Monitoring Physical Health and Side-Effects of Psychotherapeutic Medications in Adults and Children: An Integrated Approach
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2018
Monitoring Physical Health and
Side-Effects of Psychotherapeutic
Medications in Adults and Children:
An Integrated Approach
Florida
Medicaid Drug
Therapy Management
Program for
Behavioral Health
medicaidmentalhealth.org
Please visit our website to view:
n Electronic versions
of our guidelines
(available in full or part)
n News and announcements
n Video presentations
n
n Alerts of recent publications
and related literature
n Resources and tools
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T
medicaidmentalhealth.org
For more information and a full list of references, visit our website at medicaidmentalhealth.org
These guidelines are available in the public domain and do not require permission from the authors
for use. However, we request when using any of its content that the publication is cited as follows:
2018 Monitoring the Physical Health and Side-Effects of Psychotherapeutic Medications in Adults and
Children: An Integrated Approach (2018). The University of South Florida, Florida Medicaid Drug
Therapy Management Program sponsored by the Florida Agency for Health Care Administration.
© March 2018
medicaidmentalhealth.org
Table of Contents
General Topics
Introduction ....................................................................................................................................................................................3
Principles of Practice.....................................................................................................................................................................5
Physical Disease and Mental Illness....................................................................................................................................14
Weight Change and Metabolic Concerns Associated with Psychotherapeutic Medications.................16
QTc Prolongation Associated with Psychotherapeutic Medications .................................................................24
Hyperprolactinemia Associated with Psychotherapeutic Medications............................................................25
Infectious Diseases: Risk Factors and Screening Recommendations.................................................................26
Substance Use Disorders.........................................................................................................................................................28
Special Populations: Women of Childbearing Age......................................................................................................39
Prevention Strategies................................................................................................................................................................44
Social Determinants of Health and Potential Barriers to Effective Treatment................................................46
List of Tables
Table 1. Child and Adolescent Assessment Scales................................................................................................ 6
Table 2. Adult Assessment Scales.................................................................................................................................. 8
Table 3. Recommended Assessments at Baseline and Subsequent Follow-up Monitoring........... 10
Table 4. Recommended Laboratory Monitoring................................................................................................. 11
Table 5. Normal Laboratory Values in Adults for Selected Measures......................................................... 12
Table 6. Modifiable Risk Factors in Individuals with Severe Mental Illness.............................................. 14
Table 7. Studies Examining Weight Change Associated with Psychotherapeutic Medications used
in the Treatment of Serious Mental Illness............................................................................................. 17
Table 8. Antipsychotic Medications and Metabolic Syndrome Risk............................................................ 21
Table 9: Waist Circumference and Race/Ethnicity............................................................................................... 21
Table 10. Risk Factors and Screening Recommendations for Selected Infectious Diseases.............. 26
Table 11. Drugs that May Cause False-Positive Results in Screening (Immunoassay) Testing........... 31
Table 12. Medications for Maintenance of Abstinence in Alcohol Use Disorders................................... 34
Table 13. Medication Assisted Therapy for Opioid Use Disorders: Methadone
versus Buprenorphine..................................................................................................................................... 36
Table 14. Nicotine Replacement Therapies and Other Medication-Assisted Treatment for
Tobacco Use Disorders.................................................................................................................................... 37
Table 15. Safety of Psychotherapeutic Medications in Pregnancy and Lactation.................................. 40
Table 16. Suggested Educational Tools and Strategies....................................................................................... 44
medicaidmentalhealth.org
Table of Contents
List of Boxes
Box 1. Physical Diseases with Increased Frequency in Serious Mental Illness........................................... 15
Box 2. ADA Target Goals for Blood Pressure, Lipid, and Glycemic Control..................................................23
Box 3. Risk factors associated with QT prolongation to evaluate for*...........................................................24
Box 4. Behaviors that Increase Suspicion for Drug Misuse or Dependency...............................................29
Box 5. When Urine Drug Screening Should be Obtained...................................................................................30
Box 6. Potential Barriers to Effective Treatment......................................................................................................46
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Page 2
Introduction
Introduction
Individuals with serious mental illness (SMI) including schizophrenia, schizoaffective disorder,
bipolar disorder, and major depressive disorder are prone to many different physical health
problems. Although physical health problems are also prevalent in the general population, they
have a greater impact on individuals with serious mental illness. Many factors contribute to the poor
physical health of individuals with serious mental illness, including disparities in health care access
and utilization, as well as provision of health care services. Studies have shown that individuals
with serious mental illness have an excess mortality, being two to three times as high as that of
the general population. This mortality gap translates to a 13 to 30 year shortened life expectancy.
Furthermore, among women of childbearing age, mental illness not only affects the mother’s well
being, but may also have significant effects on fetal outcomes, particularly when patients do not
receive recommended care during pregnancy.
Based on the complex behavioral and other health needs of the SMI population, an integrated
approach is critical for reducing morbidity and early mortality. The Substance Abuse and Mental
Health Services Administration (SAMHSA) defines an integrated approach to care as “the systematic
coordination” of mental health, substance abuse, and primary care services. Integrated care
bridges the gap that often occurs between the medical and behavioral health care systems, and
produces the best health outcomes for individuals with SMI. There are different models and levels
of integrated care that providers can adopt depending on their practice setting and its available
resources. The most feasible for many providers treating individuals with SMI is the clinical
practice integration approach in which collaboration is built into service protocols and there are
mechanisms to consult and collaborate with other providers. There is no one model of integration
that works best for individuals with SMI. Ultimately, integration efforts should incorporate the
patient perspective and be matched to the patients’ needs.
When treating patients with serious mental illness, clinicians must be prudent in making treatment
decisions, be aware of patients’ concomitant physical illnesses, and be cognizant of potential
medication side effects that may exacerbate physical health conditions present. When patients have
physical health conditions that may be affected by the use of psychiatric medications, clinicians
should use their best judgment in making decisions regarding patient care based on integration
of evidence from the literature and clinical experience as well as the individual patient’s symptoms
and risk factors. In creating this publication, the goal was to provide monitoring recommendations
based on the most recent available evidence in order to administer better quality care and help
minimize the potential adverse health effects of psychiatric medications, while ultimately improving
patients’ overall health and well-being.
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Page 3
Introduction
Process for Creating the Guidelines
Every two years, the Florida Medicaid Drug Therapy Management Program brings together a
diverse array of stakeholders and experts to update the guidelines. This year’s group of stakeholders
known as the Florida Expert Panel was comprised of: Florida primary care providers, psychiatrists—
including providers from community mental health centers and medical directors of health plans—
ARNPs, academicians, and pharmacists. The 2018 Florida Expert Panel met in Tampa, Florida on
February 17, 2018 to review and update the guidelines first published in 2014 and revised in 2016.
The panel listened to presentations on the latest evidence-based practices, discussed the
guidelines, proposed revisions, and reached a consensus about whether to revise and adopt a
particular set of guideline recommendations. Thus, the final guidelines are a product of an in-depth
review of the literature with an emphasis on the highest level of clinical evidence (e.g., randomized
controlled trials, systematic reviews) and expert panel consensus on the strength of the evidence.
The names of the meeting attendees and meeting presentations are available on the program
website at www.medicaidmentalhealth.org. Financial disclosures are available upon request.
Organization
This publication provides information regarding common physical health conditions that occur
with greater frequency in the seriously mentally ill population, documents screening/monitoring
recommendations for these physical health conditions, provides guidelines regarding management
of pregnant/lactating women, and explores potential barriers that may adversely affect healthcare
delivery, as well as treatment adherence in this population.
Disclaimer
The 2018 Monitoring Physical Health and Side-Effects of Psychiatric Medications in Adults and
Children: An Integrated Approach guidelines reflect the current state of knowledge at the time
of publication on effective and appropriate care. The inevitable changes in the state of scientific
information and technology mandate that periodic review, updating, and revisions will be needed.
These guidelines may not apply to all patients; therefore, each guideline must be adapted and
tailored to the individual patient. Proper use, adaptation, modifications, or decisions to disregard
these or other guidelines, in whole or in part, are entirely the responsibility of the clinician who uses
these guidelines. The authors and expert panel members bear no responsibility for treatment decisions
and outcomes based on the use of these guidelines.
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Page 4
Principles of Practice
Note: Strongly recommend coordination of care between primary care, psychiatry, specialists,
and other providers to facilitate optimal outcomes.
Comprehensive Assessment
nnA comprehensive health assessment includes:
FF A full medical history
FF An assessment of psychiatric co-occurring disorders and physical comorbidities
FF An assessment for trauma, suicide, violence, and substance use disorders
FF Assessment of pregnancy intentions in women of childbearing age
FF Assessment of a patient’s social determinants of health (e.g., health literacy,
transportation, food insecurity, housing stability)
FF Relevant medical work-up, physical examination, and nutritional status evaluation
nnSerious behavioral health conditions are chronic in nature; therefore a long-term,
continuous management plan of chronic conditions is essential:
FF Measurement-based care to assess symptoms, side-effects, and adherence
FF Integration of psychiatrists and primary care providers
FF In pregnant and post-partum patients, integration of psychiatrists and obstetrician-
gynecologists
FF Collaborative/shared decision-making with patients and family/caregivers
FF Psychosocial assessment
FF Assess of social support system (housing, family, other caregivers, etc.)
FF Evaluate the factors that pose a risk to the continuity of care (medication adherence,
social determinants of health, etc.)
FF Assess involvement with legal system and interact with law enforcement as needed
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Page 5
Principles of Practice
Measurement-Based Care for Behavioral Health Conditions
nnQuestionnaires and rating scales are strongly recommended for the initial diagnostic
assessment and evaluation of treatment outcomes. These instruments can be helpful in
providing supplemental information to the provider’s clinical judgment.
nnIntegration of rating scales into routine clinical practice and for all follow-up appointments
is also strongly suggested.
nnClinicians should use rating scales to assess symptom severity during the initial evaluation
and treatment, when medication changes are implemented, and/or when the patient
reports a change in symptoms.
Notes:
• Effort should be made to communicate between primary care providers, psychiatrists, caseworkers, and other team
members to ensure integrated care.
• Prior to initiating any intervention (e.g., psychosocial, medication), assess and document the risks/benefits of treatment.
• Education should be age-appropriate and targeted to the condition.
Measurement Scales
Internet links to the following psychiatric assessment scales are available on the Program website
at www.medicaidmentalhealth.org. These scales were selected because they are brief and can be
completed in the primary care office.
Table 1. Child and Adolescent Assessment Scales
Condition/ Type of
Name of Scale Age range # of Items
Symptoms Assessment
ADHD ADHD Rating Scale IV – Home Version Parent rating 5-17 18
ADHD Parent rating 55
NICHQ Vanderbilt Assessment Scales 6-12
Teaching rating 43
Anxiety Severity Measure for Generalized Patient self-
11-17 10
Anxiety Disorder report
Cognitive,
emotional & Pediatric Symptom Checklist (PSC) Parent rating 4-16 35
behavior problems
Depression PHQ-9 Modified for Adolescents Patient self-
11-17 9
(PHQ-A) report
Depression Center for Epidemiological Studies Patient self-
6-17 20
Depression Scale for Children (CES-DC) report
Manic symptoms Child Mania Rating Scale Patent rating 5-17 21
Mental health
DSM-5 Parent/Guardian-Rated Level
domains across
1 Cross-Cutting Symptom Measure- Parent rating 6 -17 25
psychiatric
Child
diagnoses
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Page 6Principles of Practice
Table 1. Child and Adolescent Assessment Scales (continued)
Condition/ Type of
Name of Scale Age range # of Items
Symptoms Assessment
Mental health
domains across DSM-5 Self-Rated Level 1 Cross- Patient self-
11-17 25
psychiatric Cutting Symptom Measure—Child report
diagnoses
Patient
self-report
PTSD Child PTSD Symptom Scale (CPSS) 8-18 24
or clinician
administered
Substance use Patient self-
The CRAFFT Screening Interview 13-18 9
(Alcohol & drugs) report
Substance use Patient self-
Drug Use Questionnaire (DAST-20) 13-18 20
(Drugs) report
Symptom severity
Brief Psychiatric Rating Scale for
across mental Clinician rating 3-18 21
Children (BPRS-C)
health domains
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Page 7Principles of Practice
Table 2. Adult Assessment Scales
Condition/ Type of
Name of Scale # of Items
Symptoms Assessment
Anxiety/general Generalized Anxiety Disorder 7-item (GAD-7)
Patient self-report 7
scale
Anxiety/general Severity Measure for Generalized Anxiety
Patient self-report 10
Disorder-Adult
Anxiety/panic Severity Measure for Panic Disorder Patient self-report 10
Bipolar disorder/
Young Mania Rating Scale (YMRS) Clinician rating 11
manic symptoms
Bipolar disorder The Mood Disorder Questionnaire (MDQ) Patient self-report 16
Childhood Adverse Childhood Experiences (ACE)
Patient self-report 10
trauma Questionnaire
Depression Patient Health Questionnaire (PHQ-9) Patient self-report 9
Depression Beck Depression Inventory (BDI) Patient self-report 21
Depression Hamilton Rating Scale for Depression (HAM-D) Clinician rating 21
Difficulties/
disability due to World Health Organization Disability
Patient self-report 36
mental health Assessment Scale 2.0
conditions
Global rating of
illness severity
Clinical Global Impression Scale (CGI) Clinician rating 3
and response to
treatment
Mental health
domains across DSM-5 Self-Rated Level 1 Cross-Cutting
Patient self-report 23
psychiatric Symptom Measures-Adult
diagnosis
Psychosis Clinician-Rated Dimensions of Psychosis
Clinician rating 8
Symptom Severity
Psychotic
Brief Psychiatric Rating Scale (BPRS) Clinician rating 18
disorders
PTSD National Stressful Events Survey PTSD Short
Patient self-report 9
Scale (NSESS)
PTSD Post-traumatic Stress Disorder Checklist
Patient self-report 20
for DSM-5 (PCL-5)
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Page 8Principles of Practice
Table 2. Adult Assessment Scales (continued)
Condition/ Type of
Name of Scale # of Items
Symptoms Assessment
Substance use The Alcohol Use Disorders Identification Test
Patient self-report 3, 10
(Alcohol) (AUDIT-C, AUDIT)
Substance use Tolerance, Annoyed, Cut Down, Eye-Opener
Patient self-report 4
(Alcohol) (T-ACE) Questionnaire
Substance use
(Alcohol Tolerance, Worried, Eye-Opener, Amnesia, Cut
Patient self-report 5
use during Down (TWEAK) Questionnaire
pregnancy)
Substance use
NIDA Drug Use Screening Tool: Quick Screen Patient self-report 4
(Alcohol & drugs)
Substance use
The CRAFFT Screening Interview Patient self-report 9
(Alcohol & drugs)
Substance
Drug Abuse Screen Test (DAST-10) Patient self-report 10
(Drugs)
Substance use
Opioid Risk Tool Patient self-report 10
(Opioids)
Screening, Brief Intervention, and Referral to Treatment (SBIRT):
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice for
providing early intervention and treatment to individuals at risk for developing substance use
disorders. SBIRT can be implemented in the primary care setting. For more information regarding
SBIRT, visit http://www.samhsa.gov/sbirt and see the Substance Use Disorders section in these
guidelines.
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Page 9Principles of Practice
General Recommendations: Baseline Monitoring of Physical Health in Patients with Serious
Mental Illness (SMI)
Table 3. Recommended Assessments at Baseline and Subsequent Follow-up
Monitoring
Assessment Baseline Follow-up Assessments
Vital signs (blood pressure, pulse, weight,
Each visit
including calculation of body mass index)
Lifestyle behaviors: smoking, diet, exercise,
Each visit
substance use, sleep
Personal/family history: hypertension, diabetes,
cardiovascular disease, cerebrovascular disease
As clinically indicated
(stroke), cancer, epilepsy, Parkinson’s disease,
thyroid disease
Dental history As clinically indicated
Sexual/reproductive function At 3 months and 6 monthly thereafter
Recommended Monitoring As Needed Based on Clinical Presentation:
nnWaist circumference
nnSedation
nnParkinsonism Screen (e.g., SAS or ESRS)
nnAkathisia Screen (e.g., AIMS or ESRS)
nnElectrocardiogram (ECG)
Note: Prior to considering medication management, clinicians should weigh the risks and benefits of treatment, including the risk
for interactions with other medications (both prescribed and over-the-counter), herbal supplements, and foods (e.g., grapefruit)
that may increase or decrease drug levels. To check drug-drug interactions, visit: https://reference.medscape.com/drug-
interactionchecker.
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Page 10Principles of Practice
Table 4. Recommended laboratory monitoring
Parameter Recommendation
Complete blood count with differential
At baseline, then as indicated (e.g., treatment with clozapine)
(CBC with diff)
Complete metabolic panel (CMP) At baseline, then as indicated
Fasting lipid profile All patients over 40 years at baseline and annually thereafter,
or sooner as indicated (e.g., cardiac history, obesity, diabetes,
hypertension)
Folate As clinically indicated
Hemoglobin A1c (HbA1c) All patients over 40 years at baseline and annually thereafter, or
sooner as indicated
Prolactin As clinically indicated (e.g., amenorrhea/oligomenorrhea, poor
sexual function, osteopenia/osteoporosis)
Thyroid stimulating hormone (TSH) As clinically indicated
Urine Drug Screen As clinically indicated
Vitamin B12 As clinically indicated
Vitamin D As clinically indicated
Notes:
Abbreviations: SAS = Simpson-Angus Scale; ESRS = Extrapyramidal Symptom Rating Scale; AIMS = Abnormal Involuntary
Movement Scale. These scales are available at www.medicaidmentalhealth.org.
There are many reasons patients may require testing earlier or more often than the recommendations noted above. If monitoring
has been obtained by primary care provider, obtain records.
Studies have shown that waist circumference is a better predictor of cardiovascular risk compared to Body Mass Index (BMI).
Check blood pressure (BP) and pulse during titration with clozapine and quetiapine.
For more information about clozapine monitoring, visit the Clozapine REMS Program at www.clozapinerems.com.
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Page 11Principles of Practice
Table 5. Normal laboratory values in adults for selected measures
Measure Normal Range*
Basic Metabolic Panel
Blood urea nitrogen (BUN) 7 – 20 mg/dL
Bicarbonate (HCO3 ), total
-
18 – 30 mEq/L
Creatinine 0.8 – 1.3 mg/dL
Glucose 70 – 100 mg/dL
Serum chloride (Cl-) 95 – 105 mmol/L
Serum potassium (K ) +
3.5 – 5.0 mmol/L
Serum sodium (Na+) 135 – 145 mmol/L
Complete Blood Count
Measure Normal Range*
Hemoglobin Males: 13 – 17 g/dL
Females: 12 – 15 g/dL
Hematocrit (Hct) Males: 40 – 54%
Females: 36 – 46 %
Mean corpuscular volume (MCV) 80 – 100 fL
Platelets 150 – 400 x 109/L
Red Blood Cells (RBCs) Males: 4.32 – 5.72 x 1012 cells /L
Females: 3.90 – 5.03 x 1012 cells/L
White Blood Cells (WBCs) 4 – 10 x 109/L
Endocrine
Measure Normal Range*
Glucose 70 – 100 mg/dL
Hemoglobin A1c (Hgb A1c) 5.6% and below
Lipids
Measure Normal Range*
High density lipoprotein (HDL) Above 50 mg/dL
Low density lipoprotein 85 – 125 mg/dL
Total cholesterol 3.5 – 5.5 mmol/L
Triglycerides 50 – 150 mg/dL
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Page 12Principles of Practice
Table 5. Normal laboratory values in adults for selected measures (continued)
Liver function tests
Measure Normal Range*
Albumin 3.5 – 5.0 g/dL
Alkaline phosphatase 20 – 90 Units/L
Alanine Aminotransferase (ALT) 10 – 30 Units/L
Aspartate aminotransferase (AST) 5 – 30 Units/L
Bilirubin, direct 0 – 6 micromols/L
Bilirubin, total 2 – 20 micromols/L
Total protein 60 – 80 g/L
Renal function
Measure Normal Range*
Blood urea nitrogen (BUN) 7 – 20 mg/dL
Creatinine 0.8 – 1.3 mg/dL
Estimated glomerular filtration rate
Above 90%
(eGFR)
*Note: Normal laboratory values may vary by facility. Always use the facility’s laboratory value guidelines for testing and
interpretation.
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Page 13Physical Disease and Mental Illness
Among individuals with serious mental illness, physical health problems including cardiovascular
disease, metabolic disorders, infectious diseases, respiratory illnesses, and sexual dysfunction
occur with greater frequency, especially when compared to the general population. Furthermore,
individuals with serious mental illnesses such as schizophrenia and bipolar disorder have a greater
relative risk of modifiable risk factors for cardiovascular disease. Relative risk is defined as the ratio
of the probability of a particular event occurring in one group compared to the probability of that
same event occurring in a comparison group.
In this section, the guidelines provide an overview of the physical ailments that occur with greater
frequency among individuals with serious mental illness, review psychiatric medication side
effects that may contribute to or exacerbate these physical conditions, and provide monitoring
recommendations in order to better evaluate and treat these physical health issues with the goal of
better health outcomes.
Note: Strongly recommend coordination of care between primary care, psychiatry, specialists,
and other providers to facilitate optimal outcomes.
Table 6. Modifiable Risk Factors in Individuals with Severe Mental Illness
Modifiable Risk Schizophrenia Bipolar Disorder
Factors Prevalence rate Relative risk Prevalence rate Relative risk
Smoking 50 – 80% 2 – 3 times the risk 54 – 68% 2 – 3 times the risk
Obesity 45 – 55% 1.5 – 2 times the risk 21 – 49% 1 – 2 times the risk
Metabolic
37 – 63% 2 – 3 times the risk 30 – 49% 2 – 3 times the risk
Syndrome
Dyslipidemia 25 – 69% ≤ 5 times the risk 23 – 38% ≤ 3 time the risk
Hypertension 19 – 58% 2 – 3 times the risk 35 – 61% 2 – 3 times the risk
Diabetes Mellitus 10 – 15% 2 – 3 times the risk 8 – 17% 1.5 – 3 times the risk
Adapted from Hert, et al., 2011a. Physical Illness in patients with severe mental disorders: I. Prevalence, impact of medications and
disparities in health care. World Psychiatry, 10(1): 52-77.disparities in health care. World Psychiatry, 10(1): 52-77.
Note. The relative risk is compared to the general population.
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Page 14Physical Disease and Mental Illness
Box 1.
Physical Diseases with Increased Frequency in Serious Mental Illness
Cardiovascular diseases – stroke, myocardial infarction, hypertension, other cardiac and vascular diseases
Nutritional and metabolic diseases – obesity, hyperlipidemia, metabolic syndrome, diabetes mellitus
Bacterial infections and mycoses – tuberculosis
Viral diseases – HIV, Hepatitis B, Hepatitis C
Neoplasms – obesity-related cancers (e.g., breast, stomach)* and smoking-related cancers (e.g., lung)
Dental problems – poor dental status
Respiratory tract diseases – COPD, impaired lung function
Urological conditions and male reproductive issues – sexual dysfunction
Female reproductive issues and pregnancy complications – obstetric complications, sexual dysfunction
Adapted from Hert, et al., 2011a.
*Note: Evidence regarding obesity-related cancers is conflicting; some studies indicate similar incidence of these cancers to the
general population but with increased mortality among individuals with SMI, while other reports indicate increased rates of
obesity-related cancers among individuals with SMI.
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Page 15Weight Change and Metabolic Side-Effects of Psychotherapeutic Medications
Note: Strongly recommend coordination of care between primary care, psychiatry, specialists,
and other providers to facilitate optimal outcomes.
Weight Change and Metabolic Concerns Associated with Psychotherapeutic
Medications
Weight changes are the most difficult issues patients and clinicians contend with and can have
an effect on patient compliance with a particular regimen. Individual psychiatric medications,
including those in the antidepressant, mood stabilizer, and antipsychotic classes, have been shown
to have differential effects on weight gain.
Management of medication-induced weight gain and other metabolic problems depends
on multiple factors, including response to different antipsychotics, severity of the metabolic
disturbance, and patient willingness to implement lifestyle changes. Individuals with new-onset
diabetes should receive an evaluation by a primary care provider.
Potential options to manage medication-induced metabolic side effects include:
nnDiet and exercise, including referral to a certified nutritionist if clinically indicated
nnSwitching to an antipsychotic with lower potential for weight gain or dyslipidemia (e.g.,
switch from olanzapine or risperidone to ziprasidone)
nnMedication management if more conservative measures are ineffective (e.g.,
antihypertensives for hypertension and statins for dyslipidemia)
Initial randomized trials have also shown evidence that metformin may be effective in helping
patients with schizophrenia lose weight. These trials found that twelve to sixteen weeks of
metformin given at 750 mg/day or higher led to loss of approximately 50 percent of weight gain
induced by antipsychotic treatment, and metformin combined with lifestyle changes had more
effect than metformin alone in two of the trials. Metformin is indicated as an adjunct to diet
and exercise to improve glycemic control in adults and children with Type 2 diabetes mellitus.
Metformin is not yet FDA-indicated for psychotropic medication-induced weight gain and is
contraindicated in individuals with known hypersensitivity or metabolic acidosis. Metformin has
traditionally been contraindicated in chronic kidney disease; however, based on recent evidence
and recommendations, metformin may be used with caution and close clinical supervision
in individuals with a GFR >30 mL/min. The primary concern is the risk for lactic acidosis in this
population.
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Page 16Weight Change and Metabolic Side-Effects of Psychotherapeutic Medications
Table 7. Studies Examining Weight Change Associated with Psychotherapeutic
Medications used in the Treatment of Serious Mental Illness
Antidepressants
Weight loss
FF Sertraline (Zoloft) – Patients in controlled trials had minimal (1-2 pound)
weight loss compared to smaller changes with placebo.
No weight change
FF Citalopram (Celexa) – Short-term placebo-controlled trial showed average
weight loss of 0.5 kg with citalopram versus 0.2 kg weight gain with placebo in
post-marketing studies; No significant changes in body mass in post-marketing
Selective
studies
Serotonin
Reuptake FF Escitalopram (Lexapro) – No difference from placebo-treated patients in
Inhibitors (SSRIs) premarketing trials.
FF Fluoxetine (Prozac) – No overall associated weight changes; weight loss of
0.35 kg reported in acute-phase treatment, at 38 weeks, 2 kg weight gain with
fluoxetine versus 2.5 kg weight gain with placebo.
Weight gain
FF Paroxetine (Paxil) – Of the SSRIs, paroxetine is most likely to cause weight
gain. Fava, et al. showed >7% increase in weight from baseline compared with
patients taking sertraline or fluoxetine.
Weight loss
FF Duloxetine (Cymbalta) – In acute placebo-controlled studies, duloxetine
treated patients had average change of -0.5 kg compared with 0.2 kg for
Serotonin
placebo treated patients. No consistent relationship between duloxetine dose
Norepinephrine
and weight change. Similar acute mean weight changes seen in duloxetine
Reuptake
versus fluoxetine treated patients (-0.7 kg versus -0.6 kg respectively).
Inhibitors (SNRIs)
FF Venlafaxine (Effexor) – Weight loss of up to 7% of body weight compared to
placebo during up to 12 weeks of treatment in studies of patients with MDD,
GAD, SAD, and panic disorders.
No weight change
FF Nortriptyline (Pamelor) – Meta-analysis of 257 RCTs found non-significant
weight change with nortriptyline.
Tricyclic
Weight gain
Antidepressants
(TCAs) FF Amitriptyline (Elavil) – Meta-analysis of 257 RCTs found average of 1.8 kg
weight gain.
FF Imipramine (Tofranil) – Average of 4.5 kg weight gain over one year in
patients treated for panic disorder.
Weight loss
FF Bupropion (Wellbutrin) – Meta-analysis of 257 RCTs found average of 1.3 kg
Other weight loss.
antidepressants Weight gain
FF Mirtazapine (Remeron) – Meta-analysis of 257 RCTs found average of 1.5 kg
weight gain.
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Page 17Weight Change and Metabolic Side-Effects of Psychotherapeutic Medications
Table 7. Studies Examining Weight Change Associated with Psychotherapeutic
Medications used in the Treatment of Serious Mental Illness (continued)
Anticonvulsants/Mood Stabilizers
Weight loss
FF Lamotrigine (Lamictal) – Mean weight loss of 4.2 kg at week 52 of therapy in
obese patients; mean weight loss of 0.5 kg in non-obese patients at week 52.
FF Topiramate (Topamax) – Meta-analysis of 257 RCTs found average of 3.8 kg
weight loss.
FF Zonisamide (Zonegran) – Meta-analysis of 257 RCTs found average of 7.7 kg
weight loss.
Weight gain
FF Carbamazepine (Tegretol) – Meta-analysis of 257 RCTs found average of 1.0
kg weight gain.
FF Gabapentin (Neurontin) – Meta-analysis of 257 RCTs found average of 2.2 kg
weight gain.
FF Lithium (Eskalith, Lithobid) – Mean weight gain of 6.1 kg at week 52 of
lithium therapy in obese patients; mean weight gain of 1.1 kg in non-obese
† patients at week 52.
FF Valproic Acid (Valproate, Valpro, Depakene) – Weight gain of 0.49 kg
after 3 weeks of treatment with up to 1500 mg/day versus placebo in healthy
volunteers.
Antipsychotics
Weight gain
FF Chlorpromazine (Thorazine) – Meta-analysis estimated mean weight gain of
2.10 kg at 10-weeks of treatment.
Typical
Antipsychotics FF Fluphenazine (Prolixn) – Meta-analysis estimated mean weight gain of 0.43
kg at 10-weeks of treatment.
FF Haloperidol (Haldol) – Meta-analysis estimated mean weight gain of 0.48 kg
at 10-weeks of treatment.
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Page 18Weight Change and Metabolic Side-Effects of Psychotherapeutic Medications
Table 7. Studies Examining Weight Change Associated with Psychotherapeutic
Medications used in the Treatment of Serious Mental Illness (continued)
Antipsychotics
Weight gain
FF Aripiprazole (Abilify) – 3-month cohort study of first-time use of atypical
antipsychotics in children and adolescents reported mean weight gain of
4.4 kg. 6-month RCT reported mean weight gain of 0.40 kg with aripiprazole.
A meta-analysis of metabolic effects associated with atypical antipsychotic
treatment in children and adolescents found olanzapine, risperidone and
aripiprazole were all associated with statistically significant weight gain.
Olanzapine was associated with the most weight gain and aripiprazole was the least.
FF Asenapine (Saphris) – A double-blind placebo-controlled study found mean
weight gain of 0.9 kg compared to placebo.
FF Brexpiprazole (Rexulti) – Weight gain with brexpiprazole was moderate (1.45
and 1.28 kg for 2 and 4 mg, respectively, versus 0.42 kg for placebo at week 6).
FF Cariprazine (Vraylar) – Mean weight gain at endpoint of 6-week in patients
with schizophrenia: 0.8 kg with 1.5-3 mg/day, 1kg with ≥4.5 mg/day versus 0.3
kg with placebo.
FF Clozapine (Clozaril) – 6-week open-label study reported average weight gain of 2.5 kg.
FF Iloperidone (Fanapt) – Mean change from baseline of 2.1 kg increase at
endpoint.
FF Lurasidone (Latuda) – The mean weight gain observed across 6-week trial in
Atypical patients with schizophrenia was 0.43 kg for lurasidone versus mean weight loss
Antipsychotics of 0.02 kg for placebo.
FF Olanzapine (Zyprexa) – Meta-analysis of 257 RCTs found average of 2.4 kg
weight gain. A 3-month cohort study of first-time use of atypical antipsychotics
in children and adolescents reported mean weight gain of 8.5 kg. CATIE trial
found an average weight gain of 2 lbs (0.9 kg) per month, more than any other
treatment group (quetiapine, risperidone, ziprasidone, or perphenazine). A meta-
analysis of metabolic effects associated with atypical antipsychotic treatment in
children and adolescents found olanzapine, risperidone and aripiprazole were all
associated with statistically significant weight gain. Olanzapine was associated
with the most weight gain and aripiprazole was the least.
FF Paliperidone (Invega) – 6-month RCT reported mean weight gain of 2.3 kg for
paliperidone ER.
FF Quetiapine (Seroquel) – Meta-analysis of 257 RCTs found average of 1.1 kg
weight gain.
FF Risperidone (Risperdal) – Meta-analysis of 257 RCTs found average of 0.8
kg weight gain. A meta-analysis of metabolic effects associated with atypical
antipsychotic treatment in children and adolescents found olanzapine,
risperidone and aripiprazole were all associated with statistically significant
weight gain. Olanzapine was associated with the most weight gain and
aripiprazole was the least.
FF Ziprasidone (Geodon) – Meta-analysis found mean weight gain of 0.04 kg.
Note: 1 kilogram = 2.2 pounds. Medications under each category (weight loss, no weight change, weight gain) are listed alphabetically.
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Page 19Prediabetes and Metabolic Syndrome
Note: Strongly recommend coordination of care between primary care, psychiatry, specialists,
and other providers to facilitate optimal outcomes.
Prediabetes
Prediabetes identifies individuals who are at increased risk for type 2 diabetes and cardiovascular
disease but do not yet meet the criteria for type 2 diabetes.
The American Diabetes Association (ADA) defines prediabetes as individuals who:
nnHave an impaired fasting glucose of 100 – 125 mg/dL (which is lower than the World Health
Organization’s criteria of 110-125 mg/dL), and/or
nnHave an impaired glucose tolerance defined by a 2-hour plasma glucose of between 100-
199 mg/dL after a 75g oral glucose load, and/or
nnHave a hemoglobin A1c between 5.7% and 6.4%
Note: Refer for further care and/or initiate treatment as clinically indicated if impaired fasting glucose, impaired glucose tolerance,
or elevated HgA1c (>5.7%).
Metabolic Syndrome
According to the American Heart Association and the National Heart, Lung, and Blood Institute,
there are five factors that make up metabolic syndrome:
nnLarge waist size (40 inches or larger for men, 35 inches or larger for women)
nnHigh triglycerides (either 150 mg/dL or higher or using a cholesterol medication)
nnLow levels of high-density lipoprotein or HDL (HDL less than 40 mg/dL for men, less than
50 mg/dL for women, or any patient using a cholesterol medication)
nnHigh blood pressure (blood pressure of 135/85 mmHg or greater or using a blood pressure
medication)
nnHigh fasting glucose level (100 mg/dL or higher)
The following tables review antipsychotic medication effects on development of metabolic
syndrome, review cutoff waist circumference values in different ethnic populations, and provide
recommended guidelines for management of these risk factors when they are present.
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Page 20Prediabetes and Metabolic Syndrome
Table 8. Antipsychotic Medications and Metabolic Syndrome Risk
Medication Low Mild Moderate High
Typical Antipsychotics
Chlorpromazine (Thorazine) — — — 4
Haloperidol (Haldol) 4 — — —
Perphenazine (Trilafon) 4 — — —
Atypical Antipsychotics
Aripiprazole (Abilify) 4 — — —
Asenapine (Saphris)* 4 — — —
Brexpiprazole (Rexulti) — 4 — —
Cariprazine (Vraylar) — 4 — —
Clozapine (Clozaril) — — — 4
Iloperidone (Fanapt)* — 4 — —
Lurasidone (Latuda)* 4 — — —
Olanzapine (Zyprexa) — — — 4
Quetiapine (Seroquel) — — 4 —
Risperidone (Risperdal) — 4 — —
Ziprasidone (Geodon) 4 — — —
Adapted from Hert, et al., 2011a. Note. mg/dL =milligrams per deciliter; mmHg =millimeters of mercury; mg/dL = milligrams per
deciliter.
*Limited data with these medications. Some of the second-generation antipsychotics above have not been extensively studied with
regard to metabolic syndrome.
Ethnicity-Specific Cutoff Values of Waist Circumference Indicating Abdominal
Obesity
Annual monitoring is recommended in a primary care setting.
Table 9. Waist Circumference and Race/Ethnicity
Females Males
North Americans ≥88 cm (≥ 35 in) ≥102 cm (≥ 40 in)
European, Mediterranean, Middle
≥80 cm (≥ 32 in) ≥94 cm (≥ 37 in)
Eastern, Sub-Saharan Africans
South Asians, Chinese, Ethnic
≥80 cm (≥ 32 in) ≥90 cm (≥ 35 in)
South and Central Americans
Japanese ≥82-85 cm (≥ 32-34 in) ≥90 cm (≥ 35 in)
Adapted from Hert, et al., 2011a.
Note. cm = centimeter; in = inch.
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Page 21Metabolic and Cardiovascular Health Issues
Type 2 Diabetes Mellitus and Hypertension: Diagnostic Criteria
Any of the following:
nnFasting plasma glucose ≥126 mg/dL
*Note: Fasting is defined as no caloric intake for ≥8 hours. In absence of unequivocal hyperglycemia, result to be
confirmed by repeat testing.
nn2-hour plasma glucose ≥200 mg/dL during oral glucose tolerance test with glucose load
containing equivalent of 75 g anhydrous glucose dissolved in water
*Note: In absence of unequivocal hyperglycemia, result to be confirmed by repeat testing.
nnHemoglobin A1c ≥6.5%
nnRandom plasma glucose ≥200 mg/dL in individuals with symptomatic hyperglycemia or
hyperglycemic crisis
Diagnostic Criteria for Hypertension
nnNormal blood pressure:Metabolic and Cardiovascular Health Issues
ADA Target Goals and ASCVD Risk Calculator
Note: Strongly recommend coordination of care between primary care, psychiatry, specialists,
and other providers to facilitate optimal outcomes.
The following recommendations were adapted from the American Diabetes Association (ADA).
Box 2.
ADA Target Goals for Blood Pressure, Lipid, and Glycemic Control
FF Blood pressure: Systolic 10%.
Link to ASCVD Risk Calculator: http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
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Page 23Q-T Prolongation Associated with Psychotherapeutic Medications
Q-T Interval Prolongation
The Q-T interval represents electrical depolarization and repolarization of the ventricles, and the
Q-Tc is this value corrected for the patient’s heart rate. In clinical trials, a prolonged Q-Tc interval
of greater than 500 milliseconds during therapy has been a threshold for concern. Clinically, a
Q-Tc interval above 470 milliseconds in females and above 450 milliseconds in males is considered
prolonged, and individual changes in Q-Tc intervals of 30 to 60 milliseconds from baseline should
heighten suspicion of increased risk of arrhythmias. Though data are limited, a prolonged Q-Tc
interval appears to be more common with tricyclic antidepressants than selective-serotonin
reuptake inhibitors (SSRIs). Antipsychotic medications have also been reported to be associated with
Q-Tc interval prolongation, particularly with ziprasidone and thioridazine, and to a lesser extent with
haloperidol and quetiapine.
EKG monitoring is recommended when administering antipsychotic medications in the presence
of co-existing risk factors for QT interval prolongation such as older age, electrolyte disturbances
(e.g., hypokalemia, hypomagnesemia), family history of sudden death, personal history of cardiac
murmur, and/or use of concomitant medications known to prolong the QT interval. See table below
for risk factors to evaluate for during initial assessment when considering use of antipsychotics or
other medications with QT prolongation.
Note: Strongly recommend coordination of care between primary care, psychiatry, specialists,
and other providers to facilitate optimal outcomes.
Box 3.
Risk factors associated with QT prolongation to evaluate for*
FF Older age (>65years)
FF Electrolyte disturbances (e.g., hypokalemia, hypomagnesemia)
FF Congenital long QT syndrome
FF Family history of sudden death
FF Personal history of heart murmur, shortness of breath with exertion, episodes of
tachycardia at rest, irregular heartbeats
FF Personal history of syncope
FF Known cardiac disease (myocardial ischemia, congestive heart failure, cardiac
arrhythmias, bradycardia)
FF Concomitant Use of other medications known to prolong QT interval
FF Concomitant medications known to inhibit metabolism of antipsychotic medications
(i.e., cause increased serum concentrations of antipsychotic medications)
FF History of liver disease
FF Endocrine and metabolic disorders
FF Central nervous system injury (e.g., stroke, infection, trauma)
*Adapted from Shah AA, et al (2014).
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Page 24Hyperprolactinemia Associated with Psychotherapeutic Medications
Hyperprolactinemia Associated with Psychotherapeutic Medications
Note: Strongly recommend coordination of care between primary care, psychiatry, specialists,
and other providers to facilitate optimal outcomes.
Antipsychotics such as risperidone are associated with hyperprolactinemia. Hyperprolactinemia
may be asymptomatic or may be associated with a wide range of clinical effects, including
decreased sexual and reproductive function (e.g., oligomenorrhea, amenorrhea), weight gain,
decreased bone density, gynecomastia, and galactorrhea. If symptomatic, other medical causes
of hyperprolactinemia (e.g., pituitary adenoma) should be ruled out. Patients taking antipsychotic
medications should be assessed and monitored for signs and symptoms of hyperprolactinemia,
with appropriate referrals when clinically indicated. Prolactin levels should particularly be monitored
in male patients prescribed antipsychotic medications due to the concern for gynecomastia, which
is potentially irreversible. Management of symptomatic medication-induced hyperprolactinemia
includes referral to a specialist, reduction in the medication dose, discontinuation of the offending
agent, or switch to a prolactin-sparing agent such as aripiprazole.
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Page 25Infectious Disease: Risk Factors and Screening Recommendations
Individuals with serious mental illness are often at increased risk for acquiring infectious diseases
such as Hepatitis B, Hepatitis C, HIV, and tuberculosis due to a greater likelihood of engaging in high-
risk behaviors such as using illicit substances and having multiple sexual partners. When planning to
screen patients for infectious diseases, patients should be informed orally and in writing that testing
will be performed. Unless they decline, they should receive explanation of the infection, how it can
and cannot be acquired, the meaning of positive and negative test results, and the benefits and
risks associated with treatment. They should also be offered the opportunity to ask questions and
decline testing. This section reviews risk factors and screening recommendations for Hepatitis C
(HCV), Hepatitis B (HBV), human immunodeficiency virus (HIV), and tuberculosis (TB).
Note: Strongly recommend coordination of care between primary care, psychiatry, specialists,
and other providers to facilitate optimal outcomes.
Table 10. Risk Factors and Screening Recommendations for
Selected Infectious Diseases
Disease Risk Factors Screening/Treatment
Recommendations
FF Past/present drug use FF 1-time screening in all adults born
FF Sex with injection drug user between 1945 and 1965
FF Blood transfusion before 1992 FF High-risk patients
Hepatitis C (HCV) FF FDA approved treatment
FF Other: Long-term dialysis,
incarceration, intranasal drug use,
getting an unregulated tattoo, infant
of HCV positive mother
FF Sexual contact with infected person FF Hepatitis B surface antigen
FF Exposure to infectious bodily fluids (HBsAg)
Hepatitis B (HBV) FF Prolonged, close personal contact with FF Either Hepatitis B core antibody
infected person (anti-HBc) or hepatitis B surface
antibody (anti-HBs)
FF Perinatal exposure to infected Mother
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Page 26Infectious Disease: Risk Factors and Screen Recommendations
Table 10. Risk Factors and Screening Recommendations for
Selected Infectious Diseases (continued)
Screening/Treatment
Disease Risk Factors
Recommendations
FF Injection drug use/sharing needles FF All persons who seek evaluation
FF Sexual contact- anal, vaginal or oral and treatment for sexually
sex; men who have sex with men; transmitted infections (STIs)
multiple partners; anonymous partners should be tested; consider rapid
without using condom; sexual contact HIV test in this population as high
with infected person; exchange sex for proportion of patients may not
drugs/money; unprotected sex with return for HIV test results.
at-risk individuals. FF Individuals suspected of recently
Human acquired HIV infection- refer for
FF History of STI (syphilis, genital herpes,
Immunodeficiency immediate consultation with
chlamydia, gonorrhea, bacterial
Virus (HIV), infectious disease specialist for
vaginosis, trichomoniasis)
evaluation (history, physical
FF Diagnosed with hepatitis, TB, or including gynecology exam in
malaria women, chest radiography, and
FF Blood transfusion or clotting factor lab tests - CBC, CMP, lipid profile,
recipient in US between 1978 and 1985 urinalysis toxoplasma antibodies,
testing for STIs and hepatitis, HIV
genotype, CD4 count and viral
load, and TB test).
FF Individuals in contact with patient who FF TB testing generally is not
has TB recommended in patients with
FF Individuals from a country where TB is low risk of TB infection.
common FF High risk patients should have
FF Patients with HIV infection or problems medical evaluation- history/
that weaken the immune system physical, TB test, chest radiograph
Tuberculosis (TB) at minimum and other laboratory
FF Symptomatic patients (e.g., fever, tests as appropriate.
productive cough, weight loss, night
sweats, fatigue, and loss of appetite)
FF Live/work in area where TB is common
(e.g., homeless shelter, and/or prison/jail)
FF Illicit drug users
Adults aged 19 years or older should also receive immunizations recommended by the Centers for
Disease Control (CDC), :
nnInfluenza – 1 dose annually
nnTetanus, diphtheria, pertussis (Td/Tdap) - Substitute Tdap for Td once, then Td booster every 10 years
nnVaricella – 2 doses
nnHuman papillomavirus (HPV) – 3 doses between 19 and 26 years old
nnHerpes zoster – 2 doses of recombinant vaccine at 50 years old or older
nnMeasles, mumps, rubella (MMR) – 1 or 2 doses depending on indication
Notes. Other immunizations may be recommended for persons with a risk factor (medical, occupational, lifestyle, or other
indication). See CDC website http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule-bw.pdf
and https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/recommendations.html.
Page 27Substance Use Disorders
One in five individuals with a serious mental illness has a co-occurring substance use disorder.
Similar to persons with SMI, individuals with substance use disorders are at risk for physical
health problems such as cardiovascular disease, lung disease, hepatitis, HIV/AIDS, and cancer. The
management of chronic disease is often complicated and more challenging in individuals with
co-occurring disorders. For example, individuals who have depression, a substance use disorder,
and medical comorbities are less likely to adhere to their treatment plan and medications for type 2
diabetes. Improvement of the health and functioning of these individuals requires the integration of
care across primary care, mental health care, and substance use services. Many of the FDA-approved
medications to help patients reduce alcohol or drug use, avoid relapse, and support abstinence
(e.g., buprenorphine, naltrexone, and acamprosate) can be used in primary care settings which
increases patient choice in being treated in the setting they are most comfortable.
Conduct a comprehensive assessment. Refer to Principles of Practice.
Note: Strongly recommend coordination of care between primary care, psychiatry, specialists,
and other providers to facilitate optimal outcomes.
Check E-FORCSE (the Electronic-Florida Online Reporting of Controlled Substance Evaluation Program,
Florida’s state prescription monitoring program), ideally prior to prescribing any medications, but at a
minimum when prescribing any controlled substance. Checking E-FORCSE is also recommended for all new
patients, with follow-up E-FORCSE monitoring at least once per year for each patient.
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
SBIRT is a model to assess and deliver early intervention and treatment to individuals with substance
use disorders and those that are at risk of developing substance use disorders.
nnScreening quickly assesses the severity of substance use and identifies the appropriate
level of treatment
nnBrief intervention focuses on increasing insight and awareness of substance use and
motivation towards behavioral change
nnReferral provides those needing treatment access to specialty care services
Recommend screening for substance use disorders using validated questionnaires (see table in Principles of Practice) prior to
patient visits. Obtain history of prescription, over-the-counter, and herbal medication use.
Pre-Screening for Substance Use Disorders
NIAAA/NIDA Pre-Screening Questions:
nn“How many times in the past year have you had 4 or more drinks in a day?” (NIAAA)
nn“How many times in the past year have you used an illegal drug or used a prescription
medication for non-medical reasons?” (NIDA)
Alcohol Use Disorders Identification Test (AUDIT): The Alcohol Use Disorders Identification Test
(AUDIT) is a 10-item screening tool developed by the World Health Organization (WHO) to assess
alcohol consumption, drinking behaviors, and alcohol-related problems. The AUDIT is available at:
https://www.drugabuse.gov/sites/default/files/files/AUDIT.pdf.
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Page 28Substance Use Substance
Disorders: Use
Screening
Disorders
and Identification
Box 4.
Behaviors that Increase Suspicion for Drug Misuse or Dependency
FF Taking a controlled substance for a long time period
FF Refusing to grant permission to obtain old records or communicate with
previous providers
FF Reluctance to undergo a comprehensive history, physical examination, or
diagnostic testing (especially urine drug screens)
FF Requesting a specific drug
FF Professing multiple allergies to recommended medications
FF Resisting other treatment options
Other aberrant behaviors:
FF Issuing threats or displaying anger
FF Targeting appointments at the end of the day or during off hours (nights or
weekends)
FF Excessive flattery
FF Calling and visiting a physician’s associates
FF Repeatedly losing a prescription
FF Requesting dose escalation
FF Demonstrating noncompliance with prescription instructions
FF Demonstrating other evidence of alcohol or illicit drug misuse
*Adapted from Standridge JB, et al (2010). Urine Drug Screening: A valuable office procedure.
For a list of screening tools for substance use disorders, refer to Principles of Practice.
Laboratory Drug Screening and Confirmatory Testing
Laboratory drug testing typically involves a two-step process: the initial drug screen for potentially
positive specimens, followed by confirmatory testing of screened positive assays.
Screening tests
Screening tests can be done in the laboratory or onsite and usually use an immunoassay of urine
or saliva. Screening tests indicate the presence or absence of a substance or its metabolite, but
can also indicate the presence of a cross-reacting, chemically similar substance. Screening tests are
either positive or negative and generally do not measure the specific levels of drugs, alcohol, or
metabolites present.
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