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Inheriting a patient on psychiatric medication: guidelines and best practices

Doctor speaking to patient with family

In the primary-care setting, providers often inherit patients on a complicated psychiatric medication regimen. For example, youth frequently have no scheduled psychiatric follow-up at the time of discharge from an acute psychiatric stay. Primary care providers are expected to manage symptoms and renew psychotropic prescriptions.

It’s important to recognize that youth are acutely hospitalized for behavioral concerns that imminently endanger themselves or others. Acute psychiatric stabilization mandates rapid resolution of suicidal, self harm or aggressive behaviors with administration of one or more psychotropic medications targeting acute symptoms and based on preliminary underlying diagnoses. In time, symptom evolution and response to medications may result in clarification and revision of diagnoses and thus interventions.

Psychotropic medications often have a latency of response of weeks or months, that will not be fully appreciated during an acute 1-2 week acute psychiatric admission. Titration to optimal dosing and monitoring for adverse effects will fall upon the primary care provider until a psychiatrist is secured.

If a patient in your practice requires continuation of psychotropic medications started elsewhere, collaboration with a psychiatrist is essential for ensuring high-quality care. Illinois DocAssist is always available to you, at no cost, to provide psychiatric consultation on your pediatric and perinatal patients. You can speak to a consultant during normal business hours by calling 866-986-2778 or scheduling a free consultation online.

Common guidelines and best practices:

  • Information gathering: It’s important to understand the rationale for use of each medication prescribed including the target symptoms and the proposed diagnoses. Always request that a parent share a discharge summary and perhaps bring in medication bottles or the name of the pharmacy. Obtain a release of information in order to request records and/or to speak with the prescribing clinician at the discharging hospital.
  • Adjusting medication dosing: Most medications may be at starting doses at discharge and will need to be increased based on tolerability and response. Mood stabilizers (Ie: Lithium Tegretol, Depakote) may require titration to a therapeutic serum level while also checking CBC, CMP, TFTS, etc.
  • Monitoring for common adverse effects: Several atypical antipsychotics may induce changes in prolactin, HA1c and other metabolic indices. Inquire about breast tenderness, galactorrhea and weight gain. Use of Depakote in females of or near reproductive age is to be avoided due to the risk of PCOS and Neural Tube Defects. Monitor menses and hormones and if Depakote is continued, ensure birth control use. Consider medication changes if adverse effects are intolerable. Adverse events and withdrawal symptoms guides can be found in the guide for psychopharmacology for pediatricians by John Hopkins University Center for Mental Health Services in Pediatric Primary Care.
  • Using care when considering medications for sleep: These are frequently initiated in hospitals but with rare exceptions, youth should not be maintained on sleep medications. Use of Trazodone and Seroquel for sleep, despite use in hospital settings, is not best practice and should not be chronically maintained. Safe medications for chronic use include clonidine or prazosin (for ADHD, PTSD related insomnia). Antihistamines should not be used long-term and Melatonin use also merits trial tapers. Insomnia due to a mood disorder, PTSD, psychoses or substance use should subside as the underlying disorder is treated.
  • Providing education and information: Always educate youth and parents about supportive psychosocial interventions including therapy, safety plans, diet, sleep and exercise. Offer counseling for safe sex and substance misuse. Always check in for compliance and address barriers through motivational interviewing.
Sources
  1. Guide to Psychopharmacology for Pediatricians – John Hopkins University Center for Mental Health Services in Pediatric Primary Carel
  2. Inheriting Patients with Complicated Medication Regimens– Wisconsin Child Psychiatry Consultation Program
  3. Riddle, M. Et Al. (2017). Psychotropic Medications in Primary Care Pediatrics. In McInerny T. K. & American Academy of Pediatrics. American Academy of Pediatrics Textbook of Pediatric Care (2nd ed pp. 481-501) American Academy of Pediatrics.
  4. Psychopharmacology in Primary Care– The WACO Guide