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"Best practice" standards suggest patients be
managed according to generally accepted treatment algorithms derived from
controlled clinical trials. Unfortunately, in psychiatry, much of this
evidence derives from patients who are less complicated than many of those in
a contemporary physician's practice. For instance, most antidepressant trials
that are large, randomized, and placebo controlled include patients 18 to 65
years of age who are not psychotic, suicidal, or bipolar; who have no
substance abuse or any other comorbid Axis I disorder, nor any prominent Axis
II or medical disorder; who take few, if any, medications, including no
psychotropic drugs whatsoever and no history of prior poor response to
antidepressants. Sound like the usual patient in your practice? Thus,
treatment algorithms are great as far as they go, but what happens when a
clinician has drilled all the way through the algorithm and the patient is
still not responding well to treatment?
The idea is to develop a set of principles that, when applied rationally,
can lead to effective use of psychotropic drugs when specific evidence-based
guidelines are unavailable for the particular patient at hand. At times, case
reports, anecdotal observations, and uncontrolled or open studies can give
some indication of the likely empiric utility of approaches that make sense.
Developing habits that apply these principles for the most difficult
treatment problems in psychopharmacology is one of the leading methods to
becoming a highly effective psychopharmacologist.
1
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Begin With the End in Mind
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A highly effective psychopharmacologist will target
complete remission for affective and anxiety disorders, not just a 50%
reduction of symptoms (called a response).3 When treating
psychotic disorders or dementias, it is not feasible to aim as high as for
depression and anxiety because the treatments are not as effective.
However, it is increasingly clear that patients taking the new atypical
antipsychotics begin to show cognitive enhancement after several months of
treatment. Outcomes can be optimized if improvement is accompanied by
simultaneous rehabilitation efforts, resulting in a higher level of
functioning than expected for treatment with conventional antipsychotics,
especially after a year or two of drug treatment plus rehabilitation.
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2
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Synergize
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If single pharmacologic actions of drugs at serotonin or
norepinephrine receptors are ineffective in treating depression or anxiety
disorders, logic indicates it may be best to combine 2 independent
mechanisms in an attempt to get an output where the whole is greater than
the sum of the parts--synergy. Good psychopharmacology can thus be bad
mathematics where 1 + 1 = 10 for efficacy of drug combinations.4
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3
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Sharpen the Saw
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The highly effective psycho-pharmacologist will find
high-quality continuing medical education programs and gain sufficient
background information to detect commercial bias and sort between
information for information's sake (of academic value) and information that
can be applied to changing diagnosing and prescribing behavior.
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4
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Put First Things First
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Many patients have side effects from psychotropic
medications that can cause premature discontinuation from medication and
the erroneous assumption that the medication is ineffective. Practical
psychopharmacologists know the difference between treatment intolerance and
treatment resistance and communicate this difference to the patient.
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5
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Think Win/Win
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Many trials of psychotropic medications are sabotaged by
side effects. An effective psychopharmacologist will practice bad
mathematics once again. In this case, the goal is to find one drug that
cancels the side effects of another, leading to 1 + 1 = 0 in terms of side
effects.4
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6
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Become Proactive
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Some psychiatric conditions are not diagnosed frequently
enough (e.g., depression in primary care, generalized anxiety disorder in
both psychiatry and primary care). In such cases, attention may be focused
on some other psychiatric or medical condition that is usually the
patient's chief complaint. When the correct psychiatric diagnosis is made,
lack of aggressively attacking the problem with proper medication type and
duration, and perhaps psychotherapy, may lead to "quitting while
ahead" and not finishing the job of extinguishing all symptoms and
returning the patient to wellness.3
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7
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Understand and Be Understood
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Poor history-taking reduces the chance of providing
effective treatment. A good history with a clear clinical logic goes a long
way toward successful results. The history-taking process helps ensure the
patient's confidence. It also ensures compliance on the road toward a good
outcome. Obtain a detailed history of illness episodes and their
relationship to life-cycle issues prior to the index episode and identify
all comorbid conditions. Train your patients to become active partners in
the long-term management of their illnesses. Well-informed
psychopharmacologists learn from each patient just as their patients learn
from them. The respectful posture that the physician is the student of the
patient's life and illness is a critical building block of a good
therapeutic alliance.
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REFERENCES
1. Covey SR. The 7 Habits of Highly Effective People: Powerful Lessons in
Personal Change. New York, NY: Simon & Schuster; 1990
2. Stahl SM. Seven Habits of Highly Effective Psychopharmacologists. To be
presented at the 153rd annual meeting of the American Psychiatric
Association; May 17, 2000; Chicago, Ill
3. Stahl SM. Why settle for silver when you can go for gold? response vs.
recovery as the goal of antidepressant therapy [Brainstorms]. J Clin
Psychiatry 1999;60:213-214
4. Stahl SM. Essential Psychopharmacology. 2nd ed. New York, NY: Cambridge
University Press; 2000
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