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Pharmacological Treatment of Mental Disorders in Primary Health Care. Geneva: World Health Organization; 2009.

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Pharmacological Treatment of Mental Disorders in Primary Health Care.

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Chapter 2Basic principles of prescribing

1.1.

The decision to prescribe a pharmacological treatment must take into consideration the potential risks and benefits to each individual patient. Health care providers should discuss with patients, family members and/or patients' carers these potential risks and benefits.

1.2.

Health care providers should consider that medicines play an important role in the doctor-patient relationship, and should make an effort to enlist, recruit and involve the patient in a collaboration related to the prescribed medication. The psychological implications of receiving a drug therapy should be discussed and taken into account.

1.3.

In general, health care providers and patients should consider that most psychiatric disorders can effectively be tackled by means of pharmacological and non-pharmacological interventions. The decision to prescribe a psychotropic agent never implies that psychological and/or psychosocial interventions are not indicated. Evidence has consistently shown that combining medicines with psychosocial interventions tends to be associated with better outcome. Consequently, health care providers should not passively consider medications as their only therapeutic strategy, and patients should not be given a message suggesting that modifications of thought, mood and conduct can be achieved by pharmacological means only. Articulated, comprehensive and individualized treatment plans may represent the best therapeutic option.

1.4.

In general, prescriptions should not be issued before a detailed clinical assessment is completed, and before having explored the psychological mechanisms underlying symptoms.

1.5.

It should be clear to the patient that the treatment is for a pre-planned period of time. This period may be related to the pharmacological properties of the drugs employed and/or to the condition under treatment.

1.6.

Titration of most pharmacological treatments for mental disorders should be done gradually, especially in the elderly and in patients with concomitant medical illnesses. The minimum effective dose should be prescribed, based on an assessment both of how much of it is required to affect the target symptoms and of the patient's social, psychological and geographical situation, i.e., a patient from a rural area who must make an arduous journey to obtain treatment will require a larger supply than one with easier access to a pharmacy.

1.7.

The dosages listed in this publication are mainly based on data available from western countries and health care providers prescribing psychotropic medicines for their patients in other parts of the world should be aware of inter-individual as well as ethnic differences in drug metabolism. Health care providers should always consult the national or local prescribing information or instructional material. The term “milligrams” has been abbreviated in mg throughout the text.

1.8.

Patients should be informed of possible side-effects, and should also be informed about possible measures to manage them, i.e., reduction in the dose, reassurance that some of these side-effects are temporary.

1.9.

Health care providers should be aware of all the substances, both medical and non-medical, being taken by the patient and the possible interactions. For example, alcohol and benzodiazepines should not be taken concurrently.

1.10.

Health care providers should be aware that some pharmacological treatments for mental disorders are under international control. The use of medicines under international control is regulated by the Convention on Psychotropic Substances, 1971 (United Nations). In addition to international control, the use of some medicines may be under national control. Health care providers must be aware that international, national, regional and local drug regulations have to be strictly followed.

1.11.

Health care providers should regularly monitor drug use, and should specifically ask how much of the medicine has been taken. It is commonplace that patient adherence to treatment varies.

1.12.

In the choice of a specific medicine, health care providers should consider the availability and continuity of supply. In situations where continuity of supply of a medicine is likely to be interrupted, its use should be avoided.

1.13.

Health care providers should be aware that a history of previous suicidal thoughts or attempts are important indications of possible suicidal behaviour. Such patients should be specifically asked about suicide and, if it is a possibility, health care providers must limit the amount of medicines prescribed and should also construct a regimen in which there is frequent clinical monitoring and also monitoring by family members and friends.

1.14.

Health care providers should always take a history of substance abuse, including abuse of psychotropic medication. This information should be taken into consideration when considering the prescription of psychotropic medication.

1.15.

Psychotropic drug discontinuation should be done gradually (25% of the dose per week).

1.16.

In general, polypharmacy should be avoided. The term polypharmacy defines the concurrent use of two or more medicines belonging to the same pharmacological class (for example two or more antipsychotics or two or more antidepressants).

Copyright © 2009, World Health Organization.

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: tni.ohw@snoissimrep).

Bookshelf ID: NBK143207

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