What drugs should psychiatrists prescribe?

 

That was a question posed by a recent paper in Academic Psychiatry (1).  The focus was on psychopharmacology agents from the perspective of older agents like lithium, monoamine oxidase inhibitors (MAOIs), and tricyclic antidepressants (TCAs).  Every few years, the debate about these drugs is rekindled – almost like the stereotypical old man shouting: “Hey you kids – get off my lawn.”   Should psychiatrists know how to prescribe older agents – of course they should. First off, the age of the agent has nothing to do with efficacy. Lithium is the best example there and it continues to have the best efficacy for bipolar disorder relative to new agents.  TCAs and MAOIs have comparable efficacy to newer antidepressants like selective serotonin reuptake inhibitors (SSRIs) but given the span of clinical trials – a strict comparison is not possible. Some authors do make unequivocal statements about both TCAs and MAOIs having superior efficacy to SSRIs. But in my opinion meta-analyses does not eliminate the differences in clinical trials technology over the past 50 years.

The authors make some of these arguments and suggest a number of biases that may be operating against prescribing these medications. Some of those biases originate in risk perception. In general, newer medications do tend to be safer.  They are certainly not without risk.  Serotonin syndrome and neuroleptic malignant syndrome are the typical rare but high-risk complications of prescribing psychiatric medications but there are many more. The rational discussion of risk involves knowing the pharmacology, knowing any risk mitigation strategies, knowing to what extent your patient can co-manage that risk with you, and the explicit informed consent discussion outlining the risks.

In my experience about 15-20% of outpatients do not tolerate modern antidepressants well at all. I have always encouraged people in that situation to try something different. TCAs and MAOIs are certainly not devoid of side effects but it is possible to change to one of those medications and the patient notices immediately that the drug is well tolerated and eventually effective.  Clinical trial data will show that as a group SSRIs are safer and better tolerated than either TCAs or MAOIs but in the clinic we are treating individuals and not groups.  On an individual basis, people are selected based on whether they tolerate a class of medications or not and that does not mean that they will not tolerate all medications.  With lithium, MAOIs, and TCAs – the informed consent discussion needs to include the potential toxicities with reassurances that the goal is to avoid side effects and complications. 

That has been my approach to psychopharmacology for 35 years. It was easier for me to have this perspective because when I started out back in 1986, the only antidepressants available were TCAs and MAOIs. I also trained with two psychiatrists, James Jefferson and John Greist who wrote the Lithium Encyclopedia and ran the Lithium Information Center.  In the days prior to the internet, it was a repository of all known hard copy references to lithium in the medical literature. There were additional formative experiences, most notable 22 years on acute care units where you are the person responsible for the total medical and psychiatric care of the patient. It was common to see patients on multiple psychiatric and nonpsychiatric medications with varying levels of adherence and instability. In some cases, they were accompanied by several shopping bags of medications and it was impossible to determine what medication was being taken and what was not. In many cases the medical providers and the psychiatric providers had never communicated and there was redundancy and drug interactions. My job in that situation was to make the best estimate of what medications could be safely started and to follow the patient closely so that they could be adjusted. That requires a good knowledge of medications that are used to treat endocrine/metabolic conditions, infectious diseases, rheumatic disorders, gastrointestinal disorders, cardiac conditions, dermatology conditions, chronic pain and neurological conditions.

In other words, most medications that are commonly used. And why wouldn’t psychiatrists prescribe everything both inside and outside of the specialty?  I have been fortunate enough to work with many Internal Medicine specialists and subspecialists. I have witnessed what happens when they encounter a medication that they do not routinely prescribe. They ask the patient about why it was prescribed and their experience with it.  They read the package insert and decide whether to prescribe it or not.  The idea that each specialty has limited knowledge about prescribing medications outside of that specialty seems like an erroneous assumption to me.  It is even clearer now that we have nonphysician prescribers with less basic science and pharmacology knowledge and less supervised prescribing training not restricted to any set group of medications. Physicians have been trained in all classes of pharmacology and should have worked out a general approach on how to safely prescribe any medication encountered.  Physicians also need to know about the range of medications in the population they are working with.  Adapting to the medications utilized by different populations is all part of the practice of medicine.  Today and in the future it is conceivable that a typical psychiatrist may cycle through 4 or 5 different practice scenarios, each one requiring unique a unique knowledge of pharmacology.

That does not mean that I am going to start diagnosing and treating arrhythmias like a cardiologist.  But it does mean that if I get a patient admitted to my inpatient service who is taking an antiarrhythmic that I should be able to decide to continue or restart it, what monitoring needs to be done, whether an ECG needs to be ordered, whether to get a Cardiology consultation or contact the patient’s cardiologist (stat or electively), and whether any medication I want to start or change will affect either the antiarrhythmic or the patient’s underlying cardiac condition. The same process is true for every medication on their list.

The typical argument I encounter with that suggestion is: “Well most psychiatrists don’t practice in that kind of intense medical environment.”  My answer is – open your eyes. It is not enough to look at a typical list of medications in an electronic health record (EHR) and focus only on the ones that psychiatrists should prescribe.  It is not enough to assume that your patient’s list of medical problems is being adequately addressed.  Psychiatry from my perspective still means that the psychiatrist has some responsibility for the total medical care of the patient. In today’s fragmented medical care environment, the psychiatrist may be the only physician the patient is seeing. When asked who their doctor is – many people will name their psychiatrist.

That opinion is bound to make some psychiatrists nervous. They may have the thought; “How can I provide that level of care when I am being reimbursed less and have to spend most of my time doing clerical work for the EHR?” That is a fair question and one without an obvious answer. If administrators were really interested in quality care, they would give primary care physicians and psychiatrists enough time for that level of analysis. Psychiatrists need more time to establish and attend to their relationship with the patient.  But the medical stability of the patient and assuring that they are not experiencing adverse effects and that treatment is effective is an absolute priority. 

Psychiatrists need to be trained to make these assessments and they need to be able to prescribe and modify a significant pharmacopeia extending well beyond what exists in a psychopharmacology text. That skill is predicated on the extensive content in basic science and clinical literature on pharmacology and also the process of learning about new drugs and how to safely prescribe them. That learning process is largely implicit and not discussed enough.  If it was, it could be applied to older medications as well.    

 

George Dawson, MD, DFAPA

 

Supplementary:

I need to add a comment to this post because a lot of practice settings are designed to support specific prescription practices.  For example, there are a lot of private practices that focus primarily on the treatment of anxiety and depression.  There is also the assumption that more complicated pharmacotherapy such as the prescription of lithium needs referral out to a psychopharmacologist. In other cases, clinics will specialize in prescribing that fits specific diagnoses rather than the universe of psychiatric disorders.  Those practices stand in contrast to patients who are unable to get adequate medical or psychiatric care and routinely have their prescriptions disrupted. 

When that does happen they can end up in between prescriptions, self rationing prescriptions, or just not taking any prescribed medication for a while. Depending on the underlying medications, that alone can precipitate a crisis that any psychiatrist or trainee should be able to recognize and address. 

The first place that kind of training occurs is during the admission and coverage of inpatient units. The first orientation to these units should be a discussion of the expectations for prescribing to inpatients in acute care settings. It is not a question of waiting for a physician to sort things out the next day or hoping that a medical consultant will see the patient and make the necessary changes.  Each physician and trainee in that setting needs to know how to make acute assessments, determine the need for medications, and either make those changes or figure out how to get help on an acute basis.  Recognizing the urgency of situations like prescribing insulin for diabetes mellitus is as important as knowing the pharmacology.  Nobody should leave trainees guessing on their first call night.

References:

1:  Balon R, Morreale MK, Aggarwal R, Coverdale J, Beresin EV, Louie AK, Guerrero APS, Brenner AM. Responding to the Shrinking Scope of Psychiatrists' Prescribing Practices. Acad Psychiatry. 2022 Dec;46(6):679-682. doi: 10.1007/s40596-022-01705-1. PMID: 36123516.

Photo Credit:

Eduardo Colon, MD. - many thanks.