Review and evaluation of the role of a psychiatric pharmacist on medication management in a gender health program

People who identify as transgender experience a significant amount of mental health concerns compared to the general population. Gender health programs offer the opportunity to provide comprehensive care for this highly stigmatized population, with the potential for psychiatric pharmacists to assist other providers and serve this need. This study aimed to evaluate the number and type of interventions made by a psychiatric pharmacist within a gender health program.


| INTRODUCTION
The lesbian, gay, bisexual, transgender, queer or questioning, and more (LGBTQ+) population experiences a high degree of psychological distress due to numerous factors including discrimination, denial of civil and human rights, social isolation, and rejection. 1 This distress can quickly manifest as depression, anxiety, or other mental health concerns. The American Psychiatric Association found that individuals who identify as LGBTQ are more than twice as likely to have a mental health disorder in their lifetime compared to their cisgender heterosexual counterparts. 2 They were also found to be more likely to use mental health services. Many reports have found similar results, emphasizing a clear need for quality mental health services for the entire LGBTQ+ community. [2][3][4][5] People who identify as transgender experience a significantly higher amount of mental health concerns compared to the general population. The 2015 United States (US) Transgender Survey found that 24% of respondents made plans to commit suicide in the year prior, compared to 1.1% of the general population. 6 Of these respondents, 7% attempted suicide in the past year, compared to only 0.6% of the US population, with 71% having attempted suicide more than once in their lifetime. Knowing this significant difference exists between groups begs the question: how is the US healthcare system measuring up to meet this need? To answer this, the US Transgender Survey asked respondents to share their experiences with healthcare providers. One-third of respondents who had seen a healthcare provider in the past year reported having at least one negative experience related to being transgender, such as verbal harassment, refusal of treatment, or having to teach the provider about transgender people to receive appropriate care. Twenty-three percent did not see a doctor when they needed to due to fear of being mistreated. 6   The interdisciplinary team is comprised of family medicine physicians, a psychiatrist, a family medicine nurse practitioner, nurses, therapists, care coordinators, victim advocates, and a psychiatric pharmacist, who joined the team in May of 2020. Referrals to the pharmacist can be made by any member of the interdisciplinary team. The pharmacist practices under a collaborative drug therapy management (CDTM) protocol focusing on management of psychiatric and neurologic disorders, which has since expanded to include gender-affirming hormone therapy and pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV). The pharmacist sees patients independently and provides mental health assessments and screenings; reviews psychiatric history; manages medications, including initiation, adjustments, and discontinuation; orders laboratory tests and monitors results; and makes referrals to other healthcare professionals.
Referrals are made specifically to psychiatrists and psychiatry residents when the patient requires further diagnostic clarification or if the patient is acutely symptomatic (eg, psychosis, suicidal ideation with plan, etc.) Otherwise, the pharmacist manages psychiatric medications while the patient may continue to follow-up with other providers for other needs. The pharmacist will also see patients who are stable from a psychiatric standpoint and only require medication management. Patient visits are billable 30-min appointments and may be completed in-person or via telehealth. The pharmacist will followup with the patient as needed, usually within 4 to 6 weeks.

| Study design
A retrospective review of the electronic medical record (EMR) was conducted analyzing mental health visits completed by psychiatric pharmacists within the Gender Health Program between May 1, 2020 and December 31, 2021. This study was deemed exempt by the local institutional review board. Patients were included if they had at least one documented visit with a pharmacist where mental health was assessed during the study time frame. Patients were excluded if they saw the pharmacist for non-psychiatric disease state management, such as pre-exposure prophylaxis or gender-affirming hormone therapy. If the patient was seen by the pharmacist more than once, data were collected from each appointment.
Each patient was assigned a unique study number. The progress notes completed by the pharmacist were assessed and data were collected by the corresponding author. Baseline demographics were collected from the first appointment with the pharmacist. The United States Department of Agriculture Economic Research Service was used for defining counties as rural vs urban based on the listed population size. 9 Distance from clinic was assessed using the patient's listed address in the EMR with the location of the program. Based on the two addresses, the distance between two points was measured utilizing Google Maps. 10 Statistical tests were performed using Minitab 18 statistical software. 11 Parametric data were reported as mean (standard deviation [SD]) and non-parametric data were reported as median (interquartile rane [IQR]). Normality was tested using the Anderson-Darling test.
The Chi-Square or Fisher's Exact tests were used to detect differences in nominal data. The significance level (alpha) was predetermined to be less than 0.05. An a priori power calculation was not performed as this was a convenience sample of all patients meeting inclusion criteria during the defined study period. Post-hoc subgroup analyses were performed during data analysis. The results of this study are presented in accordance with Enhancing the QUAlity and Transparency Of health Research (EQUATOR) and The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

| Study outcomes
The primary outcome of this study was number and type of inter-

| Demographic and appointment details
A total of 106 patients had a visit with the psychiatric pharmacist during the study time frame. Thirteen patients were seen for pre-exposure prophylaxis or hormone adjustments and were excluded from analysis, leaving a total of 93 patients for analysis. Baseline demographics are listed in Table 1. Insurance status equates to >100% due to some people having more than one insurance type. Despite the median (IQR) distance from clinic being listed as 13 (6,43)

| Subgroup analyses
The

| Post-Hoc billing analysis
A sample of the pharmacist's visits were audited from the fourth quarter of 2021. These data demonstrated that >80% of visits were billed at Level One charges (Current Procedural Terminology Code 99211) and allowed the pharmacist to bill as an independent provider. Additionally, some visits were non-billable and were a combination of shared, in-person and telehealth visits, which were excluded from the post-hoc analysis.

| DISCUSSION
To our knowledge, this is the first study to provide intervention measures highlighting the benefit of adding a pharmacist to a gender health program. Current literature focuses on assessing pharmacist and patient perceptions, emphasizing the need for education within the pharmacy curriculum, or strictly describing the pharmacist's role. 8 Despite knowledge of the mental health disparities that transgender people face, no study assesses the potential benefit of adding a psychiatric pharmacist to the interdisciplinary team. This benefit has been previously described in various practice settings and with different patient populations, excluding the transgender population. 12 The positive effect on medication management evident by this retrospective, observational study affirms the role of a psychiatric pharmacist on the interdisciplinary team. The pharmacist made numerous interventions during the study period, with an emphasis on depression and anxiety medication management, which is unsurprising given the previously described psychological distress experienced by this population. 6 With a vast majority of patients having depression and anxiety diagnoses, most medication adjustments were with antidepressants. Medication initiation occurred most frequently, which allows the patient to trial a medication prior to the provider visit.
Thus, giving the provider more time to focus on non-medication related issues. Moreover, the psychiatric pharmacist is the most wellsuited to assist with medication management given the extensive education and training, usually including two additional years of residency training following graduation from pharmacy school.
Currently, with the national psychiatrist shortage, it may take three months before a patient in the program can be seen by a psychiatrist and 8 weeks to be seen by a family medicine provider. 13 While data specific to time to available pharmacist appointment were not collected, these visits generally occurred within 3 weeks of referral.
Additionally, most patients in this study (75%) had not seen a psychiatrist at the institution in the year prior; this pharmacist visit may have been their first encounter with a psychiatric provider in some time.
With a more flexible schedule, shorter appointment durations, and potential for telehealth, the pharmacist may be more readily accessible to complete assessments, begin medication therapy, titrate doses, manage side effects, and/or follow-up with the patient prior to the first appointment with a provider. This study provides additional insights into the mental healthcare of transgender people, but also leaves further unanswered questions.
Future directions include assessing patient satisfaction with pharmacist vs provider appointments, analyzing potential mental health changes and differences in interventions based on hormone therapy, conducting an in-depth pharmacoeconomic analysis of pharmacistbilling in this setting, and completing a further analysis of the differences in interventions based on the gender identity (eg, seeing which medications were involved, determining the specific intervention differences, and assessing potential follow-up differences).

| CONCLUSION
Psychiatric pharmacists have the potential to provide comprehensive mental healthcare for the transgender community. The pharmacist in this study had the opportunity to bridge gaps in access to care to healthcare providers by initiating and managing medications, providing thorough education, and referring patients to further resources. These results affirm the accessibility and role of the pharmacist on the interdisciplinary team caring for LGBTQ+ patients. The hope is that this study can be uti-

FUNDING INFORMATION
There was no external funding for this research.