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Advisers’ Viewpoints: Fighting polypharmacy in psychiatry


 

Editors’ Note: Psychiatric polypharmacy is becoming increasingly prevalent among patients across all age groups, including children and adolescents and geriatric patients (Mens Sana Moogr. 2013 Jan-Dec;11[1]:82-99). As we begin the new year, we asked members of the Editorial Advisory Board whether they have received referrals they thought were taking too many psychiatric medications and what approach they used to offer those patients more effective treatment. In some cases, details have been tweaked to protect anonymity. Here are some of their responses:

Empowering the patient

Psychiatric polypharmacy described in the cited review article was very common in both the outpatient clinics and hospitals in which I worked. And diagnostic reviews and medication recommendations are increasingly a reason for psychiatric consultations in all settings.

Dr. Lee H. Beecher

Dr. Lee H. Beecher

Most psychiatrists also look at potentially unnecessary or harmful prescriptions for all diagnoses from all prescribers. This important task is often assigned to psychiatrists who work in behavioral health homes or other mental health interdisciplinary teams. So, notions of polypharmacy include all prescriptions affecting a patient’s cognition and overall health, as well as the appropriate use of psychotropic medications.

To do appropriate prescribing and monitoring of prescribed medications, psychiatrists are learning about the great advantage of empowering the patient, her family, and/or her chosen support network with accurate information and medication recommendations. Effectively communicating advice and recommendations to an ever-expanding group of other prescribers (nurses, primary care personnel) is vital as well. This often is easier said than done.

My patients carried written medication lists (and/or smartphone entries), including medication dosages, indications, and accurate contacts for all their prescribers. That sometimes opened a discussion about the quality and accessibility of these individuals or clinics. Also, in Minnesota, we have the Prescription Drug Monitoring Program (MNPMP), which permits prescribers to monitor all controlled-substance prescriptions from all sources; this is very useful to me as an addiction psychiatrist.

Unfortunately, many organizations today rarely allow psychiatrists enough face-to-face time with patients or plans for timely follow-up or monitoring of patients they see or supervise. Clearly, quality and continuity of care are enhanced with a trusting relationship with patients. This is very important in reducing ill-advised polypharmacy and as an aid to improving patients’ prescription medication adherence.

Physicians need to speak up to bosses when our hiring organizations do not allow us enough patient time. We have empirical evidence that an entry in the electronic health record (EHR) does not ensure good clinical care. In fact, there is mounting evidence that too much physician time is spent inputting the EHR, actually, and this detracts from quality clinical care. Clearly, both we and the patient need to know when and who will revisit the patient’s medication plan; track if this is done; and confer in an ongoing way with our patient (and/or family/support) about health care insurance coverage, and their ability and willingness to pay for all treatments and prescriptions.

Moreover, we seldom know if the patient can afford our prescribed medications. Is she willing or able to return for a timely follow-up visit? Are there transportation issues to address? Provision for home visits, etc.? These are essential details of person-centered care.

I empathize with authors’ concerns about clinical psychiatrists as “pharmacopsychiatrists.” Limiting the “medication manager” role can help lead us to doing quality clinical psychiatry; there is much we psychiatrists can do to tackle the polypharmacy problem.

–Lee H. Beecher, M.D.

Mentoring younger psychiatrists

When I was running the Community Mental Health Council, I worked with a psychiatrist who was fond of prescribing quetiapine, aripiprazole, ziprasidone, benzotropine, fluoxetine, mirtazapine, and citalopram, alprozalam, and sometimes a hypnotic as a sedative.

Dr. Carl C. Bell

Dr. Carl C. Bell

On several different occasions I tried to guide him away from treating those with mental illness as neurochemistry factories, and he told me that his philosophy was to “keep patients as quiet as possible.”

I felt uncomfortable dictating to him how to prescribe meds so as to avoid polypharmacy; although a couple of times I was thinking about reporting his polypharmacy practices to the state licensing board, but he seemed to stay just inside the boundaries of reasonable care.

My experience is that many newly trained psychiatrists do not understand that prescribing meds to prevent the side effects of akathasia, dystonia, or akinesia probably can be stopped after a patient is on antipsychotics for a month or 2 or that anticholinergic meds halve the blood level of most antipsychotics, and I have inherited patients from other psychiatrists who have had these patients on anticholinergic medications for decades.

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