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

When someone is managing a mental health condition, medication isn’t just another pill in a routine-it’s often the difference between stability and crisis. But here’s the hard truth: medication safety in mental health care is falling through the cracks. People are getting the wrong dose, missing critical blood tests, or having their meds stopped abruptly during hospital transfers-all because systems aren’t talking to each other. And the consequences? Hospitalizations, overdoses, even deaths that could have been prevented.

Why Mental Health Medications Are Different

Psychotropic drugs aren’t like antibiotics or blood pressure pills. They affect how your brain works. Lithium, clozapine, valproate-these aren’t just medications. They’re high-alert drugs. One wrong dose, and you could end up with kidney damage, seizures, or life-threatening blood disorders. Yet, they’re often prescribed in settings where staff aren’t trained to handle them safely.

In general medical wards, nurses check the five rights: right patient, right drug, right dose, right route, right time. In mental health units? Many still rely on paper charts, unclear handwriting, and rushed handovers. A 2021 review from New Zealand’s Health Quality & Safety Commission found that over 40% of medication errors in psychiatric care happened during transitions-when someone moved from a hospital to a community clinic, or from prison to home.

And it’s not just about mistakes. Patients with serious mental illness often struggle with memory, motivation, or trust. They might skip doses because they don’t feel like taking pills. Or they might hide them to sell or trade. One nurse in Saskatchewan told me, “I’ve had patients swallow meds and then say they didn’t take them. We have to watch them take every pill-no exceptions.”

The Breakdown in Care Coordination

Imagine this: You’re discharged from a psychiatric hospital on lithium. Your discharge summary says “continue 600mg daily.” But your GP, who’s never treated someone on lithium before, doesn’t know you need monthly blood tests to check your kidney and thyroid function. Three months later, you’re dizzy, nauseous, and your lithium level is dangerously high. That’s not a rare case. In England, only 40% of patients on lithium get the required blood tests in primary care.

Why? Because mental health care and physical health care are still treated like separate worlds. Your psychiatrist sees you every six weeks. Your GP sees you for a cold. Your pharmacist fills the script. Nobody connects the dots.

NHS England’s 2017 guidelines pointed this out clearly: “Medicines reconciliation must happen every time a person moves between settings.” But in practice? It rarely does. In prisons, where mental illness rates are 3-5 times higher than the general population, medication errors are even more common. People come in on one set of meds, get switched without proper review, and leave with no plan.

What Actually Works: The Proven Fixes

The good news? We know what reduces harm. And it’s not fancy tech-it’s simple, repeatable systems.

• Medicines reconciliation isn’t optional. Every time someone enters or leaves a hospital, prison, or care home, their entire medication list must be reviewed side-by-side with what they were taking before. No assumptions. No “I think they were on…”
• Electronic prescribing cuts prescribing errors by up to 55%. No more illegible handwriting. No more wrong doses because someone misread “0.5” as “5.”
• Clinical pharmacists embedded in mental health teams reduce errors by 25%. They spot drug interactions, check if a dose is too high for an elderly patient, or flag that mirtazapine is being used off-label for sleep-something NHS England warns can lead to abuse.
• The ten rights and three checks (used in Saskatchewan and adopted elsewhere) go beyond the basics. Right patient. Right medication. Right dose. Right route. Right time. Right documentation. Right reason. Right response. Right to refuse. Right education. And you check all of them before, during, and after giving the med.

One clinic in Perth started using a shared digital care plan. Every time a patient saw a GP, psychiatrist, or pharmacist, the same document updated in real time. Within six months, missed lithium checks dropped from 60% to 12%. No magic. Just consistency.

Polypharmacy: The Silent Killer

Many people on mental health meds are also taking pills for diabetes, high blood pressure, pain, or sleep. That’s not unusual. But when you stack five, six, or seven drugs together-especially with antipsychotics, antidepressants, and benzodiazepines-the risk of dangerous interactions skyrockets.

A 2023 study in the UK found that 1 in 3 patients on multiple psychotropics had at least one potentially harmful interaction. Some combinations can slow your heart to a dangerous rhythm. Others can make you fall over from dizziness. Yet, prescribers rarely sit down and ask: “Do you really need all of these?”

NICE guidelines say: “Ask three questions before prescribing: Is it safe? Does it work? Is it necessary?” Too often, the answer is “We’ve always done it this way.”

The fix? Regular med reviews. Every three months. With the patient present. With a pharmacist. With a checklist. If a drug isn’t helping, or if it’s causing more harm than good, it should come off. Not just “left on” because no one remembered to take it off.

Who’s Responsible? The Culture Shift

Medication safety isn’t just the job of the psychiatrist or the pharmacist. It’s everyone’s job.

- Doctors need to write clear, specific prescriptions-not “take as needed” for antipsychotics. Include the reason: “For auditory hallucinations, not sedation.”

- Nurses need training on high-alert meds. Not just how to give them, but how to spot early signs of toxicity.

- Pharmacists need access to mental health records. Right now, most community pharmacies don’t even know their patient is on clozapine.

- Patients need to be partners, not passive recipients. They should know why each med is prescribed, what side effects to watch for, and who to call if something feels wrong.

And here’s the biggest barrier: blame culture. When something goes wrong, people get punished. That makes staff hide mistakes. The fix? A “just culture.” One where errors are reported without fear, systems are fixed, and learning happens. The American Society of Health-System Pharmacists says this isn’t optional-it’s foundational.

What You Can Do Right Now

If you’re a patient or a caregiver:

• Keep a written list of every medication you take-including doses, times, and why you’re taking them.
• Ask your prescriber: “Is this still necessary? Could anything be taken off?”
• For lithium, clozapine, or valproate: Ask if you need regular blood tests-and if you’ve had them in the last 3 months.
• Don’t stop meds suddenly. Even if you feel fine, some drugs can cause seizures or psychosis if stopped cold turkey.
• Ask for a care coordinator. Someone who knows your whole history and can make sure your GP, psychiatrist, and pharmacist are all on the same page.

If you’re a clinician:

• Use electronic prescribing. If your clinic still uses paper, push for change.
• Start every visit with: “What meds are you taking now?” Not “Are you still on your meds?”
• Document the reason for every prescription. Not just “depression.” Say “sertraline for low mood and fatigue, target dose 100mg.”
• Involve a pharmacist in your team meetings. Even once a month.

The Bottom Line

Medication safety in mental health isn’t about perfection. It’s about reducing preventable harm. We know how to do it. We’ve got the tools. We’ve got the guidelines. What’s missing is the will to make it routine.

The WHO calls mental health medication safety a “high-risk situation” for a reason. But high-risk doesn’t mean hopeless. It means urgent. And urgent means acting now-before the next person falls through the cracks.