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Last Updated:  07/23/2007

Copyright © 2005
Alameda County Behavioral Health Care Services

 


Guidelines for Psychotropic Medication Practices  Printer Friendly Version

 
Table of Content

I.

Case Documentation

II.

Prescription and Monitoring Practices

III.

Antipsychotic Medications

IV.

Mood Stabilizers

V.

Antiderpressants

VI.

Anxiolytics

VII.

Hypnotics

VIII.

Psychostimulants

IX.

Antiparkinsonians

X. Miscellanous

I.   CASE DOCUMENTATION

A.   The Physician Initial Note must contain the following:

  1. Date of patient contact (month, day, year)

  2. Reason for referral

  3. Recent course of illness

  4. Mental Status Exam

  5. Clinical impressions

  6. Five Axis DSM-IV diagnosis

  7. Treatment plan specifying target symptoms and behaviors

  8. Documentation of completed or non-completed Medication Consent Form

  9. Prior medication trials and duration

  10. Past and current drug, ETOH and smoking use

  11. Allergy assessment

  12. Current medication and dose

  13. Patient medical history including concurrent disease states

  14. Family history

  15. Physician signature (with degree)

  16. Clinical risk assessment for patients who are pregnant or breast-feeding

B.   The Physician Progress Note, on each medication visit, must contain the following:

  1. Date (month, day, year)

  2. Location where service provided

  3. Type and duration of service

  4. Description of service related to diagnosis, symptoms, established goals, and expressed in terms of changes in the individual’s functioning. If there is little progress, a clear explanation of the limited progress must be included.

  5. Description of response to/outcome of medication therapy

  6. Assessment of lab data if applicable

  7. Assessment of medication compliance

  8. Description of adverse drug experiences or documentation if none present

  9. Clinical risk assessment for patients who are pregnant or breast-feeding

  10. Physician signature (with degree)

C.   The Discharge Summary is complete

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II.   PRESCRIPTION AND MONITORING PRACTICES

A.  Informed Consent form completed and current

B.  Medication Orders

  1. Each medication order includes the date, drug name, route, strength, and directions for administration

  2. Each order is signed or co-signed by the attending psychiatrist

  3. The Medication Order Sheet “Pink Sheet” is self-explanatory, current, complete and updated on each patient visit as indicated

  4. The IM Medication Administration Record (MAR) is completed and accurate

C.  The psychiatrists must see each patient in a face to face evaluation at least once every three months

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III.   ANTIPSYCHOTIC MEDICATIONS

A.  Usual indications

  1. Schizophrenia

  2. Delusional disorders

  3. Schizo-affective disorders

  4. Schizophreniform disorder, brief reactive psychosis, or psychotic disorder NOS

  5. Bipolar disorder

  6. Major depressive episode with psychotic features

  7. Borderline personality disorder

  8. Other appropriate indications as documented

B.  Antipsychotic dosage range within the approved dosing guidelines for Alameda County BHCS or, if antipsychotic dosage range outside the dosing guidelines, chart documentation supports dosage. Please note:

  • quetiapine (Seroquel) doses should be at least 400mg within 3 months of initiation.

  • aripiprazole (Abilify) initiated at doses of 5-15mg, and should be maintained at that dose for at least 4 weeks.

  • ziprasidone (Geodon) should be titrated to 120-160mg within the first two months of treatment

  • C.  Dosing

    1. No “as needed” dosing (prn) of antipsychotic agents without documented rationale

    2. Clozapine Monitoring Committee Guidelines are being followed for all patients taking clozapine

    D.  If an additional antipsychotic medication is simultaneously prescribed, the rationale is documented.

    E.  Adjunctive Monitors

    1. Baseline assessment of movement disorders documented

    2. If possible symptoms of T.D. are noted, AIMS examination done at least every 6 months

    3. Weight: Measured at baseline, at every visit for 9 months, then every 3 months thereafter

    4. Glucose: Measured at baseline, at 6 months, then annually

    5. Cholesterol/triglycerides: Measured at baseline, at 6 months, then annually

    6. Prolactin (for clients on risperidone or any conventional agent): Measured at baseline, at 6 months, then annually

    7. Electrocardiogram (for clients on thioridazine or ziprasidone): Obtain baseline ECG only in clients at risk* for QTc prolongation.  Periodic monitoring would be dependent on changes in electrolyte status (hypokalemia or hypomagnesemia) as a result of diuretic therapy, diarrhea, etc.

    *These drugs are contraindicated in clients with a known history of QT prolongation (including congenital long QT syndrome), with recent acute myocardial infarction, with uncompensated heart failure, or with a history/family history of syncope or sudden cardiac death. These agents should not be used with any drug that prolongs the QT interval, and should be discontinued in patients who are found to have a QTc interval over 500 milliseconds.

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    IV.   MOOD STABILIZERS

     A.  Usual indication

    1. Bipolar disorder mixed, manic or depressed

    2. Schizoaffective disorder

    3. Bipolar disorder NOS

    4. Cyclothymia

    5. Borderline personality disorder

    6. Refractory depression

    7. Other appropriate indications as documented

    B.  Mood stabilizer dosage range within the approved dosing guidelines for Alameda County BHCS, or if dosage range outside the dosing guidelines, chart documentation supports dosage

    C.  No “as needed” dosing (prn) of mood stabilizers

    D.  If more than one mood stabilizer is simultaneously prescribed, the rationale is documented

    E.  Serum Levels

    1. Serum level assessed both prior to and after a dosage adjustment as indicated, except for patients taking divalproex sodium (valproic acid), when levels at these times may be ordered solely based on clinical judgment of need

    2. Serum level of the mood stabilizer, when measured, is within the therapeutic range:

    • Lithium                  0.6 – 1.2 mEq/L

    • Valproic Acid         50 – 125 mcg/ml

    • Carbamazepine          4 – 12 mcg/ml

    1. If serum level outside therapeutic range, chart documentation supports dosage

    2. Once stabilized, serum levels of carbamazepine and valproic acid drawn at least every 6 months; for lithium, every 12 months

    F.  Adjunctive Monitors

    1. Prior to initiation: assessment of renal, hepatic, hematological, thyroid function, and electrolytes, as well as pregnancy status

    2. Maintenance assessment:

    • Lithium: renal and thyroid function tested yearly

    • Valproic acid: hematological and hepatic functions tested twice yearly

    • Carbamazepine: hematological and hepatic function tested quarterly

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    V.   ANTIDEPRESSANTS

    A.  Usual indication

    1. Major Depression

    2. Dysthymia

    3. Bipolar disorder, depressed

    4. Schizoaffective disorder, depressed

    5. Anxiety disorders (Panic, OCD, GAD, PTSD)

    6. ADHD

    7. Other appropriate indications as documented

    B.  Antidepressant dosage range is within the approved dosing guidelines for Alameda County BHCS or if dosage range outside the dosing guidelines, chart documentation supports dosage

    C.  No “as needed” dosing (prn) of antidepressant agents, without documented rationale.

    D.  If an additional antidepressant medication is simultaneously prescribed, the rationale is documented.

    E.  Laboratory studies

    1. Baseline and maintenance laboratory assessments as indicated for tricyclic agents

    2. Baseline liver function tests upon initiation of nefazodone

    3. Maintenance liver function tests every six months during continuation of nefazodone (in addition to monitoring for clinical signs and symptoms of hepatic dysfunction in medical progress notes)

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    VI.   ANXIOLYTICS

    A.  Indication

    1. Anxiety disorders (Panic, OCD, GAD, PTSD)

    2. Acute psychomotor agitation

    3. Alcohol or sedative withdrawal

    4. Anxiety associated with other mental disorders

    5. Akathesia or tardive dyskinesia

    6. Bipolar disorder (clonazepam or lorazepam recommended)

    7. Other appropriate indications as documented

    B.  Dosage Range

    Anxiolytic dosage range is within the approved dosing guidelines for Alameda County BHCS or if dosage range outside the dosing guidelines, chart documentation supports dosage

    C.  No more than one antianxiety agent at one time, unless from different pharmacological class, except during the transition from one agent to another.

    D.  No use of benzodiazepines in patient with history of, or concurrent abuse of drug and alcohol, or history of addiction to antianxiety agents, unless supported by chart documentation.

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    VII.  HYPNOTICS

    A.  Indication

    1. Insomnia

    B.  Dosage Range

    Hypnotic dosage range is within the approved dosing guidelines for Alameda County BHCS or if dosage range outside the dosing guidelines, chart documentation supports dosage

    C.  No more than one hypnotic agent prescribed at one time

    D.  No use of benzodiazepines in a patient with history of, or concurrent abuse of drug and alcohol, or history of addiction to antianxiety agents, unless supported by chart documentation.

    E.  No use of chloral hydrate in patients with marked hepatic or renal impairment

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    VIII.  PSYCHOSTIMULANTS

    A.  Indication

    1. ADHD
    2. Refractory Depression

    3. Other appropriate indications as documented

    B.  Dosage Range

    Psychostimulant dosage range is within the approved dosing guidelines for Alameda County BHCS or if dosage range outside the dosing guidelines, chart documentation supports dosage

    C.  Adjunctive Monitors

    1. Height and weight every 6 months
    2. Pulse every 3 months, and blood pressure in patients > 12 years every 6 months

    D.  No use of stimulants in a patient with history of, or concurrent abuse of drug and alcohol, or history of addiction to stimulants, unless supported by chart documentation.

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    IX.    ANTIPARKINSONIANS

    A.  Indication

    1. Alleviation of extrapyramidal side effects (EPS) induced by antipsychotic drugs

    2. Prophylaxis of EPS induced by antipsychotic medications 

    B.  Dosage Range

    Antiparkinsonian dosage range is within the approved dosing guidelines for Alameda County BHCS or if dosage range outside the dosing guidelines, chart documentation supports dosage

    C.  Documentation

    1. If antiparkinsonian medication is used with any atypical antipsychotic (clozapine, risperidone, olanzapine etc.) justification of specific need must be documented.

    D.  No more than one antiparkinsonian agent prescribed at one time, unless documentation supports use

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    X.   MISCELLANEOUS

    A.  Gabapentin: The literature has demonstrated no efficacy of this agent in mood stabilization.  Specific rationales for use should be clearly written into the progress notes and medication treatment plans.

    B.  Topiramate: At present, there is no evidence-based literature to support its use as a mood stabilizer. Specific rationales for use should be clearly written into the progress notes and medication treatment plans.

    C.  Controlled Substances: No use of any controlled substance in a patient with a history of substance abuse, unless supported by appropriate chart documentation.

      References

    1. Kahn DA, Ross R, Printz DJ. The expert consensus guideline series: medication treatment of bipolar disorder 2000. Postgraduate Medicine Special Report. April 2000.

    2. McEvoy JP, Scheifler PL, Frances A. The expert consensus guideline series: treatment of schizophrenia 1999. J Clin Psychiatry 1999;60 (supp 11). 

    3. McIntyre JS, Charles Sara. APA Practice Guidelines 1996. American Psychiatric Association. 347pages.

    4. Marder SR, Essock SM, Miller AL et al. The Mount Sinai Conference on the Pharmacotherapy of Schizophrenia. Schizophr Bulletin 2002; 28(1): 5-16.

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