Admittedly, the older agents may be more difficult to use than newer ones. Nonetheless, these older agents have a crucial role to play in psychopharmacology. MAOIs and tricyclics are important alternatives for certain subpopulations and for patients who do not respond to SSRIs or newer agents (
+9,
+10,
+11). Lithium remains the standard for the treatment of euphoric mania and bipolar depression and for maintenance treatment of bipolar disorder (
+7,
+8). Clinicians, faced with increasingly large caseloads and fewer resources, may need additional supports to effectively make use of these evidence-based medications.
Soon after the introduction of lithium in the United States, lithium clinics were developed that organized care by using integrated teams of psychiatrists and medical paraprofessionals who implemented structured treatment protocols. These included standardized schedules for patient visits and use of symptom rating forms. Because much of the treatment protocols could be carried out by paraprofessionals under the supervision of psychiatrists, evidence-based care could be delivered to large numbers of patients at modest cost. Similar clinic models have been used to ensure the safe and effective use of clozapine.
In primary care settings, the rates and quality of depression care have also been improved by the use of multifaceted interventions that utilize nonphysicians to support evidence-based care by physicians. A designated care manager—usually a nurse or a social worker—provides patient education, monitors depressive symptoms with use of standardized rating scales, reminds patients of appointments and laboratory tests, assesses for side effects, provides feedback to the prescribing physician, and may provide short-term manualized psychotherapies. In these programs, primary care providers have easy access to evidence-based guidelines and psychiatric consultation. Both care managers and providers use computerized patient registries that track patients' progress and automatically remind providers of necessary follow-up.
Strategies borrowed from these models could be implemented in specialty mental health settings to improve the appropriate use of tricyclics, MAOIs, and lithium. The elements pertinent to supporting use of these agents include evidence-based protocols and active follow-up by clinical support staff. Organized patient education could provide added benefit by motivating patients to monitor symptoms and side effects and adhere to medication regimens and dietary restrictions. For psychiatrists in training, exposure to such systems of care could provide needed skills in the proper use of these medications.