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Guidelines for Psychotropic Medication Practices 

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 

  1. 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 diagnosis (current edition)
    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

  2. 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. Complete list of currently prescribed medications including strength, route and directions for administration.
    6. Description of response to/outcome of medication therapy
    7. Assessment of lab data if applicable
    8. Assessment of medication compliance
    9. Description of adverse drug experiences or documentation if none present
    10. Clinical risk assessment for patients who are pregnant or breast-feeding
    11. Physician signature (with degree)

  3. The Discharge Summary is complete


II.   PRESCRIPTION AND MONITORING PRACTICES

  1. Informed Consent form completed and current

  2.  
  3. 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 current, complete and updated whenever a medication change is made. Log must match the current MD progress note
    4. The IM Medication Administration Record (MAR) is completed and accurate

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

III.   ANTIPSYCHOTIC MEDICATIONS 
  1. Usual indications11
    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

  2. 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 300mg within 1 months of initiation. (No use for sleep or anxiety disorders)11
    • aripiprazole (Abilify) initiated at doses of 2-15mg, and should be maintained at that dose range for at least 2 weeks before any dosage adjustments. (Aripiprazole should be dosed only once daily)
    • ziprasidone (Geodon) should be titrated to 120-160mg within the first month of treatment.

  3. 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

  4. If an additional antipsychotic medication is simultaneously prescribed, the rationale is documented. (Documentation as outlined in the “Practice Guideline: Polypharmacy”, Attachment #1).

  5.  
  6. Adjunctive Monitors11,13
    1. Baseline assessment of movement disorders documented
    2. If possible symptoms of T.D. are noted, AIMS examination done initially and 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
      • If glucose level is outside the normal range, at least on of the following must be documented:
        • A change of medication or dose
        • Discussion of physical health lifestyle improvements
        • A primary care referral or conversation with the physician
    5. Cholesterol/triglycerides: Measured at baseline, at 6 months, then annually
      • If the lipid levels are outside the normal range, at least one of the following must be documented:
        • A change of medication or dose
        • Discussion of physical health lifestyle improvements
        • A primary care referral or conversation with the physician
    6. Prolactin (for clients on risperidone or any conventional agent): if possible symptoms of hyperprolactinemia (amenorrhea, gynecomastia, galactorrhea etc.) are noted: 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.


IV.   MOOD STABILIZERS 
  1. 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

  2. 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

  3.  
  4. No “as needed” dosing (prn) of mood stabilizers

  5.  
  6. If more than one mood stabilizer is simultaneously prescribed, the rationale is documented. (Documentation as outlined in the “Practice Guideline: Polypharmacy”, Attachment #1).

  7.  
  8. 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
    3. If serum level outside therapeutic range, chart documentation supports dosage
    4. Once stabilized, serum levels of carbamazepine and valproic acid drawn at least every 6 months; for lithium, every 12 months


  9. 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

V.   ANTIDEPRESSANTS 
  1. 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

     
  2. 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

  3.  
  4. No “as needed” dosing (prn) of antidepressant agents, without documented rationale.

  5.  
  6. If an additional antidepressant medication is simultaneously prescribed, the rationale is documented. (Documentation as outlined in the “Practice Guideline: Polypharmacy”, Attachment #1).

  7.  
  8. 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)

  9. Pediatric Antidepressant Use
    1. Recommended follow-up as clinically indicated.
    2. In addition to securing informed consent:
      • Documentation within the patient’s chart indicates that discussions with the patient/caregiver took place regarding the potential risk of clinical worsening upon initiation or change in dose of medication, including “activation” and suicidal ideation.

VI.   ANXIOLYTICS 
  1. 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

  2. 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

  3.  
  4. No more than one antianxiety agent at one time, unless from different pharmacological class, except during the transition from one agent to another.

  5.  
  6. 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.

VII.  HYPNOTICS 
  1. Indication
    1. Insomnia

  2. 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

  3.  
  4. No more than one hypnotic agent prescribed at one time

  5.  
  6. 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.

  7.  
  8. No use of chloral hydrate in patients with marked hepatic or renal impairment


VIII.  ADHD MEDICATIONS 
  1. Indication
    1. ADHD
    2. Refractory Depression (psychostimulants only)
    3. Other appropriate indications as documented

  2. Dosage Range
    Medication dosage range is within the approved dosing guidelines for Alameda County BHCS or if dosage range outside the dosing guidelines, chart documentation supports dosage

  3.  
  4. Adjunctive Monitors for psychostimulants
    1. Height and weight every 6 months (in children and adolescents)
    2. Pulse every 3 months, and blood pressure every 6 months (in patients > 12 yrs old)

  5. Adjunctive Documentation for Adult ADHD
    1. For an adult patient seen by a BHCS psychiatrist the treatment of ADHD must only be for ADHD as a secondary diagnosis. The patient must also be concurrently undergoing treatment by the psychiatrist for a primary psychiatric diagnosis.
    2. The Connors’ Adult ADHD Rating Scale (CAARS) Self Reporting & Screening Version must be scored at both assessment and again after 30 days of medication treatment. The scores must be documented within the BHCS patient chart.

  6. 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.

IX.    ANTIPARKINSONIANS 
  1. Indication
    1. Alleviation of extrapyramidal side effects (EPS) induced by antipsychotic drugs
    2. Prophylaxis of EPS induced by antipsychotic medications 

  2. 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

  3.  
  4. Documentation
    1. If antiparkinsonian medication is used with any atypical antipsychotic (clozapine, risperidone, olanzapine etc.) justification of specific need must be documented.

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

X.   MISCELLANEOUS 
  1. 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.

  2.  
  3. 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.

  4.  
  5. Atomoxetine: In order for the pharmacy to dispense atomoxetine, the four scores (A through D) of the Connors’ Adult ADHD Rating Scale (CAARS) Self Reporting & Screening Version must be written on the backside of the prescription at initiation and again after 30 days of medication treatment.

  6.  
  7. 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.

  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.

  5. Citrome LS, Volavka J. Atypical antipsychotics: revolutionary or incremental advance? Expert Rev. Neurotherapeutics 2 (1), 2002, 69-88.

  6. Citrome LS, Volavka J. Optimal dosing of atypical antipsychotics in adults: a review of the current evidence. Harvard Rev Psychiatry 10:280-291, 2002.

  7. Davis JM, Chen N. Dose response and dose equivalence of antipsychotics. J Clin Psychopharm. 24(2) 2004, 192-208.

  8. Harvey PD, Green MF, Keefe RS et al. Cognitive functioning in schizophrenia: a consensus statement on its role in the definition and evaluation of effective treatments for the illness. J Clin Psych 65(3) 2004, 361-372

  9. Volavka J, Czobor P, Sheitman B, et al. Clozapine, olanzapine, risperidone, and haloperidol in the treatment of patients with chronic schizophrenia and schizoaffective disorder. Am J of Psychiatry 159: 255-262, 2002.

  10. Marder SR, Essock SM, Miller AL et al. The Physical Health Monitoring of Patients with Schizophrenia Am J Psych 161 (8) 2004, 1334-1349.

  11. Schneeweiss S, Avorn J. Antipsychotic agents and sudden cardiac death-how should we manage the risk? NEJM 2009;360:294-295.

  12. Ray WA, et al. Atypical antipsychotic drugs and the risk of sudden cardiac death. NEJM 2009; 360: 225-35.

  13. ADA,APA,AACE. Consensus development conference on antipsychotic drugs and obesity and diabletes. Diabetes Care 2004; 27(2): 596-601.