It’s been said that prescribing medication for our patients is as much art as science. Certainly, the science of psychopharmacology has exploded over the past three decades. Our understanding of how and where medications work has become identifiable and precise. Effects and side effects have been studied and catalogued. The “artful” application of this knowledge requires keen awareness of these effects combined with intimate knowledge of the patients whom we are treating.
Medical training promotes the growth of decision trees – called algorithms – in the minds of physicians. When your doctor conducts an evaluation, he is – ideally and automatically – identifying signs and symptoms of disorder or disease; sizing up your temperament, beliefs, prejudices, opinions, and fund of knowledge; placing these observations in the context of your family and social milieu; and drawing a developmental timeline between where you are from and where you are now. Some of the questions that form the branches of the decision tree are:
- Do you have symptoms of a disorder (e.g., anxiety, depression, insomnia, disorganized thinking)?
- If so, do you have symptoms of a disorderthat could be helped by medication?
- If so, would you be willing to take medication to alleviate symptoms?
- If so, what are the chances of having side effects that you would not be willing to live with in order to alleviate symptoms?
- What medication is most likely to have the desired effect and least likely to cause you troubling side effects?
- What factors in you or your environment will interfere with your ability to remain adherent to a medication regimen (e.g., ambivalence about taking medication, forgetfulness/distractibility, distracting/chaotic environment, financial issues)?
Jennifer is an 18-year-old college freshman who is home after her first semester away. She is distressed by her inability to perform up to her standards and talks to her parents about withdrawing from school. She breaks down in tears as she describes waking up each morning with a feeling of nausea in the pit of her stomach. Several times a week she has episodes where she struggles to catch her breath, feels her heart racing and has to sit down because she feels faint. She started seeing a therapist at the student counseling center but had to stop at winter break. Her parents arrange for a consultation with a psychiatrist. Upon evaluation, it turns out that Jennifer had milder episodes during her last two years of high school. Her mother had similar episodes in college but “toughed it out.” Later on, as an adult, she had several severe episodes shortly after starting a new job. She was treated with fluoxetine (Prozac), which seemed to help. As a psychiatrist you’re thinking, “This sounds like a pretty typical Panic Disorder.” Further questioning confirms this impression, including consideration of medical illness that might present with similar symptoms. Talk therapy, such as CBT (Cognitive Behavioral Therapy) is a treatment option, but the therapy your patient has had so far hasn’t helped much and she is eager for symptom relief so she can get back to school.
In the case study above, we have symptoms of a disorder, symptoms that could be alleviated by medication, and a patient willing to choose this option. Your doctor could choose from various SSRI’s (Selective Serotonin Reuptake Inhibitors), but since a close relative (her mother) responded well to fluoxetine, there is reason to believe that this patient would also respond well. You present this recommendation to the patient and her family, carefully reviewing the therapeutic effects and side effects. Her mother’s prior favorable experience helps with acceptance and “buy in.” Because the medication is available as a generic, cost will not be an impediment to treatment. You stress the importance of adherence to the medication regimen, set up an easy to remember plan for taking the medication, discuss a timeline for treatment, and make follow-up plans.
Admittedly, this is a fairly uncomplicated, “softball” scenario. Psychiatrists are usually faced with much more complicated scenarios that require mindfulness of much more complicated decision algorithms. Because psychiatric disorders appear as an amalgamation of symptoms that are often difficult to categorize into discernable and discreet diagnosis, sometimes the best we can do is to make an educated hypothesis and then use medications to best address particular symptoms. Multiple symptoms may be symptomatic of a single disorder, or there may be multiple symptoms that are symptomatic of two or more disorders. Such situations may require the use of multiple medications. In these circumstances. Your psychiatrist must be mindful of principles of rational combined psychopharmacology: the use of two or more psychiatric medications combined in a rational way.
The brain is a highly complex organ with numerous circuits, neurotransmitters (chemicals that transmit nerve impulses from one cell to another) and receptor sites (places on the nerve cell where neurotransmitters act). An understanding of this complexity is essential for combining medications in a rational way. For example, sometimes Major Depression will respond better to two medications than to one. Choosing two antidepressants that work in the same way would not be rational because you would just be duplicating effects. Choosing two that work on different neurotransmitters or on different receptor sites would make sense because you would be adding something different. This sort of strategy is done all the time in medicine, as in the treatment of hypertension or in the use of chemotherapy for cancer.
Medicating mindfully is interplay between art and science. The art is comprised of the skill with which the practitioner uses this knowledge to grow and prune their own mental decision tree, plus the skill with which they are able to elicit their patient’s personal data to populate the tree and come to a rational treatment recommendation.