Training 

Frontline Staff

MedTEAM

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

www.samhsa.gov

Training 

Frontline Staff

MedTEAM

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services
Acknowledgments

This document was prepared for the Substance Abuse and Mental Health Services Administration 

(SAMHSA) by the New Hampshire-Dartmouth Psychiatric Research Center under contract 

number 280-00-8049 and Westat under contract number 270-03-6005, with SAMHSA, U.S. 

Department of Health and Human Services (HHS). Pamela Fischer, Ph.D., and Crystal Blyler, 

Ph.D., served as SAMHSA Government Project Officers.

Disclaimer

The views, opinions, and content of this publication are those of the authors and contributors 

and do not necessarily reflect the views, opinions, or policies of the Center for Mental Health 

Services (CMHS), SAMHSA, or HHS.

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or copied without permission from SAMHSA. Citation of the source is appreciated. However, 

this publication may not be reproduced or distributed for a fee without the specific, written 

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Recommended Citation

Substance Abuse and Mental Health Services Administration. MedTEAM: Training Frontline Staff. 

HHS Pub. No. SMA-10-4548, Rockville, MD: Center for Mental Health Services, Substance Abuse 

and Mental Health Services Administration, U.S. Department of Health and Human Services, 2010.

Originating Office

Center for Mental Health Services

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Rockville, MD 20857

HHS Publication No. SMA-10-4548

Printed 2010
Training Frontline Staff

Training Frontline Staff is intended to help mental health 

authorities, agency administrators, and program leaders 

think through and develop training to teach the principles, 

processes, and skills necessary to deliver effective Medication 

Treatment, Evaluation, and Management (MedTEAM) services. 

This booklet includes information about developing the 

following types of training:

 New documentation practices;

 Ongoing training on medications; and

 Integrating outcome measures into clinical assessments.

MedTEAM

For references, see the booklet, The Evidence.
This KIT is part of a series of Evidence-Based Practices KITs created 

by the Center for Mental Health Services, Substance Abuse and 

Mental Health Services Administration, U.S. Department of Health 

and Human Services.

This booklet is part of the MedTEAM KIT that includes a DVD, 

CD-ROM, and seven booklets:

How to Use the Evidence-Based Practices KITs

Getting Started with Evidence-Based Practices

Building Your Program

Training Frontline Staff

Evaluating Your Program

The Evidence

Using Multimedia to Introduce Your EBP
What’s in Training Frontline Staff

How To Use This Booklet ......................................... A

Prepare program-specific information ...................................B

Prepare agency-specific information ......................................B

Visit an existing team ..........................................................C

Recruit a consultant .............................................................C

Cross-train ..........................................................................C

Module 1: New Documentation Practices .....................1

Why provide documentation training? ..................................2

Who should attend? ............................................................2

What information should be conveyed? ................................2

How should training be structured? ......................................3

Module 2: Ongoing Training on Medications ................1

Develop treatment guidelines or algorithms ..........................2

Keep up with scientific breakthroughs ...................................5

Develop ongoing training ....................................................7

Module 3: Integrating Outcome Measures into 

Clinical Assessments ..................................1

Identify outcome measures ..................................................2

Train staff ...........................................................................3

MedTEAM

Training Frontline Staff 

How To Use This Booklet

Training Frontline Staff helps mental 

health authorities, agency administrators, 

and program leaders think through and 

develop training to teach staff the 

principles, processes, and skills necessary 

to deliver effective Medication 

Treatment, Evaluation, and Management 

(MedTEAM) services.

Review this booklet along with the 

Introductory Video (English and Spanish 

versions) and Practice Demonstration

Video on the DVD in this KIT.

To make the content easy to manage, we 

divided the booklet into three modules:

The Three Modules in 

Training Frontline Staff

1 New documentation practices

2 Ongoing training on medications

3 Integrating outcome measures 

into clinical assessments

Training Frontline Staff A 
Since being part of a team is an essential part 

of MedTEAM, we recommend that you conduct 

group training rather than simply giving 

MedTEAM staff materials to read on their own.

We have found that practitioners prefer to read 

training materials and then discuss them with 

colleagues as a group. Working through training 

materials as a group creates an opportunity to 

discuss and master the practice principles and skills 

that are essential to effective MedTEAM practice.

Prepare program-specific information

As outlined in this booklet, prepare to give 

MedTEAM staff information about MedTEAM 

policies and procedures. These include the following:

	Assessment forms and procedures;

	Treatment forms and procedures;

	Criteria upon which the program’s fidelity to 

the MedTEAM model will be assessed; and

	Outcomes that will be monitored.

You will find sample forms in Building Your Program

and Evaluating Your Program in this KIT.

Prepare agency-specific information

You should also develop a plan to train MedTEAM 

staff about other policies and procedures that may 

be relevant to the agency in which MedTEAM 

operates. Depending on state, local, and agency 

policies, a number of considerations can affect 

availability of medications, procedures for prescribing 

them, and documentation of consumer education 

and adverse events. Some common examples 

include the following:

	Medication procurement: MedTEAM staff 

should be aware of policies related to accessing 

medications such as formulary restrictions 

and lack of or restricted insurance coverage.

	Prior approval: MedTEAM staff should 

be aware of procedures and documentation 

requirements related to obtaining prior approval 

for medications and medication visits.

	Informed consent: MedTEAM staff should 

receive training on how to share information 

about the risks and benefits of specific 

medications, ascertain consumers’ 

understanding of key information, and 

document their consent for treatment. 

Training should also include privacy and 

confidentiality policies related to sharing 

information with third parties such as treatment 

providers in outside agencies, general medical 

providers, and families or other supporters.

	Incident reporting: MedTEAM staff must 

know how to report adverse events, including 

to the U.S. Food and Drug Administration 

(FDA) or drug manufacturer when necessary. 

Training should also include information about 

what to do if staff know about illegal activity, 

threats of harm to self or others, and suspected 

abuse and neglect.

B Training Frontline Staff
Training Frontline Staff C

Visit an existing team

After staff members participate in MedTEAM 

trainings, we suggest that they observe an 

experienced, high-fidelity MedTEAM program. 

If MedTEAM staff are familiar with the 

MedTEAM model before their visit, the visit 

will be more productive. Rather than having to 

take time to explain the basics, the host program 

will be able to show the new MedTEAM staff 

how to apply the basics in a real-world setting.

Recruit a consultant

Ensuring that staff follow the MedTEAM 

evidence-based model can be challenging. It 

entails facilitating a team development process, 

applying what MedTEAM staff members have just 

learned about MedTEAM in their own clinical 

work with consumers, and offering ongoing 

feedback through clinical supervision.

It is very easy to stray from the MedTEAM model 

and do something similar to but not quite the 

same as MedTEAM. Sometimes this happens 

because MedTEAM staff believe they are 

diligently following the MedTEAM model, but 

they miss some of the more subtle aspects of it. 

In other cases, MedTEAM starts well, but as 

more consumers are admitted to the program 

and pressure mounts, MedTEAM staff reverts 

to older, more familiar ways of working.

To ensure that your MedTEAM staff follows 

the MedTEAM model, work with an experienced 

consultant throughout the first year of operation. 

A consultant can provide ongoing telephone 

and in-person support to help you with your 

challenging leadership role.

Cross-train

It is important that staff throughout your agency 

develops a basic understanding of MedTEAM. 

Cross-training will ensure that other staff 

members support the work that the MedTEAM 

staff undertakes.

As discussed in Building Your Program, we also 

recommend that you use these materials to train 

members of your MedTEAM advisory committee. 

The more information that advisory group members 

have about MedTEAM, the better they will be able 

to support MedTEAM and its mission.

Training is also an opportunity for MedTEAM staff 

and advisory group members to become familiar 

with one another. Make sure that the advisory 

group members and MedTEAM staff introduce 

themselves and that they are familiar with one 

another’s roles.

To help you conduct MedTEAM training, 

we include these multimedia materials in 

the MedTEAM KIT:

	Introductory PowerPoint presentation;

	Sample brochure; and

	Introductory Video.

Once trained, you or your MedTEAM staff will 

be able to use these materials to present routine, 

inservice seminars to ensure that all staff members 

within the agency are familiar with MedTEAM.

Training Frontline Staff 

Module 1: New Documentation Practices

One of the core elements of MedTEAM is ensuring that documentation gives 

MedTEAM staff members the information they need for medication decisions 

at the time of the medication visits. Typically, as agencies put MedTEAM into 

practice, documentation forms and procedures for collecting core information 

change. This module describes the benefits of providing documentation training, 

who should attend, and the types of information that support MedTEAM staff 

in mastering new documentation practices.

Effective medication treatment depends 

on two types of information:

	Information about consumers; and 

	Information about medications.

This module focuses on collecting and 

documenting consumer information. 

It assumes that you have updated your

documentation and developed procedures 

outlining when, how, and by whom the 

information will be collected.

For more information including sample 

documentation forms, see Building Your 

Program in this KIT.

New Documentation Practices 1 Module 1
Module 1 2 New Documentation Practices

Why provide documentation training?

Documentation training is a vital element 

for effective medication treatment. MedTEAM 

staff must know about the elements of effective 

documentation and where information can 

be found in the medical record.

Changes in procedures will also change the 

types of tasks that staff complete. Staff must 

understand the rationale for these changes 

and new work expectations.

Who should attend?

Documentation training should involve everyone 

who documents medication information in the 

medical record. It is important to adequately 

inform everyone who will be affected by changes in 

documentation about the reasons for such changes.

Carefully consider the roles of each staff member 

when deciding who will attend this training. 

Documentation training is a good opportunity 

to ensure that all staff members are in agreement 

about the types of information that should be 

documented, the reasoning behind it, and how 

staff is expected to work together to accomplish 

this goal.

What information should be conveyed?

A basic principle of MedTEAM is that, if 

information about consumers is important enough 

to influence treatment decisions, then it is important 

enough to record. Training should emphasize that 

good documentation means capturing enough 

information from each medication visit so that 

another prescriber can read the medical record 

and understand the treatment decisions.

Start your documentation training by articulating 

the mental health system’s or agency’s goal for 

implementing MedTEAM. Provide reasons for 

putting the evidence-based practice in place. 

Consider using the Introductory Video on 

the DVD in this KIT to give an overview 

of MedTEAM. If staff members believe that 

MedTEAM can help them improve medication 

treatment, they will be much more inclined 

to welcome these changes.

Introduce new procedures

Some of the procedures for MedTEAM may 

be new for your agency. For example, while some 

agencies rely solely on prescribers to provide 

medication treatment, MedTEAM has found that 

it is more effective to manage medications using 

a team approach. It is important to discuss these 

changes with your MedTEAM staff. Explain the 

rationale for using a team approach, involving 

consumers, and requiring supervision.
New Documentation Practices 3 Module 1

Introduce new staff roles

Training should also address the responsibilities 

of each MedTEAM staff member in medication 

management. A MedTEAM staff member can 

fill out certain sections of your MedTEAM 

documentation forms, such as weight, scale scores, 

and recent medication history before consumers 

see the prescriber. The shared responsibility model 

for medication management can generate valuable 

information for the prescriber to address problem 

areas in more depth while seeing consumers, 

instead of just eliciting basic information during 

the meeting.

During the training, share information about staff 

roles and responsibilities. Providing background 

and rationale for MedTEAM is likely to increase 

staff support for these changes. For more information 

about establishing staffing criteria, see Building 

Your Program in this KIT.

Review new forms and instructions 

One way of ensuring that documents are 

done correctly, by the designated people, is to 

incorporate instructions into the actual document. 

For example, for each data element, you can 

list the job title of the responsible person (case 

manager, nurse, prescriber, etc.). In addition, 

in paper documents, you can place the form on 

the front of each page while keeping instructions 

for filling out the form on the back of the page. 

In electronic medical records, you can include 

information icons that contain instructions on 

each item when users click on the icon.

Use your new documentation training as a 

venue to review and refine your new forms and 

instructions for completing them. Refining the 

forms and procedures as a group can increase 

staff’s commitment to implementing MedTEAM.

How should training be structured?

The training can be easy and straightforward. 

Convene two to four sessions of group training.

One option is to structure your training around 

reviewing the MedTEAM fidelity scales as a way 

of describing the evidence-based model. Present 

the results of your agency’s baseline fidelity 

assessment and generate discussions for how 

to introduce changes in response to those results.

A second option is to conduct a hands-on training 

whereby MedTEAM staff complete exercises 

to become familiar with new forms (paper or 

electronic) and procedures. Such training helps 

orient staff about who collects what information 

and where it is documented.

A helpful training exercise that you may use is to 

have trainees fill out the new MedTEAM form as 

they think it should be filled out. Then review the 

forms for discrepancies and discuss the differences 

as a group.

Another option is to structure your documentation 

training around reviewing and discussing case 

examples. On the next few pages are some 

examples that you may use to show staff how 

MedTEAM documentation practices can improve 

medication management.
Module 1 4 New Documentation Practices

Case Example 1: Clinic Self-Assessment

The Southside clinic conducted its first MedTEAM 

fidelity assessment using the organizational and 

prescriber fidelity scales. After the assessment, 

the MedTEAM staff and advisory committee 

met to discuss the results.

The assessment showed areas where the clinic was 

already providing services that were consistent with the 

evidence-based model. For example, current medications 

were consistently documented and medication doses 

were often within the recommended range.

The assessment also indicated areas where medication 

management could be improved. For example, the 

medical record review showed poor documentation 

during intake or admissions. Many sections of the 

forms or, at times, the entire form were incomplete.

MedTEAM staff and advisory committee members 

discussed the assessment results. Staff pointed out 

that the current forms are very long and detailed, 

with most sections requiring them to enter free text. 

Furthermore, the time allotted for initial visits is 

insufficient to obtain and record all the information.

The assessment also showed that information about 

past medication and family history was frequently 

missing from the medical records. While the forms 

have sections for this information, little to no 

information was provided in these sections.

Discussion

How can the clinic use the information from 

the MedTEAM fidelity assessment to improve 

medication management?

While there is no single correct answer to this 

question, here are a few ideas.

The MedTEAM advisory committee commends 

staff members on the areas in which they are 

doing well and focuses on improving the clinic’s 

documentation forms. The MedTEAM staff and 

advisory committee examine the forms and realize 

that much of the information requested can be 

gathered using checklists.

They also conclude that the form gathers some 

information that is not very useful and does not 

relate to the consumers they serve. The medical 

records director and chief medical officer agree 

to streamline the form and bring it back to 

the committee.

After discussing the fidelity assessment results, 

the MedTEAM staff and advisory committee 

have a picture of the quality of the medication 

management provided at their clinic. They 

prioritize changes to the documentation and place 

a new emphasis on gathering past medication and 

family histories.
New Documentation Practices 5 Module 1

Case Example 2: Medication Visit upon Intake (or Admissions) 

Dr. Roberts works in a busy community mental health 

agency. Typical consumer visits are 30 minutes for 

intake visits and 15 minutes for followup visits.

Today, Dr. Roberts has an intake visit with a new 

consumer, Manuel. Based on the medical records 

Dr. Roberts received from Manuel’s previous 

mental health provider, he has a history 

of paranoid schizophrenia.

Manuel’s prior records include information about the 

last 10 years of his care. Dr. Roberts is able to quickly 

find his diagnoses from a discharge summary of 

Manuel’s last hospitalization.

This summary also provides a rough estimate of the 

number of lifetime hospitalizations, summary of 

course of illness, and age of the onset of Manuel’s 

illness. Dr. Roberts lacks information about the 

number of hospitalizations in the last year or past 5 

years, which could give a better picture of the impact 

of Manuel’s disease on his recent functioning.

The past medication history gives Dr. Roberts minimal 

information. The history contains only the names of 

medications Manuel has taken. While this is helpful, 

vital elements are lacking, including highest dose, 

duration of treatment with each medication, and 

responses to each medication.

This poor documentation of past medical history leaves 

Dr. Roberts uncertain about how to proceed with 

Manuel’s treatment. Unfortunately, due to his current 

symptomatology, Manuel cannot reliably help fill 

in these gaps. Dr. Roberts does not know if any or 

all of these medication trials were adequate in terms 

of dose or duration, so she may inadvertently use 

a medication that previously gave Manuel little help, 

or she may overlook a medication that did not receive 

an adequate trial in the past.

Discussion

How does the information that Dr. Roberts has 

compare with the information that MedTEAM 

recommends collecting and documenting? 

How could Dr. Roberts ensure that she has 

access to needed information?

While there is no single correct answer to this 

question, here are a few ideas.

Using standardized documentation forms that 

capture needed information would have given 

Dr. Roberts a sound basis for making medication 

decisions at this intake visit.

MedTEAM recommends collecting 

and documenting this information

	Diagnoses

	Symptoms and severity

	Illness history (including age of onset, 

hospitalizations, and suicide attempts)

	Past medication history (dose, duration, 

interactions, tolerability, and response)

	Current medications (dose, duration, 

interactions, tolerability, and response)

	Assessment of the effectiveness of current 

medications and any plans for future 

medication changes

	Current medication adherence

	Current side effects and treatments 

for them

	Current consumer functioning

	Consumer preferences and goals

	Contact information for previous providers
Module 1 6 New Documentation Practices

Although this information may be available, 

the inability to access it when needed makes 

it difficult for Dr. Roberts to provide effective 

medication treatment.

To ensure that Dr. Roberts has the needed 

information at the time of the medication visits, 

MedTEAM staff could do the following:

	Review the documentation before the 

appointment date;

	Ask consumers for contact information for 

their current pharmacy and follow up on 

missing information;

	Ask consumers for contact information for their 

past providers and follow up on missing 

information; and

	Ask consumer to bring in current medication 

bottles and a list of current medications (both 

psychiatric and nonpsychiatric).
New Documentation Practices 7 Module 1

Case Example 3: Treatment-Refractory Consumers

Chris is reviewing a medical record to determine 

whether a consumer’s schizophrenia is refractory 

to treatment. The agency has never required an 

annual update or review. Consequently, to conduct 

a comprehensive medication review, Chris reviews 

5 years worth of Progress Notes.

Chris finds that the consumer has been treated with 

the following medications:

	Haloperidol—20 mg/day for 2 years;

	Risperidone—6 mg/day for 7 months; and 

	Quetiapine—800 mg/day for the last 4 months.

The consumer continues to be symptomatic despite 

adhering to medication as verified by pill counts.

Based on the evidence, Chris determines that the 

illness is treatment-refractory because two or more 

antipsychotic trials of adequate dose and duration 

have failed to relieve the symptoms. He finds that the 

consumer has not been given a trial of clozapine, even 

though current evidence supports a trial of clozapine 

for treatment-refractory schizophrenia.

Discussion

How does Chris’ comprehensive medication review 

support effective medication management? How 

could MedTEAM facilitate this process?

While there is no single correct answer to this 

question, here are a few ideas.

In this case, the treating prescriber had been seeing 

the consumer for only 4 months and knew that the 

consumer had taken multiple medications, 

but information about what had worked and 

to what degree was not readily accessible. Chris’ 

comprehensive medication review provided 

clear evidence on which to base a diagnosis 

of treatment-refractory illness. Armed with 

this information, the treating prescriber and 

the consumer agree on a trial of clozapine, which 

dramatically improves the consumer’s psychotic 

symptoms and quality of life.

Treatment-refractory illness can be difficult 

to determine if a comprehensive medication 

summary is unavailable. It often takes searching 

much of the medical record and then using clinical 

judgment to make this assessment.

MedTEAM facilitates this process by clearly 

documenting the following information for each 

medication prescribed in the past:

	Dose;

	Duration;

	Response;

	Rationale for medication changes;

	Desired outcomes; and 

	Rating method.

The rating method establishes a plan to guide 

decisions. For example, the plan may be to 

increase medication dose or change medications 

if symptoms are not improved by a specific time 

period. Access to this type of clear information 

would have saved Chris a good deal of time. 

Chris would not have had to read through 5 

years of Progress Notes.

MedTEAM also recommends conducting an 

annual update or review. By completing an annual 

review using MedTEAM documentation forms, 

MedTEAM staff would have been able to diagnose 

the illness as treatment-refractory earlier.
Module 1 8 New Documentation Practices

Case Example 4: Integration of Psychiatric and Medical Care

Jamie is reviewing medical records using the 

MedTEAM Fidelity Scales. As she reviews the record 

of a consumer who was diagnosed with schizoaffective 

disorder, she notes that he is being treated with 

an atypical antipsychotic (olanzapine) and a mood 

stabilizer (divalproex sodium). He has taken this 

regimen for 8 months with good results.

Jamie notes that the prescriber is monitoring side 

effects, such as tardive dyskinesia; extrapyramidal 

symptoms; and elevated blood glucose, lipids, 

and weight. She finds that the consumer’s weight 

is taken at each visit. Two brief rating scales, the 

Abnormal Involuntary Movement Scale (AIMS) to 

monitor tardive dyskinesia and the Simpson-Angus 

Scale (SAS) to monitor extrapyramidal symptoms, 

were conducted when the olanzapine was started 

and then every 6 months after that.

The consumer’s blood glucose and lipids were taken 

when the olanzapine was started. He has gained 12 

pounds since starting the current medication regimen 

and the blood glucose and lipids were slightly 

elevated at baseline but were not measured again 

until 8 months later. These recent laboratory values 

show that his fasting blood glucose is elevated to 134 

mg/dL, low-density lipoprotein (LDL) cholesterol has 

elevated to 190 mg/dL, and high-density lipoprotein 

(HDL) cholesterol has decreased to 32 mg/dL. 

The consumer was switched to olanzapine because 

he experienced extrapyramidal symptoms on 

risperidone. He showed no signs of tardive dyskinesia 

at baseline initiation of olanzapine, but did have some 

extrapyramidal symptoms, specifically, hand tremor. 

The consumer had been prescribed benztropine 

3 months before starting olanzapine and has been 

on it for 11 months.

Two months ago, the prescriber performed another 

AIMS and SAS. No side effects of tardive dyskinesia 

or extrapyramidal symptoms were present. The 

prescriber informed the consumer of the ongoing 

risks of obesity and weight gain and their relationship 

to long-term risks of cardiovascular disease and 

diabetes mellitus if the current treatment continues. 

The prescriber noted that the consumer said he 

wanted to stay on olanzapine because, “This is the 

best medication I have ever been on. This is the first 

time in a long time that I have not been bothered 

by the voices.”

Discussion

Which side effects did the prescriber effectively 

monitor and treat? Which side effects could have 

been monitored and treated more effectively? 

How could a team approach help in this process?

While there is no single correct answer to these 

questions, here are a few ideas.

Jamie found that weight, tardive dyskinesia, and 

extrapyramidal symptoms were being monitored 

regularly. She found that blood glucose and lipids 

were not being followed regularly—just once at 

baseline and then 8 months later. The consumer is 

still being prescribed benztropine for extrapyramidal 

symptoms, which are no longer present.

Jamie’s review highlights a common problem 

in mental health systems that are not integrated 

with other medical care. Often basic monitoring 

is performed, sometimes only initially, but then 

medical issues are not properly addressed because 

they are not psychiatric symptoms per se.
New Documentation Practices 9 Module 1

One way that MedTEAM helps with this process 

is to develop a relationship with the consumer’s 

primary care provider to ensure the MedTEAM 

staff know the following:

	Medications prescribed;

	Symptoms and side effects that are being 

monitored; and

	Interventions that are provided.

If prescribers are uncomfortable prescribing 

nonpsychiatric medications or taking the lead 

on interventions involving nonpsychiatric medical 

issues, then they must ensure that the consumer 

is treated and regularly monitored by another 

provider who can address these issues and remain 

informed of the consumer’s progress. With the 

consumer’s agreement, the prescriber can also 

keep nonpsychiatric providers informed of the 

care that they are providing.

For a more in-depth discussion on collaborating 

with nonpsychiatric providers to ensure routine 

physical health monitoring, particularly for 

consumers taking second-generation antipsychotic 

medications, see Treatment Guidelines referenced 

in Module 2 of this booklet and The Evidence in 

this KIT.
Module 1 10 New Documentation Practices

Case Example 5: Access to Hospital Records

Working in a walk-in clinic, Dr. Murphy saw Gerald 

who missed his last two appointments with his treating 

prescriber. During this time, Gerald ran out of his 

medication and subsequently was admitted to 

the hospital.

Gerald tells Dr. Murphy that they changed his 

medications in the hospital, but he cannot remember 

the names of the new medications.

Discussion

What would you do if you were Dr. Murphy?

While there is no single correct answer to this 

question, here are a few ideas.

The timely receipt of consumer-related information 

from other treatment facilities is a particularly 

vexing problem. Prescribers often face this situation 

and commonly ask the consumer to wait as they 

(or another staff member) call the hospital to request 

a fax copy of the consumer’s discharge summary.

In MedTEAM, agencies develop a systematic 

plan to prevent this situation from occurring. 

For example, agency and hospital administrators 

collaborate to develop access to shared electronic 

medical records.

If Dr. Murphy had access to a shared electronic 

medical record, she could quickly see what Gerald 

is taking and avoid delays waiting for faxed copies 

of medical records.

Developing clear procedures for sharing medical 

records between facilities allows prescribers to 

be more efficient and more confident in situations 

such as Gerald’s.
New Documentation Practices 11 Module 1

Case Example 6: Treatment Team Meetings 

Treatment team meetings occur weekly at the Maple 

Oaks Mental Health Center. Members of the treatment 

team are able to share information about consumers 

they have seen over the past week.

Today, Roxanne, the team’s supported employment 

specialist, shares some very important information 

about Catherine, a consumer who has schizophrenia. 

Catherine has been employed at a local craft store 

for 3 years. She is very hard working and has been 

one of the store’s most dependable employees.

However, over the past week or so, Catherine has not 

been performing as well at work. She has reported 

to work late a few times and always seems to be tired. 

Both problems are unusual for Catherine and they 

seem to be frustrating her a great deal.

Catherine’s prescriber, Dr. Ruiz, informs the team that 

Catherine has recently started a new antipsychotic 

medication. Dr. Ruiz called Catherine a few days after 

she started the medication and Catherine stated 

everything was going well at the time.

Dr. Ruiz also asked Catherine to call if she had any 

questions or if she experienced any side effects, but 

Dr. Ruiz had not received any calls from Catherine.

Discussion

How can treatment team meetings help improve 

the care that consumers like Catherine receive?

While there is no single correct answer to this 

question, here are a few ideas.

Dr. Ruiz might not have heard anything 

about Catherine’s side effects until their next 

appointment in 2 weeks, if she had not learned 

it from Roxanne.

Now, Dr. Ruiz can schedule Catherine earlier to 

evaluate her tiredness. The tiredness might be a 

side effect of her new medication, but also could 

indicate the onset of a medical problem, such as 

diabetes or hypothyroidism. This shared 

information allows Dr. Ruiz to address the problem 

more quickly and help prevent Catherine from 

stopping her medication or losing her job.

Summary

Offering training on new documentation 

practices is the key to effectively 

implementing MedTEAM.

Tailor the content and structure of your 

training to best meet the individual needs 

in your agency.

Training Frontline Staff 

Module 2: Ongoing Training on Medications

Effective medication treatment depends on keeping up with the latest scientific 

evidence and using it to inform medication decisions. However, the rapid pace 

of scientific discoveries makes this task particularly challenging. This module 

describes the benefits of offering ongoing training on medications, who should 

attend, and the types of information that support MedTEAM staff in keeping 

up with this large body of evidence.

One core element of MedTEAM 

is that the latest scientific evidence 

guides medication decisions. Since the 

evidence base for medications evolves 

quickly, it is impossible to provide a 

comprehensive and current summary of 

it in this KIT. Instead, this module gives 

you guidelines to help you develop your 

own treatment guidelines or algorithms 

for medication treatment that are based 

on the latest evidence.

This module also gives you suggestions 

for how to develop a systematic plan and 

ongoing training to help MedTEAM staff 

keep up with scientific breakthroughs 

in medication treatment and use that 

information to update treatment 

guidelines at least annually.

Ongoing Training on Medications 1 Module 2
Module 2 2 Ongoing Training on Medications

Develop treatment guidelines 

or algorithms

Practice guidelines are systematically developed 

statements designed to inform clinical decisions 

by summarizing scientific evidence about the types 

of medications that have worked best for specific 

groups of consumers. Algorithms are evidencebased or consensually agreed-upon stepwise 

instructions for patient care (Parks, 2007).

Two aspects of serious mental illnesses have 

led to developing a number of guidelines and 

algorithms that make recommendations for 

sequencing specific medications for long-term 

medication treatment.

	First, these illnesses are typically recurrent 

or chronic.

	Second, the first treatment typically does not 

work for the duration of the consumer’s illness.

Therefore, most consumers will respond 

inadequately to at least one medication and 

need either a medication change or addition.

Is one guideline 

or algorithm recommended?

No guideline or algorithm has been found to 

be superior to others. However, some generally 

shared characteristics span many of the currently 

available guidelines. For example, in treating 

schizophrenia, the following three tenets are 

shared across numerous guidelines and algorithms:

	Antipsychotics are the core of 

medication treatment;

	Clozapine is recommended for those with a 

history of inadequate response to two or more 

other antipsychotics; and 

	Combination antipsychotics are a last resort 

because they lack a strong evidence base.

Medication training for MedTEAM staff can 

begin with a review of treatment guidelines and 

algorithms. Reviewing existing treatment 

guidelines and algorithms annually is one way to 

keep up on the latest scientific evidence.

So long as core recommendations such as the 

tenets described for treating schizophrenia are 

followed, you may choose from the range of 

published guidelines and algorithms in developing 

your own and make local modifications in 

recommended medication sequences, as indicated.

The key is to start with medications that are 

effective, simple to use, and tolerable for the 

consumer. It is important to remember that 

decisions should be made together with consumers 

and based on the history, preferences, medication 

side effect profile, medical status, concomitant 

medications, and other variables that may apply 

to specific situations. No algorithm or guideline 

can account for every individual circumstance 

and provide a single concrete recommendation for 

each consumer. Thus, it is ultimately the 

prescribers’ responsibility to integrate the best 

evidence from scientific research with their clinical 

expertise and the consumer’s experience, and 

partner with the consumer in making 

medication decisions.

The following is a list of treatment guidelines 

and algorithms that were available at the time that 

this KIT was published. As a part of your training, 

review these materials or other more recent 

guidelines relevant to your population of focus to 

adopt one that follows the best expert consensus 

based on the latest research.
Ongoing Training on Medications 3 Module 2

Examples of treatment algorithms and guidelines

American Psychiatric Association Schizophrenia Guidelines. (2004). Retrieved from 

http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm

Canadian Psychiatric Association. (2005). Canadian clinical practice guidelines for the 

treatment of schizophrenia. Canadian Journal of Psychiatry, 50(Suppl 1). Retrieved from 

http://ww1.cpa-apc.org:8080/Publications/Clinical_Guidelines/schizophrenia/november2005/index.asp

International Psychopharmacology Algorithm Project. (2007). http://www.ipap.org

Lehman, A. F., Kreyenbuhl, J., Buchanan, R. W., Dickerson, F. B., Dixon, L. B., Goldberg, 

R., et al. (2004). The Schizophrenia Patient Outcomes Research Team (PORT): Updated 

treatment recommendations 2003. Schizophrenia Bulletin, 30, 193-217. Retrieved from 

http://schizophreniabulletin.oxfordjournals.org/archive

McEvoy, J. P., Scheifler, P. I., & Frances, A. (Eds.). (1999). The Expert Consensus Guideline Series: 

Treatment of schizophrenia 1999. Journal of Clinical Psychiatry, 60(Suppl 11), 4-80. Available from 

http://www.psychguides.com

Mellman, T. A., Miller, A. L., Weissman, E. M., Crismon, M. L., Essock, S. M. & Marder, S. R. (2001). 

Evidence-based pharmacologic treatment for people with severe mental illness: A focus on 

guidelines and algorithms. Psychiatric Services, 52, 619-625.

Miller, A. L. (2004). PORT treatment recommendations. Schizophrenia Research, 30, 601-604.

Moore, T. A., Buchanan, R. W., Buckley P. F., Chiles, J. A., Conley, R. R., Crismon, M. L., et al. (2007). 

The Texas medication algorithm project antipsychotic algorithm for schizophrenia: 2006 update.

Journal of Clinical Psychiatry, 68, 1751-1762.

Texas Department of State Health Services, Texas Medication Algorithm Project (TMAP) and Texas 

Implementation of Medication Algorithms (TIMA). (2007). Antipsychotic algorithm for the treatment 

of schizophrenia. (2007). Available from http://www.dshs.state.tx.us/mhprograms/TIMA.shtm

U.S. Department of Veterans Affairs & U.S.Department of Defense. (2004). Management of 

persons with psychoses. Washington, DC: U.S. Department of Veteran Affairs. Available from 

http://www.guideline.gov/browse/DisplayOrganization.aspx?org_id=954
Module 2 4 Ongoing Training on Medications

What should be included in your guidelines?

Written guidelines or algorithms should specify 

what constitutes an adequate trial for each 

medication including the following:

	Duration of medication trial;

	Medication sequencing;

	Dosing recommendations; and

	How to assess outcomes.

For the prescriber trying to decide which drug 

to try next for symptomatic consumers, knowing 

which prior treatments have been true failures 

versus insufficient trials is obviously critical. 

However, evidence may differ on the length 

of time needed for an adequate medication trial.

For example, most guidelines available at the 

time of publication state that to determine if 

an antipsychotic medication is working well, 

a consumer must take the medication between 

4 and 12 weeks. However, more recent metaanalyses of newer data suggest that the minimum 

may be closer to 2 weeks. For more information, 

see The Evidence in this KIT.

While the question of the duration that constitutes 

an adequate trial of antipsychotics is unresolved, 

the trend is definitely toward the conclusion that 

periods shorter than 12 weeks may be adequate, 

with the likely exception of clozapine.

When changing antipsychotic medications, 

a medication that the consumer has not tried 

before may be a better option than one that has 

been used for 2 weeks or more at an adequate 

dose without producing good results.

In addition to what constitutes an adequate 

medication trial, your treatment guidelines 

or algorithms should include a plan to identify 

and treat consumers with treatment-refractory 

disorders (that is, consumers whose symptoms 

have inadequately responded to medication).

In your plan, specify criteria for identifying 

consumers whose disorders are treatmentrefractory. Develop procedures to identify, 

track, and respond to the needs of this group 

of consumers. For example, schizophrenia 

in consumers who have taken two or more 

antipsychotic medications without improvement 

may be defined as treatment-refractory. A 

plan for identifying this group of consumers 

may include conducting a chart review every 6 

months. To respond to the needs of this group 

of consumers, clozapine may be offered as long 

as no contraindications exist.
Ongoing Training on Medications 5 Module 2

Keep up with scientific breakthroughs

Keeping abreast of the evidence base for medications 

is a challenge. Many prescribers rely on routine 

self-training to access new scientific evidence. 

However, routine self-training is complex. Many 

sources of information about medications exist 

including the following:

	Continuing Medical Education 

(CME) programs;

	Primary research literature;

	Research reviews and meta-analyses;

	Pharmaceutical representatives and programs; 

and 

	Medication-related Web sites and newsletters.

Despite the challenge, prescribers are expected 

to keep up to date. Below are some tips for how 

you can help ensure that MedTEAM staff members 

have the latest and most accurate information that 

is available from medication research.

Pull information from multiple sources

The role of the pharmaceutical industry in educating 

prescribers is a subject of active discussion in the 

medical community. A variety of regulations and 

ethical guidelines exist, with others being considered 

at the time of this writing. Regardless of internal 

or external constraints, however, it is unreasonable 

to expect the pharmaceutical industry to supply 

all the necessary and sufficient information that 

prescribers need to know to stay current. This is 

especially true when generic drugs compete with 

brands still on patent and when non-drug alternative 

treatments exist. Rather than relying solely on 

information provided directly by the pharmaceutical 

industry, ensure that prescribers have easy access 

to information gathered from multiple sources 

such as those in the following table.

Examples of medication information sources

Category Resource Web site

Drug Information Epocrates Online – Free drug and clinical 

reference for the Web browser

http://www.epocrates.com/products/online/index.html

Food and Drug Administration: Center 

for Drug Evaluation and Research

http://www.fda.gov/cder/drug/default.htm

Food and Drug Administration: 

Drugs@FDA

http://www.accessdata.fda.gov/scripts/cder/drugsatfda

MedlinePlus: Medicines http://www.nlm.nih.gov/medlineplus/medicines.html

Drug Interactions Indiana University, Division of Clinical 

Pharmacology: Drug Interaction Table 

(Cytochrome P450 System) 

http://medicine.iupui.edu/clinpharm/ddis

Drugs in Pregnancy 

and Lactation

Briggs Update: Drugs in Pregnancy 

and Lactation

http://www.briggsdrugsinpregnancy.com 

Centre for Addiction and 

Mental Health (CAMH)

http://www.camh.net/Publications/Resources_for_

Professionals/Pregnancy_Lactation/index.html

Drugs in Pregnancy and Breastfeeding http://www.perinatology.com/exposures/druglist.htm

Organization of Teratology 

Information Specialists

http://www.otispregnancy.org

Pregnancy-Related Issues in the Management 

of Addictions (PRIMA)

http://www.addictionpregnancy.ca/
Module 2 6 Ongoing Training on Medications

Obtain Internet and library access

In treating individual consumers, specific questions 

often arise that are not addressed by summary 

tables such as those above. These questions 

may not even be covered in comprehensive 

psychopharmacology texts. MedTEAM staff 

members with Internet and library access can 

search for the most up-to-date evidence.

Considerable information is available through the 

Internet. A plethora of Web sites are devoted to 

specific mental illnesses and psychiatric issues. 

Unfortunately, the quality of information varies 

hugely from source to source. Timeliness and 

reliability of information may be difficult to judge.

Other sources of information are medication 

newsletters that review and evaluate recent 

information about medication treatments in 

psychiatry. You can subscribe to these individually, 

but MedTEAM staff may want to agree on one or 

two with the greatest value and ask the MedTEAM 

leader to subscribe to them. The following table 

lists some examples of medication newsletters.

Medication newsletters Web site

Biological Therapies in Psychiatry http://www.btpnews.com

The Brown University Child and Adolescent 

Psychopharmacology Update

http://www.wiley.com/WileyCDA/WileyTitle/productCd-CPU.html

The Brown University Geriatric Psychopharmacology Update http://www.wiley.com/WileyCDA/WileyTitle/productCd-GPU.html

The Brown University Psychopharmacology Update http://www.wiley.com/WileyCDA/WileyTitle/productCd-PU.html

The Carlat Psychiatry Report http://www.thecarlatreport.com

Child & Adolescent Psychiatry Alerts http://www.alertpubs.com/child.htm

Current Psychiatry http://www.currentpsychiatry.com

Journal Watch: Psychiatry http://psychiatry.jwatch.org

Psychiatry Drug Alerts http://www.alertpubs.com/Psych.htm

Psychiatry Weekly http://www.psychiatryweekly.com

Psychopharm Review 

(formerly International Drug Therapy Newsletter)

http://www.lww.com/resources/cmeinfo/internationaldrugtherapy.html

Establish a team approach

Time and effort to access the most updated 

scientific information often competes with time 

devoted to consumer care. One approach to keeping 

up to date on medications is for MedTEAM staff 

to divide the work if the staff is of sufficient size. 

Develop procedures for how MedTEAM staff can 

work together to access information on scientific 

updates and expert recommendations.

The systematic plan should include procedures 

for updating treatment guidelines or algorithms 

annually including specifying who is involved in 

the update process.

Consider designating a staff member who may 

serve as a point person within your agency for 

medication updates. Have that person routinely 

update staff during treatment team meetings 

or other inservice sessions.

Some agencies may also further specify the roles so 

that one staff member serves as a point person for 

medications related to schizophrenia and another 

for mood disorders. Designated MedTEAM staff 

may participate in additional training activities.
Ongoing Training on Medications 7 Module 2

Develop ongoing training

Your systematic plan for helping MedTEAM 

staff keep up with the evidence should include 

ongoing training on medications. This section 

provides information that may be incorporated into 

medication training for MedTEAM staff.

The Web sites in the previous tables are useful 

for finding answers to a variety of medicationrelated questions, but they are updated at 

variable intervals and, therefore, cannot possibly 

incorporate all of the most recent literature 

findings, or even the most recent meta-analytic 

studies. The rest of this section on medications is 

devoted to training on how to efficiently search the 

literature to find answers to medication questions.

Conduct literature reviews

Effectively answering drug information questions 

takes time, practice, and knowledge about where 

to look for information. Some drug information 

questions (for example, examining a medication’s 

elimination half-life, determining whether a 

medication has been noted to cause a given side 

effect, or understanding the available dosage 

strengths) can readily be answered using tertiary 

literature sources such as drug references or 

textbooks. But more complex questions such as, 

Is medication A better than medication B?, often 

require reviewing the primary or secondary literature.

An excellent framework to use in developing 

and asking answerable clinical questions has been 

created by the Monash Institute of Health Services 

Research (2006). In this framework, every clinical 

question should be broken down into a PICO format.

P = Population (or consumer) 

I = Intervention or indicator

C = Comparison or control 

O = Outcome

This framework allows users to clarify the question, 

identify the information necessary to answer the 

question, translate the question into searchable 

terms, and develop and refine the search strategy. 

The great advantage of this approach is that it can 

save users considerable time searching through 

extraneous and irrelevant literature.

Use search engines

Anyone connected to the Internet can access 

PubMed, a free Internet search engine for 

accessing citations and abstracts of life science 

and biomedical research articles.

To access PubMed, go to: http://www.pubmed.gov.

Some full-text articles may be available free of 

charge by the publisher through PubMed. If you are 

affiliated with a large hospital system, government 

agency, or university, you may have access to 

resources such as OVID or other searchable 

bibliographic databases or to medical journal 

subscriptions that are typically not free to the public. 

These resources provide more full text articles.

Good search strategies are essential to getting 

manageable, yet adequate, numbers of 

references. Searching clinical questions too 

broadly may generate thousands of articles and 

cause you to spend hours going through articles 

unrelated to the clinical question. Conversely, 

questions that are too narrow in scope can yield 

too few results, missing information that may 

be relevant to the clinical question.

Practice the PICO approach to avoid these pitfalls. 

The following case examples and exercises can be 

used to train MedTEAM staff on how to create 

efficient search strategies.
Module 2 8 Ongoing Training on Medications

Case Example 1 

Manuel, a 27-year-old consumer, comes into the 

clinic for his monthly appointment. He has continuing 

symptoms of paranoia and complains of daily auditory 

and visual hallucinations.

The provider wishes to change Manuel’s antipsychotic 

medicine, but Manuel is reluctant. He feels that the 

olanzapine has been the best antipsychotic to date 

for his symptoms. He is currently on olanzapine 

20 mg daily.

Manuel asks the provider, “Why can’t we just increase 

the dose?”

Exercise

	Use the PICO framework to develop a clinical 

question to inform medication decisions 

for Manuel.

	Use an available search engine to 

access research articles related to your 

clinical question.

	Examine the level of evidence in the studies 

that you found.

 Did these studies look at a large number 

of consumers?

 What types of studies are they (for example, 

randomized control trials, case studies, etc.)?

 Which populations were included in 

the studies?

 Based on the research that you found, what 

would you say to Manuel?

While there is no single correct answer to this 

question, here is one approach to answering 

these questions.

The PICO framework could be developed 

as follows:

P = symptomatic consumers with schizophrenia

I = high-dose olanzapine

C = no drug treatment or olanzapine at recommended doses

O = further reduction of symptoms 

Search the literature by using PubMed and the 

PICO framework to develop usable search terms. 

For instance, if we typed in symptomatic consumers 

with schizophrenia, we would generate no results 

from this search.

On the other hand, just using schizophrenia and 

olanzapine would likely yield thousands of results 

because it would yield any schizophrenia-related 

article that mentions olanzapine in the text.

Start with a combination of terms such as 

symptomatic, schizophrenia, high dose, and 

olanzapine. Searching the literature is an iterative 

process. Examine your search results and use them 

to guide further searches, if needed.

Alternative terms may be more productive. 

Symptomatic may only yield limited results. You 

could try alternative search terms such as positive 

symptoms, hallucinations, psychosis, or other 

related terms.
Ongoing Training on Medications 9 Module 2

The same could be true for high dose. This term 

may be represented in the literature more often 

as super-therapeutic or maximal dose. You may 

even try searching using just the term dose if the 

alternatives do not yield results. When results are 

limited, the comparison does not necessarily have 

to be put in as an additional search term.

Searching terms such as no treatment or treatmentas-usual may not have much of an effect on the 

search. Typically, the comparison is useful if you 

would like to restrict your search. For instance, 

if you were interested only in studies examining 

high-dose olanzapine versus clozapine, then using 

the comparison search term clozapine would be 

highly valuable.

In most PICOs, we are searching for the outcome, 

but including the outcome term may also restrict 

search results in undesirable ways. If you get 

inconsistent results for the use of high-dose 

olanzapine in schizophrenia, for example, searching 

terms such as symptom improvement or symptom 

reduction may limit the results to only positive 

studies, omitting negative studies.

PubMed and OVID offer other ways to limit 

searches. If the original search terms yield too 

many results, use PubMed or OVID to further 

restrict the search to studies only in humans, 

or studies in English, or studies available only 

in full text.

There are also many subheading categories that 

you can use if a term is “mapped.” When mapping 

search terms, you can limit the search to certain 

subcategories, or if your search yields too few 

results, you can “explode” the term to capture 

related terms.

In Manuel’s case, evidence is limited for benefits 

of olanzapine doses higher than 20 mg/day. Some 

data indicate that olanzapine doses greater than 

20 mg may benefit consumers who only partially 

respond to an adequate trial of olanzapine 20 mg 

(Volavka et al., 2002; Lindenmayer et al., 2001).

The Clinical Antipsychotic Trials of Intervention 

Effectiveness (CATIE) study also used doses 

up to 30 mg/day (Lieberman et al., 2005) and 

a randomized controlled trial of consumers with 

treatment-resistant schizophrenia compared high 

dose olanzapine (up to 45 mg/day) to clozapine 

(Meltzer et al., 2008).

After reviewing these studies, you may inform 

Manuel that evidence shows that higher doses of 

olanzapine have helped some consumers, but the 

evidence is not so strong that he can feel assured 

that a dose increase will be effective.

Sharing information about the most updated 

research evidence with consumers is key to the 

shared decisionmaking process. Partner with the 

consumer to integrate the best evidence from 

systematic research, your clinical expertise, 

and the consumer’s experience when making 

medication decisions.
Module 2 10 Ongoing Training on Medications

Case Example 2 

Tami, a consumer with a long history of schizophrenia, 

has taken four antipsychotic medications without 

improvement. Her prescriber wanted to try clozapine, 

but Tami does not wish to have her blood drawn. 

Therefore, Tami does not consent to clozapine treatment.

The prescriber understands that polypharmacy is viewed 

as a last resort, but wonders if any new studies show 

its value in this situation.

Exercise

	Use the PICO framework to develop a clinical 

question to inform medication decisions 

for Tami.

	Use an available search engine to 

access research articles related to your 

clinical question.

	Examine the level of evidence in the studies 

that you found.

 Did these studies look at a large number 

of consumers?

 What types of studies are they (for example, 

randomized control trials, case studies, etc.)?

 Which populations were included 

in the studies?

 Based on the research that you found, what 

would you say to Tami?

While there is no single correct answer to this 

question, here is one approach to answering 

these questions.

The PICO framework could be developed 

as follows:

P = consumers with treatment-resistant schizophrenia

I = antipsychotic polypharmacy

C = clozapine or single antipsychotic use

O = reduction of symptoms

Search the literature by using PubMed and the 

PICO framework to develop usable search terms. 

Possible search terms include treatment resistant, 

schizophrenia, antipsychotic, or polypharmacy. 

Alternative terms may include antipsychotic 

augmentation, clozapine, or monotherapy.

Do not use outcome terms for your initial search. 

If this search yields a large number of results, then 

it could be further limited with an outcome search 

term such as symptom reduction.

To date, very limited data support using 

polypharmacy. A few studies examined augmenting 

clozapine with other agents (Stahl & Grady, 2004). 

However, the results have been mixed. Only one 

trial examining polypharmacy did not include 

clozapine. The findings suggest no difference 

between using two typical antipsychotics 

versus using monotherapy with an alternative 

typical antipsychotic.

After reviewing these studies, tell Tami your findings 

and use them as a basis of discussion to make a 

shared decision about her medication treatment.
Ongoing Training on Medications 11 Module 2

Case Example 3

Dr. Jones is having a discussion with the case manager 

on his team, Robin, who is concerned about the 

pronounced negative symptoms of a consumer 

named Julio.

Julio has been on haloperidol decanoate for 4 

years with good results in the reduction of positive 

symptoms. Julio’s negative symptoms (primarily 

asociality and poor hygiene) have always been 

pronounced. None of the three first-generation 

antipsychotics he has tried have helped in this area.

Robin recently heard that atypical antipsychotics 

were much better than typical antipsychotics for 

negative symptoms and cognition. Dr. Jones has heard 

variable comments on this issue from colleagues and 

at lectures but has not researched this issue himself. 

The conversation sparked his interest and he wants 

to examine the literature more closely to arrive at 

his own conclusion.

Exercise

	Use the PICO framework to develop a clinical 

question to inform medication decisions 

for Julio.

	Use an available search engine to 

access research articles related to your 

clinical question.

	Examine the level of evidence in the studies 

that you found.

 Did these studies look at a large number 

of consumers?

 What types of studies are they (for example, 

randomized control trials, case studies, etc.)?

 Which populations were included 

in the studies?

 Based on the research that you found, 

what would you say to Robin and Julio?

While there is no single correct answer to this 

question, here is one approach to answering 

these questions.

The PICO framework could be developed 

as follows:

P = consumers with schizophrenia experiencing 

negative symptoms

I = atypical (second generation) antipsychotic

C = typical (first generation) antipsychotics 

O = improvement in negative symptoms 

Search the literature by using PubMed and 

the PICO framework to develop usable 

search terms. Possible search terms include 

schizophrenia, negative symptoms, asociality, 

atypical antipsychotic, or second-generation 

antipsychotic, typical antipsychotic, or firstgeneration antipsychotic.

Do not use outcome terms for your initial search. 

If this search yields a large number of results, then 

it could be further limited with an outcome search 

term such as improvement.

This case was included to show the decreased 

utility of a very broad search. Even though a proper 

PICO framework is developed, the topic areas are 

very broad, so a literature search in PubMed or 

OVID generates a very large literature result.

In cases like these, limit the search to systematic 

reviews, meta-analyses, or those articles available 

in full-text format only. Alternatively, refine the 

PICO framework to examine the specific atypical 

antipsychotic or a specific negative symptom.
Module 2 12 Ongoing Training on Medications

This example highlights why it can be difficult to 

develop a PICO framework and how your PICO 

framework can be refined if the desired results are 

not produced. The more specific the inquiry; the 

fewer results you will receive.

In this case, newer studies such as CATIE have 

questioned the superiority of atypical antipsychotics 

versus typical antipsychotics in terms of reducing 

negative symptoms (Weiden, 2007). The literature 

to date tends to be inconsistent as to whether atypical 

antipsychotics really do improve negative symptoms.

Many studies show improvement of only certain 

symptoms and no improvement on others. These 

conflicting results show the importance of carefully 

evaluating the literature and the design of the 

studies to see if study results can be applied to 

the case you are reviewing.

After reviewing the studies, tell Robin and 

Julio of your findings and use them as a basis of 

discussion to make a shared decision about his 

medication treatment.
Ongoing Training on Medications 13 Module 2

Case Example 4

Anna, a 26-year-old consumer with schizophrenia, 

has recently become pregnant. She is currently on 

aripiprazole for her symptoms.

She is concerned that continuing the antipsychotic 

may harm her baby. She wants to know exactly 

what can happen to her child and if she can use 

aripiprazole during any part of her pregnancy.

Her prescriber reads the drug information reference 

and sees that aripiprazole is listed as Pregnancy Risk 

Factor C.

Exercise

	Use the PICO framework to develop a clinical 

question to inform medication decisions 

for Anna.

	Use an available search engine to 

access research articles related to your 

clinical question.

	Examine the level of evidence in the studies 

that you found.

 Did these studies look at a large number 

of consumers?

 What types of studies are they (for example, 

randomized control trials, case studies, etc.)?

 Which populations were included in 

the studies?

 Based on the research that you found, 

what would you say to Anna?

While there is no single correct answer to this 

question, here is one approach to answering 

these questions.

The PICO framework could be developed 

as follows:

P = pregnant consumer with schizophrenia 

I = aripiprazole 

C = no medication 

O = risk and benefits with aripiprazole in pregnancy 

Search the literature by using PubMed and 

the PICO framework to develop usable search 

terms. Possible search terms include pregnancy, 

schizophrenia, and aripiprazole.

Since the topic is relatively specific, start your 

search with these terms only. If your search is more 

general, like atypical antipsychotic, then other 

search terms may be needed.

This example allows us to briefly discuss specific 

populations in literature searches. This can be a 

pitfall because very specific populations may have 

limited research data pertaining to them. For 

instance, it may be impossible to find an article 

about tardive dyskinesia in African American 

females with schizophrenia and mental retardation. 

However, if a less specific population is defined, 

such as tardive dyskinesia in African Americans, 

then the literature search may produce results 

that can apply to the more specific population.

In the case of Anna’s pregnancy, much of the 

relevant information is in the tertiary literature, 

drug references, or package insert for aripiprazole. 

Aripiprazole is listed as Pregnancy Risk Factor C. 

That means that in animal studies, aripiprazole 

demonstrated developmental toxicity, including 

possible teratogenic effects in rats and rabbits.
Module 2 14 Ongoing Training on Medications

Pregnant animals treated with very high doses 

of aripiprazole were found to have slightly 

prolonged gestation, decreased fetal weight, 

undescended testes, delayed skeletal ossification, 

fetal mortality, skeletal abnormalities, still births, 

and abortions. Some maternal toxicity was seen 

at 30 mg/kg; however, no evidence suggested that 

these developmental effects were secondary to 

maternal toxicity.

No adequate and well-controlled studies in pregnant 

women exist. It is not known whether aripiprazole 

can cause fetal harm when administered to 

a pregnant woman or whether it can affect 

reproductive capacity. The effect of aripiprazole 

on labor and delivery in humans is also unknown.

Aripiprazole was excreted in milk of rats during 

lactation. It is not known whether aripiprazole 

or its metabolites are excreted in human milk.

According to this research, aripiprazole should be 

used during pregnancy only if the potential benefit 

outweighs the potential risk to the fetus. It is also 

recommended that women receiving aripiprazole 

not breast feed.

After reviewing the studies, tell Anna of your findings 

and use them as a basis of discussion to make a 

shared decision about her medication treatment.

Summary

Use the information in this module 

to develop a systematic plan to help 

MedTEAM staff keep up with the 

evidence related to medications.

Offer ongoing training and develop 

treatment guidelines or algorithms to 

guide medication treatment to support 

prescribers in their effort to integrate the 

latest scientific evidence during the shared 

decisionmaking process.
Training Frontline Staff 

Module 3: Integrating Outcome Measures 

into Clinical Assessments

A core element of MedTEAM is using quantitative outcome measures to help 

prescribers and consumers evaluate whether medications are having the desired 

effect. This module provides information to help you identify outcome measures 

and develop a plan for collecting them and training MedTEAM staff to integrate 

these measures into clinical assessments.

Measuring outcomes is at the heart 

of medication management for serious 

mental illnesses, just as accurately 

measuring blood pressure and glucose 

is at the heart of medication management 

of hypertension and diabetes. 

However, staff who are accustomed to 

conducting these assessments without 

quantitative measures may resist the 

idea of integrating outcome measures 

into clinical assessments.

A number of reasons support using 

quantitative outcome measures. 

First, routinely using medication-related 

outcome measures helps prescribers 

and consumers evaluate whether 

medications are having the desired 

effect. It can be difficult to determine 

whether improvements have been made 

between visits when using global terms 

such as somewhat psychotic or other 

subjective terms.

Integrating Outcome Measures into Clinical Assessments 1 Module 3
Second, outcome measures offer a common 

language to promote a clearer description 

of consumers’ symptoms and conditions. 

In contrast, it is difficult, if not impossible, 

for another prescriber to interpret symptom 

levels when global or subjective terms are used.

Identify outcome measures

Prescribers may assume that objective scales with 

demonstrated reliability across raters will be too 

lengthy to use in busy clinic settings. However, 

brief scales have been developed for schizophrenia, 

bipolar disorder, and major depressive disorder. 

For example, measuring positive symptoms in 

schizophrenia is highly relevant for managing 

antipsychotic medications. Although negative 

symptoms can affect medication-related 

behaviors such as adherence, the evidence that 

negative symptoms can be positively affected by 

medications is less robust.

Brief scales to measure positive and negative 

symptoms of schizophrenia have been developed 

for the Texas Medication Algorithm Project (TMAP). 

They are available in the Clinician’s Procedural 

Manual for Schizophrenia Treatment at 

http://www.dshs.state.tx.us/mhprograms/TIMA.shtm.

Brief scales developed through TMAP to measure 

depressive and bipolar disorder symptoms are 

available from the same Web site in the Major 

Depressive Disorder and Bipolar Disorder 

Clinician’s Procedural Manuals, respectively.

The following resources include additional 

psychiatric rating scales for you to review and 

consider, including scales to assess common 

symptoms such as anxiety, depression, and insomnia:

	Rating Scales in Mental Health (2nd ed.) 

(Sajatovic & Ramirez, 2003); and 

	Handbook of Psychiatric Measures (2nd ed.) 

(Rush, First, & Blacker, 2008).

Monitor side effects

In recent years, concern has grown about the 

potential of the newer antipsychotic medications 

to cause serious medical problems including weight 

gain, diabetes, hyperlipidemia, hyperprolactinemia, 

and cataracts. Marder et al., (2002) reported 

on recommendations for monitoring side effects 

that were developed at a consensus conference 

of psychiatrists and experts in obesity, disease 

prevention, diabetes, cardiology, endocrinology, 

and ophthalmology.

At the time of publication, these were the most 

comprehensive guidelines for monitoring physical 

side effects of antipsychotics since the introduction 

of second-generation antipsychotics.

We recommend that you scan the current 

literature for similar compilations of critical side 

effects to monitor for your population of focus. 

Incorporate a process for regularly monitoring 

medication side effects into your MedTEAM 

training plans.

Module 3 2 Integrating Outcome Measures into Clinical Assessments
Integrating Outcome Measures into Clinical Assessments 3 Module 3

Train staff

Proper training is vital to obtaining reliable 

outcome measures that may be integrated into 

clinical assessments. Training should not be 

a one-time event. If MedTEAM staff work in 

isolation and are not periodically rechecked, 

they may “drift” to more idiosyncratic ways of 

interviewing and scoring. Thus, you should have 

a regular program to reassess MedTEAM staff 

who collect outcome measures and, when needed, 

retrain them.

If your agency adopts the Positive Symptom 

Rating Scale (PSRS) or Brief Negative Symptom 

Assessment (BNSA), consider using the Practice 

Demonstration Video contained in the DVD that 

accompanies this KIT. This video discusses the 

core principles described below and other issues 

specific to using these measures to inform clinical 

assessments. Video training components for 

other outcome measures are often available from 

the developers of the instruments.

Conduct checks on the outcome ratings of 

MedTEAM staff every 6 to 12 months. Assess the 

reliability of ratings by comparing MedTEAM staff 

ratings of a taped interview with ratings by expert 

or experienced raters. Scores within one point 

of the criterion rating by experienced raters are 

considered correct. To be judged reliable, a rater’s 

scores should be correct at least 80 percent of the 

time, based on at least two interviews.

Core principles for training

When collecting outcome measures for clinical 

assessments, every MedTEAM staff member 

should keep in mind some general principles. 

Following these principles will help the rater 

produce more reliable and accurate ratings.

	Always use the anchor points, no matter how 

many times you have administered the rating 

scale. Attending to the anchor points will make 

your ratings more consistent and increase the 

likelihood that your ratings will agree with 

those of other MedTEAM staff rating the 

same consumers.

	Finish the entire interview before deciding on 

final ratings. While the questions are typically 

asked in sequential order, consumers may 

add information later in the interview that 

alters the rating. Use information from the 

entire interview to make your final decision on 

each item.

	Pay close attention to item definitions.

Item definitions may include examples of 

symptoms that are less familiar to you. Read 

definitions carefully.

	Pay close attention to the phrasing of anchor 

points. Often anchor points will contain the 

word or. This word should alert you that only 

one of two statements must be true to assign 

a particular rating.
Module 3 4 Integrating Outcome Measures into Clinical Assessments

Many behavioral rating scales use anchor points 

to guide the rater. The purpose of anchor points 

is to have all raters use the same criteria in making 

ratings. Studies have shown that reliability or 

consistency of ratings falls markedly when raters 

use “clinical judgment” instead of anchor points 

to do ratings.

It is critical that ratings be done on the basis of 

concrete observations, guided by anchor points. 

The place for clinical judgment is in interpreting 

ratings, not in making the ratings. For example, 

thoughts rated as delusions might reflect different 

cultural beliefs, or affect rated as flat might be due 

to medication effects. The clinical note is the place 

to indicate possible explanations for observed ratings.

Cultural, ethnic, and racial considerations

A fairly extensive literature exists about 

pharmacokinetic and pharmacodynamic 

differences among racial or ethnic groups. 

Pharmacokinetics is the study of drug metabolism, 

which affects the amount of a drug in the system. 

Pharmacodynamics is the study of differences in 

drug effects that are independent of differences 

in drug metabolism.

Pharmacodynamic differences between groups 

can be in main effects of the drugs, but are often 

found in sensitivity to drug side effects. Related to 

pharmacokinetic and pharmacodynamic differences 

across individuals and groups is a growing literature 

on genetic determinants of drug effects, with 

many relevant genes being distributed differently 

in different populations.

The majority of the pharmacokinetic literature 

examines phenotypic Cytochrome P450 enzyme 

variants. These liver enzyme polymorphisms can 

often lead to clinically relevant differences in drug 

metabolism, producing variations in psychotropic 

efficacy and side effects.

The following analysis about schizophrenia 

illustrates the importance of considering 

culture, race, and ethnicity in managing 

psychotropic medications.

A good deal of research has found that symptoms 

of schizophrenia are very similar across cultures 

and across racial and ethnic groups. Cultural 

competency for this disorder is much more 

about recognizing when beliefs and behaviors 

are culturally appropriate and not symptoms 

of the disorder. Moreover, we must understand 

cultural determinants of social, family, and 

personal reactions to these symptoms.

With regard to antipsychotics, studies have not 

identified marked racial or ethnic differences in 

metabolism of antipsychotics (Arranz & de Leon, 

2007). However, variations in drug metabolism 

are seen between racial or ethnic populations 

in other drugs that can affect the metabolism 

of antipsychotics. For example, 7 to 10 percent 

of Caucasians, versus 1 to 2 percent of Asians 

have polymorphisms at CYP2D6, which make 

them poor metabolizers of drugs that go through 

this pathway (Arranz & de Leon, 2007).
Integrating Outcome Measures into Clinical Assessments 5 Module 3

Fluoxetine is a strong inhibitor of CYP2D6, which 

is a major pathway for metabolism of aripiprazole 

and haloperidol. That is, a Caucasian is 4 to 5 times 

more likely than an Asian to be a poor metabolizer 

and 4 to 5 times more likely to have problems due 

to high levels of these antipsychotics when they are 

used in combination with fluoxetine.

Controlled studies of consumers of Asian descent 

have found that they often require lower doses of 

antipsychotics compared to Caucasian populations 

to produce the same antipsychotic effect (Ng et al., 

2005; Lin & Finder, 1983).

The evidence supporting differences between 

other ethnic populations is not as strong. Some 

data suggest consumers of Hispanic or African 

American descent may require different 

antipsychotic doses than Caucasian populations, 

but reports are conflicting on this issue in 

metabolic genotyping studies (Frackiewicz, 

Herrera, Sramek, Collazo & Lawson, 2002; 

Arranz & de Leon, 2007).

Pharmacogenetics is the study of genes that relate 

directly to drug actions. Variations in these genes 

between populations can cause differences in drug 

effects in the populations.

Pharmacogenomics is a term sometimes used 

interchangeably with pharmacogenetics, but can 

also include the study of genes that relate to drug 

effects beyond the primary sites of drug actions.

Pharmacogenetic and pharmacogenomic research 

is difficult to conduct and replicate because of 

many factors. These factors include, but are not 

limited to, the following:

	Study design;

	Large number of subjects necessary to perform 

the studies;

	Clinical and environmental differences between 

sample populations; and 

	Heterogeneity of contributing factors.

Much of the pharmacogenetic literature explores 

the short-term (weeks to months) changes in gene 

expression of receptors, transporters, and growth 

factors in response to psychotropic drugs.

An example of a replicable pharmacogenetic finding 

that affects clinical practice is the discovery that 

Asian consumers with HLA-B*1502 allele are at 

10 times the risk of developing Stevens-Johnson 

syndrome or toxic epidermal necrolysis when 

exposed to the antiepileptic/mood stabilizer, 

carbamazepine, than Caucasian populations. 

(See carbamazepine package insert: 

http://www.pharma.us.novartis.com/product/pi/pdf/

tegretol.pdf.) 

HLA-B*1502 allele genetic testing is now 

recommended in Asian consumers before initiating 

carbamazepine. (See carbamazepine package insert.)

As more genetic tests become available and further 

well-controlled studies in homogeneous populations 

are conducted, researchers will give providers a 

clearer sense of the magnitude of the effects of 

genetic differences on response to psychotropic 

medications and of the value of testing 

for gene variants.

Incorporate this evolving evidence into your 

training on clinical assessments to increase 

the validity of your outcome measure ratings 

for consumers of diverse backgrounds.

Summary

Implementing MedTEAM entails new 

documentation practices, keeping up with 

scientific breakthroughs on medications, 

and integrating outcome measures into 

clinical assessment.

Offer training on these topics to effectively 

implement MedTEAM.


28612.0510.8712010401

HHS Publication No. SMA-10-4548

Printed 2010