Treating Schizophrenia: Bringing Together Pharmacists and Clinicians for Patient Care

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Schizophrenia remains one of the most challenging psychiatric conditions to manage, not just due to its complex pathophysiology, but also because of the systemic and logistical hurdles that complicate treatment.¹ While the priorities of psychiatric clinicians include accurate diagnosis and medication selection, pharmacists can play a crucial role in supporting adherence, contributing to the prevention of medication errors, and addressing real-world barriers to care. Unfortunately, their expertise is often underutilized.

Due to the nature of health care utilization, it may often be the case that pharmacists are the only, or most consistent, health care professional to interact with a patient between psychiatric visits. As a result of these increased touchpoints, pharmacists may be the first to recognize issues with adherence, adverse effects, or gaps in care, which are essential components of managing serious mental illness. However, it is still less common for their insights to be integrated into a team-based approach to treatment. While pharmacists can serve as a bridge between patients and prescribers, certain barriers continue to prevent pharmacists from fully leveraging their expertise in schizophrenia management. Increasing awareness of the specific ways in which pharmacists may serve as meaningful members of a collaborative care team can potentially inform both immediate, practical and long-term, systemic changes.

Recommendations for Clinical Coordination in Schizophrenia Treatment

Antipsychotic medications vary significantly in their pharmacodynamics and pharmacokinetics, which influences both efficacy and tolerability.² While psychiatric clinicians assess a range of factors when making medication recommendations, such as individual patient symptoms and adverse effect profiles, pharmacists bring different perspectives on how these medications behave in real-world settings, including awareness of metabolic variability, potential drug-drug interactions, or nuances related to medication formulation.

An example of how pharmacists and prescribers can effectively collaborate around treatment planning is related to the selection of an oral relative to a long-acting injectable (LAI) antipsychotic medication.³ In the treatment of schizophrenia, a central consideration among patients and their care teams should be what formulation will work best for that person’s unique circumstances and needs. Both oral medications and LAIs are effective; however, the distinction arises in frequency and means of administration. This is an illustration of how including pharmacists in conversations about treatment selection can be strategic in helping individuals understand the dosing requirements of a daily pill compared with an injection that takes place on a revolving basis, perhaps once a month or every other month. Moreover, having a pharmacist on the care team will give prescribers greater insight into whether prescriptions are being filled on a timely basis, or injections are being appropriately administered as recommended.

Underscoring the importance of this approach, the risks of inconsistent medication histories and unverified prior doses are concerning. One colleague described a case in which a patient was prescribed an LAI after a hospitalization, but due to a lack of communication between the inpatient and outpatient teams, he received an additional loading dose within the same month. This resulted in severe akathisia and an avoidable rehospitalization. Pharmacists, if properly integrated into the care team, could help reduce such errors by ensuring accurate medication reconciliation during times of care transitions—something that remains a major gap in many psychiatric treatment settings.

The practicalities of LAI administration present an additional scenario where pharmacist-provider coordination may be beneficial. Although LAIs are designed to deliver a consistent medication dose over time, a missed injection can lead to unpredictable fluctuations in drug levels, potentially precipitating withdrawal effects or symptom recurrence. In some cases, patients picking up their LAIs at the pharmacy are required to travel to a separate clinic for administration, adding an extra step that can introduce unnecessary complications. I have encountered situations where patients skipped injections due to stressful or unsafe conditions at the clinic, or attempted to self-administer when clinical staff were unavailable, both of which resulted in preventable hospitalizations.

Pharmacists can and should be administering these medications to eliminate these gaps in care. In states where regulations allow pharmacist-administered injectables and reimburse all parties accordingly for their involvement, incorporating LAIs into this practice could streamline treatment and improve adherence. Pharmacists can relatedly play a key role in ensuring timely administration by tracking injection schedules. Open communication with prescribing clinicians is advantageous in these circumstances.

This level of collaboration between pharmacists and providers is also important because of natural differences in patients’ metabolisms, which can affect recommendations about medication and dosing choice. In psychiatric treatment, metabolism often does not receive enough attention, yet it can dramatically impact outcomes. Some patients metabolize antipsychotic medications much more quickly, making it challenging to reach therapeutic levels, while others process them more slowly, increasing the likelihood of adverse effects. This variability explains why 2 patients on the same dosage of a medication may respond very differently.⁴ Pharmacists frequently encounter cases where a prescribed dose does not align with a patient’s metabolic profile, often requiring adjustments.

In recent years, there has been growing interest in pharmacogenetic testing to better understand how genetic differences may impact a patient’s response to psychiatric medications. Although it is not yet widely used to guide antipsychotic prescribing, pharmacogenetics may become a helpful tool in identifying patients at risk for poor efficacy or increased adverse effects.⁵ As we see such advances in diagnostics and treatment become more established, there is value in setting the early precedent for how clinical teams can best collaboratively utilize these tools.

Beyond genetic and metabolic factors, pharmacists may also assess clinical considerations, such as renal and hepatic function, which can influence both the selection and dosing of certain antipsychotic medications, including LAIs.⁶ In patients with impaired organ function, these assessments can inform more individualized recommendations to support safe and effective treatment. In my clinical experience, these are elements of treatment planning that are enhanced through collaboration across care teams that include pharmacists.

A final relevant recommendation for increased pharmacist involvement relates to the potential for drug-drug interactions, which can either weaken or intensify the effects of antipsychotics.⁴ In the management of serious mental illness, polypharmacy is common, which ideally necessitates the regular assessment of a person’s medication history and profile to scan for unintended interactions. For instance, enzyme-inducing medications can reduce plasma concentrations of antipsychotics, rendering them less effective. Conversely, enzyme inhibitors can elevate levels, increasing the risk of toxicity.⁷ Pharmacists, whose training includes considerable focus on pharmacokinetics, are uniquely positioned to work closely with prescribing clinicians to ensure patients’ experience of their medications is as safe and efficacious as possible.

By proactively integrating pharmacists into schizophrenia treatment teams, clinicians can ensure that both oral and long-acting formulations are optimized based on individual patient needs, metabolic considerations and real-world adherence patterns, and that patient safety remains paramount.

Barriers to Effective Schizophrenia Treatment

While treatment selection and clinical factors like pharmacokinetics and metabolic variability are essential considerations in schizophrenia care, systemic and logistical challenges often create additional obstacles to effective care. These may include fragmented care coordination, medication tracking failures, and access barriers that affect continuity of care. Pharmacists witness these challenges first-hand, often facing difficulties in verifying whether patients have received their medications, determining the last administration date, and correcting prescription errors caused by fragmented care coordination.

Many patients cycle through different health care facilities, leading to medication reconciliation failures that increase the risk of duplicate dosing or missed prescriptions. Without access to a centralized medication history, pharmacists must rely on phone calls, faxes, and patient recall to determine past prescriptions. Unlike vaccine records, which are often logged in state immunization registries, psychiatric medications, including LAIs, do not have a standardized tracking system, making it difficult to ensure appropriate continuity of care. This gap creates opportunities for medication errors, treatment delays, and inconsistent patient monitoring across different care settings.

Adherence challenges remain a major concern, particularly for patients who experience significant adverse effects, stigma, or difficulties accessing treatment. Mental health providers may only see a patient once every few months, whereas pharmacists interact with them more frequently, making them strategically positioned to detect adherence concerns early. For example, pharmacists often observe cases where patients stop taking their medications due to emerging adverse effects—circumstances that could be managed through medication adjustments or alternative formulations if pharmacist recommendations were more routinely incorporated into psychiatric care.

By strengthening collaboration between pharmacists and prescribers, schizophrenia treatment can become more patient-centered and effective. A coordinated care approach that fully integrates pharmacists can help minimize medication errors, improve adherence, and enhance treatment continuity.

The Case for Clinical Collaboration in Psychiatry

As one psychiatrist colleague noted, some of the most valuable clinical updates he receives come from pharmacists, who flag concerning symptoms or report patients who appear to be struggling with adherence. Implementing regular pharmacist-prescriber touchpoints could significantly enhance care coordination, particularly for patients with complex medication regimens.

Psychiatric pharmacists—advanced practice clinical pharmacists who specialize in mental health—are uniquely positioned to support these teams. With extensive training in psychopharmacology and a patient-centered approach, they can help manage complex medication regimens, address adverse effects, and support overall treatment adherence. A physician-conducted survey showed how 75% of physicians find their jobs to be easier when the primary care team includes a clinical pharmacist.⁸ As demand for psychiatric care grows, the US is projected to face a shortfall of over 12,000 adult psychiatrists by 2030—meaning the supply of psychiatrists will meet only about 68% of the expected need. Integrating psychiatric pharmacists may help fill critical care gaps, improve outcomes, and reinforce the mental health workforce.⁹

An ongoing consideration is how to better incorporate pharmacists into psychiatric care in ways that grant them appropriate regulatory and reimbursement status. Practically speaking, until such a time that professional regulations are changed to empower pharmacists in this capacity, building and executing fully cross-functional, collaborative care teams remains up to individual providers and institutions.

Pharmacists in general could play a greater role if they were granted provider status, allowing them to conduct more formalized medication reviews, initiate adherence interventions, and even prescribe dosage adjustments under collaborative practice agreements. Some states have implemented expanded pharmacist authority in chronic disease management and infectious diseases, yet their role in psychiatric care has remained largely unchanged, with little expansion in scope of practice in this field.¹⁰ As a pharmacist who works closely with my psychiatry colleagues, it is my belief that policymakers should continue to explore how pharmacists’ expertise in medication management is best formalized in support of patient outcomes.

In my work, I have directly experienced and observed how incorporating pharmacists into structured care teams allows them to contribute to treatment adjustments and develop more effective medication tracking systems. This form of active engagement contributes to optimized management of complex, chronic medical conditions. The anticipated result of such collaboration across the clinical spectrum is a meaningful benefit to patient outcomes.

I believe that systemic change requires us as practitioners to make the case for a better approach to care. I also believe that an effective way to make that case is to demonstrate how effective partnership and patient-centered care teams are already making a difference in psychiatric care. Ultimately, better pharmacist-clinician collaboration could transform schizophrenia treatment, ensuring that patients receive the most effective, consistent, and well-coordinated care possible.

Dr McGuire is an associate professor of pharmacy practice and psychiatry at Belmont University.

References

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