Medication Safety and Mental Health: How to Coordinate Care to Prevent Harm

When someone is managing a mental health condition like depression, bipolar disorder, or schizophrenia, the right medication can be life-changing. But the wrong dose, a missed check-up, or a poorly coordinated transition between providers can turn treatment into a danger. Medication safety in mental health isn’t just about giving the right pill-it’s about making sure every step of the process, from prescription to daily use, is designed to prevent harm.

Why Mental Health Medications Are Different

Psychotropic drugs-medications that affect the brain-are not like antibiotics or blood pressure pills. They work slowly, their effects are subtle, and stopping them suddenly can trigger severe withdrawal or even relapse. Lithium, clozapine, and certain antipsychotics carry serious risks if not monitored closely. For example, lithium requires regular blood tests every three months to stay within a safe range. But in England, only 40% of patients on lithium get those tests done, according to NHS England data from 2017.

These drugs also interact with other medications people may be taking for physical health issues-diabetes, heart disease, or chronic pain. When you combine mood stabilizers, antidepressants, and painkillers without checking for interactions, the risk of side effects like confusion, heart rhythm problems, or kidney damage goes up fast.

And then there’s the human factor. People with serious mental illness may struggle with memory, motivation, or trust. They might forget to take their meds, hide them to avoid side effects, or sell them to get money. In prisons and other secure settings, medication diversion is a documented problem. One nurse in Saskatchewan reported having to watch patients swallow their pills to make sure they weren’t hiding them.

The Three Big Risks: Medication, People, and Systems

The World Health Organization breaks down the biggest dangers into three areas:

• Medication: High-alert drugs like clozapine and lithium need special handling. They’re powerful, have narrow safety windows, and can cause organ damage if levels get too high.
• People: Impaired thinking, communication gaps, or trauma can make it hard for patients to understand instructions. Doctors may not know the full history, especially if care is split between a primary care provider and a psychiatrist.
• Systems: Paper records, rushed appointments, and poor handoffs between hospitals, clinics, and jails create blind spots. A patient discharged from a psychiatric unit might get sent home with a new prescription-but no one tells their family doctor.

These three risks often stack up. A patient with schizophrenia gets discharged from the hospital with five new meds. Their primary care doctor doesn’t know about the discharge. The pharmacy doesn’t flag interactions. The patient forgets to take one because they’re paranoid the pill is poisoned. Within weeks, they’re back in the ER.

What Works: Proven Strategies for Safer Care

There are clear, evidence-backed ways to reduce harm. They’re not fancy. They’re simple-but they require discipline.

1. Medicines Reconciliation at Every Transition

Every time a patient moves from one care setting to another-hospital to home, jail to clinic, emergency room to outpatient care-a full list of all their medications must be reviewed and verified. This isn’t just checking what’s written on a slip of paper. It means asking: Why is this drug here? Is it still needed? Has the dose changed?

New Zealand’s health commission found that formal reconciliation cuts medication errors by up to 60%. In practice, that means a pharmacist or nurse sits down with the patient and their records-community prescriptions, hospital discharge summaries, even notes from the jail infirmary-and builds one accurate list. No assumptions. No guesses.

2. Electronic Prescribing

Handwritten prescriptions are a relic-and a danger. Illegible writing, wrong doses, forgotten refills-all common with paper. Electronic systems reduce these errors by 55%, according to New Zealand’s 2021 review. They flag drug interactions, remind doctors about required blood tests, and send alerts when a patient hasn’t picked up a prescription.

But technology alone isn’t enough. If the system doesn’t connect mental health records with primary care, you still have gaps. The goal is one shared record that follows the patient-no matter where they go.

3. Clinical Pharmacists in the Team

Pharmacists aren’t just the people who hand out pills. They’re medication experts. When they’re part of the mental health team, error rates drop by 25%. They review all meds for interactions, check if doses are appropriate for age or kidney function, and educate patients in plain language.

In New Zealand, some clinics now have a dedicated medicines coordinator-a pharmacist or nurse who tracks who’s on what, when tests are due, and who needs a follow-up. That person becomes the glue holding the system together.

4. The Ten Rights and Three Checks

In Saskatchewan, psychiatric nurses use a strict framework called the “Ten Rights and Three Checks.” Before giving any medication, they verify:

• Right patient
• Right medication
• Right dose
• Right route
• Right time
• Right documentation
• Right reason
• Right response
• Right to refuse
• Right education

And they check it three times: when pulling the med, when preparing it, and when giving it. No shortcuts. This system cuts down on mistakes caused by distraction or fatigue.

Red Flags: When Medication Safety Is at Risk

Watch for these warning signs:

• More than five psychiatric medications prescribed at once-polypharmacy increases side effects and confusion.
• Antidepressants like mirtazapine prescribed for sleep or anxiety without a clear diagnosis. This is off-label use and increases risk of misuse.
• No documented reason for each medication. If a doctor can’t say why a drug was started, it shouldn’t still be going.
• Missing blood tests for lithium, clozapine, or valproate. These aren’t optional-they’re life-saving.
• Patients stopping meds suddenly because they feel fine. Many don’t realize stopping can cause seizures, psychosis, or suicidal thoughts.

In one case, a man in his 50s stopped his antipsychotic because he thought he was “cured.” Two weeks later, he was hospitalized with hallucinations and severe agitation. His family didn’t know the risks. His doctor didn’t follow up.

Who’s Responsible? It Takes a Team

Medication safety isn’t the job of one person. It’s a team sport.

• Patients and families: They need to know what each drug is for, what side effects to watch for, and when to call for help.
• Psychiatrists: Must document the reason for every prescription and coordinate with primary care.
• Primary care doctors: Often the first to see patients in crisis. They need training on mental health meds-not just physical health.
• Pharmacists: Must review all meds, flag interactions, and educate patients.
• Nurses: Implement safety checks, observe medication use, and report concerns.

In England’s prison system, they’ve started using shared care plans. A psychiatrist and a GP sign off together. A pharmacist reviews all meds monthly. A nurse checks for diversion. That’s the standard every community clinic should aim for.

What You Can Do-Whether You’re a Patient or a Caregiver

You don’t need to be a doctor to help keep someone safe.

• Keep a written list of every medication-name, dose, reason, and when it was started. Update it every time something changes.
• Ask: “Why am I taking this? What happens if I stop?” Don’t accept vague answers.
• Ask for a copy of your discharge summary when leaving a hospital or clinic. Bring it to your next doctor’s visit.
• Use a pill organizer with alarms. If you’re worried about forgetting, ask if a family member or nurse can supervise doses.
• Report if you’re being asked to take a med you don’t recognize-or if you’re being pressured to stop one suddenly.

If you’re a caregiver, don’t assume the system has it covered. Follow up. Ask questions. Be the advocate.

Where We’re Falling Short

Despite all the guidelines, gaps remain. General practitioners often lack training in mental health meds. One study from King’s College London found many GPs don’t know how to manage lithium or recognize early signs of toxicity. In rural areas, there’s no pharmacist on-site. In jails, records are paper-based and disconnected.

We’re also missing follow-up. Patients leave the hospital with a prescription and a pamphlet. No one calls to see if they picked it up. No one checks if they’re having side effects. That’s not care-that’s neglect.

The Bottom Line

Medication safety in mental health isn’t about perfection. It’s about consistency. It’s about making sure no one slips through the cracks because of a broken system. The tools exist. The guidelines are clear. What’s missing is the will to use them everywhere, every time.

It’s not enough to prescribe the right drug. You have to make sure it’s taken the right way, monitored the right way, and stopped the right way. Because for someone with a mental illness, the difference between safety and harm can come down to one missed blood test-or one unanswered question.