Too many cooks? The complications of cross-prescribing psych meds
Key Takeaways
Avoiding co-prescribing errors requires a commitment to patient-centered communication between primary care providers and psychiatrists, experts say.
The US is facing an increased demand for mental healthcare, and an insufficient supply of mental healthcare providers. This may elevate the need for effective provider-provider collaboration.
Clinicians should commit to comprehensive documentation, patient-centered communication, and provider-provider partnerships.
People are struggling right now. One need look no further than the demand for mental healthcare to see it.
A March 2022 WHO scientific brief estimates that the pandemic triggered a 25.6% increase in anxiety disorders and a 27.6% increase in major depressive disorder worldwide in 2020.[]
Complicating matters, those in need of mental health support may have a hard time getting it. The Kaiser Family Foundation estimates that as of Sept. 30, 2021, the US was meeting only 28.1% of total demand for mental healthcare. To meet that demand, the healthcare system needs about another 6,500 healthcare professionals.[]
For primary care providers (PCPs) and psychiatrists alike, the increase in demand and insufficient supply of clinicians has likely translated to a steady influx of patients seeking mental healthcare.
It also may create a dangerous game of who-prescribed-what for patients managing mental health conditions with their PCP and psychiatrist, a problem complicated by a lack of EHR interoperability or errors of omission from patients.
What can be done to solve this complex communication problem? MDLinx spoke with a PCP and a psychiatrist to gather their insights on avoiding the hazards of cross prescription.
Communication is key
Amanda Zeglis, DO, is a practicing psychiatrist and member of the MDLinx advisory board. Yalda Jabbarpour, MD, is a practicing FM and medical director of the Robert Graham Center for Policy Studies in Washington, D.C.
Like Zeglis, Jabbarpour has extensive experience in managing mental health conditions. Both agreed that successful co-management revolves around communication.
"Maintaining an open line of communication is key when collaborating in any form—the same applies to the dynamic between PCPs and psychiatrists."
— Amanda Zeglis, DO
To this end, when EHRs work, they work well, Jabbarpour said.
“Everyone is busy during their day,” she said. “They might not have time to pick up the phone during working hours because they’re seeing patients. Having that connector of the EHR where I can read your notes, you can read my notes, I can send you a message—people are used to communicating like this.”
This underscores the utility of thorough and comprehensive documentation. But of course, EHRs don’t always play so nicely with each other. Zeglis said that this is when providers—not patients—must coordinate care between themselves.
Patient-centered communication
“It may take more effort for both the PCP and psychiatrist to ensure the patient is being optimally managed—and to prevent it from becoming like a game of telephone, with the patient being in the middle of coordinating his or her own care,” Zeglis said.
According to Jabbarpour, patient-centered communication will look different depending on a patient’s needs and desires.
It might mean connecting a patient with generalized anxiety disorder to a therapist, and discussing the patient’s case with that therapist—with the patient’s permission, of course. Or, on the other end of the spectrum, it might mean true co-management with a psychiatric patient.
“And in that situation, once again, the patient has to be the center,” Jabbarpour said.
"The goal is to never be communicating about a patient without their permission about these sensitive topics."
— Yalda Jabbarpour, MD
Patient-centered communication may also reduce some of the hazards associated with co-management between PCPs and psychiatrists.
Mitigating cross-prescribing issues
One of the keys to avoiding cross-prescribing dangers is treating communication as an ongoing process, Zeglis said.
“Longstanding communication is optimal,” she said. “Not only ensuring open lines of communication when initially evaluating a patient, but also throughout the continued management of the patient in order to stay up-to-date on changes made between both providers on the patient’s behalf.”
In addition, Jabbarpour underscored written communication. It’s critical for all notes to be comprehensive and up to date, especially active prescriptions and their dosages.
"You need it written down in front of your face, and so do patients. "
— Yalda Jabbarpour, MD
This is an essential part of patient-centered communication, Jabbarpour explained. Patients must be empowered with an understanding of what they’re being prescribed and the potential interactions.
And providers must know and maintain their care continuity to avoid cross prescribing errors, and that continuity includes their pharmacy as well as their psychiatrist.
“Pharmacists have a really good feedback loop,” she said, adding that they will often catch potential drug-drug interactions, or cross-prescription errors.
When to refer out
Zeglis and Jabbarpour offered nearly identical insights: It’s time to refer out when the provider no longer feels comfortable or equipped to help.
For PCPs, Jabbarpour said decisions to refer out often hinge on familiarity. First diagnoses can be challenging and may be grounds for seeking a specialist’s perspective. So can the severity of a patient’s problem.
Some PCPs may have experience treating more challenging conditions like schizophrenia. Others may not. Or, perhaps they’re trying to help a patient with depression and anxiety and aren’t making progress.
“When I have maximized everything in my toolbox and it's not working, then it's time to see a specialist,” Jabbarpour said.
According to Zeglis, the implications for this type of collaboration are clear.
"At the end of the day, the collaboration that serves the patient optimally is the one that should be pursued."
— Amanda Zeglis, DO
What this means for you
Patient-centered communication that is comprehensive and thorough goes a long way in reducing cross-prescribing errors. So does a commitment to provider-provider collaboration and maintenance of care continuity, which includes pharmacies and pharmacists as well as PCPs and psychiatrists. Know the patient’s preferences and proceed accordingly.