Psychopharmacologist Gives Seven Best Practices for Patient Care

With the advances of the last few decades, scientific data show that the effectiveness of psychiatric treatments are equivalent to other branches of medicine, Ira D. Glick, M.D., professor emeritus in psychiatry and behavioral science at Stanford University School of Medicine, told attendees at a session on Wednesday.

“We can help almost everybody to varying degrees. We must now conduct our practices like the rest of medicine,” he said. When practicing psychopharmacology, Glick said there are best practices for patient care that the profession should embrace. Doing so, however, requires psychiatrists to find ways to overcome the obstacles posed by time limits on patient care, documentation tasks, and securing pay for their work.

Seven of Glick’s best practices for psychopharmacology include the following:

• Practice evidence-based medicine. “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, if you want to helpful to patients,” he said. Another critical step includes taking a thorough medical and psychiatric history from the patient and a family member or caregiver, just as other medical specialists do, he said. Glick gives patients a comprehensive form to complete prior to their first appointment that includes an inventory of their life difficulties and key events; marital and sexual past; 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 when he goes over the form at the patient’s first session.


• Do differential diagnosis. Glick believes the diagnosis is a critical part of the treatment plan, preferring to include input from family or caregivers when possible in this process. 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 often calls patients’ previous clinicians to obtain information. “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, and just as important he explains it to the family and significant others, he said. “As part of good patient care, I spend a significant amount of time talking to the family.” 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.”


• Show you care, give patients hope. Glick, who said he’s still providing lifetime care for many of his patients, says 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 helps keep them out of the hospital because he can intervene earlier in the case of an acute exacerbation. “I tell them that once I start treating them, they’re like family.” Despite treating patients with serious chronic illnesses, he said he always finds a way to turn it around and offer patients hope of improvement, he said.
  
  Conference attendee Tina Zielinski, M.D., of Grapevine, Texas, said for the past 15 years she has also made it a habit to provide her patients with her personal cellphone number so they can call her in a psychiatric emergency. She reported that only in rare cases, typically when patients are inebriated, have they abused this. “Those calls I do not have to answer,” she said. She recalled one instance when she received a call from a patient who was starting to get manic. Because she and the patient were able to connect so quickly, she was able to stop his antidepressant 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 and capture details in the chart. 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 who have had lifelong schizophrenia that they can reduce their feelings of fear, paranoia, and anger, but may not be able to completely resolve the hallucinations. “I tell them ‘We will make life livable for you even with the symptoms you have.’” 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 the patient what he’s written. He makes sure to mention the progress the patient has made.


• Don’t forget psychotherapy. Glick said 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 10 minutes.”


• Less is more, and admit what you don’t know. Glick said too many psychiatrists are still taking a “shotgun” approach: He sees patients for the first time who are taking a mood stabilizer, an antipsychotic, an anxiolytic, and a sleeping pill. “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. When treating severe psychiatric illnesses, he said the main thing is to save the life of the patient, being honest about side effects. ■