Jan 29, 2020
By Smita Das, MD
Jordan, a new patient, comes to our psychiatry visit toting a bag full of medications. We start to discuss his psychiatric history. I ask about previous diagnoses and he replies, “everything,” noting the multiple diagnoses behind the stuffed bag. We dig further into his medication history and current prescriptions. Jordan’s not entirely sure which medications he’s supposed to be on, what they do, or when to take them. He recalls receiving one prescription in the emergency room, another from a primary care doctor, a third from a previous psychiatrist, and so on.
While Jordan’s case is extreme, variations of this scenario happen in mental health medication prescribing all too often. Current health care system constraints mean mental health care prescribing can be disjointed, hurried, and poorly coordinated, with inadequate follow-up. The result can be substandard prescribing practices, which may lead to poor outcomes and a frustrating experience for already-struggling patients. Numerous studies show that these systemic issues lead to lower patient satisfaction, worse outcomes, and a greater risk of patients not taking medications as prescribed. What follows are some of the key factors behind these poor outcomes.
Most mental health medication management today happens in primary care. Primary care physicians (PCPs) are strong partners in mental health prescribing since they understand the patient as a whole and are more available in the community. On the other hand, primary care visits are often short (15-20 minutes in some settings), so getting a patient’s full psychiatric history in that timeframe, on top of addressing the patient’s other medical concerns, is not easy. This strained system only contributes to the problems outlined below.
A patient’s psychiatric history is complex. Not only are there symptoms to address, such as low mood, loss of interest in activities, and poor sleep, but there are also important contributing factors to consider before prescribing a medication. A patient’s full psychiatric history contains medical and social components as well—who are their support systems, where do they live or work, what substances are they using, what chronic medical illnesses do they have? In addition to getting that history, there is the overarching need for a level of comfort between patient and physician, given the sensitive nature of the information.
All of the components gathered from the patient’s history help form the assessment and treatment plan. At this stage, people can be misdiagnosed. For example, poor concentration can be a symptom of numerous conditions, including anxiety, attention deficit disorder (ADD), depression, and bipolar disorder. Let’s say the initial diagnosis is incorrect—that patient could then be stuck with the wrong diagnosis as they continue in care with other providers.
There are several different things that could explain how Jordan came to accumulate a bag full of medications in the first place. Some of those prescriptions may be for the wrong diagnosis. And others may have only been temporary. For example, certain short-term medications can help treat anxiety while a patient is waiting for the gold standard treatment (an SSRI) to take effect. Or, the patient may continue on the temporary medication indefinitely. Some of the medications may have been prescribed to treat temporary side effects. Meanwhile, others should have been stopped long ago once symptoms have been resolved, but were accidentally continued.
Even more concerning? Doctors sometimes prescribe medications without considering a patient’s characteristics. Then, when those medications are ineffective because they’re not the right fit or produce that person’s most despised side effect, a provider may prescribe yet another medication. Now the patient is on multiple medications to treat a single condition (otherwise known as “polypharmacy”), when a thoughtful review of their needs could have prevented this. Worse yet, the patient’s symptoms now take longer to improve. While there are rules to help guide mental health prescribing, they’re not always easy to implement in a time-strained system.
In the studies used to approve medications like antidepressants, participants are seen frequently (sometimes weekly), complete many assessments, and get lots of time with providers. In reality, follow-ups rarely happen that frequently, and a patient may stop taking their medication long before their follow-up appointment three months in the future. In other words, medications that work in studies may not work so well in our stressed health care systems, which could stem partly from having fewer touchpoints with care providers.
Probably the most important aspect of mental health prescribing is that the patient takes the medication they’re prescribed. Involving the patient in the decision-making process helps raise their chances of taking the medication. The patient should be central to this process–they may have particular side effects they are concerned about, or previous responses to a particular medication, and deserve to be part of an informed discussion. What’s more, a thorough consent process can prepare patients for a medication’s possible side effects and give them a sense of how long it will take to see benefits from the medication. This is especially important since side effects and not perceiving benefits are two major contributors to people discontinuing medication.
Let’s reconsider Jordan’s case. A longer appointment guided by structured questions and evidence-based material could help inform his assessment and treatment plan more effectively. In this case, Jordan may receive just one or two diagnoses rather than being diagnosed with “everything.” Shared decision-making and thorough, informed consent can help both Jordan and his physician decide together what medications make sense to start or not. And the proper follow-up and check-ins can help guide care along the way, so Jordan feels better faster.
Strange as it may sound, I love when patients bring in a bag full of medications—it can spark a crucial dialogue and occasionally, a mystery to be solved. Taking a thorough history, listening to the patient, involving them in medication decisions, and following them closely often leads to great outcomes. This is not only a win for the patient, but also incredibly satisfying to me as a physician seeking to improve the quality of mental health care.
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DISCLAIMER: The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
ABOUT THE AUTHOR
Smita Das, MD, PhD, MPH is Medical Director of Psychiatry at Lyra Health. She is an addiction psychiatrist and public health researcher, serving as a leader in local and national committees in psychiatry. She also practices at Stanford University School of Medicine, where she is a clinical assistant professor.