Complex Prescribing of Psychotropics

Question 1

Essential principles PMHNP should follow prior to prescribing

Answer 1

-Symptom-focused psychiatric illness history.
-History of past symptoms and episodes
-Previous treatment and response
-Medical history
-Current medications including OTC
-Suicide and homicide risk assessment
-Pregnancy status
-Substance use
-PMHNP should assess patient’s current symptoms
-Checklists can be useful
-Written statements from the patient may be documented
-Avoid diagnostic and prescription bias

Question 2

Useful principles PMHNP should follow prior to prescribing

Answer 2

Mental status examination
Information from other sources besides the patient
Family history
Patient’s views about their medications
Sexual orientation
Concerns expressed by the patient

Question 3

Consider before prescribing

Answer 3

Diagnosis and Treatment
Monotherapy
Medication Overlap an Indications
Choosing a starting dose:
Standard dosing vs. Half-dosing vs.
Higher doses

Question 4

Medical workup to be considered by PMHNP’s

Answer 4

-Presence of liver disease
-Pregnancy testing
-TSH levels for patients with depression
-CMP, liver function tests, electrolytes, kidney function, blood sugar, CBC, TSH
-Monitor for therapeutic drug levels recommended prior to prescribing
-Fasting blood sugar and lipids recommended for patients starting an atypical antipsychotic
-Testing for HIV and Hepatitis for those at risk
-Obtain baseline blood levels for certain medications (e.g. mood stabilizer)
-AIMS scale recommended for baseline prior to prescribing antipsychotics

Question 5

Complex prescribing of psychotropics

Answer 5

Shared goals between the PMHNP and the patient
PMHNPs should work with patients in deciding the psychotropic medication
Ideally, it is a mutual partnership
Listen patient’s wishes
Patients may be resistant to starting a psychotropic medication
Address current concerns the patient may have

Question 6

PMHNP’s should be able to properly answer questions from patient regarding medications:

Answer 6

-A discussion about length of treatment, potential addiction, symptom relief, side effects
-Discuss alcohol intake, nicotine use and illicit drug use
-Consider cultural practices and views of traditional medication
-Address other concerns patients as they arise

Question 7

What types of patients is half dosing recommended for when prescribing psychotropics?

Answer 7

Geriatric patients
Children (<14 y/o)
Patients afraid of taking medications
Patients who may perceived themselves as being sensitive

Question 8

What increments should medications be adjusted by in outpatient setting

Answer 8

In outpatient settings, increments of 25 to 50% for mild to moderate symptoms

Question 9

How does dosing change in the outpatient setting?

Answer 9

In inpatient settings, larger doses may be necessary

Question 10

Starting psychotropics(general considerations)

Answer 10

-Titration may be necessary
-Increase patient monitoring in inpatient settings
-In outpatient settings increase follow-up visits
-Order and assess therapeutic drug blood levels for dose adjustment
-Emergency medications for higher acuity of symptoms
-Long-acting formulation for non-compliance
Follow regulations and practice guidelines

Question 11

Starting psychotropics: loading doses

Answer 11

-They may be required to rapidly control patient’s symptoms in inpatient and emergency
Settings, (Inpatient vs. Outpatient)
-A combination of psychotropics may be required for stabilization
-Valproic Acid, Lithium

Question 12

Follow up for psychotropic medication prescribing

Answer 12

-Follow-up time may depend on the patient’s condition
-Normally, in outpatient settings, follow-up may occur in 1 to 2 weeks
-Early follow up may depend on:
–Patient’s symptoms
–Patient’s medical conditions
–Patient’s wishes

Question 13

What to address in follow up visit.

Answer 13

-In inpatient settings, a follow-up may occur within a day or two
-An outpatient follow-up visit may be limited to 30 minutes
-review progress notes, current medications, and labs prior to follow-up visits
-Check for target symptoms
-Assess the patient’s response
-Assessment and treatment of side effects
-Discuss patient’s medical changes
-Assessment may include additional information from others
-Key questions should be asked
-Target symptom assessment
-Quantifying the patient’s responses
-Assess any potential medical changes that may be occurring
-Consider additional laboratory evaluation
-Maintain therapeutic alliance with the patient

Question 14

Medication adherence

Answer 14

Medication non-adherence is common
PMHNPs should work with their patients to promote adherence
Recommendations include the following:
Establish an initial contract with their patients
Prescribe a simple medication regimen
Provide written directions
Schedule regular follow-ups

Question 15

Medication trials

Answer 15

-Clinical decisions that PMHNPs should make depending on various factors
-Guidelines include continuing medication for 30 days before switching
-In inpatient settings, continue the medication for 15 days before switching
-Guidelines will vary according the patient’s condition
-Gradual switching and cross-titration may be indicated

Question 16

Switching antipsychotics

Answer 16

-Switching antipsychotics may be necessary in certain patients
-Switching medications can cause rebound psychosis, withdrawal, activation, insomnia
-Keep in mind receptor binding characteristics
-Do not allow gaps in between administration of antipsychotics
-Cross-titration (two antipsychotics) is usually performed over a period of time.
-Switching can be performed using antipsychotics from the same class
-Clozaril should be switched slowly (4 weeks)
-Switching a “pine” (e.g. olanzapine) to another “pine” (e.g. asenapine) can be done in 1 week
-Switching a “pine” (e.g. olanzapine) to a “done” (e.g. risperidone) should be done within 2 weeks
-Switching a “done” (e.g. risperidone) to a “pine” (e.g. asenapine) should be titrated over 2 weeks

Question 17

Difference between “pines” and “dones”-antipsychotics.

Answer 17

will need to look up

Question 18

What to discuss/consider re: polypharmacy

Answer 18

Polypharmacyis not uncommon
Weigh pros and cons
Combinations of psychotropics occur to manage symptoms
Should be avoided whenever possible
May be required when synergisticeffects of psychotropics outweighrisks