Medication Management and Finding a Qualified Psychiatrist
Polypharmacy risk, what a real medication review looks like, how to track outcomes and side effects, and the five questions to bring to every psychiatry visit. The list the appointment is built around.
5
Five questions to ask at every visit. Bring them written down. Lead with them. They turn a fifteen-minute med check into a real medication review.
Name, dose, prescriber, start date, indication, and current evidence of benefit. One page. Bring to every visit.
Behavior log, side-effect checklist, sleep and appetite log. Three months of data per medication change before deciding it works.
Is each med still needed? Is each med working? Side effects? Interactions? What is the deprescribing plan if any?
Write the one-page medication audit tonight.
One page. Columns: medication name, dose, prescriber, start date, indication, current evidence of benefit, observed side effects, last reviewed. Every psychotropic medication. Every other prescription. Every over-the-counter the adult takes regularly. The audit is the brief for every future psychiatry visit. Most families discover, in writing the audit, that at least one medication has been on the list for years without anyone having asked whether it is still needed.
The polypharmacy default
Autistic adults with co-occurring intellectual disability are prescribed multiple psychotropic medications at substantially elevated rates compared with the general population. Medications accumulate across years and prescribers, often without anyone asking whether each is still needed.
Medication audit, one page
Name, dose, prescriber, start date, indication, evidence of benefit, side effects. Every visit. Update before the appointment. The audit is what makes a medication review actually happen.
The fifteen-minute med check
Standard psychiatry visits for stable patients are fifteen minutes. Without preparation, the visit is a refill. With the five-question list, the visit becomes a real review.
Trial period per change
Most medication changes need three months of stable observation before efficacy can be judged. Avoid stacking changes; one change, three months, then decide.
Side-effect surveillance
Weight, metabolic labs (glucose, lipids, A1c), tardive movements, sedation, GI symptoms, mood change. The clinician orders the labs; the family tracks the observable signs.
Deprescribing is real
A good psychiatrist proposes deprescribing when a medication has stopped working or was never working. The willingness to deprescribe is a quality signal worth screening for.
The five questions to ask every visit
When we changed psychiatrists, the new one spent the first appointment doing nothing but reviewing the medication list. Our son had been on seven psychotropic medications across four prescribers. Two had been added during a hospitalization in 2014 and never reviewed since. By the end of the first year with the new psychiatrist, we were down to three medications and our son was clearly more himself. The hospital meds had been doing nothing for ten years. Nobody had asked.
Finding and working with a qualified psychiatrist
- Identify candidate psychiatrists trained in dual diagnosis (NADD, DM-ID-2) or with documented developmental disabilities experience.
- Schedule a comprehensive medication review (not a standard fifteen-minute med check) as the first appointment.
- Bring the one-page medication audit. Lead the visit with the audit.
- Ask the five questions. Document the answers.
- Calendar quarterly med-check appointments with the audit updated before each one.
- One-page medication audit complete
- Dual-diagnosis psychiatrist identified
- Comprehensive review appointment scheduled
- Five questions written down for the visit
- Side-effect log started
- Metabolic lab schedule documented
- Quarterly review on calendar
Psychiatry that does not deprescribe is psychiatry that only adds. The capacity to remove medications is a qualification, not a luxury.
The full story · For readers who want context
When Bruce and his wife changed psychiatrists in 2023, after twelve years with a clinician who saw their son for fifteen minutes once a quarter and renewed the same prescriptions every time, the new psychiatrist did something Bruce had never seen any clinician do. She spent the entire first appointment, ninety minutes, doing nothing but reviewing the medication list. She made Bruce read aloud each of the seven psychotropic medications their son was taking, the dose, the prescriber, the year it started, and the original indication. She asked Bruce when each medication had last been formally evaluated for benefit. Bruce did not know. The chart did not show. Two of the seven medications had been started during a 2014 inpatient hospitalization, when their son was twenty-one, and had never been reviewed since. They had simply been refilled by successive prescribers across ten years. The new psychiatrist began a methodical taper of one medication at a time, three months between changes, with detailed family logging at each step. By the end of the first year with her, their son was on three medications instead of seven. He was sleeping better. His baseline mood was visibly improved. The two 2014 hospital medications had been doing nothing useful for a decade. Nobody had asked. That is what a real medication review looks like, and it is the difference between psychiatric care and prescription refilling.
The polypharmacy problem in plain language.
Here is what they will not tell you on the front of any psychiatric practice website. Adults with autism and co-occurring intellectual or developmental disability are prescribed multiple psychotropic medications at substantially higher rates than the general adult population. The pattern has been documented in administrative claims data, Medicaid utilization studies, and clinical surveys for decades. Aman, Lakhdir, Doan, Tsiouris, and others have published extensively on the prevalence and clinical correlates. Specific estimates vary by study and population, but the direction is consistent: this population sees more medications, accumulates them across years and across prescribers, and frequently lacks systematic review of whether each medication is still needed.
The accumulation rarely happens through anyone’s bad intent. It happens through the structure of the system. A medication is started during a crisis. The crisis stabilizes. The medication remains. A new clinician inherits the patient, sees a stable patient on stable medications, and continues the regimen. Years pass. A new symptom emerges. A new medication is added. The old medications continue because nobody is sure they are not contributing to the stability. The list grows. The cumulative side-effect burden grows. The therapeutic effect of the original medications becomes impossible to assess because too many variables are in play. This is the polypharmacy default.
What a real medication review looks like.
A real medication review is not a fifteen-minute appointment. It is a structured exercise that takes ninety minutes to two hours and starts with a written, current, complete medication list. The clinician reviews each medication individually. For each one, the clinician asks: what was the original indication? Is that indication still active? What is the documented evidence the medication is helping right now (not when it started)? What side effects has the patient experienced? What interactions exist with other medications on the list? What would happen if this medication were tapered?
If the indication is no longer active, or there is no documented current benefit, or the side-effect burden outweighs the benefit, the medication becomes a candidate for tapering. The clinician proposes a taper plan. The plan is structured: one medication at a time, three-month observation between changes, detailed family logging throughout. Stable patients on multiple medications can often be reduced by one or two medications per year without destabilization. Some patients cannot be reduced; the review still happens, and the rationale for continuing each medication gets documented for the next review.
The five questions to bring to every visit.
Quarterly fifteen-minute med checks are the standard format for stable patients. Without preparation, the visit becomes a refill conversation. With the five-question list, the visit becomes a real review compressed into fifteen minutes. Bring the questions written down. Hand the list to the clinician at the start of the visit. Lead with them.
One: Is each medication still needed? For each medication on the list, the family asks the clinician to articulate the current indication. If the clinician cannot, the medication is a candidate for review.
Two: Is each medication working? Working means there is observable evidence of benefit, not just stability. Stability could mean the medication is helping, or it could mean the medication is irrelevant and the patient is stable for other reasons. The family brings the behavior log; the clinician helps interpret whether the medication can be credited.
Three: What side effects has the family observed? Side effects include the obvious (sedation, weight gain, GI symptoms) and the easily-missed (subtle cognitive slowing, mood blunting, movement disorders, metabolic changes shown on labs). The family is often the best source for the easily-missed.
Four: Have interactions been checked? When any new medication is prescribed by any clinician (psychiatrist, primary care, neurologist, GI), the full medication list should be screened for interactions. Most electronic health records do automated interaction checking, but the family should still ask, particularly when prescribers do not share an EHR.
Five: What is the deprescribing plan? For any medication that has been on the list for years without recent review, the family asks for a tapering plan or a written rationale for continuing it. The willingness to engage this question, even when the answer is “we are not deprescribing right now and here is why,” is the marker of good practice.
Tracking outcomes and side effects.
The family carries the data-collection burden between visits. The minimum dataset: a daily behavior log that captures sleep, appetite, mood indicators, activity level, any concerning behaviors; a side-effect checklist updated weekly; weight tracked monthly; metabolic labs ordered by the prescriber at standard intervals (typically every six months for patients on second-generation antipsychotics; annually for most other psychotropics).
For antipsychotic medications specifically, the AIMS (Abnormal Involuntary Movement Scale) exam should be performed by a clinician every six months to screen for tardive dyskinesia. Many psychiatrists do not do this routinely. Ask. Request it. Document the result. Tardive dyskinesia is a serious, often irreversible side effect of long-term antipsychotic use, and early detection is the only mitigation available.
Finding a qualified psychiatrist.
Dual-diagnosis training, defined as expertise in psychiatric care for adults with intellectual and developmental disabilities, is the key qualification. The National Association for the Dually Diagnosed (NADD) certifies clinicians and maintains a directory. The Diagnostic Manual-Intellectual Disability (DM-ID-2) is the major reference text for this clinical area; clinicians familiar with it are typically qualified. Several academic medical centers maintain developmental disabilities psychiatry programs (the Greater Cincinnati Medical Home Network for Adults with Developmental Disabilities, the Penn Medicine Adult Developmental Disabilities Health Program, Boston Children’s Hospital adult continuation services, others).
Screening candidate psychiatrists: ask about NADD affiliation, DM-ID-2 familiarity, dual-diagnosis training, and clinical caseload (the clinician who has fifty patients with developmental disabilities has more pattern recognition than the one who has three). Ask how often they reduce medications. Ask whether they collaborate with primary care, neurology, and other specialists. Ask how they handle communication when the patient cannot reliably self-report symptoms.
The hospitalization legacy problem.
Many medications that families discover have been on the list for years without review trace back to a specific hospitalization where the medication was added under acute circumstances. The hospital adds the medication. The patient stabilizes. The patient discharges. Outpatient prescribers continue what the hospital started. Years pass. The original acute indication is long resolved, but the medication continues because nobody is sure removing it is safe.
Bruce’s son’s case is typical. Two medications added during a 2014 inpatient stay. Stable patient discharged. Outpatient psychiatrist continued the medications because the discharge plan said so. New outpatient psychiatrist in 2018 continued them because the prior psychiatrist had. By the time Bruce’s family switched in 2023, the hospital medications had nine years of inertia behind them. The new psychiatrist’s value was breaking the inertia. The breaking of inertia is the deprescribing skill.
What other states make easier.
Several state Medicaid programs include dedicated developmental disabilities psychiatry consultation lines that primary care physicians and outpatient psychiatrists can call for case consultation (Pennsylvania, Massachusetts, Wisconsin, Vermont have particularly active programs). The Massachusetts Child Psychiatry Access Program model has been adapted in several states for adults with developmental disabilities. Several academic medical centers run continuing-medical-education programs for community psychiatrists on dual-diagnosis care. NADD’s annual conferences and training resources are the largest national-level training infrastructure for this clinical area. Michigan funds psychiatric services through Community Mental Health and managed care, but with less coordinated state-level dual-diagnosis consultation infrastructure than peer states. Other states made different choices. Michigan didn’t, fully.
Your assignment this week.
Tonight: write the one-page medication audit. Every medication. Every detail. This week: identify two candidate dual-diagnosis psychiatrists. Within thirty days: schedule a comprehensive review appointment (not a fifteen-minute med check) with the most promising candidate. Bring the audit. Bring the five questions. Within ninety days: a clearer picture of what is working, what is not, and what can be tapered. None of this guarantees fewer medications. All of it guarantees a clearer view of whether the current medications are doing what they should. Other states make this clearer with consultation infrastructure. Michigan didn’t, fully. Now we know what we are fighting. Together.