Objective. To analyze the cost avoidance resulting from clinical interventions made by pharmacy students completing an advanced pharmacy practice experience (APPE) at a psychiatric hospital. Methods. A retrospective database review of documented clinical interventions by pharmacy students was conducted to classify interventions by type and significance. Interventions were assigned a cost avoidance value determined by an evaluation of the literature. Results. Three hundred-twenty interventions were documented by 15 pharmacy students during the 1-year study period. The majority of interventions were related to psychiatric medication classes and most (n 5 197; 61.6%) were classified as being of moderate significance. The most common interventions included patient education (13.1%), order clarification (11.6%), therapeutic dosing adjustments (10.9%), and laboratory order monitoring (8.8%). The estimated cost avoidance from all interventions made by pharmacy students was approximately $23,000. Conclusions. Pharmacy students completing APPEs at a psychiatric hospital contributed to a variety of significant clinical interventions and provided considerable cost avoidance value to the institution.

Fluoxetine is a bicyclic antidepressant that is a specific and potent inhibitor of the presynaptic reuptake of serotonin. It has essentially no effect on the reuptake of norepinephrine or other neurotransmitters. Similarly, it has negligible binding affinity for neurotransmitter receptor sites. It is well absorbed after oral administration, with absolute bioavailability in dogs of approximately 72 +/- 27.6%. The mean Tmax is between 4 and 8 hours, and it is approximately 94% protein bound. After a single dose, the elimination half-life is 1-3 days. After long-term administration, the elimination half-life averages 4 days. Its pharmacokinetics appear nonlinear. It is metabolized to an active metabolite norfluoxetine, which is also specific for the inhibition of serotonin reuptake. Norfluoxetine's elimination half-life averaged 7 days after long-term administration. Little is known about potential drug interactions; however, fluoxetine appears to have minimal clinically relevant interactions. Fluoxetine is indicated in the treatment of major depression. Its efficacy is comparable to the tricyclics and it has a similar onset of action. Although doses as high as 80 mg/day have been used, the optimal dosage range appears to be 20-40 mg once daily. Fluoxetine has been used with success in obsessive-compulsive disorder and intention myoclonus, however, its use in these disorders remains investigational. The frequency of side effects is low and dose related; the most common effects are nausea, anxiety, insomnia, anorexia, diarrhea, nervousness, and headache. Eight reports of intentional overdose with fluoxetine alone resulted in no deaths and mild adverse effects. It will be marketed as 20-mg capsules under the brand name of Prozac. Although fluoxetine should be added to formularies, its use should be reserved for treatment of those who do not respond to or do not tolerate tricyclic agents.

ClinicalTrials.gov identifier: NCT00130923.

Despite its poorly described pharmacology, effectiveness, and safety, use of St. John's wort (SJW) is largely unsupervised and unexplored, and can potentially lead to adverse outcomes. We conducted a telephone survey of 43 subjects who had taken SJW to assess demographics, psychiatric and medical conditions, dosage, duration of use, reason for use, side effects, concomitant drugs, professional consultation, effectiveness, relapse, and withdrawal effects. Most subjects reported taking SJW for depression, and 74% did not seek medical advice. Mean dosage was 475.6+/-360 mg/day (range 300-1200 mg/day) and mean duration of therapy was 7.3+/-10.1 weeks (range 1 day-5 yrs). Among 36 (84%) reporting improvement, 18 (50%) had a psychiatric diagnosis. Twenty (47%) reported side effects, resulting in discontinuation in five (12%) and one emergency room visit. Two consumers experienced symptoms of serotonin syndrome and three reported food-drug interactions. Thirteen consumers experienced withdrawal symptoms and two had a depressive relapse. These data suggest the need for greater consumer and provider awareness of the potential risks of SJW in self-care of depression and related syndromes.

Neuroleptic malignant syndrome (NMS) is associated with essentially all of the currently available antipsychotic agents. The signs and symptoms associated with the syndrome are hyperpyrexia, defined by body temperature > 38°C; extreme muscle rigidity, with or without elevated creatine Phosphokinase or hyperreflexia; and other symptoms such as altered level of consciousness and/or autonomic dysfunction as manifested by labile blood pressure, tachycardia, tachypnea, urinary or fecal incontinence, pallor, or diaphoresis. This potentially fatal syndrome complicates the treatment of patients with recurrent psychotic symptoms because of the possibility for recurrence of the NMS. A case of recurrent NMS is presented in which the patient was rechallenged with an antipsychotic agent. In addition, 41 reported cases of antipsychotic rechallenge after NMS are reviewed. The results of the review suggest that neuroleptic rechallenge following NMS is associated with an acceptable risk of recurrence in most patients. However, close monitoring for NMS and careful selection of patients for antipsychotic rechallenge is mandatory. A minimal time period of five days before rechallenge may also reduce the risk of recurrent NMS. Recurrence was not associated with patient age or gender, nor the antipsychotic agent used.