Saturday, 23.09.2017

American Society of Clinical Psychopharmacology
Model Psychopharmacology Curriculum

Donald F. Klein commentary

 

            A difficult practical situation arises when a patient has been placed on a drug that turns out to be slightly, perhaps, effective. Some new medication must be started, but what about the old perhaps effective one?  It seems rational to remove it, thus avoiding interactions and unnecessary prescriptions. However, patients are often reluctant to do so since there may have been some benefit. Doctors also may be reluctant to do so, to avoid the complications of building a new medication up while weaning off the old. The temptation is to just let it ride.

            Unfortunately, patients with difficult to treat conditions often end up stuck with quite a few interactive, possibly deleterious, medications that raise concerns about withdrawal symptomatology as well as markedly increased patient (and doctor) anxiety about loss of even minor   benefit.

            Some perspective might be gained from a forgotten episode…

            In the 1960s, Hillside Hospital, a 200 bed psychoanalytic hospital had an average length of stay of 10 months.  An increasing number of variously diagnosed, impaired patients were admitted on various pharmacologic combinations,

            The scientific medical staff, Drs. Fink and Klein, wished to observe patients in their state prior to receiving medication as well as studying medication effect. The psychoanalytic ethos viewed pharmacotherapy as a contaminant to psychotherapy. The new Director Lewis Robbins MD, a training analyst from Topeka, recognized the clinical importance of medication and a pervasive lack of knowledge concerning their application. All could agree that if medication had been very useful, hospitalization should have been unnecessary.

            This led to an enforced clinical policy that all patients would be clinically withdrawn from all psychoactive drugs for a one month period. To ensure this, none of the residents, only Drs. Fink and Klein, could write orders for that first month. Dr Klein was available to immediately come to any scene where staff was pressing to have a patient medicated. This was usually caused by staff dissension as to the patient being manipulative. Most insecure were the staff members who now could not sedate without prompt consultation.  This went smoothly.  Everyone, including the patient, knew that if needed, quick medical attention would come.   Most relevant to current practice, there was rarely a deteriorative state that required starting an emergency pharmacologic program, despite previous complex medication programs.

            I certainly don't expect that such a program is currently possible and it certainly has never been imitated. However, current relevance is that continuity of care and the availability of emergency consultation are economical goals.  In that context the relatively quick discontinuation of failed medication is possible without undue pharmacological concern.

 

Donald F. Klein

September 22, 2016