The Month of March on 9C

Posted by Shannon Hough at Sunday, April 18, 2010

I spent the month of March back at UMHS, on 9C, the inpatient psychiatry unit. Like most people, I was unsure of what to expect. The unit is a locked unit, and some patients are admitted via court orders or after being certified by a physician involuntarily. I spent the first few days becoming acquainted with the team and the unit staff and refreshing up on the side effects of psych drugs. Early on, my preceptor asked me what I would like to focus on during the rotation. I tried to think of things that I had done little of thus far. I chose patient counseling and journal club presentations. I may have regretted those journal clubs, but am glad that I had a chance to do some patient counseling.

I know, you think that patient counseling sounds like the last thing you would do with a patient who is requiring a psychiatric hospitalization. But I'm pretty sure that if you can counsel a patient during an acute psychiatric episode, you're pretty well equipped to provide good patient counseling!

True to my blogging form, I have story about a patient that I met while on this rotation. I met Mr. X during one of my first days. As some background information, he was not hospitalized voluntarily and had a number of personality disorders, as well as schizophrenia. He also had a court order to take his medications, after some legal proceedings. I will never forget the first time that we entered his room. The medical student taking care of Mr. X introduced the team and asked the patient, "How are you feeling today?". This question prompted the patient to speak for about 10 minutes on a number of unrelated topics ranging from his perceived history as a recording artist, relationship with a pop star, religious convictions, telepathic abilities, and his opinion regarding antipsychotic medications.

Our goal as a team was to get the patient to voluntarily take oral medications, which worked better for him than a long-acting injectable medication that we would be forced to give him if he refused. His list of previous medication trials was lengthy, and were either related to "that didn't work" or "that gave me side effect X". Many of the side effects were surprisingly accurate (although, I'm still not sure about his complaint of "itchy bone marrow").

I felt that the role of the pharmacist to care for this patient was huge. Even once the patient agreed to take the medication, and the orders were written, if the nurse came to administer the medications at a bad time, he could potentially refuse them based upon any ideas in his head. So I made recommendations right away for side effect prevention in this particular patient. Any adverse effects related to the medications could then cause Mr. X to put this agent on his list of medications that he would not take. I wanted to be sure the medication had a fair chance to work.

My patient counseling moment with Mr. X came related to a side effect concern as well. He was taking Depakote, which in his experience had led to hair loss. The mechanism for this side effect is through zinc and selenium deficiency from the medication, so supplementation with zinc and selenium may help to reduce the hair loss.

One afternoon, my preceptor and I approached Mr. X over his afternoon dish of ice cream. I introduced myself as part of the team, who had heard his concerns about hair loss with Depakote. This provoked Mr. X to tell me about something with his legs, but then eventually circle back to agreeing to talk about the topic. I then told him that the zinc and selenium could help to reduce his hair loss. He then told me medications did not make any sense at all and that he didn't need to take any. Some yelling (par for the course) may have occurred. I was a little bit flustered, but continued to ask him if he'd like to try the zinc and selenium. To my surprise, he calmly said yes, that he would like to try it, and thanked me for talking to him. We definitely called it a success!