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Article Excerpt
Research from a variety of sources demonstrates that psychotropic medications have induced a number of unanticipated physiological and psychological client reactions. Although a great deal of literature is published concerning potential expected side effects from psychotropic medications, little is understood regarding other unexpected reactions that may cause significant client discomfort. These unanticipated psychotropic reactions may be considered as effects that may be rare and therefore not accounted for in randomized clinical drug trials. Like any medication, psychotropic medications do not produce the same effect in everyone. Some people may respond better to one medication than another. Mental health counselors are advised to be aware that some unexpected reactions can be important in determining client outcomes. In this article, we discuss the client's right to be informed about unanticipated side-effects of their medication regimen and the ethical question as to how much information to give clients.
********** Treatment of diagnosable mental health disorders with psychotropic medications can be problematic. While some mental health professionals propose that psychotropic medications have little or no therapeutic value, and in certain cases may produce damaging side effects (Breggin & Cohen, 2000; Glasser, 2003; Glenmullen, 2001), others recommend caution in the use of psychotropic medications and stress that side effects cannot be predicted (Burns, 1999; Ingersoll, Bauer, & Burns, 2004). Still other professionals suggest that mental health counselors who do not refer for psychotropic medication evaluation as an adjunct treatment to mental health counseling may risk unethical practice (Buelow, Hebert, & Buelow, 2000; King & Anderson, 2004). Regardless of the position taken, few advocates discuss the unanticipated reactions that clients may have to psychotropic medications. While some clients experience annoying expected side effects, other clients may experience completely unanticipated effects, and still others may experience no known side effects. Variables such as age, sex, body size, body chemistry, physical illnesses, drug interactions, diet, and habits such as smoking can influence the medication effect. These unanticipated reactions are rare and they are not usually accounted for in randomized clinical drug trials conducted by pharmaceutical companies. More common side effects, which are discovered during these trials, are normally conveyed on drug warning labels issued by the U.S. Food and Drug Administration.
Furthermore, when clients take multiple psychotropic medications or other prescription medications, there is a possibility that their body's unique chemical biology may create symptomatology that cannot otherwise be accounted for. If unanticipated effects do occur, clients may incorrectly believe they are suffering from an additional unrelated physiological or psychological malady. This may lead prescribing physicians to presume that these unexpected symptoms are evidence of a new medical condition that requires further assessment and perhaps additional medication treatment. Alternatively, family members, mental health counselors, and others may be tempted to dismiss clients' symptomatology as psychosomatic presentations. These issues can be challenging for mental health counselors who may be the first to hear of their clients' unanticipated reactions (King & Anderson, 2004; Sansone, Gaither, & Rytwinski, 2004). Moreover, the ethical issues surrounding unanticipated medication reactions can be crucial to client well-being. Mental health counselors would do well to systematically and ethically address the issues of unanticipated effects from psychotropic medications. This begins with a basic understanding of psychopharmacological effects.
PSYCHOPHARMACOLOGY AND THE MENTAL HEALTH COUNSELOR
Essential Knowledge
Education of basic psychopharmacology is of "paramount importance" (Scovel, Christensen, & England, 2002) to competent and ethical mental health practice (King & Anderson, 2004). Ingersoll and Rak (2006) explain that codes of ethics advise mental health counselors to be "knowledgeable about all treatment options that clients may encounter" (p. 48) and ethical guidelines for mental health counselors mandate "knowledge of relevant scientific and professional information related to the services they render, and recognize the need for ongoing education" (American Mental Health Counselors Association [AMHCA], 2000, Principle 7). Psychopharmacology is one of these scientific treatment options. Basic and on going knowledge of scientific developments related to psychopharmacology is essential because "the interface of mind and brain, psychology and biology, and pharmacotherapy and psychotherapy is the cutting edge of neuroscience in our new millennium" (Gabbard & Kay, 2001, p. 1961). Specifically,
The brain has emerged as the central focus for studies of mental health and mental illness. New scientific disciplines, technologies, and insights have begun to weave a seamless picture of the way in which the brain mediates the influence of biological, psychological, and social factors on human thought, behavior, and emotion in health and in illness. (Satcher, 2000, p. 7)
Mental health counselors are further advised to receive graduate-level training to identify "basic classifications, indications, and contraindications of commonly prescribed psychopharmacological medications so that appropriate referrals can be made for medication evaluations and identifying effects and side effects of such medications" (Council for Accreditation of Counseling and Related Educational Programs [CACREP], 2001, p. 90; emphasis added). When given permission by their clients, mental health counselors can report unusual or significantly disturbing effects to their clients' prescribing physicians.
Collaborative Treatment
With the escalating influence of managed care, the practice of employing a psychiatrist or other physician to prescribe psychotropic medication while a mental health professional, (e.g., psychologist, social worker, or mental health counselor) provides psychotherapy is becoming a standard for treating mental health disorders (Gabbard & Kay, 2001; Glick 2004). The literature refers to this approach as split treatment, collaborative treatment, concurrent care, or shared treatment (Beitman, Blinder, Thase, & Safer, 2003; Bradley, 1999; Meyer & Simon, 1999). When this approach is used, the prescribing physician typically conducts a brief 15-minute medication management session three or four times a year and a mental health counselor meets with the client in weekly or biweekly counseling sessions. Of course, this split treatment approach does not take away responsibility from the prescribing physician, but rather creates an advantageous collaborative relationship between the client, the mental health counselor, and the client's physician to maximize treatment adherence and effectiveness (Bentley & Walsh, 2000; Diamond, 2002; Himle, 2001; Meyer & Simon, 1999; Sansone, Gaither, & Rytwinski, 2004).
In this split treatment approach, mental health counselors who have frequent contact with their clients (Sansone, Gaither, & Rytwinski, 2004) are in a prime position to become aware of potential negative psychotropic side effects (CACREE 2001; Faiver, Eisengart, & Colonna, 2000). In addition to self-reports by their clients, counselors can routinely inquire about how the client is responding to medications and record changes in reactions in case notes or case conceptualization software. With the client's approval, mental health counselors can and should report significant findings to prescribing physicians (Ingersoll & Rak, 2006; King & Anderson, 2004).
Empirical research demonstrates the reality of enhanced client treatment outcomes when counselors and prescribing physicians work together. For example, Katon et al. (1996) found that a multifaceted model for the treatment of major depression, founded on client education and a two-way relationship between mental health professionals and prescribing physicians, consistently resulted in improved medication adherence, increased client satisfaction with depression care, and greater cost-effectiveness of treatment compared to usual care by primary physicians alone. This example suggests that "although medication side effects, drug interactions, and prescription refills are medical, a patient's worsening depressive symptoms fall into both the therapeutic and the pharmacologic realm" (Meyer & Simon, 1999, p. 244).
Counselor Roles
Bentley and Walsh (2000) elaborated on the specific roles that mental health counselors can take in identifying effects and side effects of psychotropic medications. In particular, mental health counselors may serve the role of (a) assistant to the physician: supporting recommendations of medication use; (b) consultant/collaborator: performing preliminary screenings to determine clients' possible needs for medication, making referrals to physicians, and regularly consulting with the physician and client; (c) advocate: assisting clients and family members in relating to physicians; (d) monitor: evaluating positive and negative effects of the medication regimen; (e) educator: providing clients and family members with information relevant to medication usage; and/or (f) researcher: using case reports and research designs to study how medications affect client behavior, how the medications interact with other interventions, and how to maintain collaborative relationships among the treatment team. Finally, Ingersoll and Rak (2006) believe "an important component of supervising mental health clinicians is discussing medications that clients are...
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