California Psychiatric Association Documents
Prescribing Guidelines For Primary Care Physicians

As result of ever expanding managed care activities, Primary Care Physicians are increasingly placed in the position of diagnosing and treating psychiatric conditions that may not require specialist care. Psychotropic medication is frequently a part of treatment and in many cases is the treatment of choice. The following guidelines represent broad standards to which the Primary Care Physician can refer while more specific information can be obtained from the references cited on the last page of the pamphlet.(1) The guidelines are based on the current scientific data available as well as many years of experience accumulated by California Psychiatric Physicians and provide a fair representation of the psychiatric community standard of care.

PRESCRIPTION AND MONITORING OF PSYCHOTROPIC MEDICATIONS

The prescription and monitoring of psychotropic medications are similar to that of other drugs that have the potential for serious and, sometimes, life threatening side effects. In some important ways, however, the use of psychotropic medication differs because these drugs often affect cognition as well as emotions. Therefore, there are significant clinical, psychological and legal issues that must also be considered. If the primary care physician has not had experience prescribing for certain medical conditions, (by implication this would include specific mental disorders with which the primary care provider has no experience), a recent legal opinion suggests referring such cases to a specialist instead.(2) Whether or not a consultation or referral is initially indicated the following principles apply:

ACCURATE DIAGNOSIS FOR PSYCHOTROPIC MEDICATION

It is critical that psychotropic medication be utilized only for established DSM-IV psychiatric diagnoses.(3-6) To prescribe for symptoms without exploring the possible etiologies may not only prolong the discomfort, but may also unnecessarily complicate a problem. There are multiple causes for insomnia, anxiety, depression and psychosis in both children and adults. Confusion, agitation and memory loss are, of course, not always symptomatic of irreversible dementia when seen in the elderly. Various medical illnesses and side effects to a variety of prescribed medications may cause symptoms that appear to be psychiatric in nature.(7) These must be ruled out.

The appropriate prescription of psychotropic medication is based on accurate diagnosis of psychiatric illness and on the initial identification of target symptoms against which the medication may be titered.

Depression, psychosis, severe anxiety and significant irritability should always trigger assessment to assure the patient does not otherwise meet the legal standard to be considered a danger to self or others. In this case, or in those situations where the patient is gravely disabled as a consequence of his or her mental illness, psychiatric consultation should be sought.(8)

ADDRESSING THE PSYCHOSOCIAL ENVIRONMENT

Not unlike medical illness, psychiatric illness is most frequently seen within a biopsychosocial matrix, and although psychotropic medication may well alleviate the biological dimensions of the problem, the rest of the situation must also be addressed. By virtue of their ongoing involvement with families, primary care physicians are in the ideal position to facilitate participation by significant others in conflict resolution when this is indicated. Use of the same supportive techniques including individual counseling, family conferences or other psychosocial interventions practiced by most family practitioners, will resolve many of the presenting situational problems.

Compliance with medication is very much enhanced when the prescribing physician also has the opportunity to work through the patient's apprehension, misunderstanding, and conflict about taking medication within the context of supportive counseling. In many situations consultation can be obtained and the consultant may be able to suggest alternative approaches to a psychotherapeutic dilemma related to compliance. If this is ineffective, psychiatric referral may be indicated. In some cases, the timely identification of, and intervention with problems in the patient's psychosocial environment may preclude the use of psychotropic medication. The Primary Care Physician's knowledge of the family and the patient's ongoing social, legal and occupational relationships places he/she in the optimal position to make these early interventions. With the patient's permission and cooperation, collaboration with family, friends, and social agencies assures comprehensive assessment and appropriate treatment no different than with utilization of the same model in primary medical problems.

DETERMINING THE APPROPRIATE MEDICATION AND TREATMENT

In initiating treatment with psychiatric medications the following are of particular importance:

Choose a medication for which the side effects are not likely to be clinically dangerous, (e.g., do not use antidepressants that are associated with a high incidence of postural hypotension in someone whose cardiovascular status would be comprised by this side effect), or which would cause non-compliance on the part of the patient.

Carefully discuss the risks and potential side effects of the medication, as well as, the possible benefits with the patient (and, if possible, with the family) and either ask the patient to sign an informed consent or document the discussion in the medical record. (See center pages for a chart describing the more important side effects of the commonly prescribed psychiatric medications.)

Avoid using doses higher than the recommended initial dose unless the situation is of such severity that vigorous intervention is warranted A psychiatric consultation should be considered in this circumstance. In many cases starting with lower than the recommended dose minimizes potential side effects that might otherwise diminish compliance. Conversely, it is critical to assure that the patient is taken to high enough doses over a long enough period of time before he or she can be said to have had an optimal therapeutic trial of the medication.

Avoid using combinations of antidepressant and sedative hypnotic/anxiolytic medication for depression. The insomnia and anxiety associated with depression will almost always resolve once the depression begins to respond to the antidepressant.

Choose a medication the patient can afford and that is cost-effective. Many of the newer psychotropic medications are very expensive but more cost-effective over the long term. In other situations, newer drugs offer no real advantage despite being more costly.

Until stabilized on the medication with amelioration of symptoms, the patient should be followed at sufficiently frequent intervals to assure that optimal dosing is achieved, and that they are experiencing no untoward effects that might be either clinically dangerous or be cause for non-compliance. Specific inquiry by the physician is usually required about sexual dysfunction which can occur as a result of psychotropic medication.(9 ) It is frequently not reported by the patient but is a common reason for non-compliance.

It is particularly important to observe for an increase in symptoms early in the course of treatment. For example, an increase in suicidal intent on any antidepressant may occur within the first few weeks of treatment, or there may be an appearance or exacerbation of psychotic symptoms in someone who has been treated with an antidepressant but really has an underlying psychotic disorder.

Do not discontinue antidepressants prematurely. Patients who respond to antidepressants require continued medication for at least six months. If a decision is made to stop the antidepressant, it should be tapered rather than stopped precipitously. This latter holds true for almost all psychotropic medication. There is increasing evidence that many patients may require relatively high-dose maintenance antidepressant medication indefinitely.

FAILURE WITH MEDICATION

Failure of medication may be a consequence of several factors including the following:

Non-compliance with treatment.

Inadequate dosing or length of time on the chosen agent. Some antipsychotic or antidepressant medications may take two months or more to become optimally effective.

Failure to respond to optimal trials of medication in the face of an accurate diagnosis, good compliance, and no complicating concomitant medical illnesses may indicate a non-resolution of ongoing psychological conflicts during the course of treatment. More intense focus on these issues is indicated and will likely facilitate improvement. If this is not an issue, a trial of a similarly acting psychotropic medication of a different class is usually indicated or, alternatively, polypharmacy may have to be considered as discussed below.

In any of the above situations the primary care physician should consider consultation with a psychiatrist and in any situation where the patient's condition continues to worsen referral should be made immediately.

THE DECADE OF THE BRAIN

The number of psychotropic medications and the complexity of their use is increasing geometrically in what has come to be known as the ``Decade of the Brain." Currently, a plethora of new psychiatric medications are being marketed, and for many of these, even specialists have had little clinical experience. In some cases, few large scale, well-controlled clinical studies have been carried out. Similarly, we know little about the long term side effects of some of the newer medications. Further, over the past several years various "augmentation strategies" have been developed to enhance the efficacy of the traditional psychotropic medications. This frequently results in the use of several medications at the same time. This has the potential of successfully alleviating symptoms in patients refractory to traditional treatment, but also has the potential of causing significant complications resulting in both clinical deterioration and increased legal liability.

Continuing education courses for primary physicians in the use of the traditional psychotropic medications will assure both confidence and competence when they are prescribed in the primary care setting. Use of the newer psychiatric drugs, as well as more complex applications of both newer and traditional psychotropic medications, including drug combinations, should be referred to the specialist.

OTHER SIGNIFICANT ISSUES

There are any number of other issues that frequently must be taken into consideration in the prescription of psychotropic medications some of the more important of which are the following:

Indications and dosing in the elderly may vary considerably. Almost invariably they require lower doses of psychotropic medication.. An exacerbation of medical illness or use of multiple concomitant drugs may influence the metabolism of psychiatric medication. The elderly should be followed closely when on these agents. (10-11)

Collaboration with parents, teachers and school nurses is essential to competently initiate and maintain stimulant medication in children and adolescents, and to monitor its' effect.(12)

Patients with mental illness frequently have significant medical illness that may be masked by the more prominent psychiatric symptoms. (13)

The ethnicity of psychiatric patients and their pharmacogenetics is particularly important in the prescription of psychotropic medication. (14)

Split treatment (e.g.., providing psychotropic medication to a patient while the patient is seen in counseling or psychotherapy by a non-medical mental health practitioner), while helpful, may also have adverse clinical consequences and may expose the prescribing physician to increased risk of legal liability. (15)

Certain of the psychotropic medications, benzodiazepines and their derivatives may cause tolerance and dependence, and should be used only for specific indications and usually for limited durations. Patients should be informed of this risk, should be informed of the danger of stopping the drugs precipitously, and in those cases where they are maintained on the medication for longer periods of time, they should be followed closely and advised of alternative pharmacological and nonpharmacological interventions that may be available. (16)

Particular attention must be paid to the risk of tardive dyskinesia in patients on neuroleptic medication. The risk will vary depending on several factors. It may, however, in some cases be irreversible producing both anguish and social dysfunction to he patient and their relatives, and increased medico-legal risk to the provider. (17)

When evaluating patients referred by non-medical mental health practitioners it is very important to reach an independent diagnosis. Limited license practitioners lack the training to assure that the psychiatric symptoms being observed are not being caused by covert medical illness, illicit drugs, or other prescribed medications. (18)

Always consider substance abuse in the etiology of psychiatric symptomology. It may be the primary cause of the manifest problem, it may be an attempt at self medication, or it may be seen independently but concomitantly with the primary psychiatric diagnosis. In any case it must be treated at the same time as the mental illness or treatment of the latter is almost never successful. (19-20)

REFERENCES

1. Psychopharmacological Screening Criteria; Kane, JM, et al., J. Clinical Psychiatry, 53:6, June 1992.

2. Hanson, C, and Askansas, A, Legal Counsel CMA; Professional Liability and Managed Care, California Physician, February 1995, pages 37-40

3. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Primary Care Version (DSM-IV-PC) Washington, DC, American Psychiatric Association, 1994. (Developed by the APA in collaboration with Primary Care Physician organizations specifically for Primary Care Providers).

4. Practice Guidelines for Major Depressive Disorder in Adults; Supplement to the American Journal of Psychiatry, Vol. 150, No. 4, April 1993.

5. Depression in Primary Care; Volume 1 and 2, U.S. Dept. of Health and Human Services, Agency for Health Care Policy and Research, Rockville, MD, 1993.

6. Deliberate Misdiagnosis of Major Depression in Primary Care; Rost, K, et. al.; Arch Fam. Med., Vol 3, April 1994

7. The Medical Letter on Drugs and Therapeutics; Vol 35, Issue 901, July 23, 1993.

8. Utilization of Psychiatry and Psychiatric Specialists in Managed Care Systems; February 1995, California Psychiatric Association, 1029 K Street, Suite 28, Sacramento, CA.

9. The Medical Letter on Drugs and Therapeutics, Vol 34, Issue 876, August 7, 1992.

10. Inappropriate Drug Prescribing for the Community-Dwelling Elderly, Willcox, SM, Himmelstein, DU, et.al; JAMA, 272, pages 292-296, July 1994.

11. Management of Drug Therapy in the Elderly; Montamat, SC, NEJM, 321, pages 303-309, 1989.

12. Pharmacologic Treatment of Attention Deficit Hyperactivity Disorder; Greenhill, LL, March 15 (1), pages 1-27, 1992.

13. Medical Evaluation of Psychiatric Patients, Koran, LM et. al.; Arch Gen Psych, 46, pages 733-740, August 1989.

14. Ethnic Racial Differences in Response to Medications, 1994, The National Pharmaceutical Council, 1894 Preston White Drive, Reston, Virginia.

15. General Guidelines for Psychiatrists Who Prescribe Medication to Patients Treated by Non-medical Psychotherapists, Appelbaum, PS, Hosp and Comm Psych. Vol 42, March 1991.

16. Benzodiazopine Dependency, Salzman;, C, Psychopharmacol Bull, 26 (1), pages 61-62, 1990.

17. Tardive Dyskinesia; Jeste, DV, Caligiuri, MP, Schiz Bull,19 (2), pages 303-315,1993.

18. Medical Problems That Present with Psychiatric Symptoms; Comprehensive Textbook Of Psychiatry, Kaplan and Sadock, Vol Edition, Williams and Wilkins, 1989, pages 1294-1295.

19. Drug and Alcohol Abuse Among Psychiatric Admissions, Crowley, TJ, et. al., Arch Gen Psych, Vol 30, January 1974.

20. Addiction Medicine and the Primary Care Physician, Smith, DE, Special Editor; The Western Journal Of Medicine, Vol 152 May 1990. (The entire edition is devoted to this theme.)

THIS BROCHURE IS INTENDED TO HIGHLIGHT SOME COMMON ISSUES FACED BY PRIMARY CARE PHYSICIANS WHO DIAGNOSE MENTAL ILLNESSES AND PRESCRIBE PSYCHOTROPIC MEDICATION FOR SUCH ILLNESSES. THESE ARE GUIDELINES ONLY AND THEIR APPLICATION TO ANY PARTICULAR PATIENT MAY NOT BE APPROPRIATE.

IT SHOULD NOT BE USED AS A SUBSTITUTE FOR CONTINUING MEDICAL EDUCATION OR REFERRAL TO AND CONSULTATION WITH QUALIFIED PSYCHIATRIC SPECIALISTS.