Principles of Choosing Psychotropics

0:00 this talk is about the fundamental principles involved in choosing psychotropic medications to treat mental illness in this talk I'll outline seven principles that I consider to be Universal for making decisions about medication treatment for most psychiatric illnesses and for most types of psychotropic medication this talk draws significantly for my personal experience and different experts may have different views on the topic I'll outline each of the seven principles in order of importance the first principle involves the safety profile of medications remember as a doctor one of your fundamental obligations is to do no harm as such you should not recommend a medication where the potential harm outweighs the potential benefit specific factors to consider here are the medication's risk of serious or

0:45 irreversible side effects such as organ failure the presence of comorbid medical illness that could increase the risk of serious side effects or drug drug interactions between the psychotropic and any other medications the patient may already be taking second consider the patients preferences this is the most nuanced principle to master and involves taking into account the patients beliefs and opinions regarding medication and mental illness which could be based on the patient's culture upbringing treatment history or other factors sometimes these beliefs may be illogical or not based on scientific fact or majority opinion however even in these cases you need to do your best to understand them and take them into account in your clinical decision- making there are two major reasons why why this is important first is the

1:32 expectancy effect which essentially means that if someone believes strongly that a treatment is going to help them it is more likely to help them second is the concept of the Therapeutic Alliance and how this Alliance impacts treatment adherence in general a person is more likely to listen to their doctor and adhere to the treatment they recommend if the person feels that they are being listened to understood and cared for the simple takeaway from this principle is that if you are trying to decide between two different medic a options that are approximately the same in terms of safety and Effectiveness and the patient has a preference between one or the other then choose the medication that the patient prefers third consider the patient prior Trials of medications it is important to know what medications the patient has previously tried including how effective it was how well

2:19 it was tolerated in terms of side effects the highest dose that was tried and the longest duration that was tried here it is important to know the concept of an adequate trial an adequate trial refers to taking a medication consistently as prescribed for an adequate duration and at an adequate dose specifically the highest dose of the medication that the patient is able to tolerate and is approved by the FDA also known as the maximum tolerated dose for complete a sake a related concept is the minimum effective dose which is the lowest dose of medication necessary to achieve the intended therapeutic effect or goal in general you should avoid using higher doses than the minimum effective dose to limit adverse effects effects fourth consider the ease of use this involves the dosing schedule or how

3:05 often the medication needs to be administered in a day and the administration round that is whether it is taken by mouth injection a skin patch or another method for example a once perday medication is easier to use than a twice per day medication and an oral medication is easier to use than an injection medication fifth consider side effects in general a medication with fewer or easier to tolerate side side effects is going to be easier to adhere to than one with worse side effects consider both the common side effects but also the side effects that may occur only rarely but are potentially serious for example organ failure heart arrhythmias or seizures sixth consider secondary benefits if possible choose a medication that targets multiple symptoms or accomplishes multiple goals

3:52 for example if the patient wants to treat both their depression and their chronic pain consider using an anti-depressant that targets both finally consider the drug cost this is perhaps an overgeneralization but in most cases newer medications for mental health problems which are still unpent and expensive are no more effective than older medications that were developed many years ago for which there are cheap generic options available and are more often covered by insurance plans if you do need to use a more expensive medication then be aware that there may be Financial assistant programs available for specific medications that's the end of this talk I I hope this provides a useful framework for thinking about choosing psychotropic medications thank you