Interprofessional Management of Psychotic Disorders and Psychotropic Medication Polypharmacy

The effective management of psychotic disorders in our society requires a focused multidisciplinary approach. Take the immense potential for this group of illnesses to affect a person’s mind: they lead to alterations in the ability to think clearly, make rational judgments or decisions, respond emotionally, communicate effectively, understand reality from imagination, and/or behave appropriately in public.¹ Most modern health care systems place an emphasis on integrated healthcare services. These optimize patient care and reduce the likelihood of regression, which may be observed with mental illness.²

Psychotic disorders such as schizophrenia, have the potential to significantly impair an individual’s ability to engage in normal functioning by disturbing their ability to stay in touch with reality and to meet the demands of everyday life. Primary psychotic conditions can be persistent in nature that can grossly impair reality, which can be interrupted by delusions, hallucinations, disorganized behavior and speech.³ An approach that involves the collaborative efforts of psychiatry and pharmacy services can be considered vital in achieving positive therapeutic outcomes in within an inpatient care setting.⁴ The ability to find effective methods to involve a variety health care disciplines in the clinical decision-making process for the management of psychotic disorders can improve it and yield benefits for the patient.⁵ According to a study conducted by Johnson-Lawrence and colleagues (2012), the implementation if an integrated mental health service in patients with depression can produce greater adherence to treatment, improvement in symptoms, and reduce delays to patient’s initiation of treatment.⁶

For any patient that is admitted to an inpatient psychiatric facility requiring immediate psychiatric evaluation and stabilization. The criteria can include: (1) imminent danger to oneself or others, (2) acute impairment of ability to perform activities of daily living, (3) impulsive or assaultive behavior, and (4), management of withdrawal states^{. 7} A patient’s first encounter may be with an attending psychiatrist who works to identify the presenting problems in order to arrive at a diagnosis. The first step in providing the correct treatment is to get a correct diagnosis. Some of the differential diagnoses that the psychiatrist may arrive at are bipolar disorder, schizophrenia, delirium, anxiety disorder to name a few. Ultimately it is through the performance of a comprehensive evaluation/assessment so that a final diagnosis is not in error.⁸ Once a diagnosis has been selected, the attending psychiatrist can consult with a clinical pharmacist specifically trained in mental health regarding appropriate drug selection(s) to ensure that there is clinical justification for the choice of these medications. In certain cases, there is the potential for psychotropic polypharmacy to occur in an impatient psychiatric facility.

Polypharmacy is defined as the use of a certain number of drugs to treat a condition regardless of the appropriateness of these drugs, even if the medications are not clinically indicated.¹⁰ Polypharmacy can be avoided through the clinical pharmacist providing assistance to psychiatrist with selecting more appropriate medications if some are not warranted in a patient.⁹ The collaboration between psychiatrists and pharmacists in the inpatient psychiatric setting has the potential to reduce the incidences of polypharmacy and lead to effective patient care as a result of (1) obtaining an accurate medication and physical history, (2) linking each prescribed medication to the psychiatric condition, (3) identifying medications that are being used to treat side effects, (4) initiating interventions to ensure medication compliance or adherence, (5) prevention by regularly considering the appropriated of the medication for the admission.^10,11 The advent of an interprofessional approach to the management of psychotic disorder s and psychotropic medication management is that psychiatrists can offer their level of expertise in providing accurate diagnoses and subsequently collaborative with clinical pharmacists which can offer their specialized area of expertise as drug specialists by providing recommendation for medication management to align with the presenting disorder. The goal for any form of collaboration that occurs between these two health professionals is to achieve the therapeutic endpoint of alleviating or reducing the symptoms that are associated with the psychotic disorder through the selection of appropriate psychotropic medication and optimizing treatment without increasing psychotropic medication utilization.¹²

References

• Hersen M, Turner S, Beidel D, eds. Adult Psychopathology and Diagnosis. 5th ed. Hoboken, NJ: John Wiley & Sons. 2007.
• Legare F, Stacey D, Briere N, et al. A conceptual framework for interprofessional shared decision making in home care: protocol for a feasibility study. BMC Health Services Res. 2011:11(23):1-7.
• Gearing RE. Evidence-based family psychoeducational interventions for children and adolescents with psychotic disorders. J Can Acad Child Adolesc Psychiatry. 2008:12(1):2-11.
• Hahn RK, Albers LJ, Reist C. Psychiatry. Blue Jay, California: Current Clinical Strategies Publishing. 2008.
• Makoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Patient Educ Couns. 2006:60(3):301-312.
• Johnson-Lawrence V, Szymanski B, Zivin K, et al. Primary care—mental health integration programs in the Veterans Affairs Health System serve a different patient population than specialty mental health clinics. Prim Care Companion CNS Disord. 2012:14(3); PCC.11m01286.
• Prunier P, Buongiorno PA. Guidelines for acute inpatient psychiatric treatment review. Gen Hosp Psychiatry. 1989:11(4):278-81.
• Guadiano BA, Zimmerman M. Prevalence of attenuated psychotic symptoms and their relationship with DSM-IV diagnoses in a general psychiatric outpatient clinic, [Epub ahead of print] 2012.
• Mojatabai R, Olfson M. National trends in psychotropic polypharmacy in office-based psychiatry. Arch Gen Psych. 2010:67(1):26-36.
• Powers RE. General principles of clinical psychopharmacology for persons with mental retardation/developmental disabilities (MR/DD). DDMED 27 Bureau of Geriatric Psychiatry. 2005:1-15.
• De las Cuevas C, Sanz E. Polypharmacy in psychiatric practice in the canary island. BMC. 2004:4(18):1-8.
• Morrison L, Duryea P, Moore C, Nathanson-Shin A. Psychiatric polypharmacy: a world of caution. Protection & Advocacy, Inc. 2012. http://psychrights.org/Articles/PAICAonPolypharmacy.htm.