What is the recommended approach for psychiatric follow-up and management?

Psychiatric Follow-Up: Structured Approach to Medication Management

For stable psychiatric patients on medication, schedule follow-up visits every 3 months, but during acute treatment phases or after medication changes, see patients weekly for the first month, then every 2-3 weeks until stabilization is achieved. 1, 2

Initial Follow-Up Timing After Starting or Changing Medications

• Schedule the first assessment within 1 week of initiating treatment or dose changes to evaluate early-onset side effects, activation symptoms (increased anxiety, agitation, suicidal thoughts with SSRIs/SNRIs), and ensure proper medication implementation 1, 3
• Continue weekly visits during the acute/stabilization phase (typically 4-8 weeks) to establish rapport, monitor response, and ensure compliance 1, 2
• Transition to visits every 2-3 weeks once initial stabilization occurs, maintaining this frequency for 2-3 months to assess efficacy, toxicity, and adherence patterns 1

Maintenance Phase Visit Frequency

• For patients with high-quality sustained response, visits can occur every 3 months (2-4 times per year) 1, 2
• Maintain at least monthly contact even for stable patients to adequately monitor symptom course, side effects, and compliance 4
• Never allow gaps longer than 3 months in monitoring, as patients with serious mental illness will disengage from treatment during extended intervals 4

Core Assessment Components at Every Visit

Target Symptom Evaluation

• Ask patients to rate symptom severity on a 0-10 scale compared to the last visit for each target symptom that prompted medication initiation 2
• Quantify symptom frequency: "How many days this week did you experience [specific symptom]?" 2
• Use standardized rating scales (PHQ-9 for depression, GAD-7 for anxiety) to objectively track changes rather than relying solely on subjective report 1, 2
• Document changes in severity, frequency, and functional impact of the specific symptoms being treated 1, 2

Medication Adherence Assessment

• Never rely solely on patient self-report or your clinical impression, as both substantially underestimate nonadherence 5, 6
• Use objective measures when possible: pill counts, pharmacy refill records, or serum drug levels (for lithium, valproate) 5, 6
• Define adherence as taking ≥80% of prescribed medication 5
• Document missed doses and reasons for non-adherence (side effects, lack of insight, logistic barriers, substance use) 2, 5
• The average patient with serious mental illness takes only 51-70% of prescribed medication, so assume nonadherence is present until proven otherwise 5

Systematic Side Effect Screening

• Systematically inquire about medication-specific side effects at every visit, as patients often fail to connect physical symptoms with psychiatric medications 1, 2
• For all psychotropic medications, assess: sedation/daytime tiredness, changes in sleep quality, appetite changes, weight fluctuations, sexual dysfunction 2
• For antipsychotics, specifically ask about: extrapyramidal symptoms (stiffness, tremor, restlessness), akathisia (inner restlessness), metabolic changes 2
• For SSRIs/SNRIs, specifically ask about: activation symptoms (increased anxiety, agitation, feeling "revved up"), suicidal thoughts, sexual dysfunction 2, 3
• For medications with cardiac effects, ask about: chest pain, palpitations, feeling like they might pass out 2

Vital Signs and Physical Monitoring

• Document at every visit: blood pressure, pulse, weight 1, 2
• For children and adolescents, also measure height to track growth 1, 2
• Weight gain is the side effect most likely to cause nonadherence in both schizophrenia and bipolar disorder 5

Functional Status Assessment

• Assess changes in social, occupational, and educational functioning since the last visit 2
• Document impact on quality of life and progress toward patient-identified functional goals 1, 2
• Evaluate self-care abilities and need for additional support services 2

Risk Assessment at Every Visit

• Screen for current suicidal ideation, plans, or intent at every visit, not just initial evaluation 7, 2
• Ask about homicidal ideation or aggressive thoughts/behaviors since the last visit 7, 2
• Assess for impulsivity and recent high-risk behaviors 7

Substance Use Update

• Review current use of tobacco, alcohol, marijuana, and other substances at every visit 7, 2
• Document any changes in substance use patterns since the previous visit, as substance use is a major contributor to nonadherence 2, 5
• Screen for misuse of prescribed medications or over-the-counter supplements 7

Medical and Psychosocial Updates

• Review any new medical diagnoses, hospitalizations, or procedures since the last visit 2
• Document changes to non-psychiatric medications to identify potential drug-drug interactions 2
• Identify new psychosocial stressors (housing instability, financial problems, relationship conflicts) that may affect symptom presentation 2
• Assess changes in social support and family involvement 2

Clinical Decision-Making Algorithm Based on Response

If Patient Shows Sustained Improvement

• Continue current regimen and maintain the monitoring schedule 1
• Discuss duration of treatment: maintain medication for 6-12 months after full symptom resolution for first episode, or up to 2 years for recurrent episodes 2, 3
• For chronic conditions (OCD, panic disorder, social anxiety), plan for several months or longer of sustained treatment beyond initial response 3
• Periodically reassess the need for continued treatment and consider dose reduction or medication-free trial after sustained remission 3

If Patient Shows Partial Response

• Optimize the current medication dose before switching or adding agents 2
• Reassess adherence using objective measures, as partial response often reflects covert nonadherence rather than true treatment resistance 5, 6
• Address specific side effects that may be limiting dose optimization 5

If Patient Shows No Response or Worsening

• First, verify adherence using pill counts or pharmacy records before concluding treatment failure 5, 6
• Consider a medication-free trial to reassess diagnosis if treatment-resistant 2
• Obtain psychiatric consultation for complex cases 2
• Evaluate for substance use as a cause of treatment failure 5

Managing Nonadherence: Targeted Interventions

When Nonadherence is Due to Side Effects

• Adjust the dose or switch to a different medication as first-line intervention 8
• Add medications to counteract specific side effects (e.g., metformin for weight gain, sildenafil for sexual dysfunction) 8
• Simplify the regimen (once-daily dosing, fewer pills) when possible 8

When Nonadherence is Due to Lack of Insight

• Switch to long-acting injectable antipsychotic when documented nonadherence is linked to repeated relapses or high-risk behaviors 4, 8
• Long-acting injectables provide certainty about medication delivery—if a patient misses an injection, you have immediate awareness and time to intervene before crisis 4
• Implement mandatory frequent monitoring (at least monthly) with the same clinician 4
• Consider involuntary treatment if the patient rejects treatment, has persistent symptoms or frequent relapses, demonstrates high-risk/suicidal/aggressive behavior, and remains poorly engaged despite outreach 4

When Nonadherence is Due to Logistic Problems or Cognitive Deficits

• Implement medication monitoring and environmental supports (pill organizers, reminder systems, Cognitive Adaptation Training) 8
• Arrange assertive community treatment for patients with severe functional impairment 8
• Simplify the treatment regimen to once-daily dosing 8

When Nonadherence is Due to Substance Use

• Address substance use disorder concurrently with psychiatric treatment 5
• Consider long-acting injectable antipsychotic to ensure medication delivery despite active substance use 8
• Increase visit frequency to weekly during active substance use 4

Psychosocial Interventions for Adherence

• Patient psychoeducation about illness and treatment is second-line for most adherence problems 8
• Cognitive behavioral therapy (CBT) targeting adherence attitudes is second-line for lack of insight 8
• Family-focused therapy and family psychoeducation groups improve adherence when family support is available 4, 8
• More frequent and/or longer visits when feasible improve adherence across multiple problem types 8

Documentation Requirements

• Record specific target symptoms and their severity using validated scales at every visit 1
• Document medication adherence patterns and barriers using objective measures when possible 1, 6
• Systematically record drug-specific side effects including weight, blood pressure, and metabolic parameters 1
• Note functional status changes and progress toward patient-identified goals 1
• Document the rationale for continuing, changing, or discontinuing medications 1

Critical Pitfalls to Avoid

• Never discharge or transfer non-adherent patients with serious mental illness to primary care without continuing specialist involvement, as this virtually guarantees treatment failure 4
• Do not wait for multiple relapses before considering long-acting injectables—early implementation prevents the deterioration that comes with repeated psychotic episodes 4
• Never rely on "no-suicide contracts" as a substitute for other interventions, as there is no evidence they prevent suicide 7
• Do not assume stable symptoms mean psychosocial assessment is unnecessary, as psychosocial factors predict relapse independent of symptom severity 2
• Never allow patient-driven agenda to completely override systematic symptom assessment, as patients may be reluctant to reveal emotional problems due to stigma 2
• Do not assume patients will spontaneously report side effects—systematically inquire about common medication-specific adverse effects at every visit 2

Discontinuing Psychiatric Medications

• Taper gradually rather than stopping abruptly to minimize discontinuation symptoms 3
• Monitor for discontinuation symptoms for 2 weeks after stopping SSRIs/SNRIs 3
• If intolerable symptoms occur during taper, resume the previous dose and decrease more gradually 3
• Allow at least 14 days between stopping an SSRI and starting an MAOI, and vice versa 3