Medication Treatment for the Severely and Persistently Mentally Ill: The Texas Medication Algorithm Project

A. John Rush, M.D.; William V. Rago, Ph.D., M.B.A.; M. Lynn Crismon, Pharm.D.; Marcia G. Toprac, Ph.D.; Steven P. Shon, M.D.; Trisha Suppes, M.D., Ph.D.; Alexander L. Miller, M.D.; Madhukar H. Trivedi, M.D.; Alan C. Swann, M.D.; Melanie M. Biggs, Ph.D.; Kathy Shores-Wilson, Ph.D.; T. Michael Kashner, Ph.D., J.D.; Teresa Pigott, M.D.; John A. Chiles, M.D.; Don A. Gilbert, M.B.A.; and Kenneth Z. Altshuler, M.D.

This article provides an overview of the issues involved in developing, using, and evaluating specific medication guidelines for patients with psychiatric disorders. The potential advantages and disadvantages, as well as the essential elements in the structure of algorithms, are illustrated by experience to date with the Texas Medication Algorithm Project, a public-academic collaboration. Phase 1 entailed assembling research findings on the efficacy of medications for schizophrenic, bipolar, and major depressive disorders. This knowledge was evaluated for its quality and relevance, integrated with expert clinical judgment as well as input by practicing clinicians, family advocates, and patients. Phase 1 (the design and development of the algorithms) was followed by a feasibility test (Phase 2). Phase 3 is an ongoing evaluation comparing the clinical and economic effects of using specific medication guidelines (algorithms) versus treatment as usual in public sector patients with severe and persistent mental illnesses.

(J Clin Psychiatry 1999;60:284-291)

Received April 15, 1998; accepted July 29, 1998. From the Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas (Drs. Rush, Suppes, Trivedi, Biggs, Shores-Wilson, Kashner, and Altshuler); the Texas Department of Mental Health and Mental Retardation, Austin (Drs. Rago, Toprac, and Shon and Mr. Gilbert); Pharmacy Practice and Administration, University of Texas at Austin College of Pharmacy (Dr. Crismon); the Department of Psychiatry, University of Texas Health Science Center at San Antonio (Drs. Miller and Chiles); Department of Psychiatry, University of Texas Health Science Center at Houston (Dr. Swann); and the Department of Psychiatry and Behavioral Sciences, University of Texas Medical Branch, Galveston (Dr. Pigott).

Supported in part by grants from the Robert Wood Johnson Foundation, the Meadows Foundation, the Moody Foundation, the Lightner Sams Foundation, the Nannie Hogan Boyd Charitable Trust, the Texas Department of Mental Health and Mental Retardation, the Center for Mental Health Services, the National Institute of Mental Health (MH-53799), United States Pharmacopieal Convention, Inc., Bristol-Myers Squibb Company, Eli Lilly and Company, Glaxo Wellcome Inc., Janssen Pharmaceutica Inc., Novartis Pharmaceuticals Corporation, Pfizer Inc, and Wyeth-Ayerst Laboratories, as well as Mental Health Connections, a partnership between Dallas County Mental Health and Mental Retardation and the Department of Psychiatry, University of Texas Southwestern Medical Center, which receives funding from the Texas State Legislature and the Dallas County Hospital District.

The authors thank David Savage and Karla Starkweather for secretarial support.

Reprint requests to: A. John Rush, M.D., Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75235-9086.