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The 7 Sins of Psychopharmacology – According to Doctors
I’ve been dealing with psychopharmacology for more than a decade now and I could easily write about the seven sins of psychopharmacology, psychiatry, or psychotherapy. It’s rare, however, to see a doctor admit to a mistake, let alone an ongoing sin. Some brave doctors, though, have spoken out on what they considered the problems in psychopharmacology to be in an effort to improve prescribing practices among all physicians.
The sins mentioned come from an editorial by Carl Salzman, MD, Ira Glick, MD, and Matcheri S. Keshavan, MD, The 7 Sins of Psychopharmacology.
The 7 Sins of Psychopharmacology
Not Performing a Comprehensive Diagnostic Evaluation
I can’t tell you the number of people who feel that they have not been considered as a whole person when a doctor has evaluated them and given them a diagnosis. In fact, most people feel that psychiatrists make snap decisions based on mere moments of conversation. I, for one, don’t think this is acceptable. It in no way meets the standard of a psychiatric evaluation and it doesn’t come close to considering all the factors in a person’s life that may have led them to where they are today. And of course, without a thoughtful diagnosis, there is little chance to create an appropriate treatment plan.
Not Correctly Handling Medication Dosage
Dosage is a major factor in the success or failure of a treatment and while drug companies and studies provide proven, safe dosage ranges, not all patients react in a standard way. Sometimes a patient requires substantially more medication than the standard dose and sometimes much less. It can be a mistake for a doctor not to push a dose higher when only a partial response is seen or not to try a lower dose when too many side effects are present. The only way to assess whether this is appropriate, however, is close communication with the patient.
Not Allowing for Suitable Treatment Duration
The authors state they have witnessed, “medication regimens are sometimes discontinued, altered, and augmented before an adequate prescribing period has allowed for a full response to the drug.” In other words, psychiatrists aren’t giving the drugs enough time to work. This is understandable considering both psychiatrists and patients want the treatment to work quickly, but the fact of the matter is, many treatments simply don’t work quickly and if they are abandoned too soon, it is not known whether they truly would have worked or not. A full medication trial is critical before crossing a treatment off the list of possibilities.
The Use of Polypharmacy.
The use of more than one drug at the same time is known as polypharmacy. This is common in many disorders like bipolar disorder, but there is little research indicating the correct usage of this practice. In fact, some studies show that adding more drugs simply increases the incidence of side effects rather than providing any further benefit. Additionally, when an additional medication is added, it’s common that previous medication is not appropriately discontinued resulting in unnecessary drugs, cost, and side effects. (This is not to suggest, however, that polypharmacy is not appropriate in some cases.)
Not Understanding the Psychological Background of the Patient
This goes back to diagnosis. It’s critical that doctors have a complete picture of a patient before initiating treatment. This may mean including psychotherapy either as part of the psychiatrist visit or ensuring psychotherapy is provided by an additional provider. Psychotherapy is not always indicated but many disorders have been shown to have better outcomes when psychotherapy is combined with medication treatment. Patients want to feel understood by a treatment provider and not just like a petri dish that someone is experimenting on.
Thinking Medication is the Solution for All Problems
The idea that there exists “better living through chemistry” (a slogan used by a drug company) is mostly a false one. As the authors say, “Not all unhappiness is depression; not all worry is anxiety. Not all restlessness is agitation, not all troubled sleep is insomnia.”
Lack of Communication
If there’s one of these sins that bothers me (and endangers patients) more than any other it’s a lack of communications between professionals. Psychiatrists must communicate with other treating doctors in order to get a full picture of a patient. For example, if one doctor prescribes a thyroid medication, it’s critical that a psychiatrist know this in order to do their job correctly. Moreover, psychiatrists should always consider proper communication with the loved ones of the person with the mental illness as the patient may not be able to express their own situation accurately due to their illness.
(Bonus Sin) Not Keeping Up with the Field.
It’s a real sin when psychiatrists don’t keep up with their own field. This may be due to a full schedule and too many patients, but that’s no excuse for not keeping up with current literature. And keeping up with psychopharmacology does not mean getting information from drug companies—it means studying published information.
(Note: I’ve taken a bit of liberty with how the authors individuate the sins. For the full editorial, please see here.)
Thoughts on the Sins of Psychopharmacology
Not all psychiatrists are guilty of all sins, of course, but some are. In next week’s article I’ll talk about how to avoid falling victim to one of these sins.