When a doctor or, much more typically, nurse practitioner has concerns about a patient’s psychiatric medication -- say, the patient hasn’t responded to treatment, or isn’t tolerating the prescribed dose -- Charles Caley might get a call.
A board-certified psychiatric pharmacy specialist and associate clinical professor at the University of Connecticut's School of Pharmacy, Caley has, since 2006, also consulted for UConn’s Student Health Services. Upon receiving a referral, he allots up to an hour for reviewing a student’s medical record and another hour for a clinical interview. He then writes a treatment recommendation to the prescriber, with the most common recommendations being to change the dosage or the medication itself.
“I’m there to try to enhance what’s being done,” said Caley, who now consults four hours each week, providing clinical services and education. “At the time I came into doing this, there was a great need for a clinical information resource, because there were two nurse practitioners at the time and the only half-time psychiatry time that they had they were going to lose, because the psychiatrist had given notification he was going to resign his position.”
“There was concern that the nurse practitioners would not have a significant amount of support. My job was to come in and try to fill that need initially. Since then, since now they’ve got two nurse practitioners [who can write prescriptions] and two half-time psychiatrists, it’s meant to be a supportive role.”
Connecticut’s use of a psychiatric pharmacy specialist is an unusual response to the growing stresses on college counseling centers nationally. In a 2007 survey of college counseling center directors, 87.5 percent reported an increase in students already on psychiatric medication prior to arriving at the counseling center. Of center clients, 23.3 percent are on psychiatric medication, an increase from 20 percent in 2003, 17 percent in 2000, and 9 percent in 1994.
An overwhelming proportion of counseling center directors report seeing increases in the number of students with severe psychological problems. And at the 63 percent of colleges providing on-campus psychiatric services, the number of consultation hours available per week is just 1.7 per every 1,000 students.
“We’re in a rural area, we have poor public transportation, we have very few mental health resources in the area where we can refer people,” said Michael Kurland, director of Connecticut’s Student Health Services. “We wanted a level of expertise, to have an individual who could consult with our providers and supplement -- not replace -- psychiatrists … to supplement what they do and enhance their ability to provide medication.”
Psychiatrists, Kurland continued, are "such a scarce resource. They don't necessarily have enough time to spend 45 minutes or an hour consulting with a patient really finding out about the medication and the impact on the patient's life."
Yet, Jerald Kay, chair of the American Psychiatric Association’s Committee on College Mental Health and psychiatry chair at Wright State University, said that while he understands the pressures on college counseling centers that might make Connecticut’s model seem attractive, it’s not an approach he could embrace. "I think that kind of care ought to be delivered by psychiatrists,” he said.
"I think it's a very creative idea, in large part driven by cost savings to the university. But it's not possible for me to be enthusiastic about it,” he said, adding that universities need instead to hire more (and, yes, more expensive) psychiatrists to deal with patients' medication issues.
"Undoubtedly I think it's a cost issue,” Kay continued. “But for me it's a quality of care issue for students at a university. And the university is obliged to provide the best care possible."
Caley, who earlier this month presented on Connecticut's use of a psychiatric pharmacy specialist alongside Kurland at the American College Health Association's annual meeting in Orlando, said he’s aware that many physicians are leery of other professionals stepping into clinical roles, as pharmacists increasingly are.
“It’s not my intent to duplicate anybody’s efforts or services,” Caley said. He added that the vast majority of his referrals come from prescribing nurse practitioners as opposed to psychiatrists. Given that nurse practitioners’ experience and training “set them up differently [regarding] their depth of knowledge with respect to drug therapy,” he said, “this sort of resource fits well."