The following are some recommendations on good medication practice from child psychiatrist Mark Chenven, MD, who offered his expertise in the May/June issue of The Carlat Child Psychiatry Report:
Start low, go slow: Most side effects are dose related, so gradual up-titration is simple common sense. This allows for the body’s homeostatic and regulatory mechanisms to respond gradually and reduces the severity of emerging side effects.
One step at a time: Making one change at a time is another sound practice as this allows for monitoring the impact of one changed variable. An exception to this rule would be a situation where you are cross titrating between two agents and/or dealing with a clinically complex problematic situation.
Consider weekend trials: Starting a new medication or making a significant dosage adjustment over the weekend affords parents and the child or teen the opportunity to monitor for both efficacy and side effects.
Seek feedback: Requesting parents or the older adolescent/young adult patient to call with any emerging concern and scheduling timely follow up visits further enhances our ability to understand and respond to medication impacts.
Longitudinal follow through is key: Ongoing routine inquiry about side effects and monitoring relevant vital signs is a core practice expectation. Also routine should be recognition of co-occurring health conditions and coordination of care with the youth’s pediatric physician.
Focus on med compliance: Compliance and non-compliance should be reviewed periodically. Use longer acting agents (eg, fluoxetine) when appropriate and work with kids and parents on developing more consistent medication use habits.
Review and reconsider: Recognizing the failure of a medication to achieve desired results needs to be considered and it should trigger a reassessment of the diagnosis and treatment plan.
Beware of polypharmacy: Multiple agents raise the risk of side effects. Combinations can have therapeutic benefits, but it is important to reassess the efficacy of all agents monitored for side effects, interactions, and other challenges.
Monitor sleep patterns: Disturbances of sleep should be addressed behaviorally when possible, and pharmacologically when warranted.
Inquire about herbals and OTC agents: Many patients and parents think that herbals, supplements, and other types of “natural” remedies are benign. Ask, or you may never be told. Learn more about these agents and work with families and youth to make mutual decisions on whether to continue them.
Check for other substances: These include cannabis, alcohol, methamphetamine, psychedelics, heroin, or use of grandma’s codeine, sleeping pills, SSRIs, etc.
Learn about life changes: Inquire about other changes in the child’s life—parental discord, changes in the family structure (siblings off to college), new or lost friends, changes in school, illnesses, accidents, bullying and everything else that can upset the applecart. All these may impact our patients’ functioning.