Antipsychotic Medication Informed Consent Form

 About Antipsychotics

First- and second-generation antipsychotic medications are commonly used to manage a variety of psychiatric symptoms, including:

- Impulsivity and aggression
- Hallucinations, delusions, bizarre thinking, and paranoia
- Acute mania in Bipolar I disorder
- Depressive symptoms in bipolar disorder
- Treatment-resistant depression

Benefits When Used as Directed

When used as directed under medical supervision, antipsychotic medications can help:

- Reduce hallucinations and delusions
- Improve mood stability in bipolar disorder
- Control impulsivity and aggressive behavior
- Manage symptoms of mania and depression
- Improve overall functioning in patients with psychotic disorders

Side Effects and Risks of Antipsychotics

All medications have the potential to cause side effects, and these can vary from person to person. Below are some common, rare, and serious side effects associated with antipsychotic medications.

Common Side Effects

First-Generation Antipsychotics:

- Constipation
- Drowsiness
- Dry mouth
- Muscle stiffness

Second-Generation Antipsychotics:

- Weight gain
- Drowsiness
- Hyperglycemia (high blood sugar)
- Muscle stiffness

Rare Side Effects

- Tardive dyskinesia (involuntary muscle movements, e.g., mouth twitching)
- Elevated prolactin (hormone imbalance)
- Elevated liver enzymes
- Akathisia (a feeling of restlessness)

Serious Side Effects

Though rare, some side effects can be life-threatening:

- Neuroleptic malignant syndrome (severe muscle stiffness and high fever)
- Agranulocytosis (a severe reduction in white blood cells, particularly associated with clozapine)

Long-Term Use

Long-term use of antipsychotic medications, especially first-generation antipsychotics, may increase the risk of developing tardive dyskinesia, a condition characterized by involuntary muscle movements. Regular monitoring is essential to minimize this risk. Second-generation antipsychotics are associated with metabolic changes such as weight gain, high blood sugar, and increased cholesterol levels.

Safety and Monitoring

To ensure the safe use of antipsychotic medications, the following precautions and monitoring steps will be followed:

1. Initial and Regular Monitoring: Blood tests and other diagnostic tools will be used to assess hormone levels and monitor for potential side effects before starting treatment and regularly throughout the course of therapy.

2. Personalized Dosing: The dosage of antipsychotic medications will be individualized based on your specific needs and monitored closely to prevent overdosing or underdosing.

3. Comprehensive Medical History: A full review of your medical history will be conducted to identify any potential contraindications or risks associated with antipsychotic use.

4. Ongoing Communication: Regular follow-up appointments will be scheduled to monitor your progress, assess treatment effectiveness, and address any side effects or concerns.

5. Emergency Contact: If you experience severe symptoms such as high fever, muscle stiffness, chest pain, shortness of breath, or sudden changes in vision, seek immediate medical attention. Call 911 or go to the nearest emergency room.

1. Personal Use: I understand that my prescription is intended for personal use only. I will not share, sell, or trade my medication, as doing so is a violation of clinic policy and potentially dangerous to others. Such actions may result in the discontinuation of my prescription and termination of treatment.

2. Provider Notification: I will not seek antipsychotic medications from other providers without informing my prescriber to ensure safe and coordinated care.

3. Medication Disclosure: I will disclose all prescribed and over-the-counter medications, including supplements and herbal products, to avoid harmful interactions.

4. Dosage and Frequency: I will not alter the dosage or frequency of my medication without consulting my prescriber. Any changes to the dosage must be approved during scheduled appointments, not via phone, after hours, or on weekends or holidays.

5. Proper Use: Antipsychotic medications should be taken exactly as prescribed and not altered in form (e.g., crushed, injected, or snorted). Altering the form of the medication may affect its efficacy and safety.

6. Drug and Alcohol Interaction: I will not combine my medication with alcohol, recreational drugs, or other prescription medications without first consulting my prescriber. Combining antipsychotics with alcohol, opioids, or other sedating substances can be dangerous and potentially life-threatening.

7. Discontinuation and Withdrawal: I understand that abruptly stopping antipsychotic medication can cause withdrawal symptoms or a return of symptoms. I will consult with my prescriber before discontinuing or tapering off the medication.

8. Storage and Disposal: I will store my medications securely out of the reach of others, particularly children and pets. Unused or expired medication should be returned to the pharmacy for safe disposal.

9. Appointment and Refill Policy: I am responsible for scheduling regular appointments and for contacting the office at least 72 hours before running out of medication for refills. Refills will only be processed during office visits or regular office hours.

10. Renewal Conditions: Renewals of my prescription are contingent upon attending scheduled appointments and complying with medication instructions. If I need to cancel an appointment, I will notify the office at least 24 hours in advance by calling (617) 991-9151.

11. Adjunctive Management Programs: I agree to participate in adjunctive management programs recommended by my prescriber, such as psychotherapy, behavioral interventions, or complementary therapies. These programs are important in helping manage my overall treatment and well-being.

12. Pregnancy: If I become pregnant or plan to become pregnant during treatment, I will inform my prescriber immediately to discuss the risks to the fetus and to plan for potential medication adjustments. Failure to notify my prescriber may result in harm to my unborn child.

13. Information Sharing: I consent to the sharing of my medical information with other healthcare professionals involved in my care when deemed medically necessary to facilitate comprehensive and coordinated treatment.

• I certify that I have read this form in its entirety. I have had the opportunity to ask questions and seek clarification on anything unclear to me. All my questions and concerns have been adequately addressed.
• I fully understand the content of this form and have no further questions. I consent to the use of antipsychotic medications as part of my treatment plan, and I understand that my treatment will be governed by this agreement.
• I accept the risks, conditions, and terms of the proposed treatment. I understand that my prescriber reserves the right to discontinue or alter my treatment plan at their discretion. I acknowledge that failure to comply with this agreement may result in the discontinuation of my antipsychotic prescription and/or termination from the practice.
• By signing this form, I voluntarily consent to treatment and accept the associated risks. I also consent to the use of electronic records and signatures and acknowledge that I have read the related consumer disclosure.

By providing my electronic signature below, I agree to the terms and conditions outlined in this agreement. I agree to the use of electronic records and signatures. I acknowledge that I have read the related consumer disclosure.

The parties acknowledge and agree that this financial agreement form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via PDF) of an original signature.