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