He argues that there are good reasons for pharmacists to specialise in psychiatry. “Medications are one of the primary treatment modalities for mental disorders and so it just sort of makes it ideal that pharmacists would be involved – particularly pharmacists who really enjoy interacting with people and communicating”, he explains.

Early in his career Professor Lynn Crismon worked in the US Public Health Service on the Navajo reservation. Here he explains what conditions were like and how he was called to assist with a case of bubonic plague soon after being posted to the Navajo reservation.

A later posting took him to a 35-bed hospital in Winslow, Arizona. He recalls that there was no psychiatrist on the entire Navajo reservation and patients had to be sent to a town some 60 miles away if a psychiatric consultation was required. He took responsibility for following up patients who were receiving psychotropic medication and his interest and expertise in the field grew.  Later he was able to use his expertise to contribute to prescribing guidelines and algorithms to optimise the use of psychotropic drugs and minimise overprescribing.

He says that the coronavirus pandemic has had a huge impact on mental health in general but especially on health care workers and on children. In the fourth video he reflects on some of the problems that this has caused and how some of the difficulties might be addressed.

“Psychiatric pharmacy is really all about people and working with people and caring for people”, says Professor Crismon. It is an area of therapeutics that offers wide variety of opportunities for progressive pharmacy practice in primary and secondary care.

Read and watch the full series on our website or on YouTube.

Commenting on the impact of the coronavirus pandemic on mental health Professor Crismon says, “the incidence of depression has increased, the incidence of suicide attempts has increased in the United States, the incidence of drug misuse has increased as well”. In addition, health care workers have been impacted by exposure to the virus and also by long working hours. “At least in the United States – I don’t know it’s the same way in the UK – we have a real shortage of almost everybody because the burnout rate is extremely high. People are dropping out of the workforce because they just can’t they can’t tolerate any more”, he says.

“I don’t think we can over emphasize the impact that covid has had on children. They’ve really missed out on a lot of their socialization and their social development that that they get at school and through social organizations and team athletics. The pressure that is that is put on parents in terms of trying to do home schooling [is immense]. I can’t imagine taking a first grader and then trying to learn on Zoom – it’s hard enough for college students”, he adds.

“Psychiatric pharmacy is really all about people and working with people and caring for people”, says Professor Crismon. Diagnosis hinges on talking to people and assessing symptoms.  In future biomarkers may be available for routine use but at present these are only research tools.  “People with severe mental illnesses have challenges with taking their medications and so for a community pharmacist, interventions to improve adherence are really important. In fact, in the United States we have some specialty pharmacies that only take care of individuals that have mental illnesses and they’re usually part of a public mental health clinic. in many states in the United States now, including Texas, a pharmacist can get reimbursed by the public insurance for giving long-acting antipsychotics by [intramuscular] injection and so there are even opportunities from that standpoint for those that want to specialize”, he explains. Some pharmacists undertake comprehensive medication management in collaboration with psychiatrists and one of Professor Crismon’s colleagues has specialised in working with chronic pain patients.

The Board of Pharmaceutical Specialties in the US provides certification for psychiatric pharmacists. A number of pharmacists outside the US are also board-certified in psychiatric pharmacy including some in the UK, Canada, Australia, western Europe and the Middle East.

Professor Crismon’s latest project is concerned with improving the quality of mental health services in primary care for children. “Right now, I’m working with a non-profit foundation that’s out of New York city – the REACH institute – whose primary goal is to improve the quality of mental health care in primary care. We don’t have enough specialists in the United States to be able to meet all the needs that children have for mental health and so we’re trying to train and support primary care clinicians”, he says.

M. Lynn Crismon is the Behrens Centennial Professor of Pharmacy and Professor of Psychiatry at Dell Medical School at the University of Texas at Austin. His specialty area is psychiatric pharmacy and clinical psychopharmacology.

Read and watch the full series on our website or on YouTube.

After completing his residency training Professor Crismon was transferred to a 35-bed hospital in Winslow, Arizona that served the Navajo population. There was no psychiatrist on the entire Navajo reservation and patients had to be sent to a town some 60 miles away if a psychiatric consultation was required. Such patients would be followed up in the out-patient clinic by social workers.

He recalls, “Our medical director came to me – I’d maybe been there six weeks or so – and he said, “I feel really uncomfortable with the psychotropic prescribing – I don’t know anything about it. You know, the social worker is sort of looking over this stuff after the meds are prescribed by the consultant – I want you to review and approve all the prescriptions for psychotropics””.

Equipped only with limited knowledge of psychotropic pharmacology he started reading avidly. “I started interacting with the patients and became really fascinated by the disease states and how they how they affect people and how they affect people’s lives and, in particular, at that point in time, with the disease schizophrenia and just the devastating impact that it has on people’s lives”, he says. About 85 percent of people diagnosed with schizophrenia have a lifelong disease and, although treatments have improved, they are still far from perfect, he adds.

His experiences stimulated his interest in psychiatry and also taught him that “you don’t need fancy buildings and expensive technology to provide good health care, you need people that really care and are committed and I also learned the importance of interdependency and relying on one another – and really learned about team-based care before it became a fad”, he says.

Psychotropic prescribing

Professor Crismon played a leading role in the development of psychotropic prescribing parameters for children in foster care. Such children typically come from impoverished families have a higher incidence of emotional and mental problems.

Professor Crismon explains, “There were a number of journalist investigations of inappropriate prescribing and, in fact, one of our state agencies started looking into the prescribing through the state Medicaid program …… and there was a real problem with just way too many medications being used in children at the same time, sometimes as many as eight and ten and twelve medications”.

In 2003, in Texas, a task force was established to examine the problem and make recommendations for improvement.  “I was on that task force and one of the recommendations was that we put together a multi-disciplinary committee to develop prescribing parameters for children that were in foster care. We released those in 2005 and we’ve updated them every two or three years since then”, he says.

In 2019 the scheme was expanded to include all children receiving mental health services through the state Medicaid program. “We saw over time that that the use overall of psychotropic medications decreased. The use of drugs within the same therapeutic class – the same mechanism of action – decreased as well as just the total number of medications. Now with all the stresses during covid that’s tweaked up a bit but it’s still much, much lower than it was when we rolled this out in 2005”, he says.

M. Lynn Crismon is the Behrens Centennial Professor of Pharmacy and Professor of Psychiatry at Dell Medical School at the University of Texas at Austin. His specialty area is psychiatric pharmacy and clinical psychopharmacology.

Read and watch the full series on our website or on YouTube.

The US Public Health Service (PHS) is a federal agency that addresses public health issues in the United States. The National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC) are both parts of the Public Health Service as are the health care that’s provided in federal prisons and the Indian Health Service.  Most of the health care professionals are commissioned into the (non-military) uniformed services explains Professor Crismon.

After graduation he learned that “the level of pharmacy practice, in the United States at least, was probably higher in the Indian Health Service than it was anywhere else”, and this stimulated him to apply for a post in the service. He was posted to the Gallup Indian Medical Center (in Gallup, New Mexico) which is the referral hospital for the Navajo Indian reservation. The Navajo reservation is about the same size as the state of West Virginia (ca 62,000 sq. Km, about twice the size of Belgium) and is largely rural. “In fact, it was pretty much a third world country inside the United States in northern Arizona, western New Mexico and in a bit of southern Utah – very few towns, a few little villages”, says Professor Crismon. “Most of the people lived in the country, over half of them didn’t have running water or plumbing. They might use a community well that was within a 30- or 40-mile radius and so there were a lot of communicable diseases that that were associated with general poor public health. At that point in time most didn’t speak most didn’t speak English”, he continues.

He had only been in post for a short time when he was called to attend a cardiac arrest on a paediatric ward. The patient was a 13-year-old Navajo girl who was thought to be suffering from bubonic plague.

He recalls, “The parents did not speak any English and there is no word in Navajo for autopsy. The closest thing would be ‘butcher’ and obviously you’re not going to ask a parent whether you that you can butcher their daughter and so we did CPR (cardio pulmonary resuscitation) on this girl for at least two hours so that the infectious disease physicians could collect all the samples that they needed to be able to confirm that she had bubonic plague and also to confirm that she did not have pneumonic plague, which would have made it highly contagious”.

During the procedure he helped with the prolonged CPR and was exposed to the girl’s saliva.  It turned out the she did have bubonic plague and he had to take a prophylactic course of tetracycline. It was, he says “an interesting introduction to practice for a brand-new pharmacist”.

Unlike the outbreaks in Europe in the Middle Ages where the plague bacteria were carried by fleas on rats, on the Navajo reservation they were carried by fleas on prairie dogs. “People’s dogs would go out and hunt and they’d stick their heads down in the prairie dog mounds and the fleas would jump on them and they’d bring them home”, he explains. A physician colleague contracted bubonic plague in this way but responded well to early treatment, he notes.

M. Lynn Crismon is the Behrens Centennial Professor of Pharmacy and Professor of Psychiatry at Dell Medical School at the University of Texas at Austin. His specialty area is psychiatric pharmacy and clinical psychopharmacology.

Read and watch the full series on our website or on YouTube.

Professor Crismon served as Dean of the Pharmacy School for 13 years until Autumn 2020 but now he is able to spend more time teaching. This includes teaching psychiatry, clinical psychology and pharmacotherapeutics to Pharm D students and also teaching in the child and psychiatry fellowship program in the Department of Psychiatry.

He argues that there are good reasons for pharmacists to specialise in psychiatry. “Mental disorders are extremely common and they create a lot of the morbidity, pain and suffering that people have throughout their lives. And, of course, severe mental disorders are also associated with the risk of suicide. Medications are one of the primary treatment modalities for mental disorders and so it just sort of makes it ideal that pharmacists would be involved – particularly pharmacists who really enjoy interacting with people and communicating”, he explains.

During the 1990s he was able to use his specialist knowledge and expertise to develop evidence-based protocols to improve outcomes from drug therapy – something that was known as the Texas Medication Algorithm Project.

The project started when the Texas State Department of Mental Health called together chairs of psychiatry from all the large academic psychiatry programs and their associate directors for research; he was “the token pharmacist”. At the meeting they discussed the challenges that existed in state-sponsored mental health care and the fact that it took so long for the evidence from research to get into clinical practice. In fact, pharmacotherapy and all the other services were substandard in public mental health care because funding was so limited, he recalls.

“We didn’t have enough money to be able to address all the issues that existed in public mental health care but we thought we had enough money to address a specific issue and since a number of us had a real interest in pharmacotherapy and really severe mental disorders we decided to focus on evidence-based practices to improve outcomes from drug therapy treatment of individuals with severe mental disorders and to give the psychiatrist the support systems that he or she needed so that they could provide better care for those patients”, he explains.

Traditionally psychiatrists have assessed patients by interviewing them and getting an overall sense of how severe their symptoms are, but there was increasing evidence at that time that measuring and quantifying the symptoms then better outcomes could be achieved. Using a structured assessment enabled clinicians to detect symptoms that might not have been apparent if general, global questions had been asked.  This approach – systematising the information and providing an overall framework for the pharmacotherapy component of care – was a major part of the initiative.

In addition, they involved mental health consumers to help identify the needs that families and patients had in in relation to their mental disorders and their treatment.  Educational programs using a variety of learning modalities including written materials, videos and pictorial methods were developed to help patients and their families.

M. Lynn Crismon is the Behrens Centennial Professor of Pharmacy and Professor of Psychiatry at Dell Medical School at the University of Texas at Austin. His specialty area is psychiatric pharmacy and clinical psychopharmacology.

Read and watch the full series on our website or on YouTube.