ment programs.

To increase the outpatient therapist’s Delivery of Mental Health Services,” Americanjournal of Psychiatry,
knowledge of and involvement in a case, the inpatient Vol. 136, October 1979, pp. 1297-1301.
6) H. C. Schulberg, “Community Support Programs: Program
social worker would telephone the day center to discuss
Evaluation and Public Policy,” American Journal of Psychiatry, Vol.
each case before and after the predischarge appoint- 136, November 1979, pp. 1433-1437.
ment. 7) B. M. Astrachan, “Mental Health Care Delivery Systems:
The patients’ outpatient records were examined three Discussion,” American Journal of Psychiatry, Vol. 135, November
months after discharge to determine whether or not 1978, pp. 1366-1367.
8) T. J. Craig, C. L. Huffine, and M. Brooks, “Completion of
they had begun outpatient treatment. Beginning treat-
Referral to Psychiatric Services by Inner City Residents,” Archives of
ment was defined as attending at least two postdis- Genera/Psychiatry, Vol. 31, September 1974, pp. 353-357.
charge sessions. The data showed that 27 of these 30 9) C. Heijn, P. G. Myerson, and P. Schmitt, “An Approach to
high-risk patients (90 per cent) actually began aftercare. the Supervision of Paraprofessionals Working With the Mentally Ill,”
BritisbJournal ofMedical Psychology, Vol. 48, Part 3, 1975, pp. 281-
Furthermore, 1 1 of the 12 patients (92 per cent) who
287.
had been involuntarily hospitalized began outpatient 10) M. Jellinek, “Referrals From a Psychiatric Emergency Room:
treatment. Twenty of the 22 patients (91 per cent) with Relationship of Compliance to Demographic and Interview Varia-
a history of prior psychiatric hospitalization also began bles,” American Journal of Psychiatry, Vol. 135, February 1978, pp.
209-213.
aftercare. These dropout rates of approximately 10 per
cent contrast greatly with the widely reported 50 per
cent rate (2, 3), and are less than half the lowest reported
DRUG HISTORIES
rates of which we are aware (4,5). Our findings are
OBTAINED BY PHARMACISTS
particularly remarkable because the subjects were all
FROM PSYCHIATRIC INPATIENTS
considered high risks to fail to begin outpatient treat-
ment.
Joel H. Dobbs, Pbarm.D.
Factors other than beginning outpatient treatment
prior to hospital discharge may have contributed to the
IDuring the past two decades pharmacists have be-
high success rate. One such factor may have been the
come increasingly involved in the direct care of pa-
effort to reduce the time between hospital discharge and
tients. In the area of mental health, pharmacists have
the first postdischarge outpatient appointment, result-
been responsible for acquiring drug histories when
ing in patients’ having their first postdischarge appoint-
patients are admitted to the hospital or to an outpatient
ment within three days of leaving the hospital.
treatment program, and have been most active in
The results of this study have both research and
outpatient settings (1-3).
clinical implications. Further research should include
Past studies of the usefulness of pharmacist-obtained
replicating this pilot study under controlled conditions,
drug histories have been undertaken in nonpsychiatric
using a larger sample and including an investigation of
settings. Covington and Pfeiffer evaluated 58 postad-
the impact of changes in dropout rates on recidivism.
mission drug histories acquired by pharmacists in a
The effectiveness of similar interventions in bridging
large general hospital (4). When the information ob-
the gaps between inpatient treatment and aftercare
tamed by the pharmacists was compared with that
programs in settings other than day treatment centers
acquired by physicians, the histories taken by pharma-
should also be studied.
cists were found to be more complete in the areas of
At present, many psychiatric patients are relegated
drug allergies, food allergies, prescription drugs used
to a revolving-door existence of acute disturbance,
before admission, and medication noncompliance. Wil-
rehospitalization, discharge, discontinuance of treat-
son and Kabat conducted a similar study of the records
ment, and relapse. The interventions described in this
of 100 patients in a large Veterans Administration
study can interrupt this cycle by helping patients stay
hospital (5). Only 57 per cent of the drugs recorded by
in treatment. The implementation of these interven-
the pharmacists were recorded by the physicians dur-
tions has the potential for reducing the human and
ing patients’ admission interviews. Physicians recorded
financial costs of psychiatric care.
only 37 per cent of the nonprescription drugs the
pharmacist identified.
REFERENCES To evaluate the effectiveness of pharmacist-acquired
drug histories, I conducted a study at Hill Crest
1) J. Cody and A. M. Robinson, “The Effect of Low-Cost Mainte- Hospital, a 125-bed private psychiatric facility located
nance Medication on the Rehospitalization of Schizophrenic Outpa-
in Birmingham, Alabama. Postadmission drug histories
tients,” American Journal of Psychiatry, Vol. 134, January 1977, pp.
73-76.
are one of several aspects of direct care for which this
2) J. G. Gunderson, J. H. Autry, III, and L. R. Mosher, “Special hospital’s pharmacy is responsible. A complete drug
Report: Schizophrenia, 1974,” Schizophrenia Bulletin, No. 9, Summer history is taken from all patients within 72 hours after
1974, pp. 16-54.
3) G. H. Wolkon, “Effecting a Continuum of Care: An Exploita-
tion of the Crisis of Psychiatric Hospital Release,” Community Mental At the time of the study, Dr. . Dobbs was assistant director of
HealtbJournal, Vol. 4, February 1968, pp. 63-73. pharmacy at Hill Crest Hospital in Birmingham, Alabama. He is
4) C. H. St. Clair, “Short-Term Follow-up After Brief Inpatient now director of psychopharmacology at Western Mental Health
Treatment,” Hospital ‘ Community Psychiatry, Vol. 26, November Center, 1701 Avenue D, Ensley, Birmingham, Alabama 35218, and
1975, pp. 741-744. assistant professor of pharmacy at Samford University in Binning-
5) R. Tessler and H. Mason, J. “Continuity of Care in the ham.

VOLUME 32 NUMBER 9 SEPTEMBER 1981 639

TABLE 1 Drug information obtained by pharmacists that drugs. Further questioning revealed that these three
was not obtained by doctors and nurses from 50 patients patients had experienced unpleasant side-effects such as
an extrapyramidal reaction or excessive sedation.
Number of
Two patients admitted to the pharmacist that they
Type of information times reported
used amphetamines chronically, one patient described
Medication discontinued by patient chronic excessive laxative use, and one admitted that he
before admission 8 regularly borrowed a benzodiazepine-type tranquilizer
Poor compliance (missed doses at from a relative. None of this information had been
least two days a week) 4 recorded in the physicians’ or nurses’ records.
Allergy identified or clarified 5
Drug histories are traditionally taken as part of a
Regular use of nonprescription drugs 3
patient’s admission history. When the present system
Regular use of prescription drugs 12
of taking medical histories was firmly established in the
Identification of medication brought
1
early part of the century, there was little drug therapy
to the hospital
Regular borrowing of medication 1 capable of altering the natural course of most diseases.
Chronic amphetamine use 2 Most prescribed medication was pharmacologically in-
active and could not cause much benefit or harm. As a
1 A total of 2 1 drugs were reported.
result, little attention was paid to medication use when
medical histories were taken.
their admission by a pharmacist or senior pharmacy However, in the past three decades many potent
student with training in interviewing techniques. drugs that profoundly influence the outcome of many
The pharmacists and students follow a standard diseases have been marketed. Some drugs have side-
interview format, asking patients about prescription effects that resemble naturally occurring disorders and
medicines taken before admission and how they were thus may confound diagnosis. The psychiatric patient
taken, the frequency of missed doses, medicines the presents a special challenge in this respect. There is
patient has stopped taking, medicines the patient has great potential for misuse or overuse of psychoactive
borrowed from others, nonprescription drugs used, medication; even when used in acceptable doses, many
alcohol intake, and medicines that have caused adverse drugs produce psychiatric symptoms. Careful attention
or unpleasant reactions. to the patient’s preadmission drug use is therefore
After the interview, the pharmacist writes a summa- imperative. This study demonstrates that a carefully
ry and assessment for inclusion in the patient’s chart. conducted drug history can reveal significant informa-
The majority of patients are not resistant to talking tion about a patient’s current and past medication
with the pharmacists. Neither the interviewers nor the usage.
patients interviewed were aware that the data collected Since the pharmacist is identified with medicine,
were to be used in a study. patients may more readily relate information of this
The study was based on a retrospective review of the type to a pharmacist. Also, since medication is the
charts of 50 patients. The charts were randomly select- principal subject of interviews like the ones described
ed by medical records personnel from the charts of all here, patients probably have more time to consider
patients older than 2 1 at the time of admission who had their answers and can recall more information.
been admitted and discharged within the preceding six Pharmacists in psychiatric facilities can contribute to
months. Pharmacists’ drug histories were compared patient care by obtaining useful information on pa-
with medical histories taken by physicians at the time tients’ drug histories. Pharmacists should, in addition,
of admission and with nursing intake records. continue to develop patient-oriented services such as
In 24 of the 50 charts (48 per cent), the pharmacists drug education and drug information consultation
recorded information not recorded by physicians or when such services are needed.
nurses. (Information recorded by physicians but not by
pharmacists was not evaluated.) A total of 36 items of REFERENCES
information were identified by pharmacists (Table 1).
1) J. H. Coleman, III, R. L. Evans, and S. A. Rosenbluth,
The greatest contribution of the pharmacists’ inter-
“Extended Clinical Roles for the
Pharmacist in Psychiatric Care,”
views was in the area of prescription drugs used; in AmericanJournal ofHospital Pharmacy, Vol. 30, December 1973, pp.
their interviews with a pharmacist, 12 patients revealed 1143-1 146.
a total of 2 1 additional prescription drugs used regular- 2) W. A. Miller and J. Corcella, “Professional Pharmacy Func-
ly. Eight patients admitted they had discontinued tions in Community Mental Health Centers,” Journal of the American
Pharmaceutical Association, Vol. 12, February 1972, pp. 68-7 3.
medication before admission, and four admitted that
3) G. L. Stimmel, “Clinical Pharmacy Practice in a Community
they regularly missed doses (at least two days a week). Mental Health Center,”Journa/ ofthe American Pharmaceutical Associa-
Allergy information presented a special problem. tion, Vol. 15,July 1975, pp. 400-401.
Allergies were identified or clarified by the pharmacist 4) T. R. Covington and F. G. Pfeiffer, “The Pharmacist-Ac-
quired Medication History,” American Journal of Hospital Pharmacy,
in the cases of five patients. In two cases, a pharmacist
Vol. 29, August 1972, pp. 692-695.
identified allergies to antibiotics that had not been 5) R. S. Wilson and H. F. Kabat, “Pharmacist Initiated Patient
previously reported. In the remaining three cases, Drug Histories,” American Journal of Horpital Pharmacy, Vol. 28,
patients reported allergies to one or more psychoactive January 1971, pp. 49-5 3.

640 HOSPITAL & COMMUNITY PSYCHIATRY