Would you ever consider prescribing statins?

[Armadillos]

I spend half my week in a community clinic working with a lot of folks with schizophrenia or bipolar 1 so have fair number on SGAs either PO or LAI.

I’m constantly getting lipid panels back that are off the chain, refer to primary care and seems less than 20% of patients ever actually go. Currently I would never consider prescribing statins because I’m not up on guidelines, but has gotten me starting to wonder. I can check any labs I want and presumably it’s not rocket science to follow whatever the most recent treatment guidelines are, if any issues came up I could refer out. I would never do this in a private setting, but in a community mental health setting working with SMI it seems like a psychiatrist prescribing statins to folks may not be so crazy.

Any thoughts?

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[splik]

Yes, it is appropriate to do so in this setting. In fact many CMHCs do prescribe metformin, statin, antihypertensives. There is this "reverse integrated care model" (primary care in psychiatric settings) where there are often protocols for when and how to prescribe meds like this. Often a good idea to have the medical director on board with this stuff if no one else is doing it. But liability in this population is extremely low, and is certainly without our scope of practice.

 

[Armadillos]

Yes, it is appropriate to do so in this setting. In fact many CMHCs do prescribe metformin, statin, antihypertensives. There is this "reverse integrated care model" (primary care in psychiatric settings) where there are often protocols for when and how to prescribe meds like this. Often a good idea to have the medical director on board with this stuff if no one else is doing it. But liability in this population is extremely low, and is certainly without our scope of practice.

I know I should google this, but your generally an infinite well of knowledge so any particular paper/book or protocol/guideline/rec about doing this in psych clinic you would recommend?

 

[lyla]

I did this during residency and my chief told me not to do it anymore, out of liability concerns.

 

[Armadillos]

I did this during residency and my chief told me not to do it anymore, out of liability concerns.

Your chief resident as a resident or a service chief as an attending?

I figured liability concerns would come up, but in a community mental health setting I imagine having center wide policies could mitigate this. Also depending on the state, the psychiatrists may have sovereign immunity anyway, so wouldn’t be a personal issue at all so long as their admins were on board.

 

[lyla]

Your chief resident as a resident or a service chief as an attending?

I figured liability concerns would come up, but in a community mental health setting I imagine having center wide policies could mitigate this. Also depending on the state, the psychiatrists may have sovereign immunity anyway, so wouldn’t be a personal issue at all so long as their admins were on board.

Chief of that service and chair of our program.

 

[splik]

Your chief resident as a resident or a service chief as an attending?

I figured liability concerns would come up, but in a community mental health setting I imagine having center wide policies could mitigate this. Also depending on the state, the psychiatrists may have sovereign immunity anyway, so wouldn’t be a personal issue at all so long as their admins were on board.

Indeed, as mentioned above, liability would be extremely low especially if medical director on board, and further still if there were clear protocols for management of common conditions. I would also recommend documented that patient was advised to see PCP for this, and reasonable attempts were made by case manager to establish patient in primary care. That said, we are physicians first and foremost, we prescribe meds that cause hypercholesterolemia and diabetes, this is within our scope of practice (depending of comfort level). I would argue going by the statistics you are more likely to be sued for negligently prescribing meds that cause metabolic syndrome and failing to treat complications, than you are for rxing basic medications when indicated.

 

[VA Hopeful Dr]

Indeed, as mentioned above, liability would be extremely low especially if medical director on board, and further still if there were clear protocols for management of common conditions. I would also recommend documented that patient was advised to see PCP for this, and reasonable attempts were made by case manager to establish patient in primary care. That said, we are physicians first and foremost, we prescribe meds that cause hypercholesterolemia and diabetes, this is within our scope of practice (depending of comfort level). I would argue going by the statistics you are more likely to be sued for negligently prescribing meds that cause metabolic syndrome and failing to treat complications, than you are for rxing basic medications when indicated.

As a PCP, I would agree with this. Ideally you'd send these people to me, but if they can't/won't come see me then cholesterol management is easy.

Use this calculator: ASCVD Risk Estimator + There is an app for this as well that I use. The advice section at the bottom will tell you everything you could ever want to know.

 

[TexasPhysician]

I see statins as very reasonable for psychiatrists. I do it sporadically. We are physicians first.

Everyone always hides behind “liability”, but there is liability in everything we do. There is no evidence that a low dose statin is of higher risk for psychiatrists than say high dose quetiapine.

 

[michaelrack]

That's a good app for patients at least 40

 

[VA Hopeful Dr]

That's a good app for patients at least 40

It'll give you lifetime risk for 29 and up.

 

[Monocles]

As much as I complain about psych interns having mandatory medicine rotations, I actually feel suuuper comfortable writing statins. A lot of times my pts don't have a PCP I'll just manage a lot of their "easier" meds. I may not know the JNC10 or whatever criteria medicine people use, but having someone on a basic bp med like lisinopril is still better than not having any.

 

[whopper]

I'd feel comfortable prescribing statins.

But that said I'd also be wary to make sure you're not enabling the person to not have a PCP. Sometimes when you treat their other disorders, the person starts getting an idea "hey my psychiatrist will treat this so I won't see a PCP."

If I notice this is to a degree where they're not seeing a PCP at least once a year and age 40+ then I start getting uncomfortable.

For better or worse I have plenty of patients who have a non-psych medical problem and I end up treating the disorder better than their other doctor. E.g. I have a guy with trigeminal neuralgia and his neurologist told him it was all psychological without trying anything. I put him on Oxcarbazepine and got the guy better within days.

Another frustrating factor, patients start asking you to refill their non-psych meds once you prescribe them their first non-psych meds, and when you ask them why they respond something to the effect of their PCP doesn't communicate well with them. Again you could be enabling. If their PCP is doing a bad job this doesn't warrant a new avenue of faxes that could be literally a dozen a day where you're refilling meds on medical issues you've never upfront evaluated, diagnosed, and decided this is the right treatment. If you're generous and allow this to happen this opens you up to wasting an hour a day at work on something that's happening cause the other doctor, well frankly, isn't doing their job well and blowing off the patient.

Getting back to statins there's emerging data it could have psych benefits. It may possibly be useful in preventing dementia, may have some adjunct benefits with depression, and and all of us know if someone's on an antipsychotic or other psych med that causes weight gain it may be needed to treat the metabolic problems.

 

[Sushirolls]

1) Find out if covered with your liability insurance.
2) Find out and get in writing that the medical director of this facility is in support, and ideally has some sort of protocol for it.
3) Document your rational for why you are doing what you are doing.

Hard 'nope' for me, I got plenty to manage already. And if this CMHC agency can't ever get the person in, who typically does damage control on the Psychotropic refill button? A PCP. Better off pushing them to get one.

 

[thoffen]

Indeed, as mentioned above, liability would be extremely low especially if medical director on board, and further still if there were clear protocols for management of common conditions. I would also recommend documented that patient was advised to see PCP for this, and reasonable attempts were made by case manager to establish patient in primary care. That said, we are physicians first and foremost, we prescribe meds that cause hypercholesterolemia and diabetes, this is within our scope of practice (depending of comfort level). I would argue going by the statistics you are more likely to be sued for negligently prescribing meds that cause metabolic syndrome and failing to treat complications, than you are for rxing basic medications when indicated.

This makes the most sense to me. If you are making every reasonable attempt to get someone better qualified to manage the comorbid conditions and are making sure you are justifying the risk of your treatments to the patient because the benefit is needed for an even worse illness, then you are not being a cowboy here.

 

[NickNaylor]

I'm surprised at the hesitancy of doing so by other posts. I agree with @splik that referral to a PCP would be ideal - and discussing this recommendation and documenting as much should be done if you're going to prescribe these kinds of medications - but in no way do I think this is outside of your scope. Read a review article on hypercholesterolemia or, hell, read the UpToDate article on diagnosis and management. I'm not by any means saying that this is all that you need to do to be competent in managing these conditions, but I would rather follow basic guidelines and treatment algorithms than do nothing. It seems to be that it would be more indefensible to monitor lipids, HbA1c, etc. - as you should be doing if you're prescribing antipsychotics - while doing nothing if you get an abnormal result under the guide of "liability" concerns. That makes zero sense to me.

 

[Armadillos]

Thanks for all the thoughts! Out of curiosity, for those who think it’s reasonable to do so, how many new statin scripts are you writing a week or month?

 

[clausewitz2]

It seems to be that it would be more indefensible to monitor lipids, HbA1c, etc. - as you should be doing if you're prescribing antipsychotics - while doing nothing if you get an abnormal result under the guide of "liability" concerns. That makes zero sense to me.

This very much. It is of a piece with the mentality that if you are super thorough in documenting every possible thing that is a shield against liability. If you clearly got the information deliberately, are aware of the possible serious negative consequences for the patient, and then just in no way demonstrated that you did a single blessed thing about it or provide any reasons why you did not address it, you are making plaintiff's counsel's case for them.

 

[whopper]

There's also such a thing a "Defensive Medicine," where the doctor does something that's actually bad practice solely for the purpose of trying to shield themselves from liability. E.g. excessive x-rays, or telling a patient to go to the hospital just cause the suicide word's been brought up even when the doctor is fairly confident the patient is not suicidal.

It is of a piece with the mentality that if you are super thorough in documenting every possible thing that is a shield against liability.

Some texts also state that very thorough documenting could be a sign of a doc who knows he's screwed up trying to mislead the reader. It's all about the context.

Phil Resnick during a lecture mentioned some guy one time added lines to his notes cause he wanted his notes to make it out like he did screen the patient for the later bad outcome that happened, when in fact the doctor did not do so, and the notes were actually lab tested and the ink from the added lines were forensically proven to have been written long after the original notes were made.

I hardly ever write statin scripts and can't remember the last time I wrote for one cause what usually happens is the patient says they'll just get it from their PCP.

 

[Splenda88]

I did this during residency and my chief told me not to do it anymore, out of liability concerns.

Don't you guys do 4-6 months of medicine? If these issues are common in your patient population and it's hard to get them to follow up with primary care physician, you should try to be up to date on latest guidelines for HTN, dyslipidemia, pre-diabetes or diabetes with A1C < 7. You are a physician after all.

I was going to consult psych for an unspecified depression the other day as a PGY1 (IM) and my attending was ticked off that I wanted to do that... He said as PCP, we should be able to manage 'minor' depression, so I reluctantly started the patient on a low dose of Remeron since he also had some issues with appetite...

 

[notdeadyet]

If the patient already has a PCP and regular follow-up, I leave it to them.

If the patient doesn’t have a PCP or has one and never goes (for whatever reason), I’ll initiate a statin (or meds like it) with recommendation that it be continued and managed by the PCP. And realistically, I’ll be the one doing it.

We are doctors.

 

[whopper]

Being frank,

Don't you guys do 4-6 months of medicine? If these issues are common in your patient population and it's hard to get them to follow up with primary care physician, you should try to be up to date on latest guidelines for HTN, dyslipidemia, pre-diabetes or diabetes with A1C < 7. You are a physician after all.

If you're scared to prescribe a statin with the medical training we're supposed to have, you didn't get enough training. I'd understand if it were say Infliximab, a high dose corticosteroid, or opioids for pain. Statins? No. Of course with any medication bad side effects can happen but statins aren't some type of radioactive dangerous med where physicians need to fear prescribing them. It's reminding me of the ridiculous consults I'd get, e.g. for depression and I see the patient and what really happened was their football team lost, or when my attendings while I was in training would order a med-consult for someone with a BP of 140/90.

 

[Ironspy]

Being frank,



If you're scared to prescribe a statin with the medical training we're supposed to have, you didn't get enough training. I'd understand if it were say Infliximab, a high dose corticosteroid, or opioids for pain. Statins? No. Of course with any medication bad side effects can happen but statins aren't some type of radioactive dangerous med where physicians need to fear prescribing them. If you're scared of a lawsuit (people are using the world "liability" on this thread), or don't feel comfortable prescribing a statin-your medical knowledge only does justice to the accusations that we psychiatrists don't know our medicine, and reminds me of the days when attendings that trained me ordered med consults for a BP of 140/90.

Some psychiatrists (myself included) believe that we are physicians first and as such I am comfortable prescribing low risk meds that are slightly out of my wheelhouse in certain situations (metformin, statins, abx for uncomplicated UTI on inpatient psych, etc). However, some people pick psychiatry bc they want to get as far from medicine as possible and many of those psychiatrists are uncomfortable with anything outside straight psych which is a shame imo.

I've been on the receiving end of this as a patient in medical school and it sucks to be turfed to some specialist, postponing care, additional time/hassle/expense for what is really a minor issue that could have been handled by the original MD. Clearly everyone has a right to practice they way they want (within reason) but getting decent care is already difficult in our fragmented health care system especially for our population and I try not to create additional barriers.