Prescribing Guidelines

Introduction

Prescribing Guidelines Manual for Psychiatric Medications

The Health Care Agency's Mental Health Services serves a target population of the most seriously and persistently mentally ill. A majority of these patients have symptoms or histories of psychoses, major mood swings, severe depressions, agitated or assaultive behaviors, and/or suicidal or homicidal ideation. These severely mentally ill patients require extensive psychiatric services, including case management, rehabilitation, and psycho-pharmacological treatment.

Psychiatric medications should be prescribed in conjunction with an individualized treatment plan that is developed by the interdisciplinary mental health team. State regulations mandate that psychiatric medication shall never be used as punishment, for the convenience of the staff, to control behavior which is not a symptom of a diagnosable disorder, or as the only treatment modality. Psychiatric medications should be part of a comprehensive treatment approach.

Psychiatric medications offer a realistic chance for a stabilizing outcome for many of these severely mentally ill patients. However, psychiatric medications may cause short-term uncomfortable side effects, rare adverse (and even fatal) reactions, and a potential for long-term disabling effects. Clinicians should therefore be familiar with the Physicians Desk Reference and utilize available research, knowledge, and clinical expertise in prescribing psychiatric medications.

Clinicians should evaluate each prescription on the basis of the benefits expected versus the risks to be incurred - both the risks from the possible side effects of the medication and the risks from not utilizing the medication. The treating clinician has the authority for making the decision as to the choice of the medication, route, and schedule of the administration, dosage and duration, and integration with the complete treatment plan - based on the clinical assessment and clinical needs of the patient.

This Prescribing Guidelines Manual will be updated on an ongoing basis, and is designed to assist the clinicians in the appropriate selection and effective use of these psychiatric medications. It highlights the clinical indications, treatment guidelines, adverse reactions, and drug-drug interactions for a number of the more frequently used psychiatric medications. The clinician should use this manual as part of the evaluation process. However, the clinician must also rely on his/her own clinical judgment and the specifics of each individual patient.

This Prescribing Guidelines Manual, therefore, does not represent one definitive standard of care. Instead, this manual attempts to offer reasonable considerations in the prescription of psychiatric medication for the mentally ill patient. In this context, the Health Care Agency's Behavioral Health Services expects the clinician to document his own choice of medication, the rationale for the choice of that medication, and the effectiveness of that medication for each patient.

Behavioral health clinicians in all Divisions recognize the value of a consumer-oriented approach that also strives to involve family and significant others in the delivery of services. Part of this awareness includes sensitivity to varying personal perspectives and cultural features regarding the use of medications. The choice of terms can affect the success of these efforts. Earlier language such as "medication compliance" incompletely recognized the consumer's contribution and potential. The term "adherence" underscored a more active consumer role, but the concept of "therapeutic collaboration" seems best to emphasize the shared opportunity for improved outcomes. This approach takes into consideration the consumer's wishes and concerns, works to align treatment with his or her core life goals, and closely monitors agreed-upon clinical markers.