Salzman, Carl MD*†; Glick, Ira MD‡; Keshavan, Matcheri S. MD*†
From the *Harvard Medical School, Beth Israel Deaconess; †Massachusetts Mental Health Center, Boston, MA; and ‡Department of Psychiatry, Stanford University Medical School, Stanford, CA.
Reprints: Carl Salzman, MD, Harvard Medical School, Beth Israel Deaconess, Boston, MA 02215 (e-mail: firstname.lastname@example.org).
How do clinicians learn to prescribe psychotropic drugs? In recent years, some teachers have attempted to formulate basic teaching principles to guide the prescription of psychotropic drugs. Keshavan, for example, has created what he has called "The Ten Commandments of Psychopharmacology" for beginning residents in psychiatry.1 Glick et al2 have detailed "teaching pearls" underlying clinical psychopharmacological practice that they have found useful in their teaching. These commandments and pearls comprise a common sense approach to all patients and would be taken for granted by most if not all clinicians, although they may not always be followed. Stahl and Davis3 have taken a different approach by formulating guidelines for teachers of psychopharmacology in which relevance and accessibility of complex information is stressed and recommendations for teaching styles and methods are provided.
Prescribing algorithms and expert consensus guidelines also are available in the literature as potential teaching tools. The 2 leading American psychopharmacology societies also have addressed the teaching of psychopharmacology. Each year at the annual meeting of the American College of Neuropsychopharmacology, a well-attended symposium addresses issues of teaching psychopharmacology and makes recommendations to improve the teaching process. The American Society of Clinical Psychopharmacology as well as the American College of Neuropsychopharmacology have each created a "model curriculum," which comprises the basic and up-to-date psychotropic drug prescribing information that a practicing clinician can refer to for self-learning.4,5
THE 7 SINS
As teachers of psychopharmacology, we have become concerned regarding current patterns of psychiatric medication use. Although the scientific basis for psychotropic drug use is expanding, we believe that certain basic principles of drug prescription have become less prominent in the teaching of psychopharmacology. We have fancifully called these concerns "The 7 Sins" in an attempt to reduce the frequent and potentially serious errors that we have observed in our combined 80 plus years of teaching psychopharmacology. We recognize that the following discussion is based entirely on our own opinions based on years of experience in teaching psychopharmacology and is not research based. We further recognize that this list is not inclusive and that other teachers, clinicians, and researchers might create a different list of prescribing problems or amend our list according to their own specifications. Nevertheless, we hope that readers of "The 7 Sins" will be able to use these guidelines for prescription of psychiatric medications in their daily practice.
THE 3 "DS"
It is important to ensure that a comprehensive diagnostic evaluation is in place before decisions are made about medication selection. This prevents inappropriate prescribing and also avoids the problem of medications interfering with the process of diagnosis. However, there is a need to go beyond the symptom-based Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria. In deciding to institute psychopharmacology treatment, clinicians must consider the context of the symptom profile and its background in individual and family psychology, course, previous symptoms, ethnic background, and others. Not all unhappiness is depression requiring antidepressants; not all worry is an anxiety spectrum disorder; not all racing thoughts are mania; and not all impairment of memory, judgment, or odd thoughts are diagnostic of schizophrenia.
Dose counts! Lack of adequate response or excessive side effects is usually dose related. Response to medication may result, in part, from pharmacogenetic and pharmacodynamic variations from patient to patient. Therefore, clinicians must be aware that some patients require only a fraction of the recommended dose, whereas others may require full doses or even doses that may exceed the recommended maximum daily recommended dose. Determining "best" dose requires an ongoing interactive, reciprocal communication with the patient and, sometimes, with others who are in close daily contact with the patient.
We have observed that medication regimens are sometimes discontinued, altered, and augmented before an adequate prescribing period has allowed for a full response to the drug. We also have observed effective drug treatments being discontinued prematurely when a patient starts to improve, leading to relapse and further suffering. Most Axis I disorders have chronic courses, and the effective doses usually need to be given for many months or years to prevent either recurrence or relapse. For ongoing disorders, psychiatric medications often must be given for many years or over a lifetime.
Even the best psychiatric medications may give only a partial response. It is understandable, therefore, that a second (or even a third) medication is sometimes added in an attempt to enhance nonresponse or partial drug response. The data to support this practice are slim. In general, using more than 1 drug from the same therapeutic class, although sometimes helpful (eg, antidepressant augmentation6), may not improve therapeutic outcome and only make side effects worse.7 (Combining psychotropic medications of different classes may be necessary to address comorbid disorders.) Unfortunately, when a new medication is added to an ongoing treatment regimen, the original drug is not always discontinued so that unnecessary polypharmacy and side effects are the result.
NOT UNDERSTANDING THE PSYCHOLOGICAL BACKGROUND OR CONTEXT OF THE PATIENT
Prescribing psychotropic drugs is an art as well as a science. Part of the art is understanding the patient's life experience rather than simply listing symptoms that become targets for medication treatment. Patients often feel better understood and have better outcome when drugs are prescribed in a context of psychological understanding between patient/family and physician. This does not imply that all psychopharmacology treatment must be combined with psychotherapy (although there are now at least 8 Axis I disorders where combined drug plus psychotherapy is better than either alone8). However, patients sometimes refer to their prescribers as "mechanics" who do not understand the complexity of their clinical situations (an attitude shared by some nonprescribing therapists). It is our firm conviction that medication prescription that is associated with sensitive inquiry into the circumstances of the patients' current (and past) psychological difficulties results in an improved therapeutic alliance and better treatment outcome. It is therefore important not to yield to the time pressures of the "15-minute med-checks" so prevalent in current practice.
THERE MAY NOT BE "BETTER LIVING THROUGH CHEMISTRY"
The phrase "better living through chemistry" was used in the past as an advertising slogan by a large pharmaceutical firm. Unfortunately, chemistry (drugs) is not the solution for all human suffering. Not all unhappiness is depression; not all worry is anxiety. Not all restlessness is agitation, not all troubled sleep is insomnia. Not all feelings of unworthiness or low self-esteem automatically indicate the need for an antidepressant and not all exuberance and elation require a mood stabilizer. Not all difficulties with concentration or memory require prescription of a stimulant.
LACK OF COMMUNICATION WITH OTHER PHYSICIANS
It is axiomatic that the physical health of a patient including other diagnostic evaluations and a knowledge of other medications that the patient is taking are each (and together) critical to effective and safe psychopharmacology practice. However, it has been our increasing impression that many clinicians do not take the time (or do not have the time) to get this information before prescribing.
LACK OF COMMUNICATION WITH OTHER MENTAL HEALTH PROVIDERS AND FAMILY MEMBERS (OR SIGNIFICANT OTHERS)
Information from other treaters and/or those close to the patient often will provide information and insights that are critically important to the accurate prescription of medications. This is obviously true for cognitively impaired patients but is also especially true for patients with mania, narcissism, and borderline personality disorder who may not present their own history accurately. Other patients also may not accurately describe their symptoms. Some patients with schizophrenia, for example, are unaware that they are ill or socially "odd." Some depressed patients may view their depressed mood as an accurate representation of the painful and existentially hopeless human condition and not even recall that they have not always felt so pessimistic. Of course, patients with addictive disorders may knowingly deny or distort their clinical history and symptom profile. In addition, some patients fearing the stigma of having "mental illness" or realistically fearing the consequences of such a diagnosis when applying for health or life insurance may prevent some patients from volunteering relevant or crucial information to make a diagnosis and prescribe correctly.
NOT KEEPING UP WITH THE FIELD, ACCURATE READING OF THE LITERATURE (OR NOT READING IT AT ALL)
Updated psychotropic drug information should not be obtained only from drug retailers, advertisements, drug company-sponsored lunches, dinners, or trips to resorts for continuing education symposia. Reading the literature to remain updated is important. Because new published information may affect a clinician's prescribing habits (or when listening to a lecture), a clinician should have at least a rudimentary know-how to evaluate such new information. This includes being able to appraise the sample size, blinding, rating instruments, the use of valid outcome criteria, and basic use of statistics. It also is important to consider the source of funding and potential bias in evaluating study results.
We hope that this brief essay will encourage the busy practitioner to recall sound prescribing practices that were probably learned during training years. Pies9 has written "7 Myths of Psychopharmacology Debunked" in an effort to clarify prescribing practices, and recent lay literature10 has confirmed that the prescription of psychotropic medication requires thoughtful care and attendance to the overall understanding of a patient's life circumstances as well as symptom profile. Medications can be helpful, so let us use them optimally, safely, and tenderly.
1. Keshevan MS. Principles of drug therapy in psychiatry. How to do the least harm. In: Keshavan MS, Kennedy JS, eds. Drug-Induced Dysfunction in Psychiatry. New York, NY: Hemisphere Publishing; 1992.
2. Glick ID, Balon R, Ballon J, et al. Teaching pearls from the lost art of psychopharmacology. J Psychiatr Pract. 2009;15:423-426.
3. Stahl SM, Davis RL. Best Practices for Medical Educators. Carlsbad, CA: NEI Press; 2009.
4. Glick I, Janowsky D, Salzman C, et al. A Model Psychopharmacology Curriculum for Psychiatric Residents. Ad Hoc Committee of the American College of Neuropsychopharmacology; 1984.
5. Klein D. The ASCP Model Psychopharmacology Curriculum, for Psychiatric Residency Programs, Training Directors, and Teachers of Psychopharmacology. 5th ed. Glen Oaks, NY: The American Society of Clinical Psychopharmacology, Inc.; 2008.
6. Blier P, Ward HE, Tremblay P, et al. Combination of antidepressant medications from treatment initiation for major depressive disorder: A double-blind randomized study. Am J Psychiatry. 2010;167:281-288.
7. Honer WG, Thornton AE, Chen EY, et al. Clozapine alone versus clozapine and risperidone with refractory schizophrenia. N Engl J Med. 2006;354(5):472-482.
8. Nathan PE, Gorman JM. A Guide to Treatments That Work. New York, NY: Oxford Press; 2002.
9. Pies R. Seven psychopharmacology myths debunked. Curr Psychiatry. 2008;7:103-104.
10. Carlat D. Mind Over Meds. New York Times Magazine; April 19, 2010.
© 2010 by Lippincott Williams & Wilkins.