Prescribing the “right” psychotropic medication isn’t about guessing or relying on trial-and-error—it’s about building a strong clinical foundation. When PMHNPs prescribe psychotropic medications using a structured, step-by-step approach, they move from haphazard care to confident, competent decision-making.
Even five different providers might recommend five different treatment plans for the same patient—but what matters most is how they got there.
A Step-by-Step Approach to Prescribing
The key to safe, effective prescribing begins before the prescription pad ever comes out. Here’s a breakdown of the steps that support confident prescribing.
1. Begin With a Thorough Assessment
Use validated screeners to help rule out conditions and gather objective data. A comprehensive psychiatric evaluation should explore symptoms, psychosocial history, risk factors, and more. The assessment is the foundation upon which all subsequent decisions will be made.
2. Keep the Assessment Ongoing
The assessment doesn’t stop after the initial visit. Every follow-up offers an opportunity to clarify the clinical picture, monitor symptoms, and refine your diagnosis. Not only is it sometimes not possible to collect all the assessment data we need in that first appointment, but oftentimes information changes or needs updated. Use subsequent sessions to continue your assessment.
3. Create a Working Diagnosis
It’s okay if you don’t land on the exact diagnosis right away. Develop a working diagnosis and maintain a differential diagnoses list. For example, your working diagnosis might be Major Depressive Disorder and your differential diagnoses might include Bipolar II disorder and PTSD.
Clinical clarity often unfolds over time. This step is critical in aligning your treatment plan with evidence-based prescribing guidelines (American Family Physician) that emphasize accurate diagnosis before initiating medication management.
4. Don’t Rush to Prescribe
It can be tempting to prescribe something at the first visit—but sometimes, waiting is the safer choice. In certain scenarios, prescribing immediately can even be considered negligent.
5. Order Baseline Labs
Before initiating medication, gather baseline labs such as a CBC with differential, CMP, TSH, lipid panel, and vitamin D levels to ensure there are no underlying medical concerns.
6. Collaborate with the Patient
Review the diagnosis, lab results, and history, then discuss medication options. Patients’ preferences, treatment goals, and past medication trials should all guide your choice. In fact, there’s an art to psychopharmacology with research that supports that how one prescribes has as much influence as what one prescribes.
Don’t Forget the Power of De-Prescribing
Prescribing isn’t always about adding something new. Sometimes, the most therapeutic action is removing a medication that’s no longer appropriate. But de-prescribing—an essential skill for PMHNPs—is rarely taught in school or addressed in typical clinical training.
That’s why I brought in an experienced psychiatric nurse practitioner to lead a special session on de-prescribing inside the Mental Health Mastermind community which is included in my Mental Disorders Crash Course. The session recording is now available for all community members to go back and watch anytime. This event is just one of the many resources included in the Mental Disorders Crash Course.
Take the Next Step Toward Confident Prescribing
If you’re ready to take your ability to prescribe psychotropic medications (and de-prescribe them) to the next level, join the Mental Disorders Crash Course. Enrollment grants you access to expert training, clinical tools, and the supportive Mental Health Mastermind community.