It’s Time to Reconcile With Medication Reconciliation

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SPECIAL REPORT: BEST PRACTICES

Psychiatric training instills in us the importance of completing a comprehensive initial evaluation of patients. We are each afforded varying time windows to complete our assessments with different documentation systems and sometimes additional information to satisfy requirements. Gathering a comprehensive psychiatric medication history along with current medical medications and over-the-counter supplements is standard practice. However, after that first visit, when we are given more time to gather this information via interview, obtain records from primary care physicians and specialists, and neatly compile a new patient assessment, how often do we revisit a comprehensive medication reconciliation?

Completing periodic medication reconciliation beyond the medications that we directly prescribe is imperative for many reasons, including potential drug interactions, duplicative prescribing, and many other treatment-affecting scenarios. Potentially detrimental drug interactions can occur via various mechanisms, and as we learn more about psychogenomics, this further complicates how we anticipate medication responses. What we prescribe in psychiatry can directly affect or be affected by medication prescribed by another provider.

For example, several years ago, I saw a new patient with very persistent depression despite them being on antidepressant medication at seemingly therapeutic doses. The patient was referred to me by their primary care physician, who had managed antidepressant therapy for several years but felt that specialty consultation was needed due to the patient’s persistent symptoms. The patient was simultaneously being treated with tamoxifen by their oncologist. Although the patient had remission from breast cancer, it is not uncommon for patients to remain on tamoxifen for several years afterward to reduce possible recurrence of disease.

Spoiler alert: There was a concerning medication interaction going on for this patient, but it was not a case of the other specialist’s medication affecting the efficacy of the antidepressants. In fact, it was the opposite—the patient was on 2 antidepressants that strongly inhibit CYP2D6, bupropion, and fluoxetine. CYP2D6 is the pathway by which tamoxifen metabolizes into its active form, endoxifen, thereby potentially reducing the efficacy of the treatment.¹ In this case, the current antidepressant regimen was not adequately treating the patient’s symptoms, which made facilitating a medication change a bit easier for us all to metabolize (pun intended). Had the patient been very stable on the antidepressant regimen, that certainly would have complicated the plan of care to ensure that our protocol was not interfering with the ongoing tamoxifen treatment provided by oncology.

Given that patients with psychiatric conditions are at higher risk of medical comorbidity,² they are more likely to be on several medications to treat medical and psychiatric symptoms and illness, resulting in polypharmacy. Polypharmacy increases the likelihood of medication interactions and adverse events.^3-5 The number of prescribed medications, notably in older patients, is the most significant predictor of adverse drug events.⁶

The medication reconciliation process is important to approach from the assessment and interview standpoint, along with appropriate documentation. Simply asking whether a patient is currently taking other medications may not prompt them to relay a comprehensive list. They may not adequately report the use of supplements or over-the-counter medications or whether there has been a medication change recently. Given the prevalence of cognitive symptoms across various psychiatric conditions, patients understandably may not remember everything when they are asked during the visit. Along with avoiding or addressing potential interactions, gathering comprehensive medication reconciliation can be incredibly helpful if a patient is experiencing an adverse effect that is unexpected, a subpar therapeutic response, or another odd occurrence that we cannot otherwise explain.

There are existing evidence-based tools available to incorporate into practice across settings to help support consistent and comprehensive medication reconciliation. One such example is the Medications at Transitions and Clinical Handoffs Toolkit, which is evidence based and supported by the Agency for Healthcare Research and Quality.^5,7

Dr Robinson is assistant professor and director of the psychiatric and mental health nurse practitioner specialty at the University of Maryland School of Nursing in Baltimore.

References

1. Flockhart DA, Thacker D, McDonald C, Desta Z. The Flockhart cytochrome P450 drug-drug interaction table. Indiana University School of Medicine. Updated 2021. Accessed September 26, 2024. https://drug-interactions.medicine.iu.edu/

2. Druss BG, Zhao L, Von Esenwein S, et al. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care. 2011;49(6):599-604.

3. Alshehri GH, Keers RN, Ashcroft DM. Frequency and nature of medication errors and adverse drug events in mental health hospitals: a systematic review. Drug Saf. 2017;40(10):871-886.

4. Brownlie K, Schneider C, Culliford R, et al. Medication reconciliation by a pharmacy technician in a mental health assessment unit. Int J Clin Pharm. 2014;36(2):303-309.

5. Gleason KM, Brake H, Agramonte V, Perfetti C. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. Agency for Healthcare Research and Quality. Accessed September 26, 2024. https://www.ahrq.gov/sites/default/files/publications/files/match.pdf

6. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Int Med. 2015;175(5):827-834.

7. Gleason KM, McDaniel MR, Feinglass J, et al. Results of the medications at transitions and clinical handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med. 2010;25(5):441-447.