Louisville Medicine Volume 69, Issue 8 - Page 11

the basic question , do patients really need all these medications ?
Many texts have been written addressing the relational nature of our work with patients . Due to many changes in the way we deliver our services and care , we have become “ dispensers of meds ” rather than “ collaborators of care .” As noted by Kinghorn and Nussbaum in their recently published prescribing guide , “ The stars that truly set the course are the relationships we establish with patients , not the medicines we prescribe .” 1 The relationship between the patient and clinician accounts for 20 % of outcome variance . 4
In the “ Dispenser ” model , it is clear that the medication is the agent of healing . The primary goal of treatment is symptom reduction . If instead you are a “ collaborator ,” symptom reduction is not the primary goal – rather , the goal is for the patient to regain the power and capacity to pursue valued purposes in life , and to heal . So if patients present in psychological pain , the simple plan ( and cultural expectation ) is that you will prescribe a medication to alleviate the symptom . However , all mental disorders emerge in relationships , fester in relationships and subside and heal in relationships . The primary task in mental health treatment is to facilitate healing within these sometimes very dysfunctional relationships . No question that medication can alleviate symptoms , but the true goal is to lower barriers to the patient ’ s ability to engage in healthy relationships .
Sometimes the body speaks what words cannot express . Patients often cannot put their main concerns and underlying problems into words , yet their symptoms communicate the distress and underlying unhappiness . Many of these symptoms have no medical explanation , “… indeed medically unexplained symptoms are a part of 40 % -50 % of primary care visits worldwide and are a regular feature of primary care practice .” 5 These individuals are rarely intentionally exaggerating their symptoms , rather they have somatic distress from the excess cortisol and hormonal imbalances they experience from chronic life stressors . COVID-19 has brought this even more to light and raises concerns about inappropriate diagnostic testing , inaccurate diagnoses and polypharmacy .
So what to do in a 10 minute appointment time for a patient in emotional distress ?
The conservative prescribing method can help you .
1 ) Validate patient ’ s distress ; note that their somatic and emotional symptoms are valid modes of experience . Ask the patient what method of treatment they prefer . If it is reasonable , go that way . If it is unreasonable , provide evidence-based alternatives to counter . Giving patients choices increases the likelihood of success .
2 ) Educate patients on the relationship of stress to the body , especially the hormonal issues of cortisol , sex hormones and insulin . Is stress the real cause ? Is there a history of trauma ? What does the symptom mean to the patient ? – and let the patient teach you .
3 ) If medication seems indicated , better to start with only one medicine at a time , and begin with low doses . If switching medications , remember to never abruptly stop a psychotropic – especially benzodiazepines and antidepressants .
4 ) Except in the cases of patients with bipolar disorder or schizophrenia , it is unwise to rely on psychotropic medication long-term without addressing underlying and complex conditions – especially trauma .
5 ) Establish clear targets for medication treatment and framework for monitoring response . Benzodiazepines should only be used after acute loss or crisis , and for no more than four to six weeks . SSRIs should be tapered after six to nine months , especially if this is the first episode .
6 ) When treatments fail and meds don ’ t work , consider a more integrative approach . The biomedical model is overly simplistic and implies that if you correct a brain chemical imbalance , all will be well . So reconsider the diagnosis – or at least what role stress and trauma history play in an individual ’ s reaction to triggers in their environment . Try to understand the connections patients have with their treatments and the clinicians that work with them . Lifestyle habits often exacerbate psychological distress : smoking , excessive caffeine , use of alcohol , bad diet are major causes of insomnia , irritability and daytime fatigue . Physical activity and breath control are more effective than medications in managing anxiety . Supplements including fish oil , magnesium and valerian root can help regulate mood instability . Acupuncture and psychotherapy are effective evidence-based treatments for depression that don ’ t require chemicals in the body .
Health care in America is too often about a clinician taking an action instead of participating in an interaction with another person . Remember always - we should see ourselves as expert collaborators , not medicine dispensers . We should not focus on what to prescribe , rather our focus should be on how and when to prescribe in collaboration with a fellow human being in need . It is high time we get back to our historical roots and remember our pledge of primum non nocere !
References :
1
Kinghorn and Nussbaum ; Prescribing Together : A Relational Guide to Psychopharmacology , 2021 APA Publishing
2
Andrew Weil , MD , Mind Over Meds , Chapter 9 , 2017 Hachette Book Group
3 https :// www . medicalnewstoday . com / articles / 322877
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4
Krupnick , Sotsky et al . 1996 , J . Consult Clinical Psychology 64 ( 3 ): 532-539
5
Haller et al , Somatoform Disorder and Medically Unexplained Symptoms in Primary Care . 2015 . Dtsch Arztebl Int 112:279-287
6
Balint M : The Doctor , His Patient , and the Illness New York , Inter Univ Press , 1957
Dr . Wernert , MHA , is the Executive Medical Director of Norton Medical Group and practices with Norton Behavioral Medicine .
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