QT prolongation

 Consider QT prolongation risk and relative benefits of medications, particularly when combining high-dose methadone (>150 mg) with QT-prolonging agents such as antipsychotics or antidepressants, or when patients are in alcohol withdrawal, or use cocaine or methamphetamine.
Provide psychoeducation, monitor ECG (especially before and after initiating medication) and consider cardiology referral if there is QTc prolongation or a complex cardiac history.

Bipolar disorder

Avoid antidepressants or consider them only after comprehensive psychiatric assessment because they can precipitate mania in bipolar disorder. Mood-stabilizing medications such as valproate or lithium require careful monitoring and psychiatric assessment.
Consider a medication that is safe for both prevention/treatment of mania and depression such as quetiapine or aripiprazole if mania is a concern.

Renal function

Adjust doses of medications such as lithium and pregabalin in patients with renal impairment because they undergo renal clearance.

Hepatic function

Remember that certain medications (e.g., duloxetine, valproate) undergo hepatic metabolism and are contraindicated in hepatic impairment or require dose adjustment (e.g., fluoxetine).

Drug-drug interactions

Work with the pharmacy team/pharmacist to identify drug interactions, including those related to cytochrome P450 enzyme inhibition or induction (e.g., vortioxetine, bupropion).

Metabolic monitoring

Monitor for metabolic side effects in patients on antipsychotic medications for any indication (e.g., psychosis, mood augmentation). Manage cardiometabolic risks.
Metabolic monitoring tools from the Early Psychosis Intervention Ontario Network

Safety assessments

Develop a safety plan because patients with mental health and substance use disorders are at risk of self-harm, harm to others and reduced self-care. The plan should include reducing the patient’s access to means such as medications that have overdose potential.

Free CAMH Safety Planning mobile app.

Neurocognitive disorders

Recognize that patients may have neurocognitive disorders (dementia) due to use of substances such as alcohol, or they may have other concurrent disorders (traumatic brain injuries, cardiovascular disorders).
Refer these patients to primary care or a memory clinic and ensure reversal of treatable causes (e.g., thiamine replacement).
Consider the need for medication reconciliation and discontinuing or tapering medications such as benzodiazepines or anticholinergic medications that increase delirium risk.
Older adults’ mental health and medication resources: CCSMH and GeriMedRisk

Seizure history

Do not use bupropion in patients with elevated risk of seizures (significant alcohol use, sedative or hypnotic use disorder/withdrawal, history of seizures such as from fentanyl).

Pregnancy

Ensure informed consent in discussions about psychopharmacology in pregnancy. Risks of treatment versus risks of untreated mental health disorder must be carefully considered.
Consider referral to perinatal mental health services and coordination of care with pregnancy care providers. Some medications have serious risks and are contraindicated in pregnancy (e.g., valproate).
Pregnancy and medication resources: Best Use of Medicine in Pregnancy and LactMed

Polypharmacy

Conduct medication reconciliation and ensure strong communication with primary care providers and other prescribers. Polypharmacy can lead to serotonin syndrome with many classes of medications (SSRIs, opioids, TCAs).
CredibleMeds medication safety resource

Download the PDF of Concurrent Disorders and Stimulant Use Disorder: A Pocket Guide to Treatment

Collaborating with Families Affected By Concurrent Disorders - A CAMH Continuing Professional Development Course

Concurrent Disorders in Primary Care - A CAMH CPD Course

Concurrent Disorders: Treatment Approaches and Applications - A CAMH CPD Course

Core Concepts of Concurrent Disorders - A CAMH CPD Course

Treating Conditions & Disorders

Concurrent Disorders Overview

Concurrent Disorders 101 - A free online tutorial

Treating Concurrent Disorders A Guide for Counsellors 

A Family Guide to Concurrent Disorders 

Partnering With Families Affected by Concurrent Disorders   

Concurrent addiction and mental health disorders: An information guide 

COMPASS - The Concurrent Outpatient Medical & Psychosocial Addiction Support Services is an outpatient service for clients with addiction/concurrent disorder concerns  

Access CAMH - Treatment Programs at CAMH