I am assessing someone and recently collected their records. The individual’s diagnoses aren’t to unusual. Run of the mill stuff, no psychoses, paranoia, delusions, or any of that stuff. There are a lot of similar diagnoses from different psych reports like MDD vs PDD. He has an ADHD dx. individual is being prescribed 11 different psychiatric drugs. 4 of them are second generation antipsychotics. 4. He takes two medications to counteract the side effects from the drugs. Is it standard of care to prescribe 4 different antipsychotics? I get the feeling the psych kind of got the patient on all of these meds and has just continued them. I understand there are uses for antipsychotics that extend beyond psychotic features but my question is is this fairly standard. It seems unusual to me but I’m not a Dr. I don’t plan on advising this client about medication because it’s not my place or my area of expertise. I’m also not licensed to do it. I’m just really curious.
Antipsychotic use
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Absolutely not. The only time I’ve seen a patient actually taking 3+ antipsychotics when they weren’t severely SPMI I reported it to the board (though not specifically because of the number of meds). Outside of severe and persistent schizophrenia, it is very difficult for me to imagine a patient needing 3 antipsychotics, let alone more than that.
What are the meds and what doses? I try not to jump to conclusions with weird or seemingly egregious med regimens, but idk how to justify that type of med list in the type of patient you’re describing.
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11? Wow. I'd love to see an explicit breakdown in writing of the rationale for that from the provider.
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This is in no way standard. 2 antipsychotics max. If not, then it needs to be clozapine.
The worse the provider, the more meds they prescribe in psych.
The worse the provider, the more meds they prescribe in psych.
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There is not enough data here to give any insights. I will give some example:
Patient on Lexapro 20mg + Abilify 2mg. Abilify was denied by insurance or whatever, then pt was tried on Brexipiprazole, also low dose. On a side note, patient gets very sick when he goes into a boat, and has used Olanzapine 2.5mg before (tried other meds, did not respond to Zofran) for nausea. At some random point his PCP prescribed him Quetiapine 25mg for insomnia, which was later switched by the psychiatrist.
There you go, MDD with 4 previous anti psychotics but nothing wrong with that.
Patient on Lexapro 20mg + Abilify 2mg. Abilify was denied by insurance or whatever, then pt was tried on Brexipiprazole, also low dose. On a side note, patient gets very sick when he goes into a boat, and has used Olanzapine 2.5mg before (tried other meds, did not respond to Zofran) for nausea. At some random point his PCP prescribed him Quetiapine 25mg for insomnia, which was later switched by the psychiatrist.
There you go, MDD with 4 previous anti psychotics but nothing wrong with that.
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This is probably just bad care.
The only exception would be something unusual like:
-He is being cross-tapered from Latuda to Geodon (2). Because he was recently in the hospital and responded well to them, they have kept on board low-dose Risperdal PRN for agitation and low-dose Seroquel PRN for insomnia (4 total). He rarely takes the Risperdal, and once the cross-taper to Geodon is done there is a plan to stop the Risperdal PRN and taper the Seroquel.
In other words, I can see hypothetical scenarios where it could be reasonable. As I am typing this, I see brosa posted another potential example. But in general if there are four long-term standing antipsychotics, yeah it's bad care.
The only exception would be something unusual like:
-He is being cross-tapered from Latuda to Geodon (2). Because he was recently in the hospital and responded well to them, they have kept on board low-dose Risperdal PRN for agitation and low-dose Seroquel PRN for insomnia (4 total). He rarely takes the Risperdal, and once the cross-taper to Geodon is done there is a plan to stop the Risperdal PRN and taper the Seroquel.
In other words, I can see hypothetical scenarios where it could be reasonable. As I am typing this, I see brosa posted another potential example. But in general if there are four long-term standing antipsychotics, yeah it's bad care.
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Sure, there can be exceptional scenarios, but even in those I think 3 max could be justified, idk how one would justify 4.
Even more troublesome is that this patient apparently does not have a primary indication for 1 antipsychotic (MDD vs PDD, ADHD, etc). Unless there’s something major missing I agree it’s most likely just bad care.
This client has no history of psychiatric hospitalization, IOP, or suicide attempt. No history of delusions or hallucinations. They are not being cross-tapered. These are the medications they take every day. Antipsychotics include Risperdal, abilify, seroquel, and zyprexa. I do not have the doses handy. In addition, this person also takes 30mg of Adderall and 2mg of klonopin. That just stands out to me. They also take an addictive sleep medication, but I can’t remember the name. It is common and if someone said it I would recognize it. This person also takes Lamotragine. That’s what I can do from memory. I’m on my phone in bed. There are two medication to counteract side effects which I have never heard of before and therefore don’t remember. I believe the other 2 are antidepressants, with one potentially being Wellbutrin. I can’t remember the last one. That’s actually 2 concerning things now that I write it out. Antipsychotics and stimulants/benzodiazepines/sleep medication. Damn what is it? Patient loves his psychiatrist who seems to have a good bedside manner. So this all seems like very poor care to me. This is a 23 year old. He is significantly overweight. Ambien. It’s Ambien. What options do I have? I’m not a medical provider. I lack the education and license. I can’t really say anything to the patient because that might seem like medical advice. What to do?
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Yea, that’s just bad care. Patient probably likes the doc because it sounds like a pill mill. Patient asks for meds, doc prescribes them. They probably do sound like they have good bedside manner if they just do whatever the patient wants. Imo that’s not bedside manner though, just cowardice.
You could report to the board, but idk that it would actually be looked at if you’re not a prescriber. Do the best you can as a therapist, but realize your chances of actually making major progress in a patient on a med list like this is low.
I can’t believe he needs a med to sleep.
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You'd figure they have that covered between the risperdal, zyprexa, seroquel and klonopin....
OP you're sure these are all current meds and not historical ones right? Like the patient is telling you he's taking all these things right now. If so that's just awful.
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I am glad that he is being referred for assessment. Diagnostic clarity could help with this case. The patient and psychiatrist are apparently trying to ameliorate a high level of emotional distress, it’s just not clear what the source of that is. I imagine they are using other maladaptive strategies to alleviate the distress. It is good that he gets out of the house to see the psychiatrist but he needs more help than that as in psychosocial supports and strategies.
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My theory is sort of like Montgomery Burns in Simpsons where has every disease so severe that they end up cancelling each other out
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When I have had discussions with psychiatrists or even PMHNPs it has been productive and helpful. As someone who has worked closely with physicians of all stripes in a hospital setting, I have learned how to interact collaboratively and how a keen awareness of scope of practice facilitates that. Unfortunately, most therapists and even many psychologists have very limited experience with that culture so it is a bit more difficult. Also, collaboration isn’t billable so in extremely busy insurance based practices it is difficult to find the time. One more reason we don’t contract or bill insurance. I just wish we had a private pay psychiatrist in town that we could work with.
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Yes, let's not get our knickers twisted over hearsay. Interns can barely do a proper med rec on admissions and discharge. And many med records are wholly outdated or have current scripts for which the patient is no longer taking. There are also discrepanices within records, as well as patients' self-report. Some don't even know what meds they're taking. Or don't care. Long story short, I wouldn't expect a "therapist" to be able to piece together a proper med rec.
And if this patient is actually on 3 or 4 antipsychotics, I highly doubt they were never psychiatrically hospitalized. Unless the therapist is part of a large organization with an expensive EMR system that can access hospital records, there's no real way to rule out past hospitalization. Minimization and denial is an actual issue, especially those who need multiple antipsychotics.
