Expert Insights in Advanced Psychopharmacology is an ongoing video series featuring members of the Psych Congress Steering Committee and Faculty. The series, which highlights key psychopharmacology topics, is designed to provide mental health clinicians with practical guidance to maximize the effectiveness of treatments.
(Part 6 of 7)
In this video, Psych Congress Steering Committee member Rakesh Jain, MD, MPH, discusses the sixth of 7 habits which clinicians can develop to be highly effective at treating anxiety disorders.
Dr. Jain is Clinical Professor, Department of Psychiatry, Texas Tech University School of Medicine, Austin. He will co-present a session on the 7 habits at Psych Congress 2020, being held virtually Sept. 10-13, 2020, with a preconference on Sept. 9, 2020.
Go to the Expert Insights in Advanced Psychopharmacology page to learn about the other habits.
Read the transcript:
Hello, dear friends. It's good to be with you again to talk about the seven habits of a highly effective anxiety disorder treating clinician. My name is Rakesh Jain, and I'm a proud member of the Steering Committee at Psych Congress.
I thought I would take a moment to remind you again why we are talking about habits. As we know from this great thought leader, Stephen Covey, habit is the intersection of knowledge, skill, and desire. At Psych Congress, we endeavor to develop great knowledge, great skills, and of course a deep desire to help our patients, and that's why developing these good habits is so important.
Today, we're going to talk about habit number 6. We'll focus on medications. Carefully navigate the paradox of medications. This effective clinician, this master clinician knows the strengths and limitations of psychotropic medications in the treatment of patients with anxiety disorders.
Here's an overview of a few very wise and practical tips on the pharmacotherapy of anxiety disorders I have been taught and I've picked up over the last 3 decades of clinical practice.
Number one, medications are not always needed, nor are they always first‑line interventions in anxiety disorders. Therefore, judicious decision‑making is important in every field of psychiatry, but it may be particularly so with anxiety disorders.
If you do decide to use medications, appropriate dose is needed for optimum outcomes. So many patients don't receive that. Along with the right dose, appropriate duration is a crucial necessity, and sadly, many patients do not receive that. These are things we must avoid.
Careful side effect management is crucial for all patients, but in anxiety disorders, it may be even more important because patients with anxiety disorders may be more prone to side effects, and more prone to leaving treatments, so we should do that at an optimum level.
By the way, should we encounter patients with no or poor response to pharmacotherapy, these are some practical tips to remember, OK? First, let's make sure the medication trial is adequate, 10 to 12 weeks. Let's make sure the maximum approved and tolerable dosage of the medication is used.
Number three, comorbid conditions, particularly personality disorders, should be identified and treated, and obviously adherence has to be confirmed. I can't tell you how many times I'm so sure the medication hasn't worked and the patient tells me, "Sorry, I've only taken it about half the time, for a variety of reasons."
Of course, I do need to make sure an underlying medical or substance related condition has been identified and addressed. Needless to say, pharmacokinetic factors are important. I need to make sure there's no drug‑drug interaction issue or a pharmacokinetic issue that is leading to challenges.
Obviously, what if there's a brand-new psychosocial issue that has popped up that's making the medications less effective now? That needs to be identified and addressed as well.
Let's pull the curtains back on this issue of treatment‑resistant anxiety disorders. Should you encounter such a patient, again, please confirm the dose and frequency were correct. Let's also make sure we have all the right diagnoses. All of them, not just one or two, but all of them.
The third is, let's, again, never, in treatment resistant‑anxiety disorder patients, forget the importance of the body below the neck, and let's not forget about substance misuse. That can often be the precipitator of challenges, and psychosocial issues must be counteracted.
This is why I've always thought of pharmacotherapy as a supporting actor in this play of treating patients with anxiety disorders. Psychotherapies are often not just first‑line, but often a necessity.
Managing side effects, we talked about that a second ago. I have found that patients with anxiety disorders may be more prone to side effects, so let's look at a list of the common side effects we see: nausea, sedation, and the opposite of sedation, insomnia, agitation, GI side effects.
Now, you and I might say, "Oh, these are only temporary," and they are, in most patients. The challenge is, with anxiety disorders, catastrophization is a significant challenge. Therefore, watchfulness is necessary.
There's no denying long‑term side effects such as sexual dysfunction, weight gain, memory difficulties, apathy. Those are real challenges to not forget about, to discuss with the patient, and to intervene as necessary.
Recommendations for managing side effects, let's first get the patient and us on the same team. Remember, collaborative care is very appropriate in all patients, but anxiety disorder patients, it may be of greater importance.
Please consider starting medications at low doses, perhaps even "subtherapeutic" doses. Titrate slowly. That is a great strategy. It doesn't mean we don't get to the right doses. It just means, sometimes hurrying too much really leads to significant challenges.
Obviously, we encourage patients to report side effects to us because if they happen, we want to offer them both an understanding and advice on how to best manage it.
By the way, making medication adjustments, switches, and augmentation, which, as I've said before, we do with every disease state, with anxiety disorders, that skill is a necessity.
In conclusion, habit number 6, carefully navigate the paradox of medications, requires us to remember, it requires skill, and knowledge, and passion. Those are 3 things we have plenty of, don't we, as Psych Congress family members.
Let's remember, our patients are apprehensive about their medications. That's part of their anxiety disorder, increased apprehension, and they do experience both higher rates of side effects and also perhaps a misperception of how challenging it is, and they may forget that these are temporary. Slow and gradual medication adjustment is indeed recommended.
Let's never forget, offering encouragement, offering enthusiasm, offering resilience to our patients is a skill not just in the therapeutic context with, say, CBT, but also the therapeutic context of psychopharmacology. That's what makes us skilled clinicians.
With that, thank you so much for joining me on this discussion of one of the habits of a highly effective anxiety disorder treating clinician. I will see you next time. Bye for now.