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The 7 Habits of Highly Effective Psychopharmacologists


									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

"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

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