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

When someone is taking medication for depression, bipolar disorder, or schizophrenia, the risk of harm doesn’t just come from the illness-it comes from how the medicine is managed. In mental health care, a simple mistake like missing a dose, mixing the wrong drugs, or failing to monitor blood levels can lead to hospitalization, suicide, or even death. Yet, across the UK and beyond, these errors happen far too often. The problem isn’t that doctors don’t care. It’s that the system isn’t built to keep people safe.

Why Mental Health Medications Are Different

Psychotropic drugs aren’t like antibiotics or blood pressure pills. They affect the brain. A small change in dose can turn a calm patient into someone agitated or suicidal. Lithium, for example, works well for bipolar disorder-but only if the blood level stays between 0.6 and 1.0 mmol/L. Too low, and it doesn’t work. Too high, and it causes tremors, confusion, or kidney damage. NICE guidelines say lithium levels should be checked every three months. But in England, only 40% of patients get those checks. That’s not negligence-it’s a system failure.

Clozapine, used for treatment-resistant schizophrenia, is even more dangerous. It can lower white blood cell counts, leaving patients vulnerable to infections. That’s why it requires weekly blood tests for the first six months. Yet, in prisons and community settings, these tests are often missed because no one is tracking them. Patients get discharged from hospital, handed a prescription, and told to see their GP. But GPs rarely have the training or time to manage complex psychiatric meds.

The Hidden Risks: Polypharmacy and Diversion

Many people with mental illness are on five, six, or more medications. One for depression, one for anxiety, one for sleep, one for high blood pressure, maybe a painkiller, and a drug for diabetes. This is called polypharmacy. It’s common. And it’s deadly.

The risk isn’t just side effects adding up. It’s interactions. A common sedative like mirtazapine, prescribed off-label for insomnia, can be diverted and misused. NHS England has warned against this practice because it increases the chance of overdose, especially when mixed with alcohol or opioids. In prisons, where mental illness rates are three times higher than the general population, medication diversion is a real problem. Pills are hoarded, traded, or crushed and snorted. Staff in secure units must watch patients swallow every pill-no exceptions.

In community settings, patients might stop taking meds because they feel better-or because they’re afraid of side effects. Or they might take extra doses to feel calmer. Without regular check-ins, these behaviors go unnoticed until it’s too late.

Medicines Reconciliation: The Lifeline Between Settings

The biggest gap in safety happens when patients move between care settings. From hospital to home. From prison to community clinic. From emergency room to psychiatrist’s office. Each time, the medication list changes. Someone forgets to mention a drug. A prescription gets lost. A pharmacist doesn’t know the patient’s full history.

Medicines reconciliation is the fix. It means comparing the patient’s current meds with what’s being prescribed at each transition. It’s not just checking a list. It’s asking: Why is this drug here? Is it still needed? Has the dose changed? Is there a better alternative?

New Zealand’s Health Quality & Safety Commission found that when reconciliation is done properly, medication errors drop by up to 60%. But it only works if it’s mandatory-and documented. In England, NHS guidelines say every transition must include a full review by a pharmacist or mental health nurse. But in practice, it’s often skipped during busy shifts or when records are disconnected.

Technology Can Help-If It’s Used Right

Electronic prescribing systems cut prescribing errors by 55%. No more illegible handwriting. No more wrong doses. No more missed drugs. But technology alone won’t fix the problem.

Many GP systems don’t talk to mental health hospital systems. A patient gets discharged from a psychiatric unit with a new medication. Their GP doesn’t see it. Two weeks later, they show up in A&E with confusion. Why? Because the new drug wasn’t added to their GP record.

The solution isn’t just better software. It’s connected software. Systems need to share data securely across primary care, mental health teams, pharmacies, and prisons. Clinical pharmacists need real-time access to medication histories. And every patient should have a single, updated list-printed and digital-that travels with them.

Who’s Responsible? The Team Approach

Medication safety in mental health can’t fall on one person. It needs a team.

- Psychiatrists must document why each drug is prescribed and when it should be reviewed.

- General practitioners need training in psychotropic meds-not just how to prescribe, but how to monitor.

- Pharmacists should be part of every transition. They’re the last line of defense against errors.

- Nurses and care workers must be trained in the ‘ten rights and three checks’: right patient, right drug, right dose, right route, right time, right documentation, right reason, right response, right to refuse, right education. And they must check each time, every time.

In Saskatchewan, psychiatric nurses are required to watch patients swallow their meds. In New Zealand, care teams hold joint case conferences with GPs and psychiatrists every month. These aren’t luxuries-they’re safety nets.

What Patients and Families Can Do

Patients shouldn’t have to fight the system to stay safe. But they can protect themselves.

- Keep a written list of every medication, including doses and why they’re taken.

- Ask: “What is this for? What happens if I stop it?”

- Know the signs of overdose or toxicity: dizziness, slurred speech, confusion, irregular heartbeat.

- If you’re being discharged, ask for a copy of your updated meds list-and confirm it’s sent to your GP.

- If you’re taking lithium or clozapine, ask if your blood levels are being checked-and when the next test is due.

Families can help by tracking changes in behavior. If someone suddenly becomes withdrawn, agitated, or confused after a med change, speak up. It could be a reaction, not just a mood swing.

The Road Ahead: What Needs to Change

We know what works. We have guidelines from NICE, WHO, and NHS England. We have evidence that reconciliation, pharmacists, and electronic systems reduce harm. But implementation is patchy.

The biggest barrier? Culture. Too many teams still treat medication safety as an afterthought. It’s seen as administrative, not clinical. But when a patient dies from a missed lithium check, it’s not administrative-it’s tragic.

We need:

• Mandatory medicines reconciliation at every transition-no exceptions.
• Training for all frontline staff on high-alert psychotropic drugs.
• Integrated digital records that follow the patient, no matter where they go.
• Pharmacists embedded in mental health teams-not just called in for emergencies.
• Regular audits to check if lithium and clozapine monitoring is happening.

And most of all, we need to stop treating mental health as separate from physical health. A person with schizophrenia needs heart checks, kidney tests, and blood work just like anyone else. Their meds don’t exist in a vacuum. Their safety doesn’t either.