The Dangers of Online Prescribing

The number of online services offering subscription-based psychiatric medication prescriptions has increased substantially in recent years. These services often promise quick access to psychiatric prescriptions while marketing themselves as an affordable option. However, there are several reasons to be wary of online prescribing services for psychiatric medication.

Three Reasons to Be Cautious of Online Prescribing Services

1. The Lack of Face-to-Face Care

Online prescribing services are absent of the benefits that come with face-to-face care. With face-to-face care, a psychiatric professional can observe non-verbal signs and symptoms that provide a more complete understanding of the best solutions and medications. Fidgeting, shifting, nervousness, signs of anxiety, and other physical indicators can be identified through traditional in-person care. Prescribing services that are entirely virutal, on the other hand, fail to catch these qualitative and often non-verbal signs.

Online prescription services also miss the ongoing assessment and evaluation necessary for extended and personalized care. Instead, they rely on brief questionnaires and online check-ins for information about the patient. This approach simply does not provide enough information to paint a complete picture of a person’s individual and complex mental health needs. Without a full in-person assessment or ongoing support, there’s an increased risk of misdiagnosis or missing other underlying conditions that could affect treatment.

Additionally, some psychiatric medications require in-person evaluation in order to be prescribed. Due to these DEA restrictions, an entirely virtual prescriber is limited to the medications they can prescribe. When looking at many of the online prescribing platforms, they often have around five medications that they offer for each set of symptoms. Psychiatric care is not “one size fits all,” so limiting the medications and available resources can cause roadblocks in providing effective care.

Telehealth is a helpful tool that can increase accessibility to care and boost convenience. However, there must be a balance. Psychiatric care should allow for what is best for the patient and their treatment plan. Allowing for a mix of in-person and virtual face-to-face care works well for many patients. Some people benefit from entirely in-person appointments or require additional monitoring that must be done in-office.

2. A Higher Financial Cost

While many online subscription services portray themselves as a cost-effective solution for getting psychiatric medication, the reality is that over time, they typically end up costing far more than traditional pharmacies and psychiatric treatment services. These services generally do not accept insurance for the cost of the subscription. They also often include recurring fees, increased prices for medications, and additional charges for services not covered in the subscription. These costs all add up quickly.

For example, a typical appointment with a psychiatrist or psychologist might be covered by insurance, and medication costs can be minimized by using conventional options available at local pharmacies. In contrast, subscription-based prescription services often bypass insurance. Instead, people seeking psychiatric care end up paying out-of-pocket. These services also often push branded medications over generic medications, which can significantly increase the final price of care. All of this leads to higher overall costs.

3. Risk of Overprescribing or Prescribing the Wrong Medications

For many people seeking psychiatric treatment, there are often solutions other than medication that can produce positive results. Lifestyle changes, implementing healthy habits, and other solutions can often be part of a comprehensive psychiatric care plan. It is common for a comprehensive treatment plan to include both medication and lifestyle modifications, along with support in following the plan.

However, online prescription services might rush to simply prescribe medication without exploring additional treatment solutions. This one-size-fits-all method can contribute to overprescribing or the use of medications that might not be ideal for the individual. It also lacks the ongoing opportunity to assess the medication response or adjust the treatment plan based on the results over time. The result can be unnecessary side effects or dependency on medications that could have been avoidable with in-person care.

The Benefits of Personalized Psychiatric Care

In contrast to online subscription-based medication services, in-person psychiatric care offers numerous important advantages tailored to each person’s unique experience. Key benefits of in-person psychiatric care over online-prescribing services include:

• A personal connection with a psychiatric professional
• The opportunity for non-verbal interaction and observation
• Ongoing support and care built around your unique needs
• Increased likelihood that insurance will help cover medications and services
• Personalized medication management and treatment plans
• Mental health services tailored for adult ADHD, anxiety disorders, mood disorders, and more – not just a “one-size fits all” approach

Get In-Person Psychiatric Care that Meets Your Mental Health Needs

If you’re looking for psychiatric care and medication management services, West End Consultation Group can help. Our psychiatric professionals offer personalized care and mental health support designed to meet your unique needs. Contact our office in St. Louis Park, MN, today to learn more.

Possible Steps To Take During The Critical Shortage of Stimulant Medications

For patients prescribed Adderall and other stimulant medications, it is no secret that the nationwide shortage of these medications has caused a strain on individuals who struggle to maintain focus without proper medication or have other debilitating symptoms. Five months into the shortage and government agencies, health organizations, industry experts and pharmacies agree that the current shortage shows no signs of slowing down.

Unprecedented Medication Shortages: The Root of The Issue

Most ADHD medications are categorized as controlled substances called central nervous system stimulants. Due to the frequent abuse of these medications, the Food and Drug Administration (FDA) and Drug Enforcement Administration (DEA) regulate the amount of pills a pharmacy can dispense. Because the DEA utilizes historical data to influence the amount of these medications that can be manufactured by regulating the quantity of restricted ingredients allocated to manufacturers, the spike in mental health diagnoses stemming from the Covid pandemic was met with an inadequate manufacturing supply. While the DEA can increase quotas for medication manufacturing if there is a legitimate demand, not all requests are accepted, and the looming threat of drug abuse can always contribute to increased regulations.

We are also facing industry-wide staffing shortages, leading to difficulties in how the shortage is handled once the medications are manufactured. Pharmacies are majorly understaffed, which limits our abilities to address the concerns and coordinate the medication refills. We are also experiencing widespread staffing issues with providers and clinical staff leaving the ones currently practicing unequipped to handle the influx of requests.

How West End Consultation Group is Working Through the Shortage

If Your Pharmacy is Out Of Stock

Reach out to nearby pharmacies to ask them if they have the Rx available. If it is available, contact your provider via the patient portal with the alternative pharmacy information.

If You are Unable to Find a Pharmacy With the Medication in Stock

Reach out to your provider via the patient portal and ask if there would be any possible alternatives that could be provided. This may not be possible without an appointment, but we will do our best to provide alternatives to your prescription.

Avoid Confusion at the Pharmacy

If possible, paper prescriptions can be provided to alleviate the stress of transferring prescriptions and waiting for a response.

Additional Medication Management Considerations

West End Consultation Group is dedicated to finding a solution to meet your needs. While the DEA hasn’t increased manufacturing quotas on Schedule II drugs, there are a number of routes you can take while waiting for a prescription refill.

• Request an Appointment With Us: There may be an alternative medication available for you to try, but this will require an appointment to discuss the options available.
• Be Persistent: Pharmacists can be reluctant to give out information on medication supply because these substances are prone to abuse. Pharmacists are also at the mercy of manufacturers, so you may be required to call every day in case a shipment comes.
• Optimize Your Pill Schedule: With the guidance of your prescribing physician, it’s possible to schedule doses on days that require a higher level of concentration. You should also always be aware of your supply and reach out to your pharmacies before you are out of medications in order to allow time to facilitate any changes that need to be made.

West End Consultation is Here to Help

We understand and emphasize the need for individuals to have access to their medication and mental health treatment resources. For patients experiencing difficulties filling prescriptions, please message your provider through the patient portal with the alternate pharmacy information and we will process requests within 48-72 hours.

Understanding how they work

By Marie Casey Olseth, MD

Many patients get referred to me after having tried multiple psychiatric medications, none of which provided effective relief of their symptoms. They are understandably frustrated and skeptical about seeing a new psychiatrist, let alone trying any new psychiatric medications.

The frustration may increase if they consult “Dr. Google” or ask non-medical professionals for information. Multiple factors must be considered before marking any decisions about prescribing psychiatric medications. That’s why I make it a priority to educate my patients on how I come to a decision about the medication- and the dosage- that I recommend. As a result, they feel more informed and more comfortable with the decision to start the medication.

Common Questions

The discussions are as varied and unique as the patients themselves, but some common themes do reoccur. Here are some examples.

“I already tried that medication and it didn’t work.”

In many cases, the patient was actually taking a psychiatric medication that would have been effective for the symptoms but had been prescribed at the incorrect dosage.

For example, one patient was recently referred to me after finding gabapentin ineffective in treating his anxiety. Further discussion revealed that he had been prescribed a dose that was sub-clinical- in other words, it should have worked, but he was not taking enough of it to be effective. He was skeptical of the recommendation to try gabapentin once again at an appropriate dose, but was later amazed at the relief it provided, essentially eliminating the formerly paralyzing impact of anxiety on his life. The correct dosage can make the difference in the effectiveness of some medications.

“2mg of Xanax everyday works fine. Why should I change it?”

Other referrals come from primary care physicians urging their patients to find safer alternatives to the higher-risk psychiatric medications they currently use. Many of these patients don’t want to eliminate the higher-risk medication- a controlled substance, for example- because they have developed an emotional attachment to and/or a dependency on the medication.

In many cases, the patient was initially prescribed the controlled substance with instructions to use it only “as needed” (sometimes written on the prescription pad or pill bottle label as PRN, for the Latin term pro re nata). The prescriber may have intended this to mean less than once each day, but, over time, some patients increase their intake to get more symptom relief, ultimately taking the medication multiple times daily.

Patients may not appreciate the many risks of certain medications and may not understand that their psychiatric symptoms could be managed with other, safer alternatives. I advise patients that, as psychiatrists, we have many tools in out medication toolbox to manage their symptoms. We draw upon our knowledge and experience to make recommendations regarding medications. Patients are often initially skeptical and nervous, but after they become comfortable with the recommendations and then transition to safer medications to manage their psychiatric symptoms, they are surprised at how effective the safer psychiatric medications are at managing their symptoms.

There are many examples of this, but using the Xanax case as an example, some patients who use Xanax multiple times each day are often surprised that their anxiety might be better controlled by some other medication. It was not until getting off Xanax that they realized how multiple doses contributed to daily discomfort and to intraday withdrawal symptoms as the effect of the medication wore off. Patients also tell me that their thinking was “foggy” while on Xanax, but that the medication we transitioned them to managed their anxiety without negative cognitive impacts.

As with any prescription medication, side effects may vary considerably from patient to patient. The treatment regimen that works perfectly for one individual may be ineffective for another, so it’s important to raise concerns with your provider.

“You are recommending two medications. I used to be on just one.”

A top priority in managing psychiatric conditions is to minimize “medication burden” – the negative impact that a drug causes on a person’s physical and cognitive health. Complications related to medication burden could be temporary, lasting only while the person takes the drug, or could result in cumulative, long-term effects.

The goal is to help patients manage their psychiatric condition with minimal medications.

Reducing medication burden often involves reducing the number of medications. Other times, it involves replacing one high-risk medication with two safer medications that, taken together, can manage the same symptoms.

Psychiatric medications as “training wheels”

Many patients want help, but do not want to take psychiatric medications. The goal is to help patients manage their psychiatric condition with minimal medications. Some psychiatric conditions are chronic and severe and do indeed require long-term use of medications. But many patients manage their psychiatric illness with a time-limited course of medications, using the drugs as “training wheels” to treat a condition while simultaneously attending regular therapy appointments to develop new skills. Ongoing therapy is similar to utilizing a personal trainer to motivate and train you, except that, in this case, the therapists work to optimize your mental health. The therapist coaches you on changing cognitive an behavioral patterns, moving from patterns that cause and reinforce psychiatric illness to patterns that promote optimal mental health.

I sometimes follow a 70/30 rule in prescribing, dosing the psychiatric medications to achieve 70 percent relief of the symptoms. This decreases the symptoms enough for a person to be comfortable enough and to have enough emotional strength to work on their symptoms in therapy. Eliminating all psychiatric symptoms with medications may remove incentives to regularly rehearse the skills and behaviors taught in therapy. For some patients, this 70/30 rule provides sufficient management of psychiatric symptoms without removing the incentive. With diligence to developing and utilizing skills taught in therapy, psychiatric medications may eventually be decreased.

How do these medications work?

Our understanding of mental illness and treatment is still evolving, as is our understanding of all illnesses and their treatments. What is known and understood regarding the brain processes of mental illness and the impact of psychiatric medications on brain chemistry is quite fascinating but may seem daunting to those outside the scientific and medical communities. I try to present some basic concepts about how medications can impact the brain before discussing the rationale of choosing one particular medication instead of another.

One approach is to compare the brain’s communication system to our personal communications with other people through emails. Our brain cells, or neurons, employ neurotransmitters (serotonin, dopamine and norepinephrine, to name a few) to communicate with other neurons, just as we use Hotmail, Gmail, or Yahoo to communicate with other people. Various psychiatric illnesses involve a disruption in these “brain emails.” The messages may not reach the intended target brain cells, or the incoming messages may overpower the neuron’s “inbox.” In either case, these disruptions can interfere with the brain’s normal mechanisms to manage anxiety, depression, stress, and other factors that affect our mental health.

Psychiatric medications can correct these disruptions in the brain’s messaging system. Some antidepressants, for example, may be used to increase the serotonin email communication between the neurons. Other psychiatric medications may optimize the dopamine or norepinephrine emails between brain cells. Various psychiatric medications with accomplish their “fix” of these email disruptions in different ways.

Summing up

Psychiatric medications can work effectively with the brain’s chemistry to manage and control symptoms and relieve suffering, but it’s critical to consider multiple factors in prescribing a particular medication, and to continue seeking alternatives if the first medication proves ineffective. These sample discussions underscore the need to help patients to understand how medications work and to engage them more fully in treatment decisions. It is an approach that my patients have come to value in seeking psychiatric care.

Mary Casey Olseth, MD, is a board-certified psychiatrist practicing at the West End Consultation Group in St. Louis Park.

Medical Disclaimer:

Please remember that all medical information provided in this post must be considered educational only.  This blog should not be relied upon as a medical judgement and does not replace a medical professional’s judgement about the appropriateness or risks of a procedure or condition for a given patient.  We will do our best to provide you with information that may help you make your own health care decisions. Please do not follow any instructions or information without first consulting with your physician or mental health provider.