How Do Clinicians Make Prescribing Decisions?
Angela Couch, RN, MSN, PMHNP-BC
Lindner Center of HOPE, Pyschiatric Nurse Practitioner
Making decisions about which medication to prescribe is a complicated process. Janicak, et al (2006, p. 1) described the complexity of the issue fairly well,
“…while improved therapies to ease a patient’s suffering are constantly emerging, the practitioner is required to continually assimilate new information about recent advances, including novel agents targeted to affect specific components of various neurotransmitter systems, combination strategies, alternative uses of existing agents, and the specialized requirements of a growing number of identified diagnostic subgroups.”
The clinician must first have identified a valid diagnosis, and determine whether treatment with medication is indicated. In some cases, psychotherapy alone may be an adequate treatment; whereas pharmacotherapy is less frequently an adequate treatment all by itself and is often paired with psychotherapy. Diagnosis will somewhat narrow the field of choices, and comorbid mental health conditions must be considered as well. If the patient has more than one mental illness, it is wonderful when there is a class of medication which may be able to treat all the symptoms in one drug, but often that is not the case. Treatment of mood disorders is often prioritized, particularly if a bipolar spectrum illness is present. For instance, though antidepressants are generally a first line treatment for anxiety related disorders, giving an antidepressant to a patient with a bipolar spectrum illness can be quite destabilizing. In that case, the mood disorder should be addressed with mood stabilizing medication prior to consideration of antidepressant use.
There are potential risks and benefits to any medication, and the clinician much consider these and discuss them with the patient. Special populations require special considerations. Treating pregnant patients, children or adolescents, the elderly, or those with certain medical conditions, may pose additional risks; this may make many medications, which might otherwise be appropriate, be contraindicated due their side effects profile. Sometimes, the potential side effects of a given medication may be beneficial to certain patients and their mental health or other comorbid symptoms, and this may help narrow the field of choices. During treatment, the patient is continually reassessed to determine if they continue to benefit from the medication, and whether they are experiencing any side effects that should be closely monitored or may require a treatment modification.
Patients may have had prior positive or negative experiences on medications, and this can also help drive the decision making process. For instance, this may help a clinician to decide whether to try the same or very similar medication again, or to consider changing class of medication. Sometimes, a close family member’s prior response to medication may be considered.
Pharmacogenetic testing is a recent advancement in pharmacotherapy. There is a lack of consensus about the value of this genetic testing. It would be misleading to state that the genetic testing results can indicate the medication to which a patient will respond favorably. However, it can identify whether patients may metabolize various drugs that pass through the CYP P450 system in different ways, which may impact outcomes or suggest dose modification. Also, there a limited number of medications for which the FDA has specific labelling regarding recommendations for certain types of metabolizers. So it is possible that pharmacogenetic testing would be a consideration in the decision making process, but not a required one. It is not often covered well, if at all, by insurance, and the out of pocket portion can be cost prohibitive for some patients.
Practice guidelines can be very beneficial. For instance, the APA has been developing practice guidelines since 1991, and these cover a wide range of topics, which undergo periodic updates. The guidelines are formed by work groups of actively practicing psychiatrists who are selected based on their experience in various topic areas. Recommendations are based on evidence that includes research studies and clinical consensus.
Last but not least, cost is a factor that unfortunately must be considered for many patients. For those that have high deductible insurances, or no insurance, many drugs may be out of reach including those that may add an extra layer of medical monitoring such as frequent laboratory testing.
In summary, decision making regarding medication choice is complex process.
APA Practice Guideline Development Process (n.d.) Retrieved from: https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/APA_Guideline_Development_Process.pdf
Janicak, P.G., Davis, J. M, Preskorn, S.H., Ayd, F.J., Marder, S.R. & Pavuluri, M.N. (2006). Principles and practice of psychopharmacotherapy (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.