You Just Inherited a Patient With a Messy Regimen
Now What???
DISCLAIMER
The content in this Substack post is for informational and entertainment purposes only and is not intended to serve as medical advice. The views expressed are those of the author and should not be considered definitive or authoritative. Do not rely solely on the information in this post to guide patient care. Always consult a licensed healthcare professional before making decisions about diagnosis, treatment, or medication.
Let’s set the scene. You open the chart and find a patient on five different psych meds. Three of them seem to do the same thing. Or there is lithium, an SSRI, low dose seroquel and lamotrigine, with no clear mood history present. Or the pt is prescribed depakote and olanzapine, for depression. You notice the patient is sedated and emotionally blunted, sleeping 12 to 14 hours per day, and gaining weight rapidly.
Yet the patient feels fine. They “feel stable.” They believe the meds are necessary. No insight into sedation. No concern for long-term side effects. Just fear of change and a strong attachment to the current regimen. Plus, they loved their old provider.
You don’t have established rapport. You are missing context. But you are now responsible for this managing this patient and regimen. What to do??
Step One: Protect the Relationship
“No one cares how much you know, unless they know how much you care.”
Even if your gut says the regimen needs adjusting, you will likely be perceived as unnecessarily rocking the boat if you attempt to make changes without an established foundation of trust.
This is not the moment to show off your pharmacology knowledge. This is the moment to listen, build rapport, and start gathering clinical history.
You might say:
“It looks like you’ve been on these medications for a long time. Can you tell me the story of how they were added?”
“Do you feel like each one helps? Or are there any you have wondered about stopping?”
“Has anyone ever talked to you about simplifying things or reviewing whether these are still the best choices?”
You are creating space for conversation. You are showing respect. You are planting seeds for future changes, even if none happen today.
Step Two: Stratify the Risk
Before you change anything, assess the risk of doing nothing. Some regimens are inefficient. Others are dangerous.
Ask yourself:
Is the patient taking two antipsychotics with no documented rationale?
Is there a QTc-prolonging med with no EKG?
Is the lithium level overdue or supratherapeutic?
Is there metabolic syndrome, active sedation, or cognitive blunting?
Is there evidence of benzodiazepine dependence or misuse?
If there are high-risk elements, you may need to prioritize labs, vitals, or collateral before altering medications. Safety comes first. If the risk is low, you can take a slower approach and focus on building buy-in.
Step Three: Chart Like It Will Be Read in Court
You may not be able to clean up the regimen right away. That is normal. But you should always document that you noticed the complexity and took thoughtful steps.
Examples:
“Patient on legacy outpatient regimen. Reports stability and expresses reluctance to change medications at this time.”
“Medication review conducted. Discussed risks of polypharmacy and monitoring needs. Patient open to gradual adjustments in future visits.”
“Noted concurrent antipsychotics without clear indication. No acute safety concerns today. Will continue to assess response and monitor side effects.”
Use objective data when available. Document weight, BMI, blood pressure, sedation level, or PHQ-9. Order labs like A1c, CMP, lithium, or EKG if indicated. This strengthens your notes and opens the door for future conversations.
Step Four: Go for the Lowest-Hanging Fruit
You do not need to fix everything today. You just need a starting point.
Ask yourself:
Is there a med the patient already dislikes or forgets to take?
Can you reduce the dose of something causing fatigue?
Can you simplify two overlapping meds into one cleaner option?
Can you taper something very slowly to test how it feels?
You are not chasing perfection. You are chasing trust, tolerability, and progress. Even one small change builds momentum.
Step Five: Play the Long Game
In outpatient psychiatry, the biggest success is often not a perfect regimen. It is continuity of care and a working alliance.
Patients who feel heard are more likely to come back. Patients who trust you are more likely to accept changes later. You do not have to deconstruct the entire regimen in one visit. You just have to stay curious, stay cautious, and stay connected.
The Bottom Line
Inheriting a messy regimen is an opportunity to practice thoughtful, relational psychiatry. Start with trust. Use data to guide decisions. Document with clarity. And remember, lasting change rarely happens all at once.