Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Workbook for Clinical & Practical Supervisors
Appendix D
Medication Management Approaches in Psychiatry Implementation Resource
Kit Pamphlet:
Information for Practitioners and Clinical Supervisors
(Draft Evaluation Edition)
Medication Management Approaches in Psychiatry
Information for Practitioners and Clinical Supervisors
Medications are a part of recovery for most people diagnosed with severe
mental illnesses. This brochure contains information about the Evidence-Based
Practice (EBP) specifically involving the systematic use of medications as a
part of the treatment for schizophrenia. This practice is termed Medication
Management Approaches in Psychiatry or MedMAP. In the near future, we hope to
expand this approach to include the pharmacological treatments for other mental
illnesses.
MedMAP is designed to involve consumers, family members and supporters, practitioners,
program leaders, and the public mental health authority in a united effort to
practice medication prescribing in the interest of recovery of the consumer.
MedMAP provides guidelines and algorithms that were developed using research
and evidence to help the agencies, practitioners and consumers achieve the best
possible recovery outcomes.
The following questions and answers address some of the common concerns regarding
MedMAP and the use of medications in the treatment of schizophrenia.
What are Medication Management Approaches in Psychiatry (MedMAP)?
Evidence-based medicine is a mixture of clinical research, expert consensus,
and practitioner expertise. MedMAP uses evidence-based medicine to guide medication
decisions. All fields of medicine use evidence-based medicine. For example,
practice guidelines derived from scientific evidence have been created and are
being used to treat a myriad of disease states including diabetes and asthma.1,2
Why is there a need for evidence-based medicine?
Studies show that actual practice patterns in health care systems often
differ substantially from evidence-based recommendations based on the current
evidence.3,4 Clearly a greater standardization of care is needed. Moreover,
since many consumers move between treatment settings and receive medications
from several different prescribers over the course of their lives, a system
to create consistency in their treatment is highly desirable. Evidence-based
practice guidelines and algorithms have demonstrated their ability to improve
outcomes in the areas of depression, cancer pain management, and the intra-operative
use of anesthetic drugs.5,6,7 MedMAP was designed specifically to address
medication management for persons diagnosed with schizophrenia.
What is the goal of MedMAP in the treatment of schizophrenia?
The goal of MedMAP in the treatment of schizophrenia is to improve
care through the optimal use of medications. Medication use can be optimized
through implementation of the following principles:
(1) utilization of a systematic approach to medication management
(2) objective assessment of the symptoms that the medications are supposed
to affect
(3) clear, concise documentation of the treatments and their outcomes
(4) efforts to enhance medication adherence through consumer education and
involvement in medication decisions.
The remainder of this document will address the tenets of MedMAP.
Why is a systematic approach to medication management important
and why is it difficult to achieve?
Thorough, evidence-based medication management helps practitioners determine
the best treatments for consumers in an efficient fashion, thereby reducing
pain, suffering, and the costs of inadequate treatment. Since all clinicians
want the best for the individuals they treat, what factors contribute to the
non-systematic use of medications? One factor is that different treatment settings
have different goals of medication management, a reality that results in variable
prioritization of medication choice. Another factor is the variation that exists
across practitioners in terms of selection, dosing, and duration of treatment.
Finally, the combination of inadequate documentation and incomplete consumer
recall can make it impossible to determine which treatments have been tried
and what effects they had. The recent proliferation of treatment guidelines
and algorithms in psychiatry is testimony to the perceived need for greater
standardization of care.
Why are objective assessments of symptoms important in the treatment
of schizophrenia and why are clinicians sometimes opposed to them?
While chronic illnesses such as diabetes and hypertension lend themselves
to quantitative outcome measurements, in schizophrenia, quantification of outcomes
has historically been reserved for the research arena. Recently, the advent
of managed care has required that clinicians provide evidence of treatment effectiveness
in order to justify cost. Another reason that objective, reproducible symptom
measurement is important in the treatment of schizophrenia is that individuals
with schizophrenia often receive treatment from many different providers in
a multiplicity of settings. The chronic nature of schizophrenia necessitates
effective communication between prescribers and objective measures of clinical
status are an integral part of this dialogue.
One reason that clinicians are opposed to incorporating objective ratings
into their practices is the belief that objective ratings are more time consuming
than global assessments. Another is the view that objective ratings do not capture
the depth and extent of an individual’s illness but instead reduce the
consumer to numbers and values. However, assessments of consumer satisfaction
indicate that most consumers welcome having the outcomes of their medication
treatment identified and measured. Moreover, brief rating scales have been developed
that are reliable and efficient to use.
Why is documentation such an important part of MedMAP and what
are some impediments to good documentation?
Thorough documentation includes information about dose and duration of
medications used and the response to treatment. Good documentation of the medication
history is the key to identifying the most effective treatment for a consumer,
but the system can prevent the flow of information.
For example, charts are often organized chronologically and by department (laboratory,
radiology, etc) so that clinicians have to go through multiple sections in order
to find the data that they need to make a decision. Another impediment to the
careful documentation of medication trials is the fact that required institutional
forms often prioritize insurance and legal issues over information necessary
for medication management.
What can facilitate consumer adherence to a treatment plan?
Selection of the “best” medications is of little value if they
are not taken as prescribed. Consumers and family members need to know about
their medications and be comfortable with them. The practitioner and the consumer
should decide on the treatment plan together because consumers who are part
of the decision-making process are often more motivated to see the plan through.
(see section on Shared Decision-Making: MedMAP Practitioner Resource Manual)
How can MedMap enhance risk management practices?
Prescribers who incorporate the four principles of MedMAP into their practices
can reduce the numbers and types of challenges to their medication selections
and monitoring. First, treatment decisions (medication selection, dosing strategies
and treatment duration) that are supported by evidence-based recommendations
carry the weight of expert consensus and the medical literature. Second, the
adoption of reproducible symptom measurements allows prescribers to quantify
severity in an objective manner that uses a common language to substantiate
treatment decisions. Third, concise and consistent documentation of medication
treatments and their outcomes is critically helpful in dealing with regulatory
agencies and with potential litigants. Finally, shared decision-making is vital
to promoting a therapeutic alliance. The presence of a positive therapeutic
alliance has been found to be the single most important factor in avoiding lawsuits
when, as will inevitably happen in the practice of medicine, undesirable outcomes
occur.
References
1. American Diabetes Association Clinical Practice Recommendations
2001. Diabetes Care 2001;24:S1-S133.
2. Li JT, Pearlman DS, Nicklas RA, et al. Algorithm for the diagnosis and management
of asthma: a practice parameter update: Joint Task Force on Practice Parameters,
representing the American Academy of Allergy, Asthma and Immunology, the American
College of Allergy, Asthma and Immunology, and the Joint Council of Allergy,
Asthma and Immunology. Ann Allergy Asthma Immunol 1998;81:415-420.
3. Lehman AF, Steinwachs DM. Patterns of usual care for schizophrenia: initial
results from the Schizophrenia Patient Outcomes Research Team (PORT) Client
Survey. Schizophrenia Bulletin 1998;24:11-20.
4. Young AS, Sullivan G, Burnam MA,et al. Measuring the quality of outpatient
treatment for schizophrenia. Arch Gen Psychiatry 1998;55:611-7.
5. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment
guidelines: impact on depression in primary care. JAMA 1995;273:1026-1031.
6. Du Pen SL, Du Pen AR, Polissar N, et al. Implementing guidelines for cancer
pain management: results of a randomized controlled clinical trial. J Clin
Oncol 1999;17:361-70.
7. Lubarsky DA, Glass PS, Ginsburg B, et al. The successful implementation of
pharmaceutical practice guidelines—analysis of associated outcomes and
cost savings. Anesthesiology 1997;86:1145-60.
Internet Resources
The following websites contain information about algorithm, guideline
and expert consensus approaches to medication management.
Texas Medication Algorithm Project/Texas Implementation of Medication
Algorithms TMAP/TIMA
TMAP began in 1996 as collaborative research effort in the state of Texas
to develop, implement and evaluate medication algorithm-driven treatment. The
medication management in TMAP consists of evidence-based, consensually agreed
upon medication treatment algorithms, clinical and technical support to implement,
patient and family education programs, and documentation of patient care and
outcomes.
TIMA is the ongoing statewide implementation phase of TMAP occurring in the
Texas Mental Health and Mental Retardation facilities.
http://www.mhmr.state.tx.us/centraloffice/medicaldirector/TIMA.html
http://www.mhmr.state.tx.us/centraloffice/medicaldirector/TMAPtoc.html
Ohio Medication Algorithm Project: Optimizing Recovery Through Best
Practices
http://www.bstpractice.com/OMAP.htm
Psychopharmacology Algorithm Project at the Harvard Medical School
Department of Psychiatry
http://mhc.com/Algorithms/
The Schizophrenia Patient Outcomes Research Team (PORT) Treatment Recommendations
http://www.ahcpr.gov/clinic/schzrec.htm
Expert Consensus Guidelines: Treatment of Schizophrenia
http://www.psychguides.com/gl-treatment_of_schizophrenia_1999.html
Training contacts and consultants for the Evidence-Based Practice
of Medication Management Approaches in Psychiatry:
1. Alexander L. Miller, MD
Mona Neaderhiser
University of Texas Health Science Center SA
Department of Psychiatry
7703 Floyd Curl Drive MSC 7792
San Antonio, Tx. 78229-3900
210.567.0330
millera@uthscsa.edu
neaderhiser@uthscsa.edu
2. West Institute at the New Hampshire-Dartmouth Psychiatric Research
Center
David Lynde
State Office Park South, Main Building
105 Pleasant Street, 2 North
Concord, New Hampshire 03301
603.271.5747
David.Lynde@Dartmouth.edu
Other Evidence-based Practices in this Series:
Illness Management & Recovery
Integrated Dual Disorders Treatment
Assertive Community Treatment (ACT)
Family Psychoeducation
Supported Employment
http://www.mentalhealthpractices.org
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