ETHICAL STANDARDS OF PRIMARY CARE IN BEHAVIORAL HEALTH
Best practices in psychopharmacology are guided by ethical standards designed to help clinicians improve the outcome of therapy. These standards outline the best methods for handling Prescribing Psychotropic Medications • Prescribers, pharmacists, aged care providers, nurses, and aged care staff all have responsibilities in facilitating the active involvement of people with psycho-behavioral conditions in decision making about the use of psychotropic medications. Supported decision making involves assisting individuals who need help making decisions. The ability of people living with psycho-behavioral conditions to make decisions regarding medications often declines but may fluctuate over time. It may also be necessary to involve a substitute decision maker to make decisions on behalf of these persons. • Psychotropic medications should not be considered as an alternative to nonpharmacological strategies/psychotherapy. If a psychotropic medication is used, nonpharmacological strategies should continue alongside pharmacological treatment. • Before prescribing psychotropic medication, informed consent should be obtained from the person living with psycho-behavioral conditions and/or their substitute decision Therapy • If a patient is exhibiting distressing psychotic symptoms and/or aggression/agitation that represents a direct threat to themselves or others, short-term use of risperidone may be considered. The prescriber should conduct an individual harm–benefit analysis. • When possible, antipsychotics should be avoided in patients with psycho-behavioral conditions and changed behaviors due to the risk of severe untoward reactions, particularly extrapyramidal side effects. If an antipsychotic is to be used, consider a second-generation antipsychotic with a lower propensity to cause extrapyramidal side effects (e.g., quetiapine or olanzapine). • If a decision is made to initiate an antipsychotic for changed behaviors, the initial dose should be low and only be titrated upward if necessary. Treatment effectiveness and dose should be reviewed every one to two weeks. • The total initial antipsychotic treatment duration for changed behaviors should not exceed 12 weeks. The anticipated treatment end date should be recorded in the medical record, behavior support plan, pharmacy dispensing history, and nursing progress notes. Treatment should not be continued beyond 12 weeks unless there has been a significant reduction in symptoms of distressing psychosis and aggression/agitation, and an assessment by a psychiatrist. • Discontinuation of Therapy Modern psychopharmacology is designed to blend elements of psychotherapy and pharmacology. This design puts the focus of therapy on the patient and the initiation of an appropriate therapy plan. Leveraging the recent research findings on neuronal connections, neurotransmitter biology, psychotherapy approaches, and psychotropic medications is the best approach Alcoreza, O. B., Patel, D. C., Tewari, B. P., & Sontheimer, H. (2021). Dysregulation of ambient glutamate and glutamate receptors in epilepsy: An astrocytic perspective. Frontiers in Neurology, 12: 652159. https://doi.org/10.3389/fneur.2021.652159 Ambwani, S., Dutta, S., Mishra, G., Lal, H., Singh, S., & Charan, J. (2021). Adverse drug reactions associated with drugs prescribed in psychiatry: A retrospective descriptive analysis in a tertiary care hospital. Cureus, 13(11): e19493. https://doi.org/10.7759/cureus.19493 Anton, S. E., Kayser, C., Maiellaro, I., Nemec, K., Möllerl J., Koschinski, A., Zaccolo, M., Annibale, P., Falcke, M., Lohse, M. J., & Bock, A. (2022). Receptor-associated independent cAMP nanodomains mediate spatiotemporal specificity of GPCR signaling. Cell, 185(7): 1130-1142. https://doi.org/10.1016/j.cell.2022.02.011 Arbring Sjöström, T. (2020). Organic bioelectronics for neurotransmitter release at the speed of life (PhD dissertation). Linköping University Electronic Press. References
psycho-behavioral conditions and the principles for the proper use of psychotropic medications. Some of the standard ethics useful in the context of this course follow.
maker. Consent should be documented in appropriate records such as the psychotropic register, medical record, behavior support plan, and nursing progress notes. When consent needs to be obtained from the substitute decision maker, treatment benefits and harms should still be explained. • Before prescribing psychotropic medication, target symptoms and the anticipated treatment outcome should be identified, quantified, and documented in the medical record, behavior support plan, and nursing progress note where applicable. • Before discontinuing a psychotropic medication, there should be a comprehensive discussion with the patient and/or their substitute decision maker. This discussion should address the rationale for trialing discontinuation, possible benefits and harms (including psychosocial and physical impact and potential discontinuation symptoms), and the tapering process involved. • Treatment discontinuation should be attempted no later than 12 weeks after treatment initiation if there is no documented sustained improvement in psychotic symptoms or aggression/agitation, or if these symptoms appear stable. Other triggers for discontinuation include serious adverse events or an inappropriate indication. • Antipsychotic discontinuation should be undertaken slowly using a tapering plan individualized to the person living with dementia to reduce the risk of discontinuation symptoms. Tapering can be done by reducing the dose by 25%–50% every one to two weeks until the lowest practical dose is reached, then after one to two weeks, stop the antipsychotic. • Antipsychotic tapering should occur more slowly for people who experienced severe distressing psychosis and aggression/agitation, who are using higher doses, or who may have been prescribed antipsychotics for a period greater than 12 weeks. • Any recurrence of distressing psychotic symptoms or aggression/agitation following antipsychotic discontinuation should be quantified and documented in the medical record, behavior support plan, and nursing progress notes. If treatment of these recurrent symptoms is not possible with adequate nonpharmacological strategies, restarting the antipsychotic or trialing a different medication may be considered.
CONCLUSION
in the treatment of psycho-behavioral conditions. Clinicians involved in prescribing, dispensing, and administering psychotropic medications should undertake education about their safe and effective use because psychotropic medications are indispensable tools in psychopharmacology.
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