Algorithmic Treatment Planning – If This, Then What?

Case 1, Episode 5

“I know she needs help. But what if she stops taking the meds? What if it makes her worse? What if she drops out?”

— A concerned grandmother

By now, you’ve gathered Sarah’s story.

You’ve considered the full picture—biological, psychological, social, developmental, cultural.

You’ve held multiple diagnostic possibilities in mind: psychosis, bipolar disorder, trauma, stimulant-induced changes.

 Now the question becomes: What do we do about it—today, tomorrow, and over time?

Welcome to algorithmic treatment planning[1]: A stepwise, dynamic approach that allows for uncertainty, individualization, and constant adjustment. Because in psychiatry, rigid plans break people. Flexible frameworks build healing.

Why Treatment Needs a Decision Tree[2]
Most treatment plans are too static.

They look like this:

1. Start medication

2. Refer to therapy

3. Follow up in 2 weeks

But real-world treatment needs to sound more like this:

• If the patient improves with supportive care, delay medication.

• If symptoms persist after sleep is restored, consider trial of antipsychotic.

• If medication causes side effects or non-adherence, adjust dose, switch agent, or use LAI.

• If substance use worsens, shift focus to harm reduction first.

This is real psychiatric care. This is adaptive psychiatry[3].

Let’s apply it to Sarah.

Step 1: Stabilize the Basics (Maslow First)[4]
Before you prescribe anything, ask: Can she sleep? Eat? Stay safe? Stay connected?

Immediate Goals:

• Restore Sleep: Sleep is antipsychotic, antidepressant, and anti-inflammatory

• Nourishment: Malnutrition can mimic or worsen psychiatric symptoms

• Connection: Daily check-ins, text-based support, or peer linkage

• Containment: Create psychological safety before offering explanations

Decision Point:

If symptoms dramatically improve with sleep and support, consider waiting before medicating.

If symptoms persist or worsen despite stabilization, proceed to pharmacologic trial.

Step 2: Initiate Thoughtful Pharmacologic Support
Sarah is experiencing distressing paranoia and auditory hallucinations, with partial insight, functional decline, and family concern.

At this point, a low-dose antipsychotic trial may be indicated.

Options to Consider:

• Aripiprazole – for mild symptoms with mood features

• Risperidone – strong efficacy, often used first-line

• Olanzapine – effective but sedating and weight-promoting

Start Low, Go Slow:

• Begin at the lowest therapeutic dose

• Monitor side effects daily or every other day

• Reinforce shared decision-making—give Sarah a say

• Provide psychoeducation about the purpose of the medication: “This is to quiet the noise, not to change who you are.”

Decision Tree:

• If side effects emerge, consider switching or lowering dose

• If non-adherence is high, consider long-acting injectable (LAI)

• If psychosis resolves but mood instability continues, evaluate for mood stabilizer

Step 3: Integrate Therapy (Timing Matters)
Sarah may not yet be ready for deep trauma work.
But she does need containment, reflection, and grounding.

Start with:

• Supportive therapy: to process fear, rebuild trust

• Psychoeducation: about stress, brain, symptoms, and self

• Behavioral activation: gentle nudges toward routine and structure

• Family support: include her grandmother as an ally 

Decision Tree:

• If insight improves, consider trauma-informed or schema-based therapy

• If engagement is low, explore peer models, art therapy, or motivational strategies

• If fear dominates sessions, prioritize safety and attunement

Step 4: Build a Long-Term Plan
This isn’t just about crisis stabilization. It’s about rebuilding a life.

Long-Term Goals:

• Identity development

• Medication evaluation (tapering, switching, optimizing)

• Therapy depth work

• Purpose, school, and belonging

• Preventing relapse or disengagement

Monitoring:

• Weekly follow-ups at first, then biweekly

• Safety plans and relapse prevention strategies

• Shared dashboards: sleep, symptoms, functioning

• Collaboration with school, family, or supports

Decision Tree:

• If she returns to class and stabilizes, continue slow med taper discussions

• If she relapses after stopping meds, reconsider diagnosis, dosing, and engagement

• If trauma surfaces later, adjust therapy focus accordingly 

A Sample Algorithm

1. Assess basic needs:
   a. Sleep/nutrition intact → Proceed
   b. Not intact → Stabilize first

2. Evaluate symptom severity:
   a. Mild → Supportive care + monitoring
   b. Moderate-severe → Consider med trial

3. Med trial outcomes:
   a. Improves → Maintain, monitor, explore therapy
   b. No response → Reassess dx, switch meds, consider LAI

4. Therapy integration:
   a. Engaged → Build insight and skills
   b. Withdrawn → Use engagement strategies, consider peer-led

5. Ongoing care:
   a. Stable → Taper plan, growth work
   b. Relapse → Refine dx, deepen support

Coming Up Next: Final Episode – Follow-Up, Relapse, and Recovery
In the final part of this case series, we’ll walk through:

• How to plan follow-ups

• How to recognize red flags early

• How to help Sarah transition from surviving to thriving

• And how to know if your plan is working

Because good psychiatry isn’t about getting it perfect the first time.

It’s about staying in relationship, adjusting as needed, and honoring the person behind the pattern.

Reflective Prompt for You: What’s your own mental algorithm when things get complex or unclear?
What’s your go-to “If this doesn’t work…” plan?

Share your thought process. It might help someone else create theirs. 

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References:

[1] Zacharoff, Kevin L. "Pain as a Disease." Pain, Drugs, and Ethics. Cham: Springer International Publishing, 2024. 13-26.

[2] Ali, Shahriyah Nyak Saad, et al. "Developing treatment plan support in outpatient health care delivery with decision trees technique." Advanced Data Mining and Applications: 6th International Conference, ADMA 2010, Chongqing, China, November 19-21, 2010, Proceedings, Part II 6. Springer Berlin Heidelberg, 2010.

[3] Barnes, Marian, and Ric Bowl. "Diversity, difference and empowerment." Taking Over the Asylum. Palgrave, London, 2001. 68-93.

[4] James, Kelsey. "Barriers to Treatment and the Connection to Maslow’s Hierarchy of Needs." Counselor Education Capstone 18 (2016): 1-35.