Psychotropic Medication Monitoring
Ashley Durkee, M.A. & Shannon Hill, Ph.D

Put simply, psychotropic medications are defined as medications that change behavior by affecting the way brain cells communicate with one another. Common types of psychotropic medications include mood stabilizers (such as Depakote and Lithium); antidepressants (such as Prozac and Celexa); anxiolytics (such as Buspar and Ativan); and neuroleptics (such as Risperdal and Abilify). This list is by no means exhaustive, and it is not the intent of this article to discuss what each medication is used for. That is a complicated topic that we will save for another set of articles. Suffice it to say that the same psychotropic medication might be used for different purposes with different people. For example, Depakote, which is most commonly described as an anti-seizure medication, is also used as a mood stabilizer for people who have Bipolar Disorder, and to suppress aggression in highly impulsive people. Like all medications, people differ in their responses to psychotropic medications. One person who suffers from depression might respond very well to Prozac while another will feel no effect and still another will be so bothered by the side effects that they don't care whether the drug is working or not.

Psychotropic medication use, especially in people with intellectual disabilities, must be monitored carefully. There are many reasons for this. First and foremost are the side effects. Neuroleptics, in particular, have been known to have side effects that can cause major problems for people. The neuroleptics in use prior to the 1990s were all classed as major tranquilizers. It was common practice in the 1950s-1970s to place people with intellectual disabilities on these medications, regardless of whether they exhibited any symptoms of disorders that the medications actually treat. As a result, people with intellectual disabilities were living life under sedation. What's worse, they often developed motor side effects such as Tardive Dyskinesia (see Vol. 4, Issue 4 for a discussion of TD). Additionally, sometimes psychotropic medications actually cause behavior problems that are worse than the ones that the doctor was hoping to treat. Strangely though, when severe behavior problems occur caregivers are often reluctant to take medications away, even if the person is no better after the medication is prescribed. They fear that if the behavior is this bad WITH the medication, how bad will it be WITHOUT the meds? It's a human thought, but it is wrong. Good, consistent monitoring of medication effects should help prevent us from making decisions based on our emotions alone.

Used correctly, psychotropic medications can do great things for the people who need them. A person who has Schizophrenia might find the medication keeps him from hearing voices and allows him the concentration it takes to manage the activities of daily life successfully. A person who is so depressed she doesn't feel like getting out of bed may begin to feel better about herself. A person who worries so much he can't leave the house may be able to let things go. So, to ensure we use the medications when they are effective and don't use them when they are not effective, it is important to monitor them carefully. Most people who take these medications simply go to the psychiatrist and tell him how their thoughts, feelings, and behaviors have changed since the last time the doctor made a medication change. There is some question about how good "most people" are at reporting this information to the doctor, though. Lots of us are intimidated and feel rushed in the doctor's office, and so we don't always ask the right questions or mention our concerns. Imagine if you had an intellectual disability. You may or may not understand what the medication is supposed to do, and you may or may not care about whether it is working; and you may or may not have the language skills to communicate about bothersome side effects. As such, psychiatrists who prescribe psychotropic medications to people with intellectual disabilities are expected to adhere to a special set of best practice guidelines.

The best practice guidelines are too extensive to cover in their entirety, but here is a sample of what they include:

• No psychotropic medication should be prescribed unless it is FDA-approved for use in treating the person's psychiatric diagnosis, or unless there is published research evidence indicating that the drug is useful in treating the behavior for which it is prescribed.
• The smallest effective dose must be used and a risk/benefit analysis must be performed, weighing behavioral effects against side effects and effects on the person's quality of life.
• Target behaviors should be identified for each medication prescribed. A baseline measurement should be taken of the target behavior and data should be collected on a consistent basis to evaluate the effectiveness of the medication.
• Input should be solicited from primary caretakers to assess target behaviors and unintended effects of the medication.
• People with intellectual disabilities and their primary caretakers should be educated about how to identify their medications, what they are prescribed to treat, and what side effects they should report to the doctor.

In order to comply with the last four bulleted points more fully, the Education & Research staff and interns, along with Behavior Specialist Le Le Martin, set out to devise a method for efficiently monitoring the relationships between medications, dosage levels, incidence of problem behaviors, and side effects. We wanted to develop a tool that would get the correct information to the psychiatrist while also educating the frontline staff members about what the medication is supposed to do and what the potential side effects could be. Using the best practice guidelines developed by the International Consensus Panel (1997), we determined what information would be important for the psychiatrist to receive from staff members and the best way to present that information.

The result is a system in which prior to a psychiatric consult, staff members from Direct Support, Vocational, and Community Life will receive a psychiatric reporting form to fill out and return to Le Le for her meeting with the psychiatrist. Each form is personalized for the specific resident about whom the information is being gathered. The forms list the behaviors for which s/he is being prescribed medication, current medications, common side effects associated with these medications, and the time period under review. The forms have spaces for staff to report their observations of the behavior in question. For example, the forms request information about the frequency (how often) and intensity (how severe) the behaviors appear to be in their interactions with the resident. Additionally, these same questions (frequency and intensity) are asked with regard to the side effects associated with the resident's medications. This way, if a medication is having negative consequences, its use can be addressed during the consult. Finally, the forms include a space for the staff to write any additional comments that they have regarding the resident's behavior, effectiveness of medication, or any other concerns or bits of information that they feel the psychiatrist should consider.

In order to meet the best practice guidelines for assessing efficacy, we decided that the best way to show the effectiveness of medications would be to implement a graphing system. Using information about target behaviors obtained from behavior reports, status reports, and clinic visits, we are working to create graphs that show the frequency of the behaviors in question alongside the amount and types of medications being prescribed (see an example, below). The goal of these graphs is to visually depict the ways in which medication changes impact behavior. This can allow the psychiatrist to easily see whether the medication is having the desired effects, so that he may adjust doses or medications accordingly.

The process of converting to this system of managing psychiatric consults is somewhat slow and sometimes tedious, but we think that in the long run it will be well worth the extra effort. Once we all get used to the new system, it should actually make psychiatric consults easier and more efficient. Our hope is that this new system of medication management will help us to better support our wonderful residents and the supportive staff who care for them. br>