Do you guys check prolactin levels?

[PistolPete]

Hey all!

As I gear up for transitioning to private practice, I've been thinking about several things, including medical malpractice and liability. I got to thinking: during residency, I have not ONCE checked a prolactin level on any of my patients who were on antipsychotics. Not once has this been requested by any attending supervising my case.

Do any of you guys routinely check prolactin levels for patients on anti-psychotics? Why or why not? Do you check them in kids who take Risperdal for autism, for example? If you do, how often do you check, and when do you refer to endocrine, if at all?

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[Shikima]

You know it'll be. What else is there? If you don't see milk expression, I wouldn't check.

 

[splik]

in adult psychiatry it's not the standard of care. i wouldn't check prolactin unless the patient was symptomatic (low libido, erectile dysfunction, gynecomastia, galactorrhea, visual field defects) or i wanted to check if pt was non-adherent to risperidone (as it should be elevated if on risperidone).

in child psychiatry, the CAMESA guidelines do recommend monitoring because prepubertal children might not have signs of hyperprolactinemia and we dont quite know the long-term consequences in children. at 3 months for risperidone, and olanzapine, and 6months after initiation of other neuroleptics and then yearly is the current recommendation.

personally i think it would be silly to refer to endocrine if you know that you've caused it. if you've caused it you need to switch to a different agent. sometimes abilify is added and appears to reverse it but obviously you want to avoid using 2 antipsychotics. sometimes bromocriptine is used as well. for kids i would probably consult with a general pediatrician (hopefully the kids have one) in the first instance, but im not a child psychiatrist

 

[Doctor Bagel]

Yeah, only if symptomatic. In my community job, though, it seemed like most of the other providers routinely checked prolactin levels, which were always elevated and lead to its own set of problems. I try to be good about explicitly asking in follow ups.

Random question -- how likely do you think it is that you'll have private practice patients on risperidone? Antipsychotics and private practice don't seem to go together that well.

 

[F0nzie]

Yeah, only if symptomatic. In my community job, though, it seemed like most of the other providers routinely checked prolactin levels, which were always elevated and lead to its own set of problems. I try to be good about explicitly asking in follow ups.

Random question -- how likely do you think it is that you'll have private practice patients on risperidone? Antipsychotics and private practice don't seem to go together that well.

You will still get the full spectrum in pp but less. The main difference is the patient lives at home with their parents instead of on the streets. I have been referring those patients to my CMHC for state paid doctors visits and services (case management, vocational rehab, groups, social events, etc).

 

[Doctor Bagel]

You will still get the full spectrum in pp but less. The main difference is the patient lives at home with their parents instead of on the streets. I have been referring those patients to my CMHC for state paid doctors visits and services (case management, vocational rehab, groups, social events, etc).

I must have a really insular view of private practice because private practice with the people I know (and what I would do) means medication management for functioning (like employed with their own insurance) folks + psychotherapy. Maybe, maybe you'd see a high functioning person with bipolar disorder. Of course that leaves the question of where people with insurance and more severe mental illnesses get treatment.

 

[birchswing]

Of course that leaves the question of where people with insurance and more severe mental illnesses get treatment.

This is exactly what I said in another thread recently. I've only seem the most normative patients in psychiatrists' waiting rooms.

 

[F0nzie]

Of course that leaves the question of where people with insurance and more severe mental illnesses get treatment.

They don't seek it unless they have insight or a family member brings them in. If it gets bad they get hospitalized or placed on court ordered treatment.

 

[birchswing]

They don't seek it unless they have insight or a family member brings them in. If it gets bad they get hospitalized or placed on court ordered treatment.

It sounds as if you're saying the more severe mental illnesses are ones that would affect a person's willingness to accept having a problem and needing help. If I were to guess which disorders those are, I would guess things like schizophrenia when it contains paranoia or delusions, bipolar disorder when it presents with mania, and maybe some personality disorders.

I've always felt as if there is a hierarchy of mental illnesses with depression and anxiety toward the bottom as less severe. But when I know what I know about the effects of refractory OCD or the paralyzing effects of agoraphobia, they don't seem less severe to me. I feel anxiety, especially, becomes diluted as a concept because people understand it through the lens of stress and anxiety they are familiar with, which might not be the same as the anxiety that another person suffers with. I think it's hard to even say what some anxiety disorders are. To me they are some of the most mysterious experiences and the hardest to conceptualize but they're cloaked in this blanket of of assumed familiarity. Anxiety to some people is a normal human drive. I don't know if that's true or not. If it is, then is an anxiety disorder a disorder of a normal human system? Or is anxiety as a disorder something else entirely? Generalized anxiety disorder for example sounds so un-exotic; it makes it sound like a garden snake in the world of illnesses. But I find it hard to even see exactly what it is. It almost seems so obvious as to be ignored as real.

I could be wrong. It might be because I experience anxiety as my predominant condition outside of iatrogenic benzodiazepine dependence that I have difficulty self-perceiving exactly what anxiety is. I know, though, that it is extremely powerful. There are times I experience somatoform issues that you would never be able to believe are from anxiety, and then when the offending mental cause goes away (and I often don't even know what the cause is until it goes away), my body returns to normal. I have learned to trust that I cannot trust my body's instincts which tell me what is causing certain phenomena. It takes a long time to get there when you start with a bad education. But the more I learn about anxiety and what it is capable of doing to a person, the more I see it's not these soluble words that make it sound so anemic--it's an all powerful, consuming thing. I guess in the end that is a very basic idea, but for some reason my education with anxiety started off with it being written off in a way that always made me think something else was at play because anxiety was this sort of minor thing that everyone has to some degree. In reality, I think it's mysterious and powerful and less binary than an issue like mania, for example.

 

[PistolPete]

Yeah, only if symptomatic. In my community job, though, it seemed like most of the other providers routinely checked prolactin levels, which were always elevated and lead to its own set of problems. I try to be good about explicitly asking in follow ups.

Random question -- how likely do you think it is that you'll have private practice patients on risperidone? Antipsychotics and private practice don't seem to go together that well.

I'll be seeing children, adolescents as well as adults. So I imagine I'll have a bunch of autistic kids on risperidone. For true bipolar adult patients, I'd imagine I'd have a few on anti-psychotics as well.

 

[Shikima]

Yeah, only if symptomatic. In my community job, though, it seemed like most of the other providers routinely checked prolactin levels, which were always elevated and lead to its own set of problems. I try to be good about explicitly asking in follow ups.

Random question -- how likely do you think it is that you'll have private practice patients on risperidone? Antipsychotics and private practice don't seem to go together that well.

Random answer - all the time.

What I'm confused are insurance companies dictating that all FGA/SGA medications require full lipid panels.

 

[notdeadyet]

Random answer - all the time.

What I'm confused are insurance companies dictating that all FGA/SGA medications require full lipid panels.

I think it all comes down to the old chestnut: Will the results of the proposed lab test change the treatment plan?

Periodic lipid panels are standard-of-care for antipsychotics because the results to that test could change the treatment plan. If someone develops dyslipidemia or metabolic syndrome through the use of antipsychotics, the treatment plan would be changed to include interventions to reduce the chances of developing potentially fatal side effects.

Periodic prolactin levels are not standard-of-care for antipsychotics because you are chasing a lab value that in and of itself has little value. If the patient describes symptoms, running the lab value can be helpful to rule-out other causes, but chasing prolactin levels without indication is probably not helpful. Although it's certainly something that needs to be mentioned as part of informed consent.

 

[Doctor Bagel]

Periodic lipid panels are standard-of-care for antipsychotics because the results to that test could change the treatment plan. If someone develops dyslipidemia or metabolic syndrome through the use of antipsychotics, the treatment plan would be changed to include interventions to reduce the chances of developing potentially fatal side effects.

I wanted to stop checking with some patients who didn't want to switch their meds (and maybe really shouldn't) who also weren't receptive to engagement around healthier diet or eating. It was also great when I couldn't get them in to see a pcp (I'm talking about you, the VA).

 

[PistolPete]

I feel that's part of the whole issue: you check a fasting lipid panel, and it's crazy high. Then you find out they can't be seen by their PCP for another 6 months, so then what? You prescribe a statin because you're the one who initially checked the lipid panel. What if they then develop side effects from the statin? It's a potential mine field for liability. Hence why I believe you really should not order a test unless you are prepared to deal with the consequences.

 

[notdeadyet]

I feel that's part of the whole issue: you check a fasting lipid panel, and it's crazy high. Then you find out they can't be seen by their PCP for another 6 months, so then what? You prescribe a statin because you're the one who initially checked the lipid panel. What if they then develop side effects from the statin? It's a potential mine field for liability. Hence why I believe you really should not order a test unless you are prepared to deal with the consequences.

Wow, I don't think I appreciated that patients are waiting 6 mos to see a primary care doc. That's crazy.

That said, I don't think prescribing a statin is a "mine field" for liability. Firstline management of dyslipidemia are medications that are low risk. And as physicians, we are not limited to 30 odd psychotropic medications. We can prescribe statins and metformin if our patients need it. We are shooting our profession in the foot if we essentially become psychologists with limited rx rights.

 

[nexus73]

Where is it taking 6 months to get into a PCP. I work in a fairly underserved place and 2 months seems to be the worst I've heard, specifically for patients with no insurance at the community clinic. If people have insurance it's more like 1-3 weeks.

 

[splik]

I feel that's part of the whole issue: you check a fasting lipid panel, and it's crazy high. Then you find out they can't be seen by their PCP for another 6 months, so then what? You prescribe a statin because you're the one who initially checked the lipid panel. What if they then develop side effects from the statin? It's a potential mine field for liability. Hence why I believe you really should not order a test unless you are prepared to deal with the consequences.

FFS it's a statin - if you can prescribe lithium, clozaril, amitriptyline, and phenelzine you can prescribe a statin. you're being ridiculous where is the liability? if you're going into private practice and you don't want to do this, simply only accept patients who have primary care docs.

 

[Shikima]

It's the idea that if you touch it, you own it. That is the liability.

And you cannot bill for hyperlipidemia as a billing code which can then increase the billing level because you're paneled only for mental health coding.

 

[WingedOx]

For all the administrative headaches at the VA, my current site more or less makes it administratively impossible for a patient to get an appointment in mental health without also getting established in General Medical Clinic. It's a bit overkill, but it makes my job SOOO much easier when the PCP is also getting the same metabolic monitoring requirements to pop up in their orders that I am. About 80% of the time the proper monitoring at the lab is done for me.

 

[PistolPete]

I was being a bit facetious, and mostly playing devil's advocate, but yes, I have heard of 6+ month waits for patients to be seen by their PCP's. This is mostly at my local VA as well as for those with Medicaid. Those with commercial insurance don't have this problem, in my experience.

I believe as psychiatrists, we are physicians first and specialists second. Which is why I'm perfectly happy to prescribe a statin to one of my patients if they need it. Even manage their blood sugars. But my real question is about liability. Just because I can, does that mean I should?

Appreciate your responses, everybody!

 

[jettavr6]

It's wise to order a fasting blood glucose and any other appropriate labs when you are prescribing medications. But I first make sure that they have a primary care physician who is able to see the patient in a timely manner. This is never a problem.

 

[WingedOx]

I was being a bit facetious, and mostly playing devil's advocate, but yes, I have heard of 6+ month waits for patients to be seen by their PCP's. This is mostly at my local VA as well as for those with Medicaid. Those with commercial insurance don't have this problem, in my experience.

I believe as psychiatrists, we are physicians first and specialists second. Which is why I'm perfectly happy to prescribe a statin to one of my patients if they need it. Even manage their blood sugars. But my real question is about liability. Just because I can, does that mean I should?

Appreciate your responses, everybody!

For better or worse that type of stuff at the VA is VERY site dependent.

 

[birchswing]

I've never had a blood test ordered by a psychiatrist in my 18 years of continuously seeing psychiatrists.

After I first went on Seroquel, I asked for a blood sugar test and my psychiatrist called me a spaz (he was a very old psychiatrist who refused to retire and eventually had his medical license taken away for being culpable in the death of one his patients). I turned out to have pre-diabetes and was able to reverse it.

I later on read that on Seroquel you should have eye exams and I asked another psychiatrist about this, and I was told Seroquel only causes eye problems in beagles. I don't know as much about that and my eyes seem fine so I can't confirm. This psychiatrist is now a fugitive from the US government and currently resides in Pakistan.

More recently I asked for a script for cholesterol just because it does actually take a long time to see my PCP and I'm 33, fat, and never had it tested, and my psychiatrist wouldn't give it to me. I am often told to "remember what this is." I've been told explicitly that what I see my psychiatrist for is med management and nothing else. If I start to talk about things going on in my life, she'll say something like, "You're still seeing your therapist to talk about that right?" I one time told her there was an aspect of my OCD I had not told her about because it was embarrassing but I thought it was important she know. I'll never forget what she said because I actually think it would make a great line in something, "Don't open any doors in here that can't be closed."

In my experience it seems the psychiatrists I've seen are not worried about being perceived as non-medical. I have had two saliva tests; both were genetic tests. I don't really think they were necessarily indicated especially since we never really went over the results, but I guess they do count as an actual procedure, if you count putting a q-tip in someone's mouth as a procedure.

 

[Doctor Bagel]

For better or worse that type of stuff at the VA is VERY site dependent.

The VA I rotated at had crazy high turnover with pcps, which seemed to leave patients being lost to follow up, especially patients who weren't motivated (or organized) enough to get an appointment. So I'd have a patient with schizophrenia who would keep on missing appointments with his pcp, and then he'd wind up without a pcp. And his lipids were still high maybe because he was on a SGA but also maybe because he ate at McDonald's every day.

Getting back to prescribing statins, I could maybe see doing it in a time of scarcity, but I don't feel like I'm the best person to prescribe a statin to a patient. I'm not as up to date on basic treatment of hyperlipidemia as any pcp would be (hopefully). Our patients really have a right to a primary care provider, especially as patients with severe mental illness die so much sooner generally due to poorly treated medical conditions. Having psychiatrists come in and prescribe statins isn't really the solution.

 

[notdeadyet]

Getting back to prescribing statins, I could maybe see doing it in a time of scarcity, but I don't feel like I'm the best person to prescribe a statin to a patient. I'm not as up to date on basic treatment of hyperlipidemia as any pcp would be (hopefully). Our patients really have a right to a primary care provider, especially as patients with severe mental illness die so much sooner generally due to poorly treated medical conditions. Having psychiatrists come in and prescribe statins isn't really the solution.

Agreed. But if you're pushing someone into diabetes, dyslipidemia, etc, you need to collaborate with the PCP, manage the side effect you're creating if there is no better qualified doc available, or limit your practice to either meds whose common side effects you feel comfortable handling or patients who have good pcp care.

This happens. We all have our limits and need to plan our practice accordingly. I worked in an early psychosis clinic all the time where we'd get referrals (appropriately) to manage patients on Clozapine because a community shrink felt it was out of his skill set.

We are not the best qualified docs to manage dyslipidemia and metabolic syndrome, but we are a lot better than a heart attack and unmanaged diabetes.

 

[Shikima]

And by no means do I want the context of my statements taken in a negative manner, rather understanding that there is a time and place for everything. There are times where I do order full blood panels, including ferritin and Vit. D as it does have implications in helping with sleep which invariably is helpful in managing psychiatric distress.

That whole mind-body connection.

 

[milesed]

I do check prolactin levels at baseline and every 3-6 months. In about 30% of kids on risperdal, I see levels get very high and take them off. It has always gone back down after stopping med so no referrals are needed yet. I consider it standard of care since it is a known issue and gynecomastia is not reversible w/o surgery.


Birchswing- you need a new psychiatrist.

 

[sunlioness]

I'm entirely underwhelmed with the data on statins, so I wouldn't prescribe one. Or take one myself. I do prescribe metformin sometimes.

I've only checked prolactin once. In a patient who was lactating and whose psychosis was best managed by risperidone. She was also concerned about her fertility. So I checked it and sent her to endocrine.


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[PistolPete]

I do check prolactin levels at baseline and every 3-6 months. In about 30% of kids on risperdal, I see levels get very high and take them off. It has always gone back down after stopping med so no referrals are needed yet. I consider it standard of care since it is a known issue and gynecomastia is not reversible w/o surgery.


Birchswing- you need a new psychiatrist.

So let's say you have a kid on risperidone who's done very well on it for 3 months. He's only been on it for 3 months. It's an autistic kid and the risperidone is being used for irritability/agitation, per FDA guidelines. You don't have a baseline prolactin because the initial child/adolescent psychiatrist never got one. He's asymptomatic. He switches insurances and is now under your care.

Do you check a prolactin level at 6 months? 12 months? If so, say it comes back super high. Do you really discontinue it and switch to Abilify? Because my mantra in residency has always been "treat the patient, not the lab."

 

[Information Underload]

I have at times checked prolactin when working with sex offenders for the opposite intent--namely to see if I should be further titrating risperidone dosage in the name of further minimizing sex drive and potentially erectile dysfunction.

 

[milesed]

So let's say you have a kid on risperidone who's done very well on it for 3 months. He's only been on it for 3 months. It's an autistic kid and the risperidone is being used for irritability/agitation, per FDA guidelines. You don't have a baseline prolactin because the initial child/adolescent psychiatrist never got one. He's asymptomatic. He switches insurances and is now under your care.

Do you check a prolactin level at 6 months? 12 months? If so, say it comes back super high. Do you really discontinue it and switch to Abilify? Because my mantra in residency has always been "treat the patient, not the lab."

I do the lab the first week they are my patient- I get them all of the time with no baseline. Yes, I stop risperdal and switch to something else. I understand the "not treating the lab", but I'm also supposed to "do no harm". There are plenty of other options out there. It stinks when they are doing well on it and then do poorly on the next med I choose, but that's why we are the specialists.

 

[Shikima]

I do the lab the first week they are my patient- I get them all of the time with no baseline. Yes, I stop risperdal and switch to something else. I understand the "not treating the lab", but I'm also supposed to "do no harm". There are plenty of other options out there. It stinks when they are doing well on it and then do poorly on the next med I choose, but that's why we are the specialists.

I have at times checked prolactin when working with sex offenders for the opposite intent--namely to see if I should be further titrating risperidone dosage in the name of further minimizing sex drive and potentially erectile dysfunction.

Sometimes it is necessary to induce such "harm" for "good"....
Wait, where's my ethics?!

 

[DD214_DOC]

So let's say you have a kid on risperidone who's done very well on it for 3 months. He's only been on it for 3 months. It's an autistic kid and the risperidone is being used for irritability/agitation, per FDA guidelines. You don't have a baseline prolactin because the initial child/adolescent psychiatrist never got one. He's asymptomatic. He switches insurances and is now under your care.

Do you check a prolactin level at 6 months? 12 months? If so, say it comes back super high. Do you really discontinue it and switch to Abilify? Because my mantra in residency has always been "treat the patient, not the lab."

I don't check them unless someone is symptomatic and there is a reason to, because you already know it's going to be elevated. Switching to Abilify will make them gain weight (in kids; kids almost ALWAYS gain weight with Abilify). Other SGA probably won't really work. I inherit many already with elevated prolactin levels, and I explain this to the parents, the reasoning behind my approach, and the uncertainty of what it actually means -- because we really don't know. I had a discussion about this with a peds endo person, who recommended not checking unless I had a clinical reason to do so.

 

[hamstergang]

I inherited a patient on Risperdal who is doing wonderfully on it once I bumped up the dose. She did terribly on over 20 other meds. Mom got anxious when I talked of prolactin, so we checked, and of course it's elevated. Now I have to try to convince mom that we should ignore the lab value we just went through the trouble of getting. I hate prolactin.

 

[milesed]

I'm confused. Why not just check the prolactin levels when checking lipids and glucose? This is the current standard of care. If those become elevated, or if they are gaining weight, don't you switch to another SGAP with less likelihood to cause metabolic problems(Abilify or geodon)? My experience is that all SGAP's can cause metabolic issues, but some are more likely that others. Research supports this.

If you know that risperdal is causing elevated prolactin which will eventually cause gynecomastia in males, it is not reversible and can be halted if caught early, why would you continue with the use of risperdal once levels are rising? You are looking at malpractice IMO. (Females are a different story)

 

[Shikima]

Wait, Abilify does or doesn't cause metabolic problems?

 

[DD214_DOC]

I'm confused. Why not just check the prolactin levels when checking lipids and glucose? This is the current standard of care. If those become elevated, or if they are gaining weight, don't you switch to another SGAP with less likelihood to cause metabolic problems(Abilify or geodon)? My experience is that all SGAP's can cause metabolic issues, but some are more likely that others. Research supports this.

If you know that risperdal is causing elevated prolactin which will eventually cause gynecomastia in males, it is not reversible and can be halted if caught early, why would you continue with the use of risperdal once levels are rising? You are looking at malpractice IMO. (Females are a different story)

Wrong. You don't routinely check prolactin unless there is a CLINICAL indication, because it more than likely is going to be elevated, although the elevation may have no clinical significance. Thus, you end up changing a medication that may be highly effective and necessary. You evaluate for clinical signs and symptoms of hyperprolactinemia, then order a test, then do something about it if it's elevated. Gynecomastia is also reversible if identified within a year of onset.

I don't see where anyone said you do nothing about significantly-elevated prolactin levels when clinically indicated.

 

[milesed]

Why not check along with the other tests though? Why wait until there is a problem that may not reverse unless they have surgery?

There are plenty of other treatment options for most w/o the same issue.

 

[DD214_DOC]

Why not check along with the other tests though? Why wait until there is a problem that may not reverse unless they have surgery?

There are plenty of other treatment options for most w/o the same issue.

Because it will be elevated and you needlessly change the medication. Try cross-tapering medications in a moderate to severe autistic kid with behavioral problems and you'll understand why there's reluctance.

On a side note, I saw a kid today on Abilify (I didn't start it) for ?? reason who has had mentrual problems for the past couple of years. Naturally the PCM didn't bother to check a prolactin level, so I did -- it came back significantly LOW. Didn't see that one coming.

Also, saw a transfer patient new to me today whose original provider needlessly ordered a bunch of labs to include a CBC at the initial intake. CBC came back significantly abnormal, but the previous provider DID NOTHING about it, didn't refer them for further evaluation, and actually told the parent and documented in the chart that the labs were normal!!!!

 

[whopper]

There is some data suggesting that high prolactin levels could regenerate the brain and might be an approach that could be used in schizophrenia-related neuro-degeneration.

This, however, is still pie-in-the-sky. It still needs to be researched and this could take several years.

I have ordered prolactin levels when 1-pt is suspected of pseudo-seizures (yes I still call it that, the term non-epileptic seizure is misleading IMHO because 1-it's not a seizure, 2-several non-epileptic seizures can happen such as in benzo withdrawal, many people with pseudoseizure have epilepsy so to say the phenomenon is non-epileptic is misleading, etc....) 2-gynecomastia.

The above are very rare. I experienced patients with pseudoseizures about once every several months in an inpatient setting.

 

[milesed]

Wait, Abilify does or doesn't cause metabolic problems?

It can, but is less likely than some others. I can't remember where I saw the study, but it broke down the SGRAP's into 3 groups with regard to metabolic problems.
1. Zyprexa, Clozaril were the worst offenders
2. Risperdal, Seroquel, Invega, Fanapt sl less likely
3. Geodon, Abilify, Saphris were least likely but all can

 

[whopper]

Abilify when it first came out was presented as if it caused no metabolic problems. Later data did show that in some, though rare, it did cause metabolic problems and that data only emerged with phase V testing (giving it to the public where now millions of people take it and this reveals more data vs when a few hundred take it).

I've seen it cause weight gain--massive weight gain but it's rare. On the order of maybe just a few people a year out of several dozens who've taken it. I forgot what the exact stats are but I believe it is lower than 10%, possibly lower than 5%.

The rarity of the metabolic problem with Abilify is still to the degree where it should be considered better than most of the others in this area.

 

[Shikima]

Moral of the story, no perfect SGA.

 

[DD214_DOC]

Abilify when it first came out was presented as if it caused no metabolic problems. Later data did show that in some, though rare, it did cause metabolic problems and that data only emerged with phase V testing (giving it to the public where now millions of people take it and this reveals more data vs when a few hundred take it).

I've seen it cause weight gain--massive weight gain but it's rare. On the order of maybe just a few people a year out of several dozens who've taken it. I forgot what the exact stats are but I believe it is lower than 10%, possibly lower than 5%.

The rarity of the metabolic problem with Abilify is still to the degree where it should be considered better than most of the others in this area.

In practice, this does not seem to apply to children and, to some extent, adolescents. I don't have access to anything I can use for a lit search, but anecdotal evidence suggests that most kids gain a significant amount of weight with abilify.

 

[splik]

this study supports your observation: http://www.ncbi.nlm.nih.gov/pubmed/24564519

 

[DD214_DOC]

this study supports your observation: http://www.ncbi.nlm.nih.gov/pubmed/24564519

I'm not surprised.

 

[vistaril]

Yeah, only if symptomatic. In my community job, though, it seemed like most of the other providers routinely checked prolactin levels, which were always elevated and lead to its own set of problems. I try to be good about explicitly asking in follow ups.

Random question -- how likely do you think it is that you'll have private practice patients on risperidone? Antipsychotics and private practice don't seem to go together that well.

interesting question....I can say that my main job is outpt insurance based med mgt, and I see a good number of patients on antipsychotics. They are less common than primary mood, anxiety, and even ADHD disorders.....but I'd say 15% of my patients has true Bipolar d/o or a psychotic d/o. And then of course there are a few patients who are going to be on antipsychotics for some other reason.

So in a day...I might see 3-4 pts on average on an antipsychotic. Also consider that many med mgt insurance based clinics do take Medicare. And some schizo patients are going to have medicare, or medicare and medicaid.

 

[Shikima]

interesting question....I can say that my main job is outpt insurance based med mgt, and I see a good number of patients on antipsychotics. They are less common than primary mood, anxiety, and even ADHD disorders.....but I'd say 15% of my patients has true Bipolar d/o or a psychotic d/o. And then of course there are a few patients who are going to be on antipsychotics for some other reason.

So in a day...I might see 3-4 pts on average on an antipsychotic. Also consider that many med mgt insurance based clinics do take Medicare. And some schizo patients are going to have medicare, or medicare and medicaid.

Are you mandated to have lipids checked on all by the insurance company or have payment withheld?

 

[vistaril]

Are you mandated to have lipids checked on all by the insurance company or have payment withheld?

I've heard some talk about that....but as of now I don't do it on every patient and haven't heard of any payments not going through. I can't say for certain though as I am an employee and have no idea what the collections look like. Im guessing they would tell me if they weren't going through.

My concern with prescribing antipsychotics is that what if someone does develop bad dyslipidemia and has an MI or whatever. Then some lawyer gets in there ear and suddenly Im being sued for risperdal possibly contributing to their MI. So what I'm often doing is giving my cmcc patients a prescription for a lipid panel and telling them to get it done and fax results over or bring them back. 97% of the time they don't do it, but I document that I've told them to do it. Who knows....you are damned if you do and damned if you don't I think.

 

[PistolPete]

I've heard some talk about that....but as of now I don't do it on every patient and haven't heard of any payments not going through. I can't say for certain though as I am an employee and have no idea what the collections look like. Im guessing they would tell me if they weren't going through.

My concern with prescribing antipsychotics is that what if someone does develop bad dyslipidemia and has an MI or whatever. Then some lawyer gets in there ear and suddenly Im being sued for risperdal possibly contributing to their MI. So what I'm often doing is giving my cmcc patients a prescription for a lipid panel and telling them to get it done and fax results over or bring them back. 97% of the time they don't do it, but I document that I've told them to do it. Who knows....you are damned if you do and damned if you don't I think.

Good point. Ultimately you can't force them to get the labs. You could, however, say that they are not following the treatment plan and discharge them from the clinic if they routinely jeopardize their health by not checking Li levels or FLP or whatnot.

I'd be very surprised if insurance companies withheld payment due to a provider not checking a FLP... they cannot tell you how to practice medicine (although prior auths sure do feel like that).