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 very 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 to be 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. It is our goal to help residents gain a better understanding of 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 that could be 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 are able to 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.
We are intentionally permissive with medications with relative contraindications or unfavorable risk/benefit ratios at the beginning of treatment. These are typically controlled substances (stimulants like Adderall and Ritalin and anxiolytics like Xanax and Klonopin). This may be perplexing to some families or other providers; however, 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 wellbeing.