Psychopharmacologist Offers 10 Best Practices for Patient Care

Advances in psychopharmacology over the last few decades have dramatically improved the effectiveness of mental health treatment, but realizing the potential of newer medications requires certain shifts in the practice of psychiatry, according to an expert at APA’s 2022 Annual Meeting.

“The scientific data show the effectiveness of our treatments is now roughly equal that of the rest of medicine. We can help almost everybody to varying degrees, just like the rest of medicine. We must now conduct our practices like the rest of medicine,” said Ira D. Glick, M.D., professor emeritus in psychiatry and behavioral science at Stanford University School of Medicine.

Glick called on psychiatrists to embrace certain best practices. His top 10 tips include the following:

• History is critical: A critical first step includes taking a thorough medical and psychiatric history from the patient, just as other medical specialists do, he said. Glick uses his own comprehensive form that patients complete—prior to their first appointment—that includes an inventory of key life events and difficulties; marital and sexual history; menstrual status, if applicable; types of psychiatric treatment, medications, and outcomes; clinician names and contact information; as well as any hospitalizations. He fills in any blanks at the patient’s first session.

• Do differential diagnosis: Glick believes determining an accurate diagnosis is a key part of the treatment plan, and he solicits input from family or caregivers in this process whenever possible. He does not accept the patients’ word on what is wrong. “Often patients come in and say, ‘I have anxiety’ or ‘I’m depressed,’ but what does that mean?” He frequently calls patients’ previous clinicians to obtain more information, he said. “When I ask what diagnosis they’ve been working with, half the time they don’t have an answer,” he said.

• Educate patient and family and agree on goals: Once he reaches a diagnosis, Glick explains it to the patient in explicit terms, for example, telling the patient that he or she has bipolar II with borderline personality disorder, including what that means. Just as important, he explains it to the family and significant others. “As part of good patient care, I spend a significant amount of time talking to the family,” he said. Then he engages in goal setting with the patient. “The first thing we need to agree on is what we’re going to do and not going to do.”

• Give patients hope: Despite treating patients with serious chronic illnesses, he said he always finds a way to offer patients hope of improvement, he said. He makes sure to mention at every session the progress that patients have made thus far in treatment. “I tell them, ‘We will make life livable for you even with the symptoms you have.’ ”

• Show you care: “I tell them that once I start treating them, they’re like family.” He gives them his cellphone number and tells them not to hesitate to call him if there’s a problem. “It’s amazing—even the sickest patients don’t abuse that,” he said, and having a way to reach him quickly allows him to intervene earlier in the case of an acute exacerbation.

  Conference attendee Tina Zielinski, M.D., of Grapevine, Texas, agreed on the importance of giving patients one’s cell phone number, and said for the past 15 years she has done the same. Only in rare cases, typically when patients are inebriated, have they abused this, she said. “Those calls I do not have to answer.” She recalled an instance when a patient was starting to get manic, and because he was able to reach her so quickly, she was able to stop his antidepressant medication before he needed hospitalization. “The patient’s father tipped him off that he should call me. The patient was ambivalent, but when I spoke to him, I agreed that his mood had changed, and that convinced him.”

• Be transparent: Glick believes in communicating realistic expectations about the effectiveness of treatment, giving a balanced presentation of pros and cons of a given medication, as well as about the likely course of patients’ illness. For example, he has told patients with lifelong schizophrenia that medication treatment can reduce their feelings of fear, paranoia, and anger but may not be able to completely resolve the hallucinations. When treating patients with severe psychiatric illnesses, he said the main thing is to focus on saving their lives, being honest about the potential side effects of treatment. When it comes to patients’ use of over-the-counter treatments or illicit substances, he said he takes a hard line and discourages their use.

• Capture details in the chart: Before Glick begins charting, he reflects to patients what he’s heard them say during their session. For complicated cases, he sometimes charts as he goes along or shows patients what he’s written.

• Don’t forget psychotherapy: Glick believes that psychotherapy and psychopharmacology are complementary, so he provides at least some therapy at every patient session. He uses different modalities as called for, he said. “I don’t do med checks that last only 10 minutes.”

• Less is more, and admit what you don’t know: Glick said too many psychiatrists are still taking a “shotgun” approach, which is not evidence based. For example, he sees many patients for the first time who are taking a mood stabilizer, an antipsychotic, an anxiolytic, a sleeping pill, and more. “Less is more,” he advised. “Try one thing at a time, and take medication changes slow.” When patients ask about a medication with which he is unfamiliar, he’s not afraid to pull out his PDR and look it up, “just like an internist would do,” he said.

• Practice evidence-based medicine: “If you want to be helpful to patients, engaging in continual lifelong learning—as well as keeping up with the scientific literature and advances in the field—are critical for the practice of psychopharmacology,” Glick said.

Ultimately, Glick acknowledged that embracing these best practices for psychiatric care requires physicians to find ways to overcome many obstacles. These include time limits on patient care imposed by managed care, burdensome documentation tasks, lack of reimbursement structure for many of these important tasks, and physician burnout, he said. ■