Prescribing Mental Health Medication

The Practitioner's Guide

Christopher Doran MD

• Editorial: Routledge
• Año: 2021
• ISBN:
  9781000426427
• Edición: 3
• Categoría: Medicine
• Categoría: Psychiatry & Mental Health

Prescribing Mental Health Medication is a comprehensive text for all practitioners who treat mental disorders with medication. This new (third) edition is fully updated and includes a variety of additional chapters.

Prescribing Mental Health Medication covers the latest digital methodologies including Internet-based mental health treatment, electronic medical records and prescriber use of social media. Including information on all psychotropic medications in use in the United States and the United Kingdom, the book incorporates clinical tips, sample dialogues for talking about mental health medications to patients, and information specifically relevant in primary care settings. It looks at:

• how to determine if medication is needed, proper dosing and how to start, stop and change medication

• specific mental health symptoms and appropriate medication

• special populations including non-adherent patients, medication abusers, those mixing alcohol and psychotropics, confused patients, children, adolescents, pregnant women and seniors

• management of medication side effects and avoidance of medication risk

• prescription of generic preparations

• organizing a prescriptive office and record keeping.

The additional chapters in this new edition of Prescribing Mental Health Medication cover topics such as combining specific medications, combining medications and psychological therapies, use of 'natural' substances in mental health treatment, successfully managing patient relapse, and appropriate prescriptions of potentially controversial medications such as stimulants and benzodiazepines.

This practical text explains the entire process of medication assessment, management and follow up for general medical practitioners, mental health practitioners, students, residents, prescribing nurses and others perfecting this skill.

Part I

The need for this book

1General principles of medication management

Mental health medication is not like other medication

The scope of the problem

Mental health in the spotlight

References

Mental health medication is not like other medication

Mental health medication is neither fundamentally chemically different nor necessarily more complicated than other prescription medication. Nevertheless, prescribing medication for the psyche is a very different process from prescribing antibiotics, pain medications, anti-hypertensives, cardiac medication, pulmonary medication or any other group of medications – for the patient and often for the practitioner.

Consider the practice of writing a prescription for penicillin. Once an assessment has been made and a medication selected, there is very little that need be considered beyond writing an accurate prescription and giving appropriate instructions. The patient has an illness, wishes to get better and comes to the prescriber for a treatment that will remedy the problem. Although patients may wish that they did not need medication, prescribing is a relatively simple and straightforward process.

When a patient comes for mental health medication, however, there are many additional issues intrinsic to the process that may complicate the prescription. Before patients even set foot in the clinician’s office, they may obsessively worry for weeks, months or even years as to whether this is a reasonable, healthy or necessary decision. They may be embarrassed to present to a practitioner and feel that it reflects negatively on them to ask for help. Patients may have strong feelings about whether they wish to have a mental health diagnosis made and recorded in their chart. Even if a correct assessment is made, they may have mixed feelings about whether or not they will allow medication to be part of their treatment.

Once the prescription is written, patients may have fears that the medication will irrevocably change their mind, their behavior or personality. They can be concerned about whether it will be necessary to take the medication for life, and whether or not their lifestyle will be significantly altered or restricted. They often worry that the medication may be habit forming, and that they may become addicted to the simple pill they are being offered. They can be concerned about what their family, spouse or friends will think of them for taking a psychiatric medication. They begin to doubt their own abilities and wonder if they are weak for having started the treatment.

Thus, these medications – whether we call them mental health medications, psychotropics or psychiatric medications – are unique in the prescribing spectrum. Whether an antidepressant is prescribed for a diagnosis of depression or in the treatment of irritable bowel syndrome, chronic pain or fibromyalgia (to name a few other common indications), the use of an “antidepressant” has extra meaning to the patient. An anti-anxiety medication often carries a similar excess “charge,” whether it is specifically for an anxiety disorder or is used as part of an anti-hypertensive regimen.

Because of their special character and meaning within our culture and practice (see Table 1.1), these medicines require the practitioner to have special knowledge, techniques and sensitivity in order to prescribe effectively. That is what this book addresses – describing and teaching the body of knowledge that, when incorporated into everyday practice, will transform a practitioner from someone who merely writes a prescription to a person skilled in mental health medication management.

Table 1.1 Factors that make mental health medications unique

• Practitioner beliefs • Media distortion • Courtroom tactics • Beliefs about the causes of mental illness • Artificial separation of the “mind” and the “body” • Conflicting beliefs about what constitutes treatment for mental health symptoms

The special nature of mental health prescription often begins with the practitioner. Many of us, in our personal or family lives, have been exposed to mental illness and/or the varying prejudices about it. On the basis of a family member’s experience with medications, shared family beliefs, professional hearsay or media presentation about psychotropics, many practitioners have mistaken notions of the purpose, therapeutic potential and safety of psychotropic medication. Unfortunately, medical and nursing training is often inadequate in counteracting these misconceptions. Even when appropriately educated, some practitioners may dismiss the evidence concerning the effectiveness of psychotropic medication and continue to rely on data based on their family or personal experience. More unfortunately, in some areas of the world, “mental illness” is still regarded as a function of societal ills without any biological cause. Solutions to emotional problems are thought to lie solely in manipulation of the person’s environment, with medications having no part to play in treatment. In parts of the UK, as recently as the early 1990s, nursing training had an explicit anti-psychiatry content, often leaving nurses highly critical of what they believed to be a malevolent medical model.¹

Beyond the healthcare community, society at large continues to foster special ideas about mental health medication. Psychotropic medications such as diazepam (Valium), alprazolam (Xanax) and fluoxetine (Prozac) have, at various times, become the most frequently prescribed medications in the world. They also have become cultural icons – the butt of jokes, the material of night-time comedians and the front-page stories of news magazines. While recent media coverage has tended to be more accurate with regard to psychotropics, in a world of sensationalism and hype where a premium is placed on sales of magazines, increasing traffic to websites and social media sites as well as increasing viewership ratings for radio and TV programs, articles designed to grab the public’s attention often ignore or distort the true facts. Such presentations reinforce erroneous beliefs and continue to make these medications uniquely mistrusted.

Courtroom cases that involve psychotropic medications, and the headlines which these cases create, further make these medications “special.” An attorney with a defendant who has no other viable defense for a crime can make the taking of a psychotropic medication the focus of the defendant’s case. While few cases have been won on this basis, the fact that psychotropic medications regularly receive headline attention as possibly being the cause of violent, suicidal, abnormal or criminal behavior does little to normalize their prescription and use. Such publicity heightens sensitivity and these medications remain potentially controversial in our medical repertoire.

We cannot discuss the prescription of psychotropics without briefly discussing the evolving (and often confused) beliefs about the causes of mental illness. Within the last century, Western civilization has struggled at different times with beliefs that mental illness is caused by demonic possession, willful sloth, religious error, poor social conditions, intemperance, poor parenting or brain dysfunction. It can be expected, then, that when we talk about medication treatment of mental illness, people’s notions of what these medicines are, what their value is and how to prescribe them are also confused and evolving. Although many mental health conditions have an etiology which contains both chemical and genetic background as well as family nurturing and environmental toxins, we are learning more about potential biological underpinnings. Psychiatry has generally become seen as a medical science based on objective data. In this paradigm the use of psychotropic medications will become further demystified. This is, however, a long and slow process. Prejudice dies hard. For the majority of current practitioners’ lifetimes, the prescription of these medications will continue to require special skills and sensitivities.

Even medical and nursing practitioners exposed to balanced teaching about mental health conditions are not strangers to misguided notions surrounding mental illness and mental health medication. They may have discussed, learned and believed “facts” that supported the now outdated notion of a split between mind and body. It has often been a standing joke in healthcare training that some practitioners treat the patient from the “neck down,” while others treat from the “neck up.” For many trainees, it has been an acceptable and routine part of medical treatment to provide medications for illnesses of the heart, kidney, liver, musculature, etc. Neurological and neurosurgical treatment can be comfortably included in this group as “normal,” because defined physical symptoms of a neurobiological disorder can be observed outwardly or by laboratory testing. Brain tumors, degenerative disorders and seizures are also easily described and documented, and are all considered to be part of the “body.” The mind, spirit and emotions, however, have been much more elusive and difficult to define, and this has been reflected in the history of our treatment of mental dysfunction.

Psychiatry’s long-standing inability to objectify and make scientific its body of knowledge was particularly complicated in the 1930s, 1940s and 1950s, with the advent and ascendancy of psychoanalysis. Psychoanalytic teaching suggested that, given enough time and intensity of treatment, talking about one’s problems in sufficient depth could remedy most, if not all, symptoms. Even major mental illnesses, which we now know to have strong fundamental biological underpinnings, were seen as expressing unresolved conflicts from childhood, neuroses or conflicts of the ego, id and superego. While useful in the treatment of certain neurotic conditions, psychoanalytic concepts only furthered the gulf between treatments for the “mind” and treatments for the “body.”

We now understand much more about brain physiology, genetics and cellular signaling mechanisms. It is clear that abnormal brain functioning may have substantial effects on major physiological systems including sleep and wakefulness, appetite, energy, concentration, memory, orderly thinking, anxiety regulation, attention, affect regulation and social relatedness. In many ways, though, we have only scratched the surface of understanding the various aspects of brain function, and how our treatments can improve mental symptoms.

The scope of the problem

Mental health problems are a worldwide epidemic. The statistics are staggering and numbers are increasing rapidly.²

• 47.6 million American adults (representing 1 in every 5) and 450 million persons worldwide experience mental health problems.
• 4.6 percent of U.S. adults experienced serious mental illness in 2018 (11.4 million people). This represents 1 in 25 adults.
• At least 1 in 5 youths aged 9–17 years currently has a diagnosable mental health disorder that causes some degree of impairment; 1 in 10 has a disorder that causes significant impairment.
• 16.5 percent of U.S. youth aged 6–17 experienced a mental health disorder in 2016 (7.7 million people).
• 10–40 percent of primary care patients have a diagnosable mental disorder.³
• Depression is the single largest cause of disability worldwide – 12 percent of the total.⁴
• Mental health and substance abuse is estimated to cost the global economy $8.5 trillion and this is expected to double by 2030.⁵
• Fi...