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The Guidelines of Practice for Medication Management in Psychiatry were developed by the TSPP Professional Practices Committee. Draft #1 was published in the December 1997/January 1998 TSPP Newsletter and was further modified by the Professional Practices Committee on February 7, 1998, November 13, 1998, and February 27, 1999. The TSPP Executive Council adopted these Guidelines on February 28, 1999. An amendment to this document was approved by the TSPP Executive Council on May 28, 2000.
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I General
A. The Professional Standards Committee of the Texas Society of Psychiatric Physicians consider these guidelines as a basic framework for the conduct of Medication Management for outpatient psychiatric patients.
B. These guidelines are provided as a supplement to the Guidelines of Practice for Adult Outpatient Psychiatric Services. Their purpose is to guide psychiatrists in the provision of medication management for patients who may receive mental health treatment from non-psychiatric physicians or non-physician mental health providers. These guidelines are not intended to be used in isolation from the Guidelines of Practice for Adult Outpatient Psychiatric Services.
C. These guidelines assume that the psychiatrist providing Medication Management will be afforded adequate time for the provision of Medication Management and not be subject to arbitrary limits of time.
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II Relationship with patient
A. The psychiatrist providing Medication Management will conduct a comprehensive diagnostic evaluation consistent with guidelines published by the American Psychiatric Association (Am J Psychiatry 1995;152:11S:63-80).
B. The psychiatrist providing Medication Management will develop a comprehensive treatment plan that includes a choice of medication.
C. The psychiatrist providing Medication Management will offer the patient a clear explanation for any diagnosis and recommended treatment. This explanation will include a rationale for all elements of the treatment plan including medication and psychosocial interventions.
D. The psychiatrist providing Medication Management will explicitly identify those components of treatment the psychiatrist will provide, and those components that will be provided by other non-psychiatric physicians or non-physician mental health providers.
E. The psychiatrist providing Medication Management will obtain the patient’s appropriate consent to communicate with other non-psychiatric physicians or non-physician mental health providers involved in the treatment of the patient.
F. The psychiatrist providing Medication Management will exercise the highest professional standards in the choice of medications and the management of continuing treatment with medications. These tasks may not be delegated to non-physician mental health providers, and require direct and ongoing personal contact with the patient at appropriate intervals. At the same time, the psychiatrist providing Medication Management may receive reports from other non-psychiatric physicians or non-physician mental health providers that inform the psychiatrist of decisions about the frequency and nature of visits with the patient.
G. The psychiatrist providing Medication Management will provide those psychological interventions necessary for eliciting accurate, reliable and appropriate information about the patient’s clinical status and response to treatment; encouraging compliance with recommended treatments including those elements of treatment provided by other non-psychiatric physicians or non-physician mental health providers; and responding to any acute developments that cannot be deferred to a future appointment.
H. The psychiatrist providing Medication Management will provide instruction and education about the patient’s diagnosis and recommended treatments.
I. The psychiatrist providing Medication Management will provide explicit instructions for emergency coverage for evenings, weekends and vacations.
J. The psychiatrist providing Medication Management will attempt to arrange for the hospitalization and treatment of any patient for whom outpatient treatment is unsafe or inadequate.
K. The psychiatrist providing Medication Management will seek appropriate consultation for any problem identified outside his/her area of expertise including appropriate medical evaluation or psychological testing.
L. The psychiatrist providing Medication Management will monitor the progress of his/her patient who is seen by non-psychiatric physicians or non-physician mental health providers. This may be accomplished by periodic review of the other treatment with the patient and/or communication with other non-psychiatric physicians or non-physician mental health providers involved in the treatment of the patient. In the event that the psychiatrist concludes that a treatment provided by another non-psychiatric physician or non-physician mental health provider is not in the patient’s best interest, the psychiatrist must so inform the patient of this conclusion and the reasons for so concluding. If possible, the psychiatrist should first discuss this conclusion with the other non-psychiatric physician or non-physician mental health provider. The patient retains the right to continue such treatment. If so, the psychiatrist should consider terminating or transferring treatment of the patient.
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III Relationship with collaborating clinicians
Whenever possible, the psychiatrist providing Medication Management will maintain a collaborative relationship with other non-psychiatric physicians or non-physician mental health providers involved in the treatment of the patient that is consistent with guidelines published by the American Psychiatric Association (Am J Psychiatry 1980;137:1489-1491).
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IV Documentation
A. The psychiatrist providing Medication Management will maintain written documentation of the diagnostic assessment; of the treatment plan; of periodic assessments of the patient’s status and progress; of any communication with collaborating non-psychiatric physicians or non-physician mental health providers; and of the details of the agreement with the patient regarding the scope of treatment provided by the psychiatrist and the scope of treatment provided by other non-psychiatric physicians or non-physician mental health providers.
B. The psychiatrist providing Medication Management may provide a written description of the agreement with the patient to the patient with a copy to be retained in the patient’s record.
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V Source Documents
1. Fromm-Reichman F. Problems of therapeutic management in a psychiatric hospital. Psychoanal Quart 1947;16:325-356.
2. American Psychiatric Association. Position statement on psychiatrists relationships with nonmedical mental health professionals. Am J Psych 1973;130:386-390.
3. American Psychiatric Association. Guidelines for psychiatrists in consultative, supervisory, or collaborative relationships with nonmedical therapists. Am J Psych 1980;137:1489-1491.
4. Brill NQ. Delineating the role of the psychiatrist on the psychiatric team. Hosp
Comm Psych 1977;28:542-544.
5. Ribner DS. Psychiatrists and community mental health centers: current issues and trends. Hosp Comm Psych 1980;31:338-341.
6. Vasile RG, Gutheil TG. The psychiatrist as medical backup: ambiguity in the delegation of clinical responsibility. Am J Psych 1979;136:1292-1296.
7. Firman GJ. The psychiatrist – nonmedical psychotherapy team: opportunities of therapeutic synergy. J Oper Psych 1982;13:31-36.
8. Pilette WL The rise of three-party treatment relationships. Psychotherapy 1988;25:420-423.
9. Bradley SS. Nonphysician psychotherapist – physician pharmacotherapist: a new model for concurrent treatment. Psych Clin N Am 1990;13:307-322.
10. Bascue LO, Zlotowski M. Psychologists’ practices related to medication. J Clin Psychology 1980;36:821-825.
11. Beitman BD, Chiles J, Carlin A. The pharmacotherapy-psychotherapy triangle: psychiatrist, nonmedical psychotherapist, and patient. J Clin Psych 1984;45:458-459.
12. Chiles JA, Carlin AS, Benjamin GA, Beitman BD. A physician, a nonmedical psychotherapist, and a patient: the pharmacotherapy-psychotherapy triangle. In Beitman BD, Klerman GL. Integrating Pharmacotherapy and Psychotherapy. Washington DC, American Psychiatric Press, 1991, pp. 105-118.
13. Mcnutt ER, Severino SK, Shomer J. Dilemmas of interdisciplinary outpatient care: an approach towards their amelioration. J Psych Ed 1987;11:59-65.
14. Goldberg RS, Riba M, Tasman A. Psychiatrists’ attitudes toward prescribing medication for patients treated by nonmedical therapists. Hosp Comm Psych 1991;42:276-280.
15. Riba M, Goldberg RS, Tasman A. Medication backup in psychiatry residency programs. Acad Psych 1993;17:32-35.
16. Grant SH, Riba MB. Contact between psychotherapists and psychiatric residents who provide medication backup. Psych Serv 1995;46:774-777.
17. Weiner HK, Riba MB. Medication backup: attitudes and practices of psychiatrists and residents. Psych Serv 1997;48:536-538.
18. Appelbaum PS. General guidelines for psychiatrists who prescribe medication for patients treated by nonmedical therapists. Hosp Comm Psych 1991;42:281-282.
19. Woodward B, Duckworth KS, Gutheil TG. The pharmacotherapist-psychotherapist collaboration. In Oldham JM, Riba MB, Tasman A. Review of Psychiatry vol 12. Washington DC, American Psychiatric Press, 1993, pp. 631-649.
20. Lazarus J, Macbeth J, Wheeler N. Divided treatment in the managed care arena: Legal and ethical risks. Psychiatric Practice and Managed Care 1997;3:3.
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Notes:
1 On May 28, 2000, the TSPP Executive Council approved a name change of the Professional Standards Committee to the Professional Practices Committee.
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