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

Nov, 25 2025

When someone is taking medication for depression, bipolar disorder, or schizophrenia, the stakes are higher than most people realize. A missed dose, a wrong pill, or a drug interaction can send a person into crisis - sometimes with deadly results. In mental health care, medication safety isn’t just about following rules. It’s about keeping people alive, stable, and connected to their lives.

Think about it: a person on lithium for bipolar disorder needs regular blood tests to avoid kidney or thyroid damage. But in England, only 40% of patients on lithium get those checks done. That’s not a glitch. It’s a system failure. And it’s not rare. Across the UK, US, and New Zealand, similar gaps show up in care coordination - especially when patients move between hospitals, prisons, GPs, and community teams.

Why Mental Health Medications Are Different

Not all drugs are created equal. Psychotropic medications - things like clozapine, valproate, or high-dose antidepressants - carry unique risks. They affect the brain, which means side effects aren’t just physical. They can change how someone thinks, feels, or even remembers to take their pills.

And here’s the catch: people with serious mental illness often have other health problems too. They might be on blood pressure meds, diabetes drugs, or painkillers. Add in alcohol or street drugs, and you’ve got a chemical cocktail that can go wrong in dozens of ways. This is called polypharmacy - and it’s one of the biggest killers in mental health care.

Unlike a broken leg, where the treatment is clear, mental health meds require constant tuning. A dose that works today might cause dizziness or weight gain next month. And if the person doesn’t understand why they’re taking it, they might stop cold turkey. That’s dangerous. Suddenly stopping antipsychotics can trigger psychosis. Tapering off benzodiazepines without help can cause seizures.

The Ten Rights and Three Checks: A Lifesaving Routine

In Saskatchewan, psychiatric nurses use a simple but powerful system called the ten rights and three checks. It’s not fancy. But it works.

The ten rights are:

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

And the three checks? Do them every single time:

Check when you pull the medication from the cabinet
Check when you prepare it
Check when you hand it to the patient

This isn’t bureaucracy. It’s a barrier against error. In one UK prison, staff started using this method after two patients were hospitalized due to wrong meds. Within six months, medication errors dropped by 68%.

Medicines Reconciliation: The Bridge Between Care Settings

The biggest danger happens when someone moves from one care setting to another - say, from a hospital to a GP’s office, or from the community into prison.

That’s when meds get lost. A patient might be on five drugs in the hospital. When they’re discharged, the GP doesn’t know about two of them. Or worse - they get prescribed something new without knowing what’s already being taken.

That’s where medicines reconciliation comes in. It’s not just a form. It’s a conversation. A trained pharmacist or nurse sits down with the patient, their family, and every provider involved. They compare every pill, patch, and injection - from the hospital, the pharmacy, the home, even the street.

New Zealand’s health commission found that when this process is done properly, medication discrepancies drop by more than half. But here’s the problem: it’s not always done. In NHS England’s own report on Health and Justice settings, they admitted that many prisons don’t have the staff or systems to do this well. Patients get moved, meds get dropped, and nobody notices until they’re back in A&E.

Electronic Prescribing: Less Handwriting, Fewer Mistakes

Handwritten prescriptions are a relic. They’re hard to read. Easy to misinterpret. And in mental health, where doses are often tiny and critical, that’s a recipe for disaster.

Electronic prescribing cuts errors by up to 55%. No more confusing scribbles. No more mix-ups between similar-sounding drugs like sertraline and selegiline. Systems flag dangerous combinations - like lithium and NSAIDs, which can spike lithium levels to toxic levels.

But technology alone doesn’t fix the problem. One GP practice in Bristol started using e-prescribing but still had issues because they didn’t link their system to the local mental health team’s records. The patient’s antipsychotic was listed in the hospital system - but not in the GP’s. The GP prescribed an antidepressant that interacted badly. The patient had a seizure.

Integration matters. Systems need to talk to each other. That means shared platforms, real-time updates, and clear access rules - not just fancy software.

Prisoners trading pills in a chaotic yard while disconnected medical records float apart, until a pharmacist connects them.

The Silent Crisis: Off-Label Use and Medication Diversion

Doctors sometimes prescribe antidepressants like mirtazapine for sleep or anxiety - even when the patient doesn’t have depression. It’s called off-label use. And in mental health settings, it’s common.

NHS England warns this practice increases the risk of diversion. That means the pills get sold, traded, or hoarded. In prisons, a single mirtazapine tablet can be worth £20. Patients trade them for food, cigarettes, or protection.

And when someone’s taking meds for sleep, not mood, they don’t understand why they’re on them. They stop. They get worse. Or worse - they overdose trying to get the same effect.

There’s a better way. Instead of prescribing mirtazapine for insomnia, use cognitive behavioral therapy for sleep (CBT-I). It’s just as effective, with no risk of abuse. But it takes time. And many GPs don’t have the training - or the funding - to offer it.

Who’s Responsible? The Team That Keeps People Safe

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

Here’s who needs to be in the room:

The patient - their voice matters. Do they understand why they’re on this med? Can they describe side effects?
The psychiatrist - they know the diagnosis, the goals, the risks.
The GP - they manage the whole body, not just the mind.
The pharmacist - they spot interactions, check doses, track levels.
The nurse - they see the daily reality: Did the patient take it? Did they vomit it up? Are they hiding pills?
The care coordinator - they link it all together. Especially during transitions.

At its best, this team meets regularly. They review meds. They adjust. They document. They talk to each other. In New Zealand, some teams use joint case conferences - a scheduled meeting where everyone shares updates. It’s simple. But it cuts hospital readmissions by 30%.

Therapeutic Drug Monitoring: The Numbers That Save Lives

Some meds need blood tests. Not because they’re dangerous - but because they’re precise.

Lithium, for example, works best when blood levels are between 0.6 and 0.8 mmol/L. Below that? It doesn’t help. Above that? It poisons you. NICE says you should test every three months. But in practice? Only 4 in 10 patients get checked.

Clozapine is even stricter. It can cause a dangerous drop in white blood cells. That’s why patients on it need weekly blood tests for the first six months. But in many areas, patients are told to go to their local lab - and then forgotten. No one follows up. No one calls if the count drops.

That’s not negligence. It’s fragmentation. Someone assumes someone else is doing it. And in mental health, where people often miss appointments or lose contact, that gap becomes a chasm.

A diverse care team holding hands around a glowing pill bottle, with digital health data swirling around them in rainbow colors.

Training Is the Missing Link

Dr. Sarah Ashcroft from King’s College London found something shocking: many GPs feel unprepared to manage mental health meds. They know how to treat high blood pressure. But when a patient comes in on olanzapine, they don’t know the side effects, the monitoring needs, or how to talk to a psychiatrist about it.

It’s not their fault. Medical school barely covers psychopharmacology. And once they’re in practice, there’s no time or money for ongoing training.

But change is possible. In one NHS trust in the West Country, they started a monthly mental health med clinic. GPs bring their toughest cases. A psychiatrist and a clinical pharmacist join by video. They review meds. They learn. They ask questions. After six months, GPs reported feeling 70% more confident managing complex cases. And medication errors dropped.

What Needs to Change - Right Now

Here’s what works - and what’s still missing:

Do: Use electronic prescribing with alerts for drug interactions.
Do: Implement medicines reconciliation at every transition - hospital, prison, GP, home.
Do: Train every clinician in the ten rights and three checks.
Do: Make therapeutic drug monitoring mandatory - and track who’s getting tested.
Don’t: Prescribe antidepressants for sleep without a diagnosis.
Don’t: Assume someone else is monitoring the patient.
Don’t: Let paper records be the only source of truth.

Medication safety in mental health isn’t about perfection. It’s about consistency. It’s about making sure the person who needs help gets it - every day, in every setting, with no gaps.

Why are mental health medications more dangerous than other drugs?

Mental health medications affect brain chemistry, which can change how a person thinks, feels, or remembers to take them. Many are high-alert drugs - like lithium or clozapine - where small changes in dose can cause serious harm. They’re also more likely to interact with other meds, alcohol, or street drugs. Plus, patients may have trouble communicating symptoms or sticking to a schedule, making errors more likely and harder to catch.

What is medicines reconciliation, and why is it important?

Medicines reconciliation is the process of comparing a patient’s current medications with what they were taking before a care transition - like moving from hospital to home or prison to community care. It catches missing, duplicate, or incorrect drugs. Without it, patients often get the wrong meds or stop taking something vital. Studies show it cuts medication errors by over 50% when done properly.

Can electronic prescribing really reduce errors in mental health care?

Yes. Electronic systems eliminate handwriting errors, flag dangerous drug interactions, and remind providers about required monitoring - like blood tests for lithium. In New Zealand, hospitals using e-prescribing saw prescribing errors drop by 55%. But the system only works if it’s connected to other care records. If the GP’s system doesn’t talk to the hospital’s, the safety net fails.

Why do some patients on lithium miss their blood tests?

Many factors: patients forget, don’t understand the need, or lose contact with services. Some live far from labs. Others fear the results or feel stigmatized. But the biggest reason? No one is assigned to follow up. NHS data shows only 40% of lithium patients in England get the required checks - even though guidelines say it’s mandatory every three months. That’s not a patient problem. It’s a system failure.

Is off-label prescribing of antidepressants for sleep safe?

No - and it’s risky. Drugs like mirtazapine are often prescribed for sleep, even without depression. But they’re not approved for that use, and they carry high risks of weight gain, drowsiness, and misuse. In prisons, they’re traded like currency. NHS England specifically warns against this practice. Better alternatives include CBT-I, sleep hygiene education, or short-term use of approved sleep aids - under supervision.

Who should be on a patient’s mental health medication team?

The patient, their psychiatrist, their GP, a clinical pharmacist, a mental health nurse, and a care coordinator. Each has a role: the psychiatrist sets the treatment plan, the GP manages overall health, the pharmacist checks for interactions, the nurse observes daily use, and the coordinator ensures everyone’s on the same page - especially during transitions. Without this team, safety gaps appear.

Next Steps: What You Can Do

If you’re a patient or family member: Ask for a full meds review. Write down every pill, supplement, and patch you take. Bring it to every appointment. Ask: “Why am I on this? What happens if I stop? Do I need blood tests?”

If you’re a clinician: Use the ten rights and three checks every time. Push for e-prescribing. Advocate for joint case reviews. Don’t assume someone else is monitoring a patient. Document everything - clearly.

If you’re a policy maker: Fund integrated systems. Train GPs. Pay for clinical pharmacists in mental health teams. Make therapeutic drug monitoring mandatory and track compliance. Stop letting paperwork replace care.

Medication safety in mental health isn’t a bonus. It’s the foundation. Get it right, and people live. Get it wrong, and the cost is measured in lives lost - and families shattered.