Updated Medication Checklist for Psychiatrists

 

I decided to update the medication list that I posted here last February.  Not much has changed but I am using it for another couple of projects that I am working on. I am currently working on a detailed look at medications psychiatrists prescribe that may interact with medications used to treat atrial fibrillation (see previous post). I am also going to try to arrange the medications on this list according to the purported mechanisms of action.  The current available systems include the Neuroscience Based Nomenclature (NbN) and the Anatomical Therapeutic Chemical (ATC) Classification.  Both of these systems will involve many more categories and reformatting of the document.  I would like to retain the single page format for convenience.

Per the previous posts on this blog, I devised this sheet in order to get a more accurate idea about what my patients had taken in the past.  I found that they were able to recall many more previous treatments by reading through the list and that it was relatively efficient. I posted this list to Twitter to solicit recommendations and corrections and made some of those changes.  Several people suggested alphabetizing the lists, but I typically put the most recent medications at the top of the list and medications that made be no longer manufactured or more rarely prescribed at the bottom. There were some recommendations for medications that are available in other countries but not the US. I would be amenable to modifying the list for specific countries if someone could edit the current list and make sure it was corrected for the country that you are practicing in.  You could also just type up your own list.  You will also find several medications that have been discontinued either for safety or economic reasons. They are on the list because there are still relevant to the medication history of many patients.

I found that this list was also useful for research projects.  I was involved in a research project last year where there was some confusion about what psychiatric medications would be allowed in a study that looked at antidipsogenic medication. I showed my list to the Principle Investigator and other colleagues working on the project and we decided in a brief meeting the drugs that would be included or excluded in the protocol by just going through the document and checking them off. 

I wrote a more detailed post on this list last February with some disclaimers.  The same disclaimers apply. I don't make any guarantees that it is comprehensive or that you will find it useful. I think it does a fairly good job of illustrating the kinds of medications that psychiatrists prescribe, but that is always relative to the practice setting. During 22 years of inpatient practice, I was responsible for prescribing all of the medications that the patient was taking.  I had access to very good consultants, but had to do the initial treatment, medication reconciliation and adjustments as well as trying to address any new medical disorders. You certainly learn a lot of medicine and pharmacology in that setting, but on the other hand it is extremely time-consuming and with today's productivity demands - I would not recommend it. Nobody pays you for doing the job of two people, even though it is very efficient and patient-centered.  

The only major class of medication excluded from the table are acetylcholinesterase inhibitors ACHEIs) including donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne).  These medications are used in the treatment of Alzheimer's Disease along with the NMDA receptor antagonist memantine (Namenda).  Psychiatrists prescribe these medications and the only reason they were not included in the table is space and the fact it would have required major formatting changes. 

Watch this space for further updates.  I will date and post links to new updates in the space below with the dates that the update occurred. I will also post the table looking at drug interactions with medications used to treat atrial fibrillation in the previous post.

George Dawson, MD, DFAPA

Link to Updates:

I have received a fair number of emails requesting this document from GDRIVE.  This link seems to work for me and it is publicly available. If it does not work for you email me and I will send you the most recent document.

Medication Checklist 07.11.2021 Link 

Medication Checklist 07.11.2021 Link  (Corrects valproate/divalproex section)

Medication Checklist 07.11.2021 Link  (Corrects misspelling of Caplyta)

Medication Checklist-Current Version

I have posted past medication checklists on this blog in the link below will take you to the current version. I developed this over the last 10 years seeing outpatients who have been treated with various psychiatric medications over the previous 5 to 50 years. During a comprehensive evaluation a history of past psychiatric treatment including hospitalizations, past medications, past psychotherapy, and other biological therapies needs to be discussed. Ideally a patient will recall ineffective therapy from the past that can just be restarted. In my current practice setting that is relatively rare. People with chronic mood disorders, anxiety disorders, and insomnia ever happened men treated with multiple psychotherapies and medications. They are typically seeing me because those past therapies have not worked. It is up to me to come up with a newer and safe approach based on my past history.

There are varied responses to the question about what medications have been prescribed in the past. If it has been a long time since the last episode of treatment many people say they can’t recall the name of the medication at all. In some cases people admit that they never really studied the name of the medication, they just took it out of the bottle at the correct time. There are some people who will get a month-long prescription from a physician and never take a single pill. When people have been treated with multiple medications the responses are more varied like “I have taken all of them”, “I have taken all of the SSRIs”, or “I’ve taken all the SSRIs and SNRIs”. Closer examination often shows that many people take anywhere from 3 to 5 antidepressants over any 20-year span. There are people have taken the same antidepressant for 20 or 30 years and wanted it to be changed.

There are many other questions pertaining to best use of medications including diagnostic clarifications. The commonest problem I see is people misdiagnosed as having bipolar disorder and then not treated in a standard way for bipolar disorder. There are also people who have bipolar disorder who do not receive standard treatment. In this era of direct to consumer advertising, many people are treated with aripiprazole or brexpiprazole who would not have been treated with dopamine receptor blocking agents in the past. That opens up an entire new category of potential side effects and comorbidities.

All these reasons make the history of medication use extremely useful in a psychiatric evaluation.  Formal versions of medication history such as the Antidepressant History Treatment Form (ATHF) have been used in research for 20 years as a standard way to document whether or not a patient has received an adequate trial of an antidepressant (dose x duration). This form generally requires collecting a lot of collateral information especially with regard to the dose. Checklist approach I am using is focused on getting the general name and class of the medication. If I think additional information is required I will try to get the necessary collateral information. But generally I am looking for class effects, especially if it is apparent that the patient cannot tolerate a particular group of medications.

Over the years I have been using it this form has been useful. It is essentially like the memory testing paradigm where you proceed from spontaneous recall to categorical recall to list prompts. This is definitely a list prompt but for much larger universe. That is often why I direct people to focus on a particular section of the list. As an example if I am seeing a young person and they have only taken one or two antidepressants and cannot recall the names, I advise them that they can probably find it in the top half of the antidepressant column. The clinical problem can be managed to subsections of the list.

A disclaimer is in order. This list is for the purpose of discussion among clinicians and possible scientific use. It is not been validated from a psychometric perspective. It is not commercial or for-profit like everything else on this blog. There is no guarantee that it will cue accurate memories of past medications. Like everything in clinical psychiatry, collateral information-in this case from pharmacies is the gold standard. Apart from its clinical use, this list can also function to illustrate the universe of medications that are applied to psychiatric disorders. There can be useful for trainees and since this list is updated, anyone who wants to take a look at current FDA approved medications. The list is generally compiled for convenience. I wanted all the medications to be listed on a single sheet - front and back. I wanted the list to be easily readable even by geriatric patients. I wanted the list to be disposable - in many cases the patient wants to take it with them in order to do future research.

That brings me to the topic of research. Most medical centers have been are large electronic health records for about 20 years at this point. Those EHRs vary significantly in their research capabilities. The obvious study of a list like this would be to see how accurate patients can recall their medication history spontaneously and with this list or a something similar. Optimal membership on the form can also be debated. I eliminated tiagabine from the anticonvulsant section as a misadventure in the treatment of anxiety from about 20 years ago. I did that in order to make room for beta-blockers and orexin antagonists. A colleague pointed out that I don’t have the old amitriptyline-chlordiazepoxide or amitriptyline-perphenazine combination medications. I started practicing over 35 years ago it was extremely common to see those medications being prescribed and thankfully that does not happen anymore. Some of the older medications on the list are of historical interest but also because older patients may have taken them.

The list can be downloaded from the link below. Let me know what you think in the comments section. Please restrict those comments to the utility of this list.

George Dawson, MD, DFAPA

References:

1: Sackeim HA. The definition and meaning of treatment-resistant depression. J Clin Psychiatry. 2001;62 Suppl 16:10-7. Review. PubMed PMID: 11480879. Full Text

Medication Checklist:

Download