Introduction to Prescribing Medication

Primer

Medication prescription is cornerstone of psychiatric practice, and indeed for many areas and specialties of medicine. Understanding principles of prescribing and being a thoughtful and careful prescriber is critically important.

Psychology of Psychopharmacology

Conservative Prescribing

Think Beyond Drugs

  1. Seek non-drug alternatives first
  2. Consider potentially treatable underlying causes of problems rather than just treating the symptoms with a drug
  3. Look for opportunities for prevention rather than focusing on treating symptoms or advanced disease
  4. Use the test of time as a diagnostic and therapeutic trial whenever possible

A Shared Care Approach

  1. Do not hastily or uncritically succumb to patient requests for drugs, especially drugs that they have heard advertised
  2. Avoid mistakenly prescribing additional drugs for refractory problems, failing to appreciate the potential for patient nonadherence
  3. Avoid repeating prescriptions for drugs that a patient has previously tried unsuccessfully or that caused an adverse reaction
  4. Discontinue treatment with drugs that are not working or are no longer needed
  5. Work with patients’ desires to be conservative with medications

Think Long-Term, not just Short-Term

  1. Think beyond short-term beneficial drug effects to consider longer-term benefits and risks
  2. Look for opportunities to improve prescribing systems, changes that can make prescribing and medication use safer

Strategic Prescribing

  1. Use only a few drugs and learn to use them well
  2. Avoid frequent switching to new drugs without clear, compelling evidence-based reasons
  3. Whenever possible, start treatment with only 1 drug at a time

Always Think About Adverse/Side Effects

  1. Have a high index of suspicion for adverse drug effects
  2. Educate patients about possible adverse effects to ensure that they are recognized as early as possible
  3. Be alert to clues that you may be treating or risking withdrawal symptoms

Skepticism About Newly Marketed Drugs

  1. Learn about new drugs and new indications from trustworthy, unbiased sources
  2. Do not rush to use newly marketed drugs
  3. Be certain that the drug improves actual patient-centered clinical outcomes rather than just treating or masking a surrogate marker
  4. Be vigilant about indications creep
  5. Do not be seduced by elegant molecular pharmacology or drug physiology (e.g. - vortioxetine)
  6. Beware of selective reporting of studies
“To write prescriptions is easy, but to come to an understanding with people is hard”
– Franz Kafka

Prescribing in Children

The following are some tips to guide prescribing in patients, especially in adolescents and the elderly (excerpted from Mark Chenven, MD, The Carlat Child Psychiatry Report):

  1. Start low, go slow: Most side effects are dose related, so gradual up-titration is simple common sense. This allows for the body’s homeostatic and regulatory mechanisms to respond gradually and reduces the severity of emerging side effects.
  2. One step at a time: Making one change at a time is another sound practice as this allows for monitoring the impact of one changed variable. An exception to this rule would be a situation where you are cross titrating between two agents and/or dealing with a clinically complex problematic situation.
  3. Consider weekend trials: Starting a new medication or making a significant dosage adjustment over the weekend affords parents and the child or teen the opportunity to monitor for both efficacy and side effects.
  4. Seek feedback: Requesting parents or the older adolescent/young adult patient to call with any emerging concern and scheduling timely follow up visits further enhances our ability to understand and respond to medication impacts.
  5. Longitudinal follow through is key: Ongoing routine inquiry about side effects and monitoring relevant vital signs is a core practice expectation. Also routine should be recognition of co-occurring health conditions and coordination of care with the youth’s pediatric physician.
  6. Focus on med compliance: Compliance and non-compliance should be reviewed periodically. Use longer acting agents (eg, fluoxetine) when appropriate and work with kids and parents on developing more consistent medication use habits.
  7. Review and reconsider: Recognizing the failure of a medication to achieve desired results needs to be considered and it should trigger a reassessment of the diagnosis and treatment plan.
  8. Beware of polypharmacy: Multiple agents raise the risk of side effects. Combinations can have therapeutic benefits, but it is important to reassess the efficacy of all agents monitored for side effects, interactions, and other challenges.
  9. Monitor sleep patterns: Disturbances of sleep should be addressed behaviorally when possible, and pharmacologically when warranted.
  10. Inquire about herbals and OTC agents: Many patients and parents think that herbals, supplements, and other types of “natural” remedies are benign. Ask, or you may never be told. Learn more about these agents and work with families and youth to make mutual decisions on whether to continue them.
  11. Check for other substances: These include cannabis, alcohol, methamphetamine, psychedelics, heroin, or use of grandma’s codeine, sleeping pills, SSRIs, etc.
  12. Learn about life changes: Inquire about other changes in the child’s life—parental discord, changes in the family structure (siblings off to college), new or lost friends, changes in school, illnesses, accidents, bullying and everything else that can upset the applecart. All these may impact our patients’ functioning.

Resources

For Providers