Stage 7: Shared Decisions & Prescribing in the Encounter
Concept 7 of 8
E7.7
Prescribing in Special Situations
Pregnancy, substance use, elderly, comorbid medical illness, polypharmacy. Each requires modified approach in the encounter.
Encounter card
Setting
When the patient is pregnant, breastfeeding, has active substance use disorder, is elderly, has significant medical illness, or is on complex polypharmacy.
Opening move
Modify the standard discussion for the specific situation. In pregnancy: risk-benefit framing of untreated illness vs medication; preferred agents. In SUD: avoid controlled substances; choose meds compatible with recovery. In elderly: start low, go slow; consider polypharmacy. In medical illness: drug interactions and organ function. Engage the patient in the situational reasoning.
Sample language
"Because you're pregnant, we need to think about both you and the baby. Untreated depression has its own risks — it's not safer to avoid all medication. Here's how we'll think about it together."
"Given your alcohol use history, I'd steer away from benzodiazepines. Here's what I'd offer instead."
"At 78, your kidneys clear medications more slowly. We'll start at a lower dose than I would for a younger patient."
"You're on 12 medications. Let's look at the whole list to make sure we're not adding interactions."
Listen for
Patient's framing of the special situation. Specific concerns. Family input. Whether the patient is ready to engage in the complexity or wants a simplified version.
Common pitfalls
Treating special situations the same as standard. Refusing to prescribe in special situations rather than modifying appropriately. Failing to engage the patient in the situational reasoning. Missing drug interactions in polypharmacy.
Red flags / escalate: Severe psychiatric illness in pregnancy with untreated risk. Active substance use during pregnancy. Severe polypharmacy in elderly with cognitive concerns.
Documentation
Document the special situation considerations, the modified plan, the rationale.
Real-world reality: Pregnancy, SUD, elderly, and other special-situation prescribing often requires coordination with OB, addiction medicine, geriatrics — substantial communication time often unbilled.
Prescribing in special situations is a sophistication of the encounter, not a simplification. Engage the patient in the reasoning.
Special situations in prescribing — pregnancy, active substance use, elderly patients, significant medical comorbidity, complex polypharmacy — require modified clinical approaches in the encounter. The general principles still apply; the specifics shift in ways the patient should understand.
Pregnancy requires risk-benefit framing in the encounter, not avoidance. "Untreated psychiatric illness in pregnancy carries real risks for both you and the baby. The question is what treatment is safest, not whether to treat. Let me walk you through the options." Coordinate with OB. Choose preferred agents (sertraline among SSRIs, lamotrigine for bipolar maintenance, lithium with care, atypical antipsychotics with reasonable data). Plan postpartum monitoring carefully — relapse is high-risk in that window.
Active substance use disorder changes prescribing in concrete ways. Avoid controlled substances when possible — benzodiazepines, stimulants, opioids should not be routine first-line in active SUD. Choose medications compatible with recovery — naltrexone for AUD or OUD, bupropion for smoking cessation, non-controlled agents for anxiety. Coordinate with addiction treatment. The patient in early recovery has different needs than the patient who hasn't yet addressed substance use.
Elderly patients: start at 25-50 percent of adult dose, titrate slowly, minimize anticholinergic burden, avoid benzodiazepines when possible (use LOT — lorazepam, oxazepam, temazepam — only when needed and short-term), address polypharmacy explicitly. Falls and cognitive impairment are the major iatrogenic risks. Choose sertraline or escitalopram over paroxetine; choose risperidone with low EPS profile or aripiprazole over older agents.
Significant medical illness: hepatic impairment shifts toward simpler-metabolism agents; renal impairment shifts toward hepatically cleared agents; cardiac disease shifts away from QTc-prolonging agents; medications themselves may cause psychiatric symptoms that need addressing.
Engage the patient in the situational reasoning. "Because you're pregnant, we need to think about this differently. Here's the trade-off..." Patients in special situations often understand the situation better than the clinician anticipates and benefit from being engaged in the reasoning rather than just receiving the modified prescription.
Prescribing in active SUD — avoid controlled substances, choose meds compatible with recovery. Margin notes on specific agents.
The anchor
Special situations — pregnancy, SUD, elderly, medical illness, polypharmacy — require modified prescribing approach in the encounter, with the patient engaged in the situational reasoning.
Elderly prescribing — start low, go slow, consider anticholinergic burden, address polypharmacy. Margin clusters on the moves.
Prove it
A 28-year-old woman with bipolar I on lithium tells you she's 6 weeks pregnant. How do you approach the encounter?