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Managing Medications
By: Jeff Bostic, MD


Primary care physicians often find themselves initiating or sustaining medication treatment for pediatric patients.  Questions emerge about how long someone should remain on medications, and when to consider stopping or tapering off medicines.
 
  1. No psychiatric medicine “cures” a disorder; instead, these medicines can improve some target symptoms the patient may have, so identifying that patient’s unique “symptom constellation” can help in the choices of medication treatments, and also in monitoring the benefit:risk ratio of continuing medications. EXAMPLE: if a patient has symptoms of depression and mild ADHD, bupropion may be address those symptoms adequately rather than an antidepressant + a stimulant. It is helpful to always clarify and monitor impacts on the primary target symptoms.
 
  1. For most mental health conditions, medications are considered when the symptoms impair the patient across multiple life domains (home, school, peers) and counseling has been ineffective.  However, even when medications are warranted, continuing therapy to develop skills remains important.  EXAMPLE: for patients receiving stimulant medicines for ADHD, continuing executive functioning skill training/coaching, often at school, remains important.
 
 
  1. If symptoms have remained improved and stable for at least 3-6 months, then consideration of decreasing medicines may be warranted, particularly if side effects tilt the balance toward risks exceeding benefits.  EXAMPLE: A patient appears much improved on a stimulant for ADHD symptoms, but then develops a facial tic; decreasing the stimulant or even attempting a less potent agent (amphetamines are more potent than methylphenidates) is preferred over adding agents to address side effects.
 
  1. Monitoring side effects throughout treatment remains important.  Forms are freely available through the American Academy of Child and Adolescent Psychiatry website (https://www.aacap.org/App_Themes/AACAP/docs/member_resources/toolbox_for_clinical_practice_and_outcomes/monitoring/medication_side_effects_monitoring.pdf) to help clinicians remain attentive and thorough, and these can often be provided to parents prior to visits or while they wait
 
 
  1. Most psychotropics the primary care clinician would prescribe, such as stimulants and alpha agonists for ADHD symptoms, or Selective Serotonin Reuptake Inhibitors (SSRI) antidepressants anxiety or depression symptoms, do not require complex monitoring.  Routine height/weight, blood pressure, and pulse are usually adequate unless other symptoms or side effects warrant additional monitoring (e.g., hair loss suggestive of thyroid abnormalities; a family history of cardiac arrhythmias, etc.).  More complex agents, such as antipyschotics, mood stabilizers such as lithium or anticonvulsants, are not ordinarily agents that primary care clinicians would be expected to initiate and monitor, so collaboration with psychiatric clinicians is warranted whenever these patients are treated by PCP’s (e.g., when patients come to the PCP on such psychotropics while awaiting referral to other mental health providers).
 
  1. Tapering medications is typically preferred when patients attempt a trial off medicine (or discontinue one agent to attempt an alternative agent). Agents vary in how long they remain in the body so consultation with psychiatric clinicians or DC MAP can help PCP’s individualize tapering based on the patient’s unique factors and specific factors of various medicines.  Tapering during times of decreased demands/stress is usually preferable (during the Summer or school vacations, etc.).
 
In all cases, PCP’s should feel encouraged to access clinicians who use psychotropics regularly for any concerns about ongoing monitoring or tapering of any psychotropics.
 
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