More than half of U.S. adults regularly take prescription medications, according to a 2017 survey by Consumer Reports. That same survey also found that the number of prescriptions for all Americans, including children, increased 85 percent from 1997 to 2016.
Many of these medications are psychotropics: Research suggests that over the course of a year, one in six American adults takes at least one psychiatric drug, including antidepressants, anti-anxiety medications and antipsychotics ( JAMA Internal Medicine opens in new window, Vol. 177, No. 2, 2017).
With so many people taking medications, and for a broad range of conditions, it’s important for practicing psychologists to know what drugs patients may be taking, why they are taking them and whether they are experiencing any side effects.
“Patients today are often coming to psychologists on significant numbers of medications, including psychotropics, some of which may be helping, some of which may not,” says Helen L. Coons, PhD, ABPP, a clinical health psychologist and assistant professor of psychiatry at the University of Colorado Denver School of Medicine.
Unfortunately, most psychology graduate training programs provide little in-depth education about psychopharmacology. So, how can a psychologist help patients manage their medications in ways that are helpful, clear and safe? Practitioners who regularly monitor medications advise that their colleagues:
Pursue training
While health psychologists, given their specialty, obviously must receive more education and training in how all medications affect patients, all psychologists should learn more about psychopharmacology because teasing apart potential medication problems and helping patients manage their regimens can significantly improve care, says clinical psychologist Virginia Waters, PhD, who has private practices in New Jersey and New York. “We are often the most stable medical caregiver for our clients and the one they speak with the most often,” she says. “As a result, our patients look to us for guidance when things are not adequately explained to them.”
APA’s Div. 55 (American Society for the Advancement of Pharmacotherapy) provides information on APA-designated psychopharmacology training programs, including four two-year master’s degree programs in psychopharmacology offered at Fairleigh Dickinson Universityopens in new window in Teaneck, New Jersey, the California School of Professional Psychology at Alliant Universityopens in new window, New Mexico State Universityopens in new window and the University of Hawai’i at Hiloopens in new window.
In addition, the Neuroscience Education Instituteopens in new window and many state psychological associations offer continuing education on medication monitoring.
Coons also suggests that psychologists who want to learn more about medications should attend their hospital’s medical rounds or get permission to shadow a colleague who has more experience in the area.
Make a list for each patient
At the beginning of every new intake session, Marlin Hoover, PhD, ABPP, of Hoover & Associates in Tinley Park, Illinois, asks clients to give him a list of their prescription and over-the-counter medications, along with dosage, time of day they’re taken, and names and contact information of the client’s health-care providers.
Coons also asks her patients to bring in a list of medications, vitamins and herbs to the first consultation. She routinely requests verbal consent from the patient on the phone when scheduling the initial appointment because it allows her to collaborate with other providers to clarify the reasons for the referral and receive up-to-date information about the patient’s medical and medication history. “Then we are providing interprofessional care from the start to improve the patient’s well-being,” she says.
Rely on proven tools
A helpful framework for communicating with other providers about a patient’s medications is the Situation-Background-Assessment-Recommendation (SBAR) toolkitopens in new window, says Bethesda, Maryland, clinical psychologist Neal Morris, EdD. Developed by the Institute for Healthcare Improvement, SBAR maps out the key points to cover when discussing a shared patient and can help psychologists stay on point and set expectations for what they’d like the physician to do to help the patient, he says, such as stopping a medication or setting up follow-up appointments. “It’s mostly used between physicians and nurses, but the same parameters work very well for psychologists referring to and communicating with prescribers,” Morris says.
He also recommends that practitioners buy a copy of “Stahl’s Essential Psychopharmacology Prescriber’s Guideopens in new window” to help build their knowledge of psychotropic drugs, their indications and potential side effects.
Morris and Hoover both also use the free Epocrates app to review safety information for medications. The app lists adult and pediatric dosing information, off-label indications, black box warnings, contraindications, adverse reactions and drug interactions.
Discuss each medication’s purpose
Morris has found that most of his patients do not understand why they’re taking a medication or how it’s supposed to help them. So, once he has a list of what they’re on, he counsels them about how they can tell if a medication is working and asks how they’ve been feeling since they started taking it.
During the initial visit, Coons asks all patients to complete standardized measures to assess symptoms and severity of mood, anxiety, fatigue, pain, post-traumatic stress disorder and sexual functioning and conducts a clinical interview to evaluate how a patient’s medications may—or may not—be working.
“It’s not uncommon for a patient to come see me for depression, anxiety or pain and to be on a significant amount of medications, but they might not be getting the appropriate dose at the appropriate time,” she says. “Or they’ve been on the same medication forever and it might have worked at the beginning, but it’s not working anymore.”
For example, a patient’s pain level or symptoms of depression may be high even when he or she is taking high doses of drugs for these conditions, she says. Coons typically urges patients to speak with their referring providers about their symptoms and to ask about other medication options. Then she discusses nonpharmacologic approaches to their pain, depression and anxiety.
Talk about side effects
Some medications, such as those for high blood pressure or muscle pain, may reduce a patient’s energy level, so they feel depressed or lose interest in things they usually enjoy, says Hoover. “Other prescription drugs can make them feel jittery or edgy and they come to you thinking they’ve developed an anxiety disorder when it’s actually a side effect of a new medication,” he says.
The psychologist can help patients attribute a symptom to a medication and then explore ways to counteract any negative side effects, he explains.
Help with adherence
Psychologists are also key to helping patients understand what to expect when taking medications—guidance that is particularly salient when patients start taking new prescriptions. Shortly after starting on certain selective serotonin reuptake inhibitors (SSRIs), for example, many patients with anxiety or depression may initially feel even more edgy or anxious, Hoover says. That’s a normal side effect and actually a sign that the medication is working. “The patient just needs to be reassured to give it a long enough time to begin working,” he says.
Many psychologists also check in with patients to find out if they are taking their medications correctly. Once the client and psychologist have developed a trusting relationship, the patient is more likely to admit whether he or she has been skipping doses or failing to take a medication at all, says Mary Alvord, PhD, a private practitioner in Maryland who sees children and adolescents with anxiety, attention-deficit hyperactivity disorder (ADHD) and depression. In such cases, the psychologist can work with the patient to determine why he or she might be skipping doses and use behavioral strategies to improve adherence, she says.
Psychologists’ input is also critical when patients go off their medications, Alvord adds. Abruptly stopping some pharmaceuticals, including SSRIs, can lead to flu-like symptoms, so psychologists should work with medical providers to determine how to support patients during transitions—for example, by slowly tapering off a medication. Psychologists can also encourage clients to speak with their prescribers if they’ve stopped adhering to their regimen due to adverse side effects.
Get outside perspectives
Particularly when working with children and adolescents, psychologists should talk with teachers or school counselors for insight on how a medication may be affecting a patient during the school day, says Alvord. “When you’re dealing with kids and teens, how they function in multiple settings is really critical information,” she says. For example, a child who is taking a stimulant to treat ADHD may be symptom-free during the day, but later in the afternoon may be distracted when the medication has worn off. “In these cases, I might encourage a parent to speak with the prescriber about possibly adding a booster dosage to help the child get through that late-afternoon homework time.”
Check in regularly
As a board-certified geropsychologist in Dublin, Ohio, Mary Lewis, PhD, ABPP, visits a rehabilitation facility for older adults every Wednesday to review her patients’ medical charts and talk to the nursing staff about any medical, cognitive or medication changes since her last visit. Then she meets with each patient to assess how they are doing physically, cognitively and emotionally, and she works with the other health-care providers to fine-tune individual treatment plans.
During a recent visit to the facility, one of her patients reported feeling depressed and told Lewis she wasn’t sure if her antidepressant was still working. “That allowed me to ask, ‘What did you feel that made you think it was helping and how are you feeling differently now?’ Then we were able to tweak our psychotherapy a bit to address her concerns,” Lewis says.
