NEW YORK – Psychiatrists often project their own ideas about the potential benefits of drugs onto patients without understanding their beliefs about medication, a psychopharmacology specialist said at the American Psychiatric Association’s Institute on Psychiatric Services.
"We call people ‘treatment-resistant’ even if they’re willing to accept all other kinds of treatment: They’re willing to come in and talk to us [and] engage us at therapists," suggested Dr. Ronald J. Diamond, professor of psychiatry at the University of Wisconsin–Madison. "They’re just not willing to take our medication."
Neil Osterweil/IMNG Medical Media
Dr. Ronald J. Diamond
However, by working with patients to better understand their beliefs about medication and recovery goals – whether they want to feel or function better, be able to hold down a job, go to school, or have better relationships – psychiatrists can use medications more effectively to help patients achieve their goals, said Dr. Diamond, who also serves as medical director of the Journey Mental Health Center of Dane County in Madison.
It is useful to consider why patients take medication in light of its inability to cure disease, he said. "Nobody believes that our medications cure bipolar [disorder] or cure schizophrenia," he said. "But that’s OK, because most of our medicines don’t cure diabetes, or chronic obstructive pulmonary disease, or hypertension, either."
Instead, people take medicine to get better, whether that means feeling physically better, having fewer symptoms, improving function, or increasing stability to prevent hospitalization.
The perception of risk from medications also is subjective, however, and a side effect deemed tolerable to the physician might prove unacceptable to the patient, Dr. Diamond said.
For example, he described a long-term patient with schizophrenia who has had a dramatic, sustained response to clozapine. "She has gained more than 100 pounds; she has completely changed her body habitus; and she says with tremendous regret and sadness, ‘I have a really terrible choice: I have choice between being a sane fat lady or a skinny crazy lady.’ "
The message that the physician delivers with the prescription also is critical to success. Telling patients that medications might help them better make decisions about changing their lives or help them to reach their goals, empowers patients and helps them to buy in to their recovery, he said.
Clinicians also need to work with patients to identify specific and concrete targets for medication, with the understanding that some targets might be better indicators of the effect of a medication than others. For example, medication might not have much effect on abnormal beliefs, or cause voices to go away, it but might make the beliefs less intrusive and the voices less distressful. Similarly, suicidal ideation might decrease but not vanish, and a patient’s behavior might improve before he senses a subjective improvement in mood.
"When we talk about what medications are going to do, we should make every medication trial a trial that we and the client agree with: What would getting better mean? What would getting worse mean? How would we know?" he said.
Medication might not work because the patient is not taking it or not taking it for long enough; it’s important that the patient understands that it might take weeks or longer before she feels an effect.
The dose might be too high or too low depending on target symptoms, or other factors might come into play such as comorbid substance abuse, medical illness, or an incorrect diagnosis to explain why a medication may not work.
"Medications do not work for everyone but, in my experience, when somebody says ‘this medication is not helping,’ we immediately assume it’s because of a psychotic loss of insight. Sometimes, the person is right, and sometimes we need to just listen," he said.
Additionally, studies have shown that compliance rates with medication for medical illnesses such as arthritis, diabetes, and hypertension often exceed 50%, and it is safe to assume that the same is true for schizophrenia, Dr. Diamond said.
The key to recovery-oriented prescribing, he emphasized, is to turn the traditional approach to medication on its head. Instead of coming into the treatment room with a diagnosis in hand and coming up with a solution to the diagnosis – medication X – psychiatrists need to start with an understanding of the problem from the patient’s point of view and details of that problem. At that point, it makes sense to come up with a joint medication solution in connection with other solutions for say, social, vocational, educational, or family problems in that patient’s life, Dr. Diamond said.