudebush VA Medical Center in Indianapolis, Indiana, is a veteran she’s never met.

“He probably lives about an hour and a half from the facility, and he actually sees his nurse practitioner via telehealth. So I’ve only talked to him on the phone,” Ansara said.

She said the veteran suffers from PTSD and had nightmares that didn’t respond to standard medications.

Ansara suggested a different medication but warned the patient that the drug came with an increased risk of adverse reactions.

“He said, ‘OK.’ And I called him back a month later and both he and his wife could not believe the difference that it made. His nightmares, although they’re still there, are far less frequent. And he’s able to engage in day-to-day life, whereas he was not able to do that before,” Ansara said.

As of January, 407 CPSs at 119 VA facilities operated under an advanced scope of practice in mental health, said Julie A. Groppi, Pharmacy Benefits Management Program Manager for Clinical Pharmacy Practice, Policy, and Standards at VA’s Clinical Pharmacy Practice Office.

“There’s a great opportunity for pharmacists in mental health — especially in substance use disorders, helping to treat patients with addiction,” Groppi added. “I continue to see this as a growth area for our pharmacists.”

That’s the case at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin, said CPS Theresa Frey.

“We have pharmacists that are in advanced roles in mental health and substance abuse,” she said. “We serve on interdisciplinary teams with other providers and in collaborative practice settings in order to treat patients and meet patients’ needs.”

Frey said she works with about 12 veterans per day at the clinic, where she manages medication therapy, schedules and reviews laboratory tests, and makes follow-up calls when needed.

“But a big part of what I do is motivational interviewing. That’s a way to meet the patients where they’re at and help them reach goals related to things that matter to them. It can be very helpful for behavior changes,” she said.

Frey said patients tell her they appreciate having someone to listen to them and help them turn their lives around.

“It’s really rewarding,” she said.

Christopher Thomas, inpatient mental health CPS at the Chillicothe VA Medical Center in Ohio, estimated that about a third of the veterans admitted to the 28-bed unit are withdrawing from various substances.

Thomas said it’s often hard for those veterans to change the behaviors that led to their admission.

“A lot of what happens is, those patients go back to where they came from. And many times, in those environments, ... they end up relapsing,” Thomas said. “For substance use disorders, it’s just kind of the nature of the beast.”

In addition to patients undergoing withdrawal, Thomas said, the unit typically houses an equal mix of patients involuntarily admitted for schizophrenia and veterans receiving care for bipolar disorder or major depression.

The unit’s treatment team consists of a psychiatrist, social worker, nurse, nurse practitioner, and Thomas, who counsels, consults, orders and reviews laboratory tests, and manages medications for a variety of conditions that affect the patients.

“It could be anything,” he said. “Diabetes, hypertension, of course, psychiatry. Because unfortunately in psychiatry, a lot of these guys have unmet medical needs that often go neglected. So when they come to the unit, it’s a good time for us to do a checkup on them.”

Thomas said he and the pharmacy and psychiatry residents who rotate through the unit do a lot of “deprescribing,” and patients are often discharged on fewer medications than when they were admitted.

“The patients really do appreciate the fact that we try to be concise and really hone in on their medications,” he said.

Thomas said perhaps the greatest challenge his patients face is adherence to their medication regimen after discharge from the unit.

“Once they get out, they start feeling better. Then they oftentimes don’t take their medications,” he said.

Thomas said he’s fortunate to serve these patients in the VA system with its “robust scope of practice.”

Groppi said that in addition to expanding VA’s CPS workforce in mental health, the agency continues to add and train social workers, psychologists, chaplains, and others to support veterans and make mental health services more accessible.

[This news story appears in the May 15, 2019, issue of AJHP.]