Newsflash: Its August. (Part 2)

Posted by Kristen Gardner at Tuesday, August 07, 2012

I am one week into my inpatient psych rotation at the National Institutes of Health (NIH) Clinical Center in Bethesda, MD!

Anyone who knows me knows that I want to be a psychiatric pharmacist! Therefore, I was super pumped for this rotation. I was first introduced to my preceptor, Dr. Gerald Overman, by Dr. Ellingrod, a researcher at the College, at the 2011 CPNP Annual Meeting a few years ago. I was really excited to get to know him better.

The rotation is very different from what I expected. I knew that it had a research focus because it was in the Clinical Center; however, I did not realize how this component would both develop and limit the experience. We cover 4 units, 2 adult and 2 pediatric. The 2 adult units are a schizophrenia unit and a mood/anxiety disorders unit which is similar to the Maize and Blue team at UMHS. The child units include a childhood onset psychosis team and a bipolar spectrum disorders team.

Positives

• It has been great to experience and observe mental illness in children and adolescents- that is something that you would not gain with a psych rotation at UMHS.
• Gaining experiencing with tapering meds as most patients need to be taken off their med to start on study medication
• Tapering a stable patient with schizophrenia off their antipsychotic = unpleasant
• I am learning how to conduct a mental status examination (AMSIT) this week!
•  AMSIT is an acronym used to help remember the major domains assessed in the mental status examination (A=appearance, speech, and behavior; M= mood and affect; S= sensory, I=intellectual, T=thought)
• This is NOT the same as a mini mental status exam (MMSE), a screening tool for dementia
• This is analogous to how critical the physical exam is in the work-up for a physical complaint
• I am really brushing up on my pharmacology because of the research nature of this rotation and reading through the protocols with the background evidence, hypothesis, and specific aims.
• There are active studies examining cognitive enhancing medications for the treatment of schizophrenia (modafinil, tolcapone), ketamine (+/- riluzole) for treatment resistant depression, and learning about one research group’s argument for a new diagnosis of severe mood dysregulation and how that differs from pediatric bipolar disorder using extreme irritability as a hallmark trait with a standard treatment of a stimulant/antidepressant. This is actually VERY fascinating so I will leave a reference JUST IN CASE you need to stop everything you are doing to understand their rationale. 

§  Leinbenluft, E. Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths. Am J Psychiatry. 2011 168(2): 129-42.

Negatives

•  The research focus limits creativity with treatment as well as patient turnover. We tend to keep the same patients on the unit that are mostly stable and just progressing through the defined protocols. Therefore, my clinical experience is not progressing as much as I had hoped it would. My preceptor and I do have huge topic discussion weekly though which provides some supplementation.

This rotation was definitely an adjustment since I had to wait to get computer training and an assigned username which didn't happen until Friday of the first week. Also, I had to learn all the major active protocols on the unit with each being nearly 100 pages. Woo-hoo! I was also introduced to at least 60 people during the first week. Normally, I am good with names; 60 names is an exception.

Additionally, I attend IRB meetings. To prepare for this, I only have to skim through 500 pages at least. No biggie.

Projects for the rotation include leading two medication education groups, one for each of the adult teams (schizophrenia and mood/anxiety), and developing a presentation to deliver to the pediatric behavioral health team. Now, normally I love giving presentations and I am not nervous so hopefully that feeling wins out over the nervousness associated with teaching top notch professional at the NIH….re: research team investigating new diagnosis. I am also writing a quick submission for the pharmacy and therapeutics (P&T) committee.

This rotation, even with its limitations, has solidified my interest in the specialty. I have really gained an appreciation for how devastating depression can be as we have many patients with treatment refractory depression on the unit. Hearing them talk about their frustration with apathy is difficult. One patient stated, “I don’t want to work because people work to buy things that make them happy, but nothing makes me happy.” I did witness hypomania after one dose of lorazepam! Oh my, it was remarkable! This patient had a mask-like facial appearance, no eye contact, barely spoke, and was apathetic. After one evening dose of lorazepam, the patient did not sleep, was a chatterbox with me (someone he has never met before), and was trying to talk his wife into buying a new home. The psychiatrist thought the patient might have been mildly catatonic (a state of immobility), and, in patients with catatonia, BDZs are first line treatment choice.  However, that did not work out as we hoped. Clearly, we stopped treatment and then re-initiated at a lower dose.

I have enjoyed learning about the patients with schizophrenia the most. I have so much respect for these patients and their strength. I always try to put myself in the patient’s shoes when providing care. For these patients, I cannot imagine functioning normally in your environment and then having your world be turned upside down and basically taken away. Not only do they have to deal with auditory hallucinations (very common) of people talking to you telling you that you are worthless and how to kill yourself, for example, but they also suffer severe cognitive deficits. In tasks related to cognition they function 20-50% of normal healthy volunteers. Some cannot spell WORLD backwards or even count backwards from 100 by 7s- they cannot even make it to 93! This is one of the things I am most passionate about as no medications substantially improve this dimension of the illness. Some treatments are being investigated- modafinil, tolcapone (a COMT inhibitor- watch out for liver toxicity!), and the second-generation antipsychotics SUPPOSEDLY help from a theoretical/mechanistic standpoint, but clinically? Who knows. 

Until next time!