| "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 | 
Begin With the End in Mind
| | 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. |
2 |
Synergize
| | 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 |
3 |
Sharpen the Saw
| | 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. |
| 4 |
Put First Things First
| | 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. |
5 |
Think Win/Win
| | 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 |
Become Proactive
| | 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 |
7 |
Understand and Be Understood
| | 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. | 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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