Essential Questions for Psychiatric Medication Management Follow-Up Visits

Timing and Structure of This Visit

Schedule this follow-up within 1 week of initiating treatment or any dose changes, then weekly during acute stabilization, transitioning to monthly visits once stable, and eventually every 2-4 months for patients with sustained high-quality response. 1, 2

Target Symptom Assessment

Ask specifically about the symptoms that prompted medication initiation—their current severity, frequency, and impact on daily functioning compared to the last visit. 1, 3

"On a scale of 0-10, how severe is your [depression/anxiety/psychosis] right now compared to when we last met?"
"How many days this week did you experience [specific symptom]?"
"How are these symptoms affecting your ability to work/attend school/maintain relationships?" 3

Use standardized rating scales (PHQ-9 for depression, GAD-7 for anxiety) to objectively track changes rather than relying solely on subjective reports. 1, 3

Medication Adherence Evaluation

Directly ask about missed doses, barriers to taking medication, and any intentional discontinuation. 3

"How many doses did you miss in the past week?"
"What gets in the way of taking your medication as prescribed?" 3
"Have you stopped taking any medications on your own? If so, why?" 3

Document specific patterns—weekend non-adherence differs clinically from complete discontinuation and requires different interventions. 3

Adverse Effect Screening

Systematically inquire about common medication-specific side effects, as patients often fail to connect physical symptoms with psychiatric medications. 2, 3

For All Psychotropic Medications:

"How is your sleep—any trouble falling asleep, staying asleep, or sleeping too much?" 3
"Have you noticed any changes in your appetite or weight?" (Document actual weight at each visit) 1, 3
"Any sexual problems—decreased interest, difficulty with arousal, or inability to orgasm?" 3
"Do you feel sedated or overly tired during the day?" 2

For Antipsychotics Specifically:

"Any stiffness, tremor, or restlessness?" (screen for extrapyramidal symptoms) 2
"Any involuntary movements of your face, tongue, or limbs?" (tardive dyskinesia screening) 2
Measure blood pressure and pulse to detect orthostatic hypotension 1

For SSRIs/SNRIs:

"Any increased anxiety, agitation, or feeling 'revved up'?" 2
"Any thoughts of harming yourself that are new or worse since starting medication?" 2

The FDA mandates close monitoring for suicidality and behavioral activation, particularly in the first few months of antidepressant treatment. 2

Suicide and Violence Risk Assessment

At every visit, explicitly screen for current suicidal ideation, plans, intent, and means, as well as homicidal thoughts or aggressive behaviors. 3

"Have you had any thoughts of killing yourself since our last visit?" 3
"Do you have a plan? Do you intend to act on it?" 3
"Have you had thoughts of harming anyone else?" 3

This assessment cannot be skipped even in "stable" patients—risk fluctuates independent of apparent symptom control. 3

Functional Status Changes

Ask about concrete changes in social, occupational, and educational functioning, not just symptom reduction. 3

"Are you able to go to work/school? How many days did you miss this week?" 3
"How are your relationships with family and friends—any improvements or new conflicts?" 3
"What activities have you been able to do this week that you couldn't do before?" 3

Functional improvement is the ultimate treatment goal and may lag behind symptom improvement. 3

Substance Use Update

Review current tobacco, alcohol, and illicit drug use, including any changes in patterns since the last visit. 3

"How much alcohol are you drinking per week?" 3
"Any marijuana, cocaine, or other drug use?" 3
"Has your substance use increased, decreased, or stayed the same?" 3

Substance use directly impacts medication efficacy and increases risk of adverse events and non-adherence. 3

Psychiatric Review of Systems

Screen for symptoms outside the primary diagnosis that may have emerged or worsened. 3

Anxiety symptoms and panic attacks 3
Sleep disturbances (insomnia or hypersomnia) 3
Impulsivity or risk-taking behaviors 3
Mood instability or irritability 3

Medical and Medication Changes

Document any new medical diagnoses, hospitalizations, or changes to non-psychiatric medications since the last visit. 3

"Have you seen any other doctors or been to the emergency room?" 3
"Are you taking any new medications, including over-the-counter drugs or supplements?" 3

This identifies potential drug-drug interactions that could cause treatment failure or adverse effects. 3

Psychosocial Stressor Assessment

Identify new or ongoing stressors affecting symptom presentation and treatment adherence. 3

"What major stresses are you dealing with right now?" 3
"Any changes in your housing, job, or financial situation?" 3
"How is your social support—do you have people you can rely on?" 3

Psychosocial distress predicts treatment failure independent of symptom severity and may warrant referral for additional psychotherapy. 3

Vital Signs and Physical Measurements

Obtain and document blood pressure, pulse, weight, and height (particularly in children and adolescents) at each visit. 1

Many psychotropic medications cause metabolic changes, weight gain, and cardiovascular effects that require monitoring. 2, 1

Cardiac Risk Monitoring (When Applicable)

For patients on medications with known QT-prolonging effects (many antipsychotics, tricyclic antidepressants), ask about cardiac symptoms. 2

"Any chest pain, palpitations, or feeling like you might pass out?" 2
"Any family history of sudden cardiac death?" 2

Consider ECG monitoring within 1-2 weeks of initiating or significantly increasing doses of Class B/B* medications (those with moderate-to-high arrhythmia risk). 2

Clinical Decision-Making Based on Response

If Sustained Improvement:

Continue current regimen and extend monitoring intervals to monthly, then every 2-4 months 1
Discuss duration of treatment—maintain medication for 6-12 months after full symptom resolution, or up to 2 years for recurrent episodes 2

If Partial Response:

Consider dose optimization, medication augmentation, or switching agents 1
Reassess diagnosis and evaluate for comorbid conditions 1

If No Response or Worsening:

Verify medication adherence before assuming treatment failure 3
Consider medication-free trial to reassess diagnosis if treatment-resistant 2
Obtain psychiatric consultation for complex cases 4

Documentation Requirements

Record the following in every note: 1, 3

Specific target symptoms and their severity using validated scales 1
Medication adherence patterns and barriers 1
Drug-specific side effects and vital signs 1
Functional status changes and progress toward patient-identified goals 1
Suicide/violence risk assessment 3
Clinical decision-making rationale 1

Critical Pitfalls to Avoid

Never allow the patient's agenda to completely override systematic symptom assessment—patients may minimize symptoms due to stigma, leading to missed deterioration. 3

Do not assume medication adherence without directly asking—non-adherence is the most common cause of apparent treatment failure. 3

Avoid skipping side effect screening because the patient doesn't volunteer complaints—many patients don't connect physical symptoms to psychiatric medications. 3

Never discharge non-adherent patients with serious mental illness to primary care without continuing specialist involvement—this virtually guarantees treatment failure. 5

Do not wait for multiple relapses before considering long-acting injectable antipsychotics in documented non-adherent patients—early implementation prevents deterioration. 5

What questions should be asked during a follow-up psychiatric medication management appointment?

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