The Texas Department of Mental Health/Mental Retardation (TXMHMR) is sponsoring a project on the use of medication algorithms in the community mental health center population. Kenneth Z. Altshuler, M.D., and A. John Rush, M.D., of the University of Texas Southwestern Medical Center and Steve Shon, M.D., medical director of TXMHMR, serve as project directors.
"We believe that TMAP [The Texas Medication Algorithm Project] is the first large-scale use of medication algorithms," Rush said, "certainly in a community mental health setting. A project like this may help to lay the groundwork for improved public mental health treatment here and in other states as well."
Medication algorithms, according to the project directors, consist of "a series of treatment steps, each of which is defined in turn by the clinical response of the patient to the preceding step." Over the past several years, treatment algorithms have been of interest to a growing number of researchers and clinicians. Recently, Allen Frances, M.D., professor and chair, department of psychiatry, Duke University Medical Center, John P. Docherty, M.D., professor and vice chair, department of psychiatry, Cornell University Medical College, and David A. Kahn, M.D., associate clinical professor, department of psychiatry, University College of Physicians and Surgeons have published the results of their tri-university (Duke, Cornell, Columbia) "Expert Consensus" surveys (Psychiatric Times February; Bipolar Disorders Letter March). Using the responses from a panel of recognized experts, they have constructed treatment algorithms for schizophrenia and bipolar disorder.
"Part of the inspiration for TMAP comes from the Expert Consensus Guidelines," said Rush. The algorithms derived from these guidelines, recently published in the Journal of Clinical Psychiatry, were incorporated at an early stage into the design of the treatment protocols. The developers of the Expert Consensus algorithms have also served as formal consultants to the Texas project.
TMAP includes modules addressing all three major mental illnesses targeted by the state system: schizophrenia, bipolar disorder and major depression. "We've made some modifications to the Expert Consensus Guidelines to make them fit our system better," Rush stated. "And we have developed our own algorithm for major depression with the help of both local and national authorities."
Broad Consensus Sought
At the invitation of TXMHMR, prominent academicians in the state and outside consultants began a collaboration with the Texas mental health community to develop optimum medication treatment guidelines. Patient advocacy groups, family members and physicians working in the community clinics have been consulted throughout the development of the project.
Others involved in the committee leading the project include Charles Bowden, M.D., professor of psychiatry, University of Texas, San Antonio; Robert Hirschfeld, M.D., department of psychiatry, University of Texas Medical Branch, Galveston; and Marcia Toprac, Ph.D., director of TXMHMR research. Clinicians applying the algorithms at project sites have been selected from the ranks of physician employees of TXMHMR.
"Texas is a logical place to test the use of algorithms on a large scale," Rush said at a recent conference. "Due to the financial constraints on the TXMHMR system, we have to focus on medication treatment and patient education, with relatively little in the way of formal psychosocial therapies. So in this setting it may be easier to discern the effect of optimizing our medication treatment."
1. Frances A, Docherty JP, Kahn DA. Expert Consensus Guideline Series: Treatment of bipolar disorder. J Clin Psychiatry. 1996;57(suppl 12A):1-88.
2. Frances A, Docherty JP, Kahn DA. Expert Consensus Guideline Series: Treatment of schizophrenia. J Clin Psychiatry. 1996;57(suppl 12B):1-58.