How Are Prescribing Decisions Made?

Many factors affect medication prescribing, including pharmaceutical industry influences, academic detailing interventions, efforts to educate providers, personal experience with a medication or class of medications, and patient requests. Research has shown that in the absence of scientific data, providers may develop rules of thumb for choosing medications or depend on familiarity with medications. For individual providers, the extent to which prescribing is evidence based or appropriately targeted is largely unknown.

In 2009 the Association of American Medical Colleges (AAMC) made recommendations that incorporated 25 principles of conservative prescribing practices. Among these were suggestions that providers seek nondrug alternatives as a first step rather than a last resort, learn to use fewer medications and use them well, start patients on only one medication at a time, avoid rushing to use new medications, and think about short- and longer-term implications of treatment. The principles were designed to help providers become more effective lifetime prescribers—an important task and a tall order. We do not know whether or how these and similar recommendations influence prescribing overall or how they affect individual providers, patients, and disorders or use of specific medications, but these would be interesting areas to examine.

Given the high cost and substantial health impact of many psychotropic medications, it is important to understand provider characteristics associated with prescribing patterns and to determine where the quality of care can be improved. In a study reported in this issue, Huskamp and colleagues took advantage of a unique data resource to identify provider characteristics associated with the adoption of new antipsychotics. Their work is timely in light of several policy initiatives. These include increased access to prescription medications under the Affordable Care Act (including new coverage for the uninsured and closure of the Medicare Part D doughnut hole) and the Mini-Sentinel pilot program sponsored by the U.S. Food and Drug Administration, which aims to conduct pharmacosurveillance to monitor safety of prescription medications.

Mental health services research often focuses on increasing access and adherence to medications. But there is also a need to understand longer-term prescribing patterns and influences. A substantial number of patients take psychotropic medications continuously for years. Therefore, appropriate prescribing is vitally important, including patient-provider communication regarding initial and ongoing need for medication treatment that accounts for associated risks and benefits. Thus understanding factors that influence provider treatment choices is essential. Future work should delve deeper into provider and patient characteristics associated with medication choice; factors associated with switches and augmentation; the extent, frequency, and nature of reevaluation of treatment need; and whether and how to discontinue treatment.