TRADITIONAL PSYCHOPHARMACOLOGY

The Current State of Knowledge

Over many decades, careful clinical experience and research has established a wide range of medications which are safe and effective for most mental health conditions. Great effort has been dedicated over several generations to understand how these medications work and for which conditions, and how physicians can best utilize them to aid patients in the remediation of symptoms, well-being and functional recovery.

There are varied classes of medications available, and even within individual categories of medications, there is considerable heterogeneity in their actions, and importantly, their side effects. With antidepressants, for instance, which of their multiple effects in the brain are most important for symptom relief, and which are associated with side effects, varies considerably. It is important to note that they are generally considered equally-effective, and there is no medication that is “stronger” or “better” than the others. This is because in the important clinical trials that test medication effectiveness, the proportion of patients who respond to each of these treatments, and the degree to which they respond, tends to be essentially identical. Nonetheless, it is well-known from clinical experience that some people respond very well to some antidepressant medications and not to others, whereas for other people, the opposite pattern could be true. At this point in time, our science does not allow us to ascertain in advance which is likely to respond to which medication. Therefore, the initial treatment of most mental health conditions requires a careful trial of medications, with both patient and physician closely tracking symptoms, side effects, function and well-being. During this process, it is essential that a patient inform the prescribing physician if they feel that any problems are emerging, such as new or worsened symptoms, or significant side effects. This is true for any condition in Medicine, and physicians will generally exert considerable effort to ascertain whether an experience is a consequence of medication use, and if so, what to do about it.

What to Expect with Psychiatric Medications

In any event, it is important to recognize that most people gain some noticeable benefit from psychiatric medications, if an accurate diagnosis is considered, the medications are prescribed in an appropriate manner, and the patient can take them consistently as prescribed. It is also important to note that many medications, especially antidepressant medications, generally require some time to confer their full benefit. These are generally not medications which can be taken and then have a clear, positive impact in a matter of hours, or even days, typically. Instead, if they are taken daily (as they are prescribed), and the prescriber monitors the response and carefully optimizes the dose over time, they will usually have some benefit after a few to several weeks. This is probably required because the biological basis for effectiveness is the many slow changes in brain structure and function that accrue in response to sustained exposure to the medication. If this benefit is not achieved to an adequate degree after an expectable period of time, then the physician and patient have many alternative options, for other medications and/or other complementary interventions, which can be biomedical (e.g. TMS) or psychotherapeutic in nature. At times, this may include combinations of medications which have complementary actions and potential synergistic effect to benefit the patient. This could include ketamine, a medication which has utility as an add-on (“adjunct”) to the antidepressant medication for those who have an inadequate response to the initial antidepressant alone.

How We Will Work with You

Given the important consideration of side effects associated with any medication, we will establish that dialogue with you as early as possible, and certainly before any prescription proceeds, as a part of the informed consent process. This is important for the use of any drug in Medicine, including over-the-counter medications, herbs or dietary supplements. Psychiatric medications are also generally safe and effective in long-term use, though some medications (usually those other than antidepressants) have some important potential consequences of long-term use. Which side effects are associated with which medications is a very elaborated issue, and we will engage you in this discussion once we achieve a proper understanding of your diagnosis and your particular clinical condition, including any medical (i.e. non-psychiatric) conditions you may also have. It is important to mention here that our program takes the issue of polypharmacy very seriously. Our goal is not to “load up” a patient with a regimen of medications that leads to numerous, intolerable side effects, but rather to employ the most parsimonious regimen that may help you the most, with a minimal or manageable pattern of side effects.

Clear guidelines have been established in psychiatry for how to proceed with medications for most major conditions, including depression, bipolar disorder, and anxiety disorders, and many other conditions. These tend to be based on either the scientific evidence available, or expert opinion. We are happy to tell you more about how we think about these guidelines and how we implement them. While these are not rigid rules for how to proceed with treatment, they ideally represent the state of knowledge about the use of psychiatric medications, and we will integrate these practices together with the considerations that might be unique to your own case. It is important to keep in mind that diverse treatments are available for most psychiatric conditions, and therefore if one does not work adequately (or is found to be intolerable), there are always alternatives. Some of the pillars of good treatment and good outcomes include ascertaining the right diagnosis, being well-informed about treatment options and what to expect, staying flexible to consider what might work best, and the perseverance and open communication of both doctor and patient. These are just a few of our basic principles of treatment, regardless of the condition for which you seek relief.