Psychotropic Medication Decision Making: Toss the Algorithms and Decision Trees Aside

At every Psychopharmacology seminar I present, the following occurs: an attendee approaches me with a question regarding drug selection. I’m provided a small measure of the client’s history and the attendee’s assessment of the client’s condition. Invariably, the next question is what medication I would recommend. The expectation is for me to help after a two or three minute conversation guided by rudimentary information at best.

These are sincere people and I am appreciative of their confidence in me. Some of them give me an incredulous stare when I say that I am unable to comment rationally on medication options given my very limited knowledge of the client’s circumstances.

There is a prevailing belief system among many in the mental health industry that medicating emotionally dysfunctional or unstable patients is linked to some formula, recipe, decision tree or algorithm. The real pros among us know that this isn’t true and that medication management is not like cooking — where formulas and recipes are critical to the success of a good tasting dish.

Experience tells me that medication selection is most often predicated on five (5) factors:

  1. Comparative studies. It’s obviously important to know whether a drug consistently outperforms placebo based on well-designed, clinically relevant studies. Another important factor is how well a drug stands up to other competitors within the same genre.
  2. Biases. Biases are influenced by our belief systems and they exist in practically every area of our lives. Medication is no exception.
  3. Clinician experience. If a drug has a consistently favorable track record across a range of applications, it will be utilized again and again.
  4. Colleague consultation. We seek the masterminds among us for recommendations and advice.
  5. Pharmaceutical industry influence. These representatives are compensated handsomely for getting prescribers to use their drug.

An issue with these five factors is that they’re too generalized. Here are four (4) others that are more measurable and better predictors of treatment response:

  • Patient previous experience with psychotropic medication. When it comes to a specific drug or drug class, find out whether the individual has used it before. If yes, what were the results; if it was discontinued, why? If it worked, try it again, unless the patient’s clinical condition has changed enough to no longer warrant its use.
  • Family history. Does the client’s history include a family member who was prescribed a medication for a similar syndrome and responded to it favorably? If so, use DNA/RNA biomarkers — hopefully to the client’s advantage — by employing the same agent.
  • Initial response. This one’s very important. After the first swallow, and with waxing and waning for at least a few days, there will be side effects. Some side effects are therapeutic. For example, a side effect of benzodiazepines is sedation, but some sedation, at least, is considered a goal when one is anxious. Most side effects however, are a nuisance and tend to annoy patients, so when in a vulnerable state, it’s easy for them to give up. If you believe the patient may be at risk for non compliance or stopping the medication altogether, some cheerleading may be necessary because the most critical phase of medication management is the first 7-10 days of treatment. Encourage clients to stay with it because most side effects will abate within a week of medication initiation. And be clear with them as to when noticeable results are likely to come — within one to two weeks for antidepressants; a few days for antipsychotics and within several hours for psychostimulants.
  • Drug characteristics. Match medication selection to the patient’s symptomatic presentation as best you can. For example, because Prozac and Wellbutrin have activating properties, they’d likely be better choices than Celexa or Paxil for a lethargic, melancholic depressed patient. For managing psychosis accompanied by acute positive symptoms, the heavy hitters would be Risperdal, Zyprexa or in treatment-resistant instances, even Clozaril. Ordinarily, Seroquel, Geodon and Abilify don’t measure up in this scenario. The point here is that one size never fits all drug-wise and requires a clinician to be discriminatory.

What about combination strategies? These abound across all psychotropic drug classes and are as long as my arm. Augmentation is viable when a patient is not responding to monotherapy or could benefit from the additive effects of other medications; it should not be employed simply because new symptoms emerge.

There’s not a drug for every symptom and we never want a patient’s drug regimen to become too bloated. When this happens, it’s difficult to discern what’s working and what isn’t.

There must be a clear rationale for each and every drug choice; decision trees and algorithms should be for reference purposes only. Haphazard selection makes for a tedious process which can test a client’s patience; so involving the client in the decision-making process is a wise strategy, because more often than not, an empowered client is a more compliant one.

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Joe Wegmann is a licensed clinical social worker and a clinical pharmacist with over 30 years of experience in counseling and medication treatment of depression and anxiety. Joe’s new book, www.pesi.com. To learn more about Joe’s programs or to contribute a question for Joe to answer in a future article, visit his website at www.thepharmatherapist.com, or e-mail him at joe@thepharmatherapist.com.