1. The Art of Psychopharmacology Ira D. Glick, M.D. Stanford University School of Medicine Richard Balon, M.D. Wayne State University School of Medicine

2. Introduction Clinical Practice of Psychopharmacology based on: Training Training Knowledge Knowledge Experience Experience The “art” (i.e. clinical pearls) combined with the science The “art” (i.e. clinical pearls) combined with the science

3. Pearls If you use meds, give a balanced presentation of pros & cons but be positive If you use meds, give a balanced presentation of pros & cons but be positive Have “real” relationship with patient (vs. being neutral) Have “real” relationship with patient (vs. being neutral) Combining psychotherapy is “complex,” supportive psychotherapy is best Combining psychotherapy is “complex,” supportive psychotherapy is best Get story from patient (in addition to other sources) Get story from patient (in addition to other sources) Get information in detail re: S & Sx Get information in detail re: S & Sx

4. Pearls Use meds earlier rather than later Use meds earlier rather than later In acute phase, don’t discuss “lifetime use” In acute phase, don’t discuss “lifetime use” Don’t do emergency treatment on Fridays Don’t do emergency treatment on Fridays There are limits to what you do in “office” There are limits to what you do in “office” There are limits to who you see at home, re: aggression, or the phone, re: clarity with pts and family There are limits to who you see at home, re: aggression, or the phone, re: clarity with pts and family

5. Pearls Explore and consider patient’s views of medication Explore and consider patient’s views of medication Information provided by therapist is useful, but only as component of the complete picture Information provided by therapist is useful, but only as component of the complete picture Don’t get seduced by marketing and advertisement Don’t get seduced by marketing and advertisement Do not make unrealistic promises to patients and families Do not make unrealistic promises to patients and families

6. Pearls Medication levels could be useful Medication levels could be useful However, don’t treat labs, treat patients However, don’t treat labs, treat patients Even very low doses could be effective in some patients (especially in the elderly) Even very low doses could be effective in some patients (especially in the elderly) Always consider lack of adherence, but be careful how you ask about it Always consider lack of adherence, but be careful how you ask about it Not all side effects are side effects (consider baseline, timing, sequence) Not all side effects are side effects (consider baseline, timing, sequence)

7. Pearls The patient comes first (vs other concerned parties) The patient comes first (vs other concerned parties) “Do the right thing” (vs compromising Rx guidelines for “wrong” reasons) “Do the right thing” (vs compromising Rx guidelines for “wrong” reasons) Less is usually more Less is usually more Do one medication change at a time Do one medication change at a time If you are in a hole, don’t dig deeper (re-evaluate progress & change what you are doing) If you are in a hole, don’t dig deeper (re-evaluate progress & change what you are doing) Clinical experience - defined as “making same mistake for 30 years” (use data with clinical experience) Clinical experience - defined as “making same mistake for 30 years” (use data with clinical experience)

8. Pearls Data takes precedence over “gut feeling” Data takes precedence over “gut feeling” Always explain what you are doing Always explain what you are doing Always involve the family/sig. others Always involve the family/sig. others An M.D. by him/herself usually can’t adequately manage one psychotic patient (need family, sos) An M.D. by him/herself usually can’t adequately manage one psychotic patient (need family, sos) Always give patient/family “hope” Always give patient/family “hope”

9. Pearls Try to do treatment changes slowly Try to do treatment changes slowly Aim to do “differential psychopharmacology” vs. “shotgun polypharmacy” in hopes something will work Aim to do “differential psychopharmacology” vs. “shotgun polypharmacy” in hopes something will work If patient resistant/ambivalent - (it’s usually the illness, not a character flaw) If patient resistant/ambivalent - (it’s usually the illness, not a character flaw) Warn patient about major SE & controversies Warn patient about major SE & controversies Be patient but consistent and persistent in long term management Be patient but consistent and persistent in long term management

10. Summary & Conclusion Know the literature Know the literature Be compassionate, but firm & prescriptive Be compassionate, but firm & prescriptive Good psychopharmacology practice is a combination of “art plus science” Good psychopharmacology practice is a combination of “art plus science”