As many of our families and fellow mental health professionals know, it can present a challenge to effectively manage medications in clinical situations where a diagnosis may be yet unknown or complicated. Traditional psychiatric prescribing practices are guided by diagnosis. At Bridge House, the entire experience is orientated around determining an accurate diagnosis. Therefore a unique approach to managing medications is required.
Medications have indications for treating sets of symptoms associated with psychiatric diagnoses. Our goal is to make as few medication changes as possible in the initial week of treatment, barring any immediately dangerous or absolute contraindications. This is intentional as we get to know the resident and also helps provide diagnostic information. We can see meanings and attachments residents have placed on their medication regimens, not all of which are accurate or beneficial for them. We utilize pharmacogenetic testing to help guide but not replace our clinical judgment. We have found this useful for people who have had multiple medication trials and have either had side effects or poor efficacy. We also have found this testing to help engage the resident in a greater understanding of how medications work.
We use a collaborative decision-making model with residents when deciding on medication strategies. Our goal is to help residents better understand how medications fit into their overall treatment plan. Instead of choosing a medication for a patient in the usual prescriptive manner, residents are invited to participate in our clinical decision-making process, which is more typically behind the scenes and only discussed among providers. Our approach involves assisting residents in evaluating risk/benefit profiles of several medication strategies appropriate for them and deciding collaboratively on what works best for them. Face-to-face weekly contact with the resident and their prescriber assists in empowering people to take the reigns of their own care and engage in the process in a meaningful way. Bridge House providers are full-time employees and members of the integrative treatment team. They can make recommendations from a place of relationship and understanding. The collaborative decision-making model empowers the resident with greater knowledge and self-awareness and helps build a sense of partnership toward the residents’ individual treatment goals. The model also provides a framework for addressing differences of opinion between doctor and patient respectfully and productively.
It can be common for a resident to enroll with pre-existing prescriptions for medications that might have relative contraindications or unfavorable risk/benefit ratios. These are typically controlled substances such as stimulants or sedatives/hypnotics. Our first response is not to immediately discontinue these medications unless it is dangerous. In our experience, we achieve better long-term success and better overall medication understanding and adherence when we allow the resident to realize that there are medications that help them get closer to their goals and medications that feel reassuring but are ultimately in contrast with their values. If this realization is not reached during a residents’ time at Bridge House, instructions for continued tapering may be given at the next steps, or the medication may be safely discontinued if we have reason to believe the resident will not be compliant with a controlled taper. Residents will not leave Bridge House on unsafe or unsustainable medication regimens. It is our hope and has been our experience that taking this approach produces improved long-term outcomes and a sustained commitment to health and well-being.Â