A Rapid Review of “Low-Threshold” Psychiatric Medication Prescribing: Considerations for Street Medicine and Beyond
Abstract
Objective:
No widely accepted clinical guidelines, and scant directly applicable pragmatic research, are available to guide the prescription of psychiatric medications in “low-threshold” outpatient settings, such as street outreach, urgent care, and crisis care, as well as walk-in, shelter, and bridge and transition clinics. Providers frequently prescribe medications in these settings without patients’ having firm psychiatric diagnoses and without medical records to guide clinical decision making. Persons who receive medications in these settings often seek help voluntarily and intermittently for mental illness symptoms. However, because of structural and individual factors, such patients may not engage in longitudinal outpatient psychiatric care. The authors reviewed the literature on psychiatric medication prescribing in low-threshold settings and offer clinical considerations for such prescribing.
Methods:
The authors conducted a rapid literature review (N=2,215 abstracts), which was augmented with up-to-date clinical prescribing literature, the authors’ collective clinical experience, and DSM-5 section II diagnostic criteria to provide considerations for prescribing medications in low-threshold settings.
Results:
For individuals for whom diagnostic uncertainty is prominent, a symptom-based diagnostic and treatment approach may be best suited to weigh the risks and benefits of medication use in low-threshold settings. Practical considerations for treating patients with clinical presentations of psychosis and trauma, as well as mood, anxiety, and substance use disorders, in low-threshold settings are discussed.
Conclusions:
An urgent need exists to invest in pragmatic research and guideline development to delineate best-practice prescribing in low-threshold settings.
HIGHLIGHTS
“Low-threshold” outpatient prescribing settings, including street outreach and shelter clinics, are those in which a medication recipient’s psychiatric diagnosis may be unknown and collateral information may be unavailable at the time of prescribing.
No prescribing guidelines and little to no research are available to inform the use of most medications in low-threshold settings.
There is a need to invest in research and guideline development to delineate best-practice prescribing in low-threshold settings.
Throughout the 1990s and 2000s, psychopharmacologic development rapidly accelerated (1). Leading psychopharmacology manuals incorporated this medication armamentarium and offered detailed, evidence-based recommendations regarding medication dosages, routes, and adverse effects (2, 3). Professional consensus statements on psychoactive medication prescription were developed to represent the prevailing recommendations within the field of psychiatry (4–6). Despite these broad advances, guidelines for the practice of street psychiatry specifically, and prescribing in “low-threshold” outpatient settings more generally, remained largely obscure; this knowledge was most often gained and passed on through on-the-ground clinical work by practitioners (7).
Low-threshold medication prescribing practices were developed to treat people living in the community with serious mental illness, some of whom were homeless and unconnected to long-term outpatient psychiatric care (8–18). Theoretically, such practices enhance care equity. They provide voluntary psychiatric care in the form of prescription medications to disproportionately underresourced populations and structurally vulnerable persons, regardless of their ability to pay (19). In practice, low‐threshold-prescribing procedures work in conjunction with behavioral and other interventions, such as mobile and community-based outreach as well as care navigation and linkages, to increase access for hard-to-reach psychiatric patient populations.
Individuals receiving care in low‐threshold-prescribing settings often do not have definitive psychiatric diagnoses or known psychiatric histories. These individuals are often not actively engaged in longitudinal outpatient care because of factors such as personal hesitancy, distrust, previous negative interactions with the mental health system, insurance or cost barriers, mental illness and substance use symptomatologies, and systemic limitations in care access, including structural racism. Low-threshold program models include street medicine, urgent care, mobile crisis, crisis stabilization, and crisis residential treatment, as well as shelter, walk-in, and bridge and transition clinics. In these dynamic settings, prescribers might not have access to basic clinical information, including medical record documentation, laboratory tests, vital signs, and collateral information. Critical auxiliary support, including social work and nursing, might be limited or absent (20). Although similar prescribing principles may apply in some emergency department settings, because emergency departments can provide involuntary care and obtain medical workups, for the purposes of this discussion, they were not considered to be low threshold.
With state and local health systems focusing their efforts on acute and subacute psychiatric crisis care (21), and the recent national implementation of the 988 Suicide & Crisis Lifeline, psychiatrists and other psychiatric practitioners (i.e., nurse practitioners, physician assistants, and others) working in such services are increasingly providing medications to historically underserved and understudied individuals. In doing so, providers confront an array of prescribing dilemmas without evidence-based guidelines (22, 23). To illuminate what is known and to identify existing knowledge gaps, this review highlights key prescribing challenges in low-threshold settings and offers considerations for psychiatric medication prescribing within these settings.
Methods
We conducted a rapid literature review on prescribing practices in low-threshold settings. We limited the review to four major searchable databases (i.e., Google Scholar, PubMed [biomedical research], PsycINFO [psychological research], and Web of Science [science and technology research]). Searches were performed by combining terms from two groups, A and B. Each term in group A (street psychiatry psychiatric medication prescribing, street medicine psychiatric medication prescribing, nontraditional outpatient psychiatry psychiatric medication prescribing, low-threshold outpatient psychiatric medication prescribing, homeless psychiatric medication prescribing, bridge services psychiatric medication prescribing, urgent care psychiatric medication prescribing, and crisis care psychiatric medication prescribing) was combined with each term in group B (consensus statement, algorithm, tips, advice, guidelines, recommendations) to produce 48 unique search terms (e.g., “street psychiatry psychiatric medication prescribing consensus statement”). Each of these terms was used to search the four databases. General searches were conducted without restrictions on period or publication type. The first 20 abstracts, or as many abstracts as resulted from each search (range 0–20), were examined. In total, 2,215 abstracts were reviewed. Of these, two were directly relevant to the topic (22, 23). Neither of these two sources attempted a review of the relevant literature or commented in detail on the specifics of outpatient psychiatric medication prescribing in low-threshold settings.
We augmented our review with up-to-date literature on clinical prescribing standards. We used this literature and our collective clinical experience to offer specific considerations for prescribing medications in low-threshold settings. To develop these prescribing considerations, we used groupings based on DSM-5 section II diagnostic criteria and codes (“schizophrenia spectrum and other psychotic disorders,” “bipolar and related disorders,” “depressive disorders,” “anxiety disorders,” “trauma- and stressor-related disorders,” “substance-related and addictive disorders”) as starting points to identify five symptom clusters (psychosis, mood, anxiety, trauma, and substance use) commonly encountered in low-threshold settings. As further detailed in the Results section, we used symptom clusters in lieu of formal DSM-5 diagnoses to illustrate the common difficulty of establishing definitive diagnoses for individuals treated in these settings (24).
We then linked these symptom clusters to psychopharmacologic considerations. These considerations were derived from a review of comprehensive psychopharmacologic texts (2, 3) and the most recent professional society and government guidelines (25–27). Because scant research has been conducted with individuals in low-threshold settings, many of the psychopharmacologic considerations were by necessity derived from research on clinical medication efficacy in conventional outpatient and inpatient psychiatric practices. We explicitly called these statements “considerations,” rather than “recommendations,” to highlight the fact that little to no research on pragmatic prescribing exists for the use of most medications in low-threshold settings.
Informed consent was not required for this study because no human research subjects were involved in the generation of the literature review or prescribing considerations. Institutional review board approval was not required given the secondary nature of the research included in this analysis.
Results
Practical Prescribing Considerations by Symptom Cluster
For psychiatric providers, perhaps the most challenging aspect of prescribing in low-threshold settings is making a DSM-based psychiatric diagnosis to justify a prescribed medication. Individuals treated in low-threshold settings often do not have access to their psychiatric records. They may not have social support from friends, family, or others who may be able to provide meaningful collateral history. They may not tolerate the lengthy probing assessments required to establish a clear DSM-5 diagnosis (7). They may not recall or may not feel comfortable disclosing previous manic episodes or past traumas. Duration of symptoms may be difficult to elicit, and substance use may complicate the diagnostic picture. For some individuals, the clinician may be able to obtain past clinical information from public databases for Medicaid recipients, the electronic medical record used in the clinical setting (e.g., the Care Everywhere feature in Epic), summaries of previous clinic or hospital discharges, collateral history from a case manager or social support, or pharmacy records. In practice, however, no widely applicable survey or standard exists for solving such diagnostic dilemmas. Prescribers instead need to rely on their acumen in the moment and use sound clinical judgment to reasonably diagnose and safely treat these individuals.
For individuals with prominent diagnostic uncertainty, a symptom-based (i.e., psychosis, mood, anxiety, trauma, and substance use) diagnostic and treatment approach may therefore be the most reasonable way to weigh the risks and benefits of medication use (Table 1). Medications can be collaboratively chosen to maximize symptom relief while minimizing risks for harm. This approach is particularly suitable when the medication recipient may not be available for a follow-up visit and when obtaining blood work may be impractical. In effect, when initially prescribing to such recipients in low-threshold settings, a provider’s best assumption might be that no in-person or laboratory monitoring may be possible.
| Symptom cluster | First-line medication class | Alternative medications |
|---|---|---|
| Psychosis | SGA | FGA |
| Mood | SRI or SNRI (depressive mood symptoms); SGA (manic or mixed mood symptoms) | Mood stabilizer (manic or mixed symptoms) |
| Anxiety | SRI or SNRI | Hydroxyzine |
| Trauma | SRI or SNRI | Prazosin |
| Substance use disorders | ||
| Opioid dependence | Buprenorphine | Injectable naltrexone |
| Alcohol dependence | Naltrexone | Disulfiram |
TABLE 1. Summary of psychopharmacologic considerations for prescribing in “low-threshold” outpatient settings, by psychiatric symptom clustera
General Considerations
Across all symptom clusters encountered in low-threshold settings, a few factors should be considered when choosing medications. First, given the significant care barriers experienced by many individuals treated in low-threshold settings, these individuals are at high risk for missing doses and running out of medication. Thus, prescribing medications with withdrawal or discontinuation syndromes, in particular medications with short half-lives, might lead to distress and later reluctance to undergo further medication trials (22). Simple medication regimens (e.g., one medication with a moderate-to-long half-life and dosed once per day) might aid in adherence. Second, gastrointestinal adverse effects can be particularly troubling for persons without access to restrooms. Slower titration or avoidance of medications with potent gastrointestinal effects should be considered (22). Withdrawal symptoms, distressing gastrointestinal effects, or any other adverse medication-related effect could influence an individual’s willingness to follow up for further treatment. Third, medications requiring refrigeration or secure storage should not be prescribed to persons who do not have access to these amenities (28). Finally, factors such as limited financial means and lack of access to personal transportation can be barriers to acquiring medications from pharmacies. Ideally, low-threshold practitioners might develop partnerships with pharmacies that deliver medications to the clinic or to nonresidential settings. Treatment team members, including peers, outreach workers, community health workers, or navigators, could help by accompanying clients to the pharmacy or even by picking up medications from the pharmacy and delivering them to clients. If nothing else, providers should attempt to use nearby pharmacies that clients could reasonably access by foot or public transportation.
Psychotic Symptoms
A first symptom cluster to consider is psychosis, which may include symptoms such as hallucinations, delusions, and disorganized thinking and behavior. Second-generation antipsychotics (SGAs) are a reasonable medication class to use in treating individuals with psychosis in low-threshold settings. SGAs do not require routine or extensive laboratory monitoring when they are prescribed for short courses, although longer-term SGA use is associated with weight gain and risk for developing metabolic syndrome and type 2 diabetes mellitus (29). SGAs are preferred over first-generation antipsychotics (FGAs) because SGAs have a lower risk for inducing debilitating extrapyramidal symptoms that can impair movement (2). Because SGAs do not differ significantly from one another in efficacy for managing psychotic symptoms, patient choice as well as past responses, adverse effect profile, and cost should be paramount drivers for selecting an SGA (30). One adverse effect that warrants special consideration for individuals who sleep in unsafe spaces (such as shelters, outdoors, and others) is sedation. Individuals who are sedated may be unable to defend themselves from unpredictable interpersonal violence (7, 22, 28).
For individuals who have a known treatment history, have been seen several times at a given clinical site, and are amenable to injection medications, long-acting injectable antipsychotics (LAIs) may be appropriate for psychosis management. Expert consensus recommends a brief oral trial (between 4 and 14 days) of the antipsychotic before administering an LAI (31). In a large, prospective trial using a national database, LAIs reduced rehospitalization rates by 20%–30% relative to oral antipsychotic medications (32). Numerous other studies have shown benefits of SGA LAIs relative to oral agents in relapse prevention and rehospitalization rate reduction (33–35). Several studies have reported that LAIs can be particularly helpful for medication adherence for persons who are not housed (36–38).
Mood Symptoms
A second symptom cluster to consider is mood-related symptoms, which include mania, hypomania, depression, and mixed mood symptoms.
Mania and hypomania.
Given the risk for injury or death during manic episodes, individuals experiencing acute mania meeting DSM-5 criteria should almost always be referred to emergency psychiatric services rather than treated in a low-threshold setting. For individuals with a compelling history of mania or hypomania who are not in the midst of an acute episode but present to a low-threshold setting for medication support, SGAs have an advantage over lithium and most anticonvulsants in that they are not dosed based on blood level and thus do not require immediate or long-term laboratory follow-up.
SGAs are preferred for mood stabilization in low-threshold settings. However, if these medications prove inadequate, valproic acid could be carefully considered as an alternative in certain cases. That said, should valproic acid be prescribed, valproic acid levels and liver function should be monitored to ensure that the individual is not experiencing toxicity (39). Any person with the physiological possibility of pregnancy should receive a birth control test before starting valproic acid, and some form of birth control should be offered if valproic acid is prescribed. Lithium should likely be avoided in low-threshold settings. Lithium requires laboratory monitoring, has a narrow therapeutic index, and lithium toxicity can be lethal. Factors such as dehydration can quickly lead to high lithium blood levels, which can damage critical organ systems, such as the kidneys (40).
Depression.
For an individual who presents with depressed mood, it is essential to first screen for previous manic, hypomanic, or mixed mood symptoms that might suggest an underlying bipolar diathesis. If concern for a bipolar diathesis is low, an antidepressant is a logical first-line treatment for depressive symptoms. A serotonin reuptake inhibitor (SRI) or serotonin‐norepinephrine reuptake inhibitor (SNRI) would be an appropriate first choice (41). SRIs and SNRIs have relatively moderate adverse effect profiles and low risk of overdose death and do not require strict laboratory monitoring. These characteristics make them ideal medication classes to prescribe in low-threshold settings (41–43).
Bupropion may be a safe and effective antidepressant option for many individuals treated in low-threshold settings. Before prescribing bupropion, it is important to screen carefully for seizure history as well as alcohol and benzodiazepine use, which can increase the risk for seizures in withdrawal settings (44).
Mirtazapine and trazodone can be effective adjuncts for treatment of patients with depressive symptoms, particularly for insomnia. However, it is again worth considering dangers associated with the sedating effects of these medications, particularly for individuals who sleep in unsafe settings, who are at risk for unpredictable violence (7, 22, 28).
SRIs and SNRIs are preferred to tricyclic antidepressants because they have greater efficacy, lower discontinuation rates, and lower risk of overdose death (45, 46). Monoamine oxidase inhibitors (MAOIs) are best avoided in low-threshold settings because they increase the risk for life-threatening hypertensive crisis if rigid dietary restrictions are not followed (47). Risks such as serotonin syndrome are also inherent in initiating MAOIs in proximity to other recent and possibly unmonitored antidepressant trials (48). Finally, although the selegiline patch is a good antidepressant option for persons who have not responded to other medication classes or who are averse to oral medications, its high cost makes it likely impractical to use in low-threshold settings (49).
Mixed mood symptoms.
If an individual cannot provide a clear treatment history and past records are not available, a conservative approach to managing depression when bipolar disorder has not been ruled out might be to prescribe an SGA for its mood-stabilizing properties. Quetiapine, for example, has been shown to be an effective monotherapy for treating patients with major depressive disorder or bipolar depression (50, 51). It is worth noting, however, that quetiapine, like antidepressants, has a risk for precipitating phase change to a mixed state, hypomania, or mania (51, 52). This risk decreases with higher quetiapine doses, and at 600 mg per day, the risk is equivalent to the frequency of phase change with lithium (51). Again, because of this medication’s sedating effects, special consideration is warranted when prescribing quetiapine to individuals who sleep in unsafe settings.
Anxiety Symptoms
Anxiety is a third symptom cluster to consider among clients in low-threshold settings. According to professional treatment guidelines, the first-line treatment for generalized anxiety disorder is an SRI or SNRI (25). Even if a formal anxiety disorder diagnosis cannot be made, given the relative safety of SRI and SNRI medications, individuals who present with primary anxiety symptoms in the absence of acute substance use or evidence of a bipolar diathesis could benefit from these medications.
Additionally, given their rapid action and U.S. Food and Drug Administration approval for a variety of anxiety presentations, benzodiazepines could be considered in the treatment of unspecified anxiety. However, as we discuss below, the risks of prescribing benzodiazepines in low-threshold settings might outweigh potential benefits.
A final class of medications that might be considered for managing anxiety is antihistamines, such as hydroxyzine. These are non–dependence-forming agents that can be effective for treating individuals with acute anxiety (53). Again, providers should use caution when prescribing these sedating medications to individuals who sleep in potentially unsafe places.
Trauma-Related Symptoms
A fourth, and common, symptom cluster seen in low-threshold settings is trauma-related symptoms. Recent evidence raises questions about whether psychotherapy, the previous treatment standard, is more effective than medication in the treatment of individuals diagnosed as having posttraumatic stress disorder (PTSD) (54). In low-threshold settings, upfront medication prescription may be appropriate during phases of engagement and shared decision making regarding possible short- or long-term therapy initiation. According to professional treatment guidelines, first-line medication classes for PTSD are SRIs or venlafaxine (an SNRI) (26). As discussed above, SRIs and SNRIs have low risk profiles and do not require routine laboratory monitoring, making them suitable for use in low-threshold settings. Some evidence suggests that prazosin can effectively manage PTSD-associated nightmares. However, in a recent trial of combat veterans, prazosin did not alleviate distressing dreams or improve sleep quality (55). Current evidence recommends avoiding benzodiazepines in acute-trauma settings, given their lack of efficacy (56).
Substance Use Disorders
A final symptom cluster that is common in low-threshold settings involves illicit substance use.
Opioid use disorder.
Three core medications are used in the maintenance management of opioid use disorder: buprenorphine, methadone, and naltrexone (57). Buprenorphine is an effective, relatively safe, and easy-to-initiate outpatient treatment for opioid use disorder. Persons with this disorder who take buprenorphine are more likely than those who do not take it to remain in treatment (58). There is evidence to support the use of buprenorphine in low-threshold settings (59, 60). As a vital arm of the opioid overdose crisis, public health services are developing and implementing programs to treat individuals with opioid use disorder with buprenorphine in low-threshold settings. One example is the street overdose response team created by San Francisco’s Department of Public Health. This team works in conjunction with the street medicine team of the Department of Public Health to address the opioid crisis in San Francisco by delivering buprenorphine to high-risk housing sites and other locations (61). Of note, during the COVID-19 pandemic, telemedicine-enabled models have made buprenorphine even more accessible (62).
Under federal law, methadone for the treatment of persons with opioid use disorder can be dispensed only by treatment programs certified by the Substance Abuse and Mental Health Services Administration (27). Oral naltrexone is challenging to use for opioid use disorder because its effectiveness is dictated by adherence (57). Without regular monitoring clinic visits and additional supports, such as psychosocial substance use treatment, naltrexone is often ineffective in its oral form. Extended-release naltrexone—an injectable medication—may be the most effective way to use naltrexone in low-threshold settings. However, if individuals are physiologically dependent on opioids at the time of naltrexone injection, they will enter excruciating precipitated withdrawal. Given the potential difficulty in ensuring that individuals treated in low-threshold settings are not opioid dependent, dosing this medication could be precarious (57).
For all persons at risk for opioid overdose, naloxone—an opioid antagonist—should be prescribed for use in the event of an opioid overdose (63). Evidence suggests that intranasal naloxone is the most effective delivery method for use by untrained community members (64, 65).
Alcohol use disorder.
Three medications have extensive evidence bases for the maintenance treatment of alcohol use disorder: naltrexone, disulfiram, and acamprosate (66). Naltrexone is a reasonable first-line medication for routine maintenance management of alcohol use disorder given that it is generally safe and well tolerated. It can reduce heavy drinking even if an individual continues to drink while taking the medication (66). If the individual tolerates naltrexone and wishes to further curb alcohol use, the provider might offer assistance in accessing tailored substance use treatment.
Both disulfiram and acamprosate work to maintain abstinence from alcohol (66). In a singular low‐threshold-setting interview, assessing for abstinence preparedness might be challenging. Even if an individual is clearly dedicated to pursuing abstinence, it may be preferable to refer the individual to a detoxification or rehabilitation program rather than to prescribe these medications, particularly if it is unclear whether the individual has experienced life-threatening alcohol withdrawal in the past.
Benzodiazepine use disorder.
No well-established, evidence-based treatment is available for benzodiazepine use disorder. To avoid life-threatening withdrawal, some research recommends cross-titrating to a long-acting benzodiazepine (67). This approach would require prescribing a controlled substance, which might generally be avoided in low-threshold settings, as discussed below.
Stimulant use disorder.
To date, no medications have produced consistent clinical trial evidence for the management of stimulant use disorders (68). In low-threshold settings, it would be reasonable to address co-occurring substance use disorders or to aid persons with stimulant use disorders in accessing contingency management services. Of note, there is evidence for the use of antipsychotic medications to treat individuals with stimulant-induced psychosis (69, 70).
Discussion
Many open questions remain about how to prescribe psychiatric medications in low-threshold settings. In the following discussion, we aim to identify some foreseeable dilemmas around prescription duration, controlled substances, other high-risk medications, novel strategies to inform prescribing practices, and value-concordant care and research.
Prescription Duration
It is important to consider whether a given prescription dosage could increase the risk of death or serious injury in the setting of overdose. Various strategies, such as bubble-packing the medication, prescribing 7 days of the medication with refills, or, if legal and feasible, holding the prescription at the low-threshold site and dispensing a week’s worth of medication at a time, could reduce this risk for self-harm.
When considering how many pills or refills of a medication to dispense, prescribers must balance a range of factors, including promoting longitudinal treatment engagement, managing acute or subacute symptoms, or continuing medications an individual is currently taking. Each goal might dictate a unique time line for prescribing initial and subsequent medications. Limiting medication fills to 30 days with no refills could encourage treatment reengagement. Follow-up visits could be essential for monitoring medication responses and offering additional resources to patients. During these visits, providers could also address adverse effects that could interfere with treatment. Further considerations that may influence duration of prescriptions include, but are not limited to, availability of prescription drug–monitoring program records for cross-referencing, availability of collateral for verification of previous medication regimens, duration of use and tolerability of the current medication, medical risk of a given prescription to a specific recipient, risk for medication misuse or diversion, and cost of the medication. Ultimately, if a patient is well known to a low-threshold service provider, the prescriber may determine that refills can be reasonably and safely dispensed to the patient. Besides these timing considerations, it is important to concretely consider where patients might receive their next medication prescription, including but not limited to the current low-threshold setting, another low-threshold setting, or an established outpatient clinic to which they have been newly connected.
Although it may be tempting to assume that the prescriptions provided in low-threshold settings will serve as a bridge to more enduring, focused, and stable outpatient psychiatric care, significant risks arise if the medication recipient does not present for follow-up care and if medications become a “bridge to nowhere.” The greatest benefit that prescribers at low-threshold settings may provide in such instances is to be welcoming and empathic, establish a therapeutic and collaborative relationship, prescribe safe and tolerable medications for symptom relief, encourage repeat visits, and work to connect the individual to additional resources. The practitioner’s goal might remain connecting the patient to long-term outpatient care even when larger social factors might nullify this possibility in practice.
Controlled Substances
Deciding whether to prescribe controlled substances in low-threshold settings can be a challenging dilemma for treatment providers. Benzodiazepines are helpful in the acute treatment of individuals with anxiety, and stimulants can manage functionally impairing attentional conditions. However, with the exception of buprenorphine, which has an evidence base for use in low-threshold settings (59, 60, 62, 71), we feel that prescription of a controlled medication requires an established treatment relationship that is grounded in mutual trust. This relationship helps ensure that these medications, for which the risks for misuse are severe, are being taken safely. The low-threshold setting often does not allow for implementation of such safeguards. Therefore, we caution against routinely prescribing controlled substances other than buprenorphine. However, many individuals served in low-threshold settings could benefit immensely from appropriately and safely prescribed controlled substances. Perhaps the most effective role prescribers could play in such situations is to help these individuals engage with longitudinal care resources in their communities, where these medications can be safely prescribed. It is also worth noting that the COVID-19 pandemic has made access to some of these additional resources more challenging. This reduced access may justify more liberal prescription of take-home supplies of controlled substances for management of substance use disorders, while the crisis persists (72).
Other High-Risk Medications: Lithium, Tricyclic Antidepressants, Clozapine
If a psychiatric medication has a narrow therapeutic index, has high toxicity risk, or requires frequent laboratory monitoring or other regular and ongoing evaluations, it may not be appropriate to prescribe the medication in a low-threshold setting. Such medications include lithium, tricyclic antidepressants, and clozapine. Safely prescribing these medications, even for short courses, is inherently difficult for individuals with an uncertain ability to follow up with treatment, unknown medication adherence, and unknown medical histories. The exception may be for individuals who received one of these medications in a previous setting (e.g., during a recent inpatient admission) and who need a short course of the medication to bridge them to an outpatient visit with a known provider. Still, risks and benefits should be weighed carefully, and collateral history would likely be needed to ensure safe and appropriate medication prescription. For example, a provider in a low-threshold setting might prescribe sufficient clozapine to prevent a patient from missing two consecutive days of the medication, which would necessitate medication retitration, a high-risk scenario. To prescribe clozapine, the provider would need to confirm the medication dose and timing of the last dose, meet federal Clozapine Risk Evaluation and Mitigation Strategy program requirements (including providing an absolute neutrophil count, in accordance with the patient’s monitoring frequency), locate a pharmacy to fill the medication, and ensure that the patient is reconnected with their long-term outpatient psychiatric clinic for subsequent clozapine refills.
Novel Strategies to Inform Prescribing Practices in Low-Threshold Settings
To gain a more complete picture of a patient’s social situation, with the hope that this broader understanding will lead to safer and more targeted psychiatric medication prescribing, prescribers could consider using the Structural Vulnerability Assessment Tool (73). Derived from social-scientific studies on social determinants of health, this structured interview guide assesses an individual’s access to the social, economic, and health resources that may affect their experience with medical and mental health services. In a low-threshold setting, the provider may modify assessment questions to specifically evaluate access to social services, proximity to mental health emergency centers, and presence of a social support system that could assist with medication management.
History of previous medication trials can also be difficult to ascertain in low-threshold settings. Individuals may be distrustful of medications if they have had adverse effects from the medications in the past. Tools such as the Psychiatric Medication History (74) might aid prescribers in gathering information about past medication experiences in a structured and prompt manner. If an individual cannot recall past medications, the provider might also contact one or more pharmacies at which the individual has previously filled prescriptions or reference shared electronic medical records (e.g., Care Everywhere) to obtain this information.
Value-Concordant Care and Research
Finally, and importantly, providing value-concordant care—or care aligned with recipients’ treatment goals and preferences—is a major challenge for psychiatric medication prescribing in low-threshold settings. This issue is especially poignant when medication preferences differ between medication recipients and providers. In such situations, to achieve value-concordant care, prescriber attention to the subjective experiences of medication recipients is crucial (75). Individuals may be hesitant or unwilling to take psychiatric medications or to participate in research conducted in these settings. The reasons for this resistance are complex and range from personal experiences to broader cultural influences. Special consideration should be made to the disempowering experiences that many individuals have had with the health care system. Indeed, these experiences have been documented in clinical research, where individuals treated in low-threshold settings have received inappropriate psychotropic medication prescriptions at high rates (23). Such experiences can foster understandable distrust toward medical institutions and their practices (76). For these reasons, it is crucial that informed‐consent discussions with patients regarding the risks, benefits, and alternatives to each recommended medication be open and honest. The decision to prescribe medications must not be made lightly. Shared decision making can help providers explore care recipients’ values and work toward a consensus for agreeable goals of care (77, 78). These goals could ultimately include more intensive and frequent psychiatric care, including regular engagement in behavioral or other therapies. Notably, prioritization of medication recipients’ preferences has been associated with longer and more stable treatment relationships with providers (79).
Limitations
Our analysis had several limitations. First, given the rapid, unsystematic nature of the literature review, it is possible that we missed studies specific to prescribing in low-threshold outpatient psychiatric settings. Still, we identified only two immediately applicable sources after a review of >2,000 abstracts obtained with an extensive list of search terms, indicating an evident dearth of literature on this topic. Second, because little evidence-based work has been published on the prescription of most medications in low-threshold settings, the data on these prescribing practices have, by default, largely been extrapolated from research conducted in more clinical and controlled settings. We used the term “considerations” rather than “recommendations” throughout this review to avoid overstating our conclusions, given the lack of published and applicable research in this area. Finally, although these medication-specific considerations were literature based, a comprehensive review of all clinical psychopharmacologic literature for each medication was beyond the scope of this study. For practice standards, we referenced well-established and comprehensive psychopharmacology texts and up-to-date professional society and government prescribing guidelines. We assume that readers of this review who are prescribers are knowledgeable about the indications, uses, benefits, and common and serious adverse effects of the medications they prescribe. We encourage prescribers to consult comprehensive prescribing resources for complete details on all medications.
Conclusions
With the growth of crisis services across the United States, including the recent national implementation of the 988 Suicide & Crisis Lifeline, voluntary outpatient psychiatric medication administration in “low-threshold” settings—settings in which a medication recipient’s definitive psychiatric diagnosis may be unknown and collateral information may be unavailable at the time of prescribing—is becoming increasingly common. This trend is especially true for persons with diagnoses of serious mental illness who receive psychiatric prescriptions from street-, shelter-, and walk-in–based providers. Here, we conducted a rapid review of prescribing practices and offered detailed practical considerations for providers treating psychosis, mood, anxiety, trauma, and substance use symptom clusters in such settings. To our knowledge, this is the first attempt at an academic review of such practices.
We reemphasize that pragmatic research is desperately needed to translate evidence-based, clinical data on psychiatric medication efficacy to real-world effectiveness. We call on influential psychiatric professional organizations, including the American Psychiatric Association and American Association for Community Psychiatry, to develop and publish guidelines that inform clinical prescribing, shared decision making, and considerations about malpractice and liability in low-threshold settings. Although both research and guideline development will be difficult and complex work, the potential payoffs in improved health and safety from evidence-based standards are enormous. Such investments could also advance the health equity mission on which many low-threshold settings are based: to provide psychopharmacological care to persons without sufficient health care access due to systemic and personal circumstances.
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