Pearls

Before modern medications and managed care, we tended to focus more on our relationships with patients. The goal was to establish a therapeutic alliance. Perhaps the idea of this kind of physician-patient relationship was what philosopher Martin Buber described as the “I-Thou” interaction. Instead of the “I-It” relationship where we mainly look at reducing symptoms, “I-Thou” recognizes the authenticity of the other and recommends reciprocity and respect.¹

After Buber, research found that a positive and hopeful relationship is a common ingredient of successful psychotherapy of any theoretical persuasion and technique.² Because the therapeutic alliance is crucial even during a brief medication check—and likely will enhance compliance—maybe we need to bring Buber back into prominence. Here’s how:

The nature of our work. Shortened time and reliance on medication can make us feel as if we are doing factory work. Think of psychiatry as much as a calling as a career.

The greeting. One of the most rewarding clinical experiences I’ve had occurred when a new patient came into my office. Before I could ask how she was feeling about seeing a new psychiatrist, she quickly said how pleased she was that I was her physician. Thinking that she might have looked up some of my writings on the Internet, I asked her why. She said that she had noticed that I smiled when I greeted my patients in the waiting room, as if I was happy to see them.

Look at your patient, not your computer. When my practice was transferring from paper to electronic records, I tried to talk to patients as I typed. One patient joked, “Hey, Doc, who are you talking to on that computer?” I got the message. I used to be able to scribble notes as we talked. Now, I maintain eye contact when I begin the session, and leave the computer until the end.

Know who your patients are. Find out what is most important to each patient, and refer to it often. What gives meaning to patients’ lives despite their psychiatric disorder will give meaning to your relationship.

You’re in this together. Make clear the limitations you are working under. Indicate that despite these obstacles, you will do whatever you can as a partnership. You may even want to apologize at times for what you can’t do, but would like to.

Saying goodbye. Always leave time for questions. Given the trend for less frequent appointments, which can make patients feel rejected, ask them if coming back at a later date seems acceptable. Let your patients know you look forward to seeing them again. Be sure to close with a handshake or other culturally appropriate gesture.

Disclosure

Dr. Moffic reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Before modern medications and managed care, we tended to focus more on our relationships with patients. The goal was to establish a therapeutic alliance. Perhaps the idea of this kind of physician-patient relationship was what philosopher Martin Buber described as the “I-Thou” interaction. Instead of the “I-It” relationship where we mainly look at reducing symptoms, “I-Thou” recognizes the authenticity of the other and recommends reciprocity and respect.¹

After Buber, research found that a positive and hopeful relationship is a common ingredient of successful psychotherapy of any theoretical persuasion and technique.² Because the therapeutic alliance is crucial even during a brief medication check—and likely will enhance compliance—maybe we need to bring Buber back into prominence. Here’s how:

The nature of our work. Shortened time and reliance on medication can make us feel as if we are doing factory work. Think of psychiatry as much as a calling as a career.

The greeting. One of the most rewarding clinical experiences I’ve had occurred when a new patient came into my office. Before I could ask how she was feeling about seeing a new psychiatrist, she quickly said how pleased she was that I was her physician. Thinking that she might have looked up some of my writings on the Internet, I asked her why. She said that she had noticed that I smiled when I greeted my patients in the waiting room, as if I was happy to see them.

Look at your patient, not your computer. When my practice was transferring from paper to electronic records, I tried to talk to patients as I typed. One patient joked, “Hey, Doc, who are you talking to on that computer?” I got the message. I used to be able to scribble notes as we talked. Now, I maintain eye contact when I begin the session, and leave the computer until the end.

Know who your patients are. Find out what is most important to each patient, and refer to it often. What gives meaning to patients’ lives despite their psychiatric disorder will give meaning to your relationship.

You’re in this together. Make clear the limitations you are working under. Indicate that despite these obstacles, you will do whatever you can as a partnership. You may even want to apologize at times for what you can’t do, but would like to.

Saying goodbye. Always leave time for questions. Given the trend for less frequent appointments, which can make patients feel rejected, ask them if coming back at a later date seems acceptable. Let your patients know you look forward to seeing them again. Be sure to close with a handshake or other culturally appropriate gesture.

Disclosure

Dr. Moffic reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Before modern medications and managed care, we tended to focus more on our relationships with patients. The goal was to establish a therapeutic alliance. Perhaps the idea of this kind of physician-patient relationship was what philosopher Martin Buber described as the “I-Thou” interaction. Instead of the “I-It” relationship where we mainly look at reducing symptoms, “I-Thou” recognizes the authenticity of the other and recommends reciprocity and respect.¹

After Buber, research found that a positive and hopeful relationship is a common ingredient of successful psychotherapy of any theoretical persuasion and technique.² Because the therapeutic alliance is crucial even during a brief medication check—and likely will enhance compliance—maybe we need to bring Buber back into prominence. Here’s how:

The nature of our work. Shortened time and reliance on medication can make us feel as if we are doing factory work. Think of psychiatry as much as a calling as a career.

The greeting. One of the most rewarding clinical experiences I’ve had occurred when a new patient came into my office. Before I could ask how she was feeling about seeing a new psychiatrist, she quickly said how pleased she was that I was her physician. Thinking that she might have looked up some of my writings on the Internet, I asked her why. She said that she had noticed that I smiled when I greeted my patients in the waiting room, as if I was happy to see them.

Look at your patient, not your computer. When my practice was transferring from paper to electronic records, I tried to talk to patients as I typed. One patient joked, “Hey, Doc, who are you talking to on that computer?” I got the message. I used to be able to scribble notes as we talked. Now, I maintain eye contact when I begin the session, and leave the computer until the end.

Know who your patients are. Find out what is most important to each patient, and refer to it often. What gives meaning to patients’ lives despite their psychiatric disorder will give meaning to your relationship.

You’re in this together. Make clear the limitations you are working under. Indicate that despite these obstacles, you will do whatever you can as a partnership. You may even want to apologize at times for what you can’t do, but would like to.

Saying goodbye. Always leave time for questions. Given the trend for less frequent appointments, which can make patients feel rejected, ask them if coming back at a later date seems acceptable. Let your patients know you look forward to seeing them again. Be sure to close with a handshake or other culturally appropriate gesture.

Disclosure

Dr. Moffic reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Mr. C, a 78-year-old nursing home resident, wants to discontinue psychotropics because he has difficulty swallowing pills. He receives cholinesterase inhibitors for dementia and an antipsychotic for occasional agitation.

A 45-year-old patient diagnosed with bipolar disorder says that she felt coerced and her personal space violated when she was administered an intramuscular antipsychotic while agitated a few days earlier.

A nurse expresses frustration to the staff psychiatrist about continued disruptive behavior of a patient who has a minimal blood level of a mood stabilizer after 5 days of pharmacotherapy. The nurse suspects the patient is hiding pills in his mouth and later discarding them.

A child psychiatrist worries about her 8-year-old patient’s lack of response to an atypical antipsychotic. The mother reveals that the child often does not take his medication because he does not like taking large pills and is afraid of choking.

Clinical scenarios such as these highlight the importance of liquid drug formulations in enhancing compliance and respecting patient autonomy. Liquid formulations of psychotropics are useful for patients who have difficulty swallowing tablets or capsules, such as children or older adults. These formulations also are helpful in acute care settings, especially for uncooperative patients. Monitoring medication ingestion to ensure compliance is another benefit of liquid formulations. Many clinicians administer intramuscular antipsychotics to relieve acute agitation¹; however, patients may consider this approach coercive, and it carries a risk of injury, especially when patients are agitated and uncooperative. Agitated patients may be amenable to ingesting liquid medication instead of oral tablets. Some liquid medications can be mixed with juice, which might help improve medication compliance in children.

The Table^2,3 lists some psychotropics that are available in a liquid formulation and their dosage strengths. Be aware of the exact strength of liquid formulations. Educate patients about how to use calibrated dosing spoons to enhance compliance and ensure patients ingest an appropriate dosage.⁴ We hope that using liquid formulations when indicated will enhance patient satisfaction and compliance, leading to improved prognosis.

Disclosure: The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Balon played no role in the peer review of this article.

Table

Psychotropic medications available in liquid formulation

Mr. C, a 78-year-old nursing home resident, wants to discontinue psychotropics because he has difficulty swallowing pills. He receives cholinesterase inhibitors for dementia and an antipsychotic for occasional agitation.

A 45-year-old patient diagnosed with bipolar disorder says that she felt coerced and her personal space violated when she was administered an intramuscular antipsychotic while agitated a few days earlier.

A nurse expresses frustration to the staff psychiatrist about continued disruptive behavior of a patient who has a minimal blood level of a mood stabilizer after 5 days of pharmacotherapy. The nurse suspects the patient is hiding pills in his mouth and later discarding them.

A child psychiatrist worries about her 8-year-old patient’s lack of response to an atypical antipsychotic. The mother reveals that the child often does not take his medication because he does not like taking large pills and is afraid of choking.

Clinical scenarios such as these highlight the importance of liquid drug formulations in enhancing compliance and respecting patient autonomy. Liquid formulations of psychotropics are useful for patients who have difficulty swallowing tablets or capsules, such as children or older adults. These formulations also are helpful in acute care settings, especially for uncooperative patients. Monitoring medication ingestion to ensure compliance is another benefit of liquid formulations. Many clinicians administer intramuscular antipsychotics to relieve acute agitation¹; however, patients may consider this approach coercive, and it carries a risk of injury, especially when patients are agitated and uncooperative. Agitated patients may be amenable to ingesting liquid medication instead of oral tablets. Some liquid medications can be mixed with juice, which might help improve medication compliance in children.

The Table^2,3 lists some psychotropics that are available in a liquid formulation and their dosage strengths. Be aware of the exact strength of liquid formulations. Educate patients about how to use calibrated dosing spoons to enhance compliance and ensure patients ingest an appropriate dosage.⁴ We hope that using liquid formulations when indicated will enhance patient satisfaction and compliance, leading to improved prognosis.

Disclosure: The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Balon played no role in the peer review of this article.

Table

Psychotropic medications available in liquid formulation

Mr. C, a 78-year-old nursing home resident, wants to discontinue psychotropics because he has difficulty swallowing pills. He receives cholinesterase inhibitors for dementia and an antipsychotic for occasional agitation.

A 45-year-old patient diagnosed with bipolar disorder says that she felt coerced and her personal space violated when she was administered an intramuscular antipsychotic while agitated a few days earlier.

A nurse expresses frustration to the staff psychiatrist about continued disruptive behavior of a patient who has a minimal blood level of a mood stabilizer after 5 days of pharmacotherapy. The nurse suspects the patient is hiding pills in his mouth and later discarding them.

A child psychiatrist worries about her 8-year-old patient’s lack of response to an atypical antipsychotic. The mother reveals that the child often does not take his medication because he does not like taking large pills and is afraid of choking.

Clinical scenarios such as these highlight the importance of liquid drug formulations in enhancing compliance and respecting patient autonomy. Liquid formulations of psychotropics are useful for patients who have difficulty swallowing tablets or capsules, such as children or older adults. These formulations also are helpful in acute care settings, especially for uncooperative patients. Monitoring medication ingestion to ensure compliance is another benefit of liquid formulations. Many clinicians administer intramuscular antipsychotics to relieve acute agitation¹; however, patients may consider this approach coercive, and it carries a risk of injury, especially when patients are agitated and uncooperative. Agitated patients may be amenable to ingesting liquid medication instead of oral tablets. Some liquid medications can be mixed with juice, which might help improve medication compliance in children.

The Table^2,3 lists some psychotropics that are available in a liquid formulation and their dosage strengths. Be aware of the exact strength of liquid formulations. Educate patients about how to use calibrated dosing spoons to enhance compliance and ensure patients ingest an appropriate dosage.⁴ We hope that using liquid formulations when indicated will enhance patient satisfaction and compliance, leading to improved prognosis.

Disclosure: The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Balon played no role in the peer review of this article.

Table

Psychotropic medications available in liquid formulation

Insurance companies and surgical teams usually require patients to undergo a psychiatric evaluation before major surgeries such as organ transplants,¹ amputations, or bariatric procedures because these surgeries are expensive, require patients to change their lifestyle, and use limited resources. Psychiatrists perform pre-surgical evaluations by diagnostic interview, observation, and obtaining collateral information. Your evaluation should address key elements and give the surgical team input about a patient’s suitability for surgery. You also can comment on treatments that would make the patient a better candidate for surgery and plan for post-surgery psychiatric morbidities.

Key elements

Major mental illness. Without adequate treatment, major mood disorders can make a patient unable to undergo surgery. In addition, these types of surgeries are substantial life events that can trigger mood episodes. Educate patients about early signs of relapse and suggest a plan of action for treatment. A patient with an uncontrolled psychotic disorder and poor social support and/or case management is not a good candidate for surgery.

Substance use. Patients with active substance dependence are poor candidates for major surgeries unless they receive substance abuse treatment. During evaluation, motivational interviewing can help guide a patient toward treatment. Ensure that patients whose substance dependence is in remission have adequate support and treatment plans to prevent relapse.

Capacity to make decisions is based on the nature of the procedure and the patient’s ability to understand the process and risk vs benefits. The threshold for capacity can vary based on the procedure and the risks.²

Treatment adherence requires compliance with close medical follow-up, complicated medications, or lifestyle changes. A history of compliance with medical directives, medications, and appointments is important. Collateral information from the surgical team or caregivers can be helpful.

Coping style and strategies. Quiz the patient about internal and external resources they have used to cope with stress. A pattern of decompensation to using primitive defense mechanisms to handle stress suggests that the patient may have a personality disorder and might be a poor surgical candidate. Ability to use relatively mature defense strategies in stressful times suggests a good candidate.

Safety. Active suicidal or homicidal ideation is problematic in patients seeking major surgical interventions. Ensure that the stress of the surgery will not trigger dangerous behaviors. A history of frequent self-harm or impulsive suicidality suggests the that patient may have an unstable axis I or II disorder and might be a poor candidate for major surgery without further treatment.

Insurance companies and surgical teams usually require patients to undergo a psychiatric evaluation before major surgeries such as organ transplants,¹ amputations, or bariatric procedures because these surgeries are expensive, require patients to change their lifestyle, and use limited resources. Psychiatrists perform pre-surgical evaluations by diagnostic interview, observation, and obtaining collateral information. Your evaluation should address key elements and give the surgical team input about a patient’s suitability for surgery. You also can comment on treatments that would make the patient a better candidate for surgery and plan for post-surgery psychiatric morbidities.

Key elements

Major mental illness. Without adequate treatment, major mood disorders can make a patient unable to undergo surgery. In addition, these types of surgeries are substantial life events that can trigger mood episodes. Educate patients about early signs of relapse and suggest a plan of action for treatment. A patient with an uncontrolled psychotic disorder and poor social support and/or case management is not a good candidate for surgery.

Substance use. Patients with active substance dependence are poor candidates for major surgeries unless they receive substance abuse treatment. During evaluation, motivational interviewing can help guide a patient toward treatment. Ensure that patients whose substance dependence is in remission have adequate support and treatment plans to prevent relapse.

Capacity to make decisions is based on the nature of the procedure and the patient’s ability to understand the process and risk vs benefits. The threshold for capacity can vary based on the procedure and the risks.²

Treatment adherence requires compliance with close medical follow-up, complicated medications, or lifestyle changes. A history of compliance with medical directives, medications, and appointments is important. Collateral information from the surgical team or caregivers can be helpful.

Coping style and strategies. Quiz the patient about internal and external resources they have used to cope with stress. A pattern of decompensation to using primitive defense mechanisms to handle stress suggests that the patient may have a personality disorder and might be a poor surgical candidate. Ability to use relatively mature defense strategies in stressful times suggests a good candidate.

Safety. Active suicidal or homicidal ideation is problematic in patients seeking major surgical interventions. Ensure that the stress of the surgery will not trigger dangerous behaviors. A history of frequent self-harm or impulsive suicidality suggests the that patient may have an unstable axis I or II disorder and might be a poor candidate for major surgery without further treatment.

Insurance companies and surgical teams usually require patients to undergo a psychiatric evaluation before major surgeries such as organ transplants,¹ amputations, or bariatric procedures because these surgeries are expensive, require patients to change their lifestyle, and use limited resources. Psychiatrists perform pre-surgical evaluations by diagnostic interview, observation, and obtaining collateral information. Your evaluation should address key elements and give the surgical team input about a patient’s suitability for surgery. You also can comment on treatments that would make the patient a better candidate for surgery and plan for post-surgery psychiatric morbidities.

Key elements

Major mental illness. Without adequate treatment, major mood disorders can make a patient unable to undergo surgery. In addition, these types of surgeries are substantial life events that can trigger mood episodes. Educate patients about early signs of relapse and suggest a plan of action for treatment. A patient with an uncontrolled psychotic disorder and poor social support and/or case management is not a good candidate for surgery.

Substance use. Patients with active substance dependence are poor candidates for major surgeries unless they receive substance abuse treatment. During evaluation, motivational interviewing can help guide a patient toward treatment. Ensure that patients whose substance dependence is in remission have adequate support and treatment plans to prevent relapse.

Capacity to make decisions is based on the nature of the procedure and the patient’s ability to understand the process and risk vs benefits. The threshold for capacity can vary based on the procedure and the risks.²

Treatment adherence requires compliance with close medical follow-up, complicated medications, or lifestyle changes. A history of compliance with medical directives, medications, and appointments is important. Collateral information from the surgical team or caregivers can be helpful.

Coping style and strategies. Quiz the patient about internal and external resources they have used to cope with stress. A pattern of decompensation to using primitive defense mechanisms to handle stress suggests that the patient may have a personality disorder and might be a poor surgical candidate. Ability to use relatively mature defense strategies in stressful times suggests a good candidate.

Safety. Active suicidal or homicidal ideation is problematic in patients seeking major surgical interventions. Ensure that the stress of the surgery will not trigger dangerous behaviors. A history of frequent self-harm or impulsive suicidality suggests the that patient may have an unstable axis I or II disorder and might be a poor candidate for major surgery without further treatment.

FDA-approved for maintenance treatment of bipolar I disorder, lamotrigine is more effective than lithium for preventing depressive relapses. Lamotrigine combined with lithium, carbamazepine, or valproate provides good protection against recurrences of mania and depression.

Unlike selective serotonin reuptake inhibitors and other antidepressants, lamotrigine does not appear to increase risk of hypomania or mania in bipolar patients.¹ Unlike valproate and lithium, it is weight-neutral and requires no serum level monitoring.² Although lamotrigine’s slow titration and prolonged period until reaching therapeutic effect limits its efficacy as monotherapy in an inpatient setting, the drug can be initiated along with quicker acting agents in the hospital and then titrated after discharge. This strategy allows close monitoring during initial exposure.

Consider lamotrigine as an adjunct for treatment-resistant major depression.³ It is useful for treating aggression and agitation in patients with traumatic brain injury⁴ or dementia.⁵ Borderline personality disorder patients treated with lamotrigine may show less affective lability, impulsivity, or aggression.^6,7 Lamotrigine can act synergistically with clozapine in some patients with refractory schizophrenia.⁸

Metabolism and drug interactions

Lamotrigine is metabolized via glucuronidation and eliminated renally. Other drugs metabolized by glucuronidation could interact with lamotrigine (Table).⁹

Table

Drug interactions associated with lamotrigine

Adverse reactions

Lamotrigine is well tolerated chronically, with fewer adverse effects than other mood stabilizers. Serious rashes, including Stevens-Johnson syndrome and toxic epidermal necrolysis, have been reported in 0.08% to 0.13% of patients treated with lamotrigine for bipolar disorder or other mood disorders.⁹ The risk of developing a skin rash within 2 to 8 weeks of therapy necessitates starting with a low dose, usually 25 mg/d, and gradually titrating.^2,9

The FDA added a warning about increased risk of suicidality to the labeling of all anticonvulsants, regardless of indication.¹⁰ In a meta-analysis of 199 trials, for every 530 patients treated with anticonvulsants there was 1 additional case of suicidality—not completed suicide.¹⁰ Inform patients and their families about the potential risk for increased suicidality and document this discussion of risk vs benefit. All patients should be monitored for worsening depression or suicidal thoughts or behavior throughout treatment.

Other potential side effects occurring in at least 5% of patients receiving lamotrigine include somnolence, headache, rash, and the dose-related side effects of nausea, vomiting, dizziness, ataxia, blurred vision, and diplopia.⁹

FDA-approved for maintenance treatment of bipolar I disorder, lamotrigine is more effective than lithium for preventing depressive relapses. Lamotrigine combined with lithium, carbamazepine, or valproate provides good protection against recurrences of mania and depression.

Unlike selective serotonin reuptake inhibitors and other antidepressants, lamotrigine does not appear to increase risk of hypomania or mania in bipolar patients.¹ Unlike valproate and lithium, it is weight-neutral and requires no serum level monitoring.² Although lamotrigine’s slow titration and prolonged period until reaching therapeutic effect limits its efficacy as monotherapy in an inpatient setting, the drug can be initiated along with quicker acting agents in the hospital and then titrated after discharge. This strategy allows close monitoring during initial exposure.

Consider lamotrigine as an adjunct for treatment-resistant major depression.³ It is useful for treating aggression and agitation in patients with traumatic brain injury⁴ or dementia.⁵ Borderline personality disorder patients treated with lamotrigine may show less affective lability, impulsivity, or aggression.^6,7 Lamotrigine can act synergistically with clozapine in some patients with refractory schizophrenia.⁸

Metabolism and drug interactions

Lamotrigine is metabolized via glucuronidation and eliminated renally. Other drugs metabolized by glucuronidation could interact with lamotrigine (Table).⁹

Table

Drug interactions associated with lamotrigine

Adverse reactions

Lamotrigine is well tolerated chronically, with fewer adverse effects than other mood stabilizers. Serious rashes, including Stevens-Johnson syndrome and toxic epidermal necrolysis, have been reported in 0.08% to 0.13% of patients treated with lamotrigine for bipolar disorder or other mood disorders.⁹ The risk of developing a skin rash within 2 to 8 weeks of therapy necessitates starting with a low dose, usually 25 mg/d, and gradually titrating.^2,9

The FDA added a warning about increased risk of suicidality to the labeling of all anticonvulsants, regardless of indication.¹⁰ In a meta-analysis of 199 trials, for every 530 patients treated with anticonvulsants there was 1 additional case of suicidality—not completed suicide.¹⁰ Inform patients and their families about the potential risk for increased suicidality and document this discussion of risk vs benefit. All patients should be monitored for worsening depression or suicidal thoughts or behavior throughout treatment.

Other potential side effects occurring in at least 5% of patients receiving lamotrigine include somnolence, headache, rash, and the dose-related side effects of nausea, vomiting, dizziness, ataxia, blurred vision, and diplopia.⁹

FDA-approved for maintenance treatment of bipolar I disorder, lamotrigine is more effective than lithium for preventing depressive relapses. Lamotrigine combined with lithium, carbamazepine, or valproate provides good protection against recurrences of mania and depression.

Unlike selective serotonin reuptake inhibitors and other antidepressants, lamotrigine does not appear to increase risk of hypomania or mania in bipolar patients.¹ Unlike valproate and lithium, it is weight-neutral and requires no serum level monitoring.² Although lamotrigine’s slow titration and prolonged period until reaching therapeutic effect limits its efficacy as monotherapy in an inpatient setting, the drug can be initiated along with quicker acting agents in the hospital and then titrated after discharge. This strategy allows close monitoring during initial exposure.

Consider lamotrigine as an adjunct for treatment-resistant major depression.³ It is useful for treating aggression and agitation in patients with traumatic brain injury⁴ or dementia.⁵ Borderline personality disorder patients treated with lamotrigine may show less affective lability, impulsivity, or aggression.^6,7 Lamotrigine can act synergistically with clozapine in some patients with refractory schizophrenia.⁸

Metabolism and drug interactions

Lamotrigine is metabolized via glucuronidation and eliminated renally. Other drugs metabolized by glucuronidation could interact with lamotrigine (Table).⁹

Table

Drug interactions associated with lamotrigine

Adverse reactions

Lamotrigine is well tolerated chronically, with fewer adverse effects than other mood stabilizers. Serious rashes, including Stevens-Johnson syndrome and toxic epidermal necrolysis, have been reported in 0.08% to 0.13% of patients treated with lamotrigine for bipolar disorder or other mood disorders.⁹ The risk of developing a skin rash within 2 to 8 weeks of therapy necessitates starting with a low dose, usually 25 mg/d, and gradually titrating.^2,9

The FDA added a warning about increased risk of suicidality to the labeling of all anticonvulsants, regardless of indication.¹⁰ In a meta-analysis of 199 trials, for every 530 patients treated with anticonvulsants there was 1 additional case of suicidality—not completed suicide.¹⁰ Inform patients and their families about the potential risk for increased suicidality and document this discussion of risk vs benefit. All patients should be monitored for worsening depression or suicidal thoughts or behavior throughout treatment.

Other potential side effects occurring in at least 5% of patients receiving lamotrigine include somnolence, headache, rash, and the dose-related side effects of nausea, vomiting, dizziness, ataxia, blurred vision, and diplopia.⁹

Relapse is common during recovery from alcohol or substance abuse. It’s estimated that >90% of patients will experience a relapse with 1 year of initiating abstinence.¹ How clinicians approach relapse may make the difference between a prolonged relapse or a brief one, and whether the patient has multiple occurrences or infrequent “slips.” We use the mnemonic RELAPSE to teach our medical students and residents the key components involved in addressing and preventing relapse in our patients.

Reconnection. After a relapse, patients often feel shame and guilt. They may be hesitant to talk about it and may skip appointments. It is critical to reconnect with patients through a clinical posture that is welcoming, accepting, and nonjudgmental.

Education. When a patient relapses, you have the opportunity to educate the patient, family, and significant others about substance use disorders and how they effect the “3 B’s” (brain, body, and behavior), and also the availability of treatment options.

Linkage. One possible reason behind a relapse is the lack or loss of ties to a support group, recovery program, faith community, or family. After an assessment, help your patient establish links to specific support systems needed to foster recovery.

Anticipation. It is important to assess with the patient precipitating events that led to the relapse and anticipate warning signs. Anticipating future triggers (eg, stress, loss, relationship difficulties, etc.) will allow patients to be proactive in maintaining recovery.

Psychiatric. The presence of co-occurring psychiatric disorders is the expectation rather than the exception. After a patient has relapsed, we strongly emphasize reevaluating whether unaddressed mood, anxiety, or psychotic symptoms have contributed to the relapse.

Social. Relapse does not occur within a vacuum. Social issues clearly impact one’s ability to abstain from substances. A clinician who assesses a patient’s social milieu (eg, finances, friends, and employment) and social skills (eg, ability to communicate, ask for help, and assertively say no) likely will be able to identify key factors that led to relapse.

Empowerment. Resuming recovery is based on hope, cultivation of a healthy self-esteem, and sense of control over one’s life. After a relapse, strive to use a person-centered, strength-based approach that supports the patient’s commitment to change and self-determination.

Relapse is common during recovery from alcohol or substance abuse. It’s estimated that >90% of patients will experience a relapse with 1 year of initiating abstinence.¹ How clinicians approach relapse may make the difference between a prolonged relapse or a brief one, and whether the patient has multiple occurrences or infrequent “slips.” We use the mnemonic RELAPSE to teach our medical students and residents the key components involved in addressing and preventing relapse in our patients.

Reconnection. After a relapse, patients often feel shame and guilt. They may be hesitant to talk about it and may skip appointments. It is critical to reconnect with patients through a clinical posture that is welcoming, accepting, and nonjudgmental.

Education. When a patient relapses, you have the opportunity to educate the patient, family, and significant others about substance use disorders and how they effect the “3 B’s” (brain, body, and behavior), and also the availability of treatment options.

Linkage. One possible reason behind a relapse is the lack or loss of ties to a support group, recovery program, faith community, or family. After an assessment, help your patient establish links to specific support systems needed to foster recovery.

Anticipation. It is important to assess with the patient precipitating events that led to the relapse and anticipate warning signs. Anticipating future triggers (eg, stress, loss, relationship difficulties, etc.) will allow patients to be proactive in maintaining recovery.

Psychiatric. The presence of co-occurring psychiatric disorders is the expectation rather than the exception. After a patient has relapsed, we strongly emphasize reevaluating whether unaddressed mood, anxiety, or psychotic symptoms have contributed to the relapse.

Social. Relapse does not occur within a vacuum. Social issues clearly impact one’s ability to abstain from substances. A clinician who assesses a patient’s social milieu (eg, finances, friends, and employment) and social skills (eg, ability to communicate, ask for help, and assertively say no) likely will be able to identify key factors that led to relapse.

Empowerment. Resuming recovery is based on hope, cultivation of a healthy self-esteem, and sense of control over one’s life. After a relapse, strive to use a person-centered, strength-based approach that supports the patient’s commitment to change and self-determination.

Relapse is common during recovery from alcohol or substance abuse. It’s estimated that >90% of patients will experience a relapse with 1 year of initiating abstinence.¹ How clinicians approach relapse may make the difference between a prolonged relapse or a brief one, and whether the patient has multiple occurrences or infrequent “slips.” We use the mnemonic RELAPSE to teach our medical students and residents the key components involved in addressing and preventing relapse in our patients.

Reconnection. After a relapse, patients often feel shame and guilt. They may be hesitant to talk about it and may skip appointments. It is critical to reconnect with patients through a clinical posture that is welcoming, accepting, and nonjudgmental.

Education. When a patient relapses, you have the opportunity to educate the patient, family, and significant others about substance use disorders and how they effect the “3 B’s” (brain, body, and behavior), and also the availability of treatment options.

Linkage. One possible reason behind a relapse is the lack or loss of ties to a support group, recovery program, faith community, or family. After an assessment, help your patient establish links to specific support systems needed to foster recovery.

Anticipation. It is important to assess with the patient precipitating events that led to the relapse and anticipate warning signs. Anticipating future triggers (eg, stress, loss, relationship difficulties, etc.) will allow patients to be proactive in maintaining recovery.

Psychiatric. The presence of co-occurring psychiatric disorders is the expectation rather than the exception. After a patient has relapsed, we strongly emphasize reevaluating whether unaddressed mood, anxiety, or psychotic symptoms have contributed to the relapse.

Social. Relapse does not occur within a vacuum. Social issues clearly impact one’s ability to abstain from substances. A clinician who assesses a patient’s social milieu (eg, finances, friends, and employment) and social skills (eg, ability to communicate, ask for help, and assertively say no) likely will be able to identify key factors that led to relapse.

Empowerment. Resuming recovery is based on hope, cultivation of a healthy self-esteem, and sense of control over one’s life. After a relapse, strive to use a person-centered, strength-based approach that supports the patient’s commitment to change and self-determination.

Myths describe a legendary story and explain a model of behavior or natural event. For example, the story of Persephone’s abduction by Hades and subsequent return from the Underworld has described the changing of seasons and the cycle of growth and rebirth.

A clinical psychopharmacology practice that may—or may not—be evidence-based also can be considered a myth. We offer principles to help “bust” or prove this type of myth.

Factors to consider

When initially evaluating a specific pharmacologic practice, ask yourself:

• Is this an FDA-approved indication?
• Is this an evidence-based practice?
• Does the medication have a plausible pharmacologic mechanism in the context of its use?
• What is the source of the information that led to this prescribing practice?
• How many different treatments have you tried?
• What is the clinician’s and/or patient’s experience?

Ideally, prescribing practices are steeped in solid evidence. For myriad reasons, data regarding medication use in some psychiatric disorders are sparse. In these cases— or when evidence-based approaches to patient care are inadequate—prescribers can rely on only theoretical postulates and clinical experience.

Clinical experience differs among providers and within a practice, which renders it difficult to operationalize. A knowledge base derives from the accumulated day-to-day work with real world patients and should not be undermined. However, examining the extent to which your practice is related to experience and/or evidence-based information may help to avoid errors in medical decision-making,¹ including:

• availability bias: judging events by the ease to which examples come to mind
• confirmation bias: confirming what you expect to find
• anchoring: not thinking through multiple possibilities
• commission bias: tendency toward action vs inaction.

Re-examining a prescribing practice is not time-consuming. Techniques include:

1. Using a database such as Dynamed (www.ebscohost.com/dynamed) or UpToDate (www.uptodate.com) to obtain summarized information regarding levels of evidence. This can be done easily with the patient in the room.
2. Performing a quick PubMed or MED-LINE search and reviewing the list of journal articles, assessing quantity of information and quality of studies (ie, looking for reputable journals and studies with good research methodology, a large number of subjects, and independent funding).
3. Reviewing abstracts with relevant information, and reading full articles if compelling.
4. Searching specifically for pertinent reviews or meta-analyses. Many databases allow you to filter articles by type. After reading a review, examine the references, and pull articles for further reading if relevant.

‘Busting’ a psychopharmacology myth doesn’t preclude its use. However, in an era when evidence-based medicine is highlighted and treatments are developed on a regular basis, it pays to think twice when prescribing, and to review the literature routinely. When engaging in shared decision making with patients, it is valuable to summarize what exists—or doesn’t—as evidence in literature and differentiate it from clinical experience.

The myth of Persephone describes the cyclical nature of the harvest; crops grow from seeds, mature in sunlight, and are harvested, then recycled during winter to grow again. Similarly, a prescribing practice should be seeded in evidence, cultivated with clinical experience, and habitually re-examined.

Myths describe a legendary story and explain a model of behavior or natural event. For example, the story of Persephone’s abduction by Hades and subsequent return from the Underworld has described the changing of seasons and the cycle of growth and rebirth.

A clinical psychopharmacology practice that may—or may not—be evidence-based also can be considered a myth. We offer principles to help “bust” or prove this type of myth.

Factors to consider

When initially evaluating a specific pharmacologic practice, ask yourself:

• Is this an FDA-approved indication?
• Is this an evidence-based practice?
• Does the medication have a plausible pharmacologic mechanism in the context of its use?
• What is the source of the information that led to this prescribing practice?
• How many different treatments have you tried?
• What is the clinician’s and/or patient’s experience?

Ideally, prescribing practices are steeped in solid evidence. For myriad reasons, data regarding medication use in some psychiatric disorders are sparse. In these cases— or when evidence-based approaches to patient care are inadequate—prescribers can rely on only theoretical postulates and clinical experience.

Clinical experience differs among providers and within a practice, which renders it difficult to operationalize. A knowledge base derives from the accumulated day-to-day work with real world patients and should not be undermined. However, examining the extent to which your practice is related to experience and/or evidence-based information may help to avoid errors in medical decision-making,¹ including:

• availability bias: judging events by the ease to which examples come to mind
• confirmation bias: confirming what you expect to find
• anchoring: not thinking through multiple possibilities
• commission bias: tendency toward action vs inaction.

Re-examining a prescribing practice is not time-consuming. Techniques include:

1. Using a database such as Dynamed (www.ebscohost.com/dynamed) or UpToDate (www.uptodate.com) to obtain summarized information regarding levels of evidence. This can be done easily with the patient in the room.
2. Performing a quick PubMed or MED-LINE search and reviewing the list of journal articles, assessing quantity of information and quality of studies (ie, looking for reputable journals and studies with good research methodology, a large number of subjects, and independent funding).
3. Reviewing abstracts with relevant information, and reading full articles if compelling.
4. Searching specifically for pertinent reviews or meta-analyses. Many databases allow you to filter articles by type. After reading a review, examine the references, and pull articles for further reading if relevant.

‘Busting’ a psychopharmacology myth doesn’t preclude its use. However, in an era when evidence-based medicine is highlighted and treatments are developed on a regular basis, it pays to think twice when prescribing, and to review the literature routinely. When engaging in shared decision making with patients, it is valuable to summarize what exists—or doesn’t—as evidence in literature and differentiate it from clinical experience.

The myth of Persephone describes the cyclical nature of the harvest; crops grow from seeds, mature in sunlight, and are harvested, then recycled during winter to grow again. Similarly, a prescribing practice should be seeded in evidence, cultivated with clinical experience, and habitually re-examined.

Myths describe a legendary story and explain a model of behavior or natural event. For example, the story of Persephone’s abduction by Hades and subsequent return from the Underworld has described the changing of seasons and the cycle of growth and rebirth.

A clinical psychopharmacology practice that may—or may not—be evidence-based also can be considered a myth. We offer principles to help “bust” or prove this type of myth.

Factors to consider

When initially evaluating a specific pharmacologic practice, ask yourself:

• Is this an FDA-approved indication?
• Is this an evidence-based practice?
• Does the medication have a plausible pharmacologic mechanism in the context of its use?
• What is the source of the information that led to this prescribing practice?
• How many different treatments have you tried?
• What is the clinician’s and/or patient’s experience?

Ideally, prescribing practices are steeped in solid evidence. For myriad reasons, data regarding medication use in some psychiatric disorders are sparse. In these cases— or when evidence-based approaches to patient care are inadequate—prescribers can rely on only theoretical postulates and clinical experience.

Clinical experience differs among providers and within a practice, which renders it difficult to operationalize. A knowledge base derives from the accumulated day-to-day work with real world patients and should not be undermined. However, examining the extent to which your practice is related to experience and/or evidence-based information may help to avoid errors in medical decision-making,¹ including:

• availability bias: judging events by the ease to which examples come to mind
• confirmation bias: confirming what you expect to find
• anchoring: not thinking through multiple possibilities
• commission bias: tendency toward action vs inaction.

Re-examining a prescribing practice is not time-consuming. Techniques include:

1. Using a database such as Dynamed (www.ebscohost.com/dynamed) or UpToDate (www.uptodate.com) to obtain summarized information regarding levels of evidence. This can be done easily with the patient in the room.
2. Performing a quick PubMed or MED-LINE search and reviewing the list of journal articles, assessing quantity of information and quality of studies (ie, looking for reputable journals and studies with good research methodology, a large number of subjects, and independent funding).
3. Reviewing abstracts with relevant information, and reading full articles if compelling.
4. Searching specifically for pertinent reviews or meta-analyses. Many databases allow you to filter articles by type. After reading a review, examine the references, and pull articles for further reading if relevant.

‘Busting’ a psychopharmacology myth doesn’t preclude its use. However, in an era when evidence-based medicine is highlighted and treatments are developed on a regular basis, it pays to think twice when prescribing, and to review the literature routinely. When engaging in shared decision making with patients, it is valuable to summarize what exists—or doesn’t—as evidence in literature and differentiate it from clinical experience.

The myth of Persephone describes the cyclical nature of the harvest; crops grow from seeds, mature in sunlight, and are harvested, then recycled during winter to grow again. Similarly, a prescribing practice should be seeded in evidence, cultivated with clinical experience, and habitually re-examined.

Presenting patients to supervisors in a cogent fashion appears to be a dying (or already dead) art among psychiatric residents. Trainees often approach the oral patient presentation as simply a routine necessity rather than a core professional skill that reflects their ability to synthesize and relay clinical information. In this article we offer suggestions on how to reclaim this lost art.

Tell a story. Think of your presentation as a story about the patient. A story has a beginning, middle, and end; in this case, the order is present illness, psychiatric history, medical history, social history, family history, examination, laboratory data, diagnostic impression, treatment plan, and prognosis. Do not intermingle these elements into a free-associative stream of consciousness or a tale of how and in what order you obtained the information. It is the doctor’s—not the patient’s—responsibility to be a good historian.¹

Define the ‘leading edge.’ For an inpatient, the leading edge might be the symptoms that led to hospitalization. For an outpatient, it is not unusual for the present illness to go back many years, which is where the presentation should begin. Resist the temptation to start more recently because to do so often leaves the listener wondering—when did this begin, and how does it fit into the bigger picture?

Respect your listeners. You want to leave your audience with a clear picture of who your patient is. Presenting a patient should call to mind the saying, “If I’d had more time, I would have written a shorter letter.” It takes more time and effort to fashion a succinct presentation than to produce a rambling narrative with extraneous material; it requires synthesis and judgment to determine what to leave in and what to leave out. George Murray, MD, a consultation psychiatrist and our mentor, is fond of saying, “Do you know how to bore your audience? Tell them everything.” Respect your listeners’ time and credit their intelligence. Your presentation should stimulate questions, not preempt them by being overly inclusive or exhausting all of your allotted time.

Do not rehash the history when presenting the assessment. The assessment is what you think about the history and examination data—how you put it all together to make sense of it diagnostically so you can approach treatment in an organized way. It is not the time to recapitulate what you should have summarized in the earlier part of your discourse. The diagnostic impression is where you can show off how you think as a physician. It is where you can shine.

Presenting patients to supervisors in a cogent fashion appears to be a dying (or already dead) art among psychiatric residents. Trainees often approach the oral patient presentation as simply a routine necessity rather than a core professional skill that reflects their ability to synthesize and relay clinical information. In this article we offer suggestions on how to reclaim this lost art.

Tell a story. Think of your presentation as a story about the patient. A story has a beginning, middle, and end; in this case, the order is present illness, psychiatric history, medical history, social history, family history, examination, laboratory data, diagnostic impression, treatment plan, and prognosis. Do not intermingle these elements into a free-associative stream of consciousness or a tale of how and in what order you obtained the information. It is the doctor’s—not the patient’s—responsibility to be a good historian.¹

Define the ‘leading edge.’ For an inpatient, the leading edge might be the symptoms that led to hospitalization. For an outpatient, it is not unusual for the present illness to go back many years, which is where the presentation should begin. Resist the temptation to start more recently because to do so often leaves the listener wondering—when did this begin, and how does it fit into the bigger picture?

Respect your listeners. You want to leave your audience with a clear picture of who your patient is. Presenting a patient should call to mind the saying, “If I’d had more time, I would have written a shorter letter.” It takes more time and effort to fashion a succinct presentation than to produce a rambling narrative with extraneous material; it requires synthesis and judgment to determine what to leave in and what to leave out. George Murray, MD, a consultation psychiatrist and our mentor, is fond of saying, “Do you know how to bore your audience? Tell them everything.” Respect your listeners’ time and credit their intelligence. Your presentation should stimulate questions, not preempt them by being overly inclusive or exhausting all of your allotted time.

Do not rehash the history when presenting the assessment. The assessment is what you think about the history and examination data—how you put it all together to make sense of it diagnostically so you can approach treatment in an organized way. It is not the time to recapitulate what you should have summarized in the earlier part of your discourse. The diagnostic impression is where you can show off how you think as a physician. It is where you can shine.

Presenting patients to supervisors in a cogent fashion appears to be a dying (or already dead) art among psychiatric residents. Trainees often approach the oral patient presentation as simply a routine necessity rather than a core professional skill that reflects their ability to synthesize and relay clinical information. In this article we offer suggestions on how to reclaim this lost art.

Tell a story. Think of your presentation as a story about the patient. A story has a beginning, middle, and end; in this case, the order is present illness, psychiatric history, medical history, social history, family history, examination, laboratory data, diagnostic impression, treatment plan, and prognosis. Do not intermingle these elements into a free-associative stream of consciousness or a tale of how and in what order you obtained the information. It is the doctor’s—not the patient’s—responsibility to be a good historian.¹

Define the ‘leading edge.’ For an inpatient, the leading edge might be the symptoms that led to hospitalization. For an outpatient, it is not unusual for the present illness to go back many years, which is where the presentation should begin. Resist the temptation to start more recently because to do so often leaves the listener wondering—when did this begin, and how does it fit into the bigger picture?

Respect your listeners. You want to leave your audience with a clear picture of who your patient is. Presenting a patient should call to mind the saying, “If I’d had more time, I would have written a shorter letter.” It takes more time and effort to fashion a succinct presentation than to produce a rambling narrative with extraneous material; it requires synthesis and judgment to determine what to leave in and what to leave out. George Murray, MD, a consultation psychiatrist and our mentor, is fond of saying, “Do you know how to bore your audience? Tell them everything.” Respect your listeners’ time and credit their intelligence. Your presentation should stimulate questions, not preempt them by being overly inclusive or exhausting all of your allotted time.

Do not rehash the history when presenting the assessment. The assessment is what you think about the history and examination data—how you put it all together to make sense of it diagnostically so you can approach treatment in an organized way. It is not the time to recapitulate what you should have summarized in the earlier part of your discourse. The diagnostic impression is where you can show off how you think as a physician. It is where you can shine.