New York State Psychiatric Institute and Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Erickson, Ehrie, Wainberg, Dixon); Psychiatry Residency Spokane, Providence Sacred Heart Medical Center, Spokane, Washington (Murray); Division of Medical Ethics, Weill Cornell Medical College, New York City (Dougherty); Department of Psychiatry and Behavioral Sciences, University of California, and San Francisco Department of Public Health, San Francisco (Goldman).
Psychiatr Serv. 2023 Mar 1;74(3):282-291. doi: 10.1176/appi.ps.20220196. Epub 2022 Aug 30.
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.
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 section II diagnostic criteria to provide considerations for prescribing medications in low-threshold settings.
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.
An urgent need exists to invest in pragmatic research and guideline development to delineate best-practice prescribing in low-threshold settings.
在“低门槛”门诊环境中，如街头外展、紧急护理和危机护理，以及随到随诊、收容所、桥梁和过渡诊所，没有广泛接受的临床指南，也几乎没有直接适用的实用研究来指导精神科药物的处方。在这些环境中，提供者经常在没有患者明确的精神科诊断和没有医疗记录来指导临床决策的情况下开具药物。在这些环境中接受药物治疗的人通常会因精神疾病症状而自愿间歇性寻求帮助。然而，由于结构性和个体因素，这些患者可能不会参与纵向门诊精神科护理。作者回顾了低门槛环境中精神科药物处方的文献，并为这种处方提供了临床考虑。
作者进行了快速文献综述（N=2215 篇摘要），并结合最新的临床处方文献、作者的集体临床经验和第二部分诊断标准，为低门槛环境中的药物处方提供了考虑因素。
对于那些诊断不确定性突出的个体，基于症状的诊断和治疗方法可能最适合权衡低门槛环境中药物使用的风险和益处。讨论了在低门槛环境中治疗有精神病和创伤表现以及情绪、焦虑和物质使用障碍的患者的实际考虑因素。
迫切需要投资于实用研究和指南制定，以划定低门槛环境中的最佳实践处方。
