Rational Psychopharmacology

Dr. Paul Putman (00:04):

If I'm going to pick a medication for a patient to offer them, I really feel like I need to understand the entire landscape. I need to know what came before and what might've come afterwards. I need to know why that medication was used in the first place, how it was demonstrated. I need to know all the comparisons to that, so that I'll be making the most informed decisions and rational decisions for my patients. So that's the approach that I took with each of the commonly used medicines in psychopharmacology.

Dr. Laura Roberts (00:39):

Hi, I'm Dr. Laura Roberts, Editor-in-Chief for the Books for the American Psychiatric Association and welcome to the APA books podcast. Hi, we have the chance to talk with Paul Putman today. He put a book together for us on rational psychopharmacology, a book of clinical skills, and it's really a superb book. Paul is a distinguished life fellow of the American Psychiatric Association, and he was a Loughlin fellow and is a member of the American College of Psychiatrists.

Dr. Laura Roberts (01:11):

He's board certified in general psychiatry by the American Board of Psychiatry and Neurology. Graduate of Austin College in Sherman, Texas, Dr. Putnam received his MD degree from University of Texas, Medical branch at Galveston. He completed his internship and residency in general psychiatry at the Medical University of South Carolina in Charleston, where he was chief resident. He's written several pieces for psychiatric news, and I hope he is going to write several books for us based on this first wonderful book. I'm really looking forward to talking with Paul today. So good morning, Paul. I'm so glad that you could join us today.

Dr. Paul Putman (01:49):

Thank you very much.

Dr. Laura Roberts (01:50):

And I'm especially glad that you put together this wonderful book for us at APA publishing. Your book is called Rational Psychopharmacology: A Book of Clinical Skills. And I just wanted to start by saying, I think it's really a very nicely written, very, very nicely written book. Very thoughtful, accessible, real, it's not just facts and figures. It's really how you think as a clinician. And I just wondered why you thought the world needed this book.

Dr. Paul Putman (02:25):

Well, I was very fortunate in my training to be under clinicians and scholarly scientists who made sure that I learned to take a scholarly and academic approach to practice. I always wanted to be in private practice largely and to see lots and lots of patients, which thankfully my career has allowed me to do.

Dr. Paul Putman (02:51):

But nevertheless, I take the same approach I would take if I were in academics and that's my teachers were very careful to make sure that I've learned that. And as I have consulted and taught myself throughout the years, it's come to my attention that every now and then I run into someone who has not had the same opportunity of their education. And they find it valuable when I share some of these skills. And so I thought as I was entering the latter stages of my career, it would be an important thing to try to share those really important clinical skills that I think really benefited my patients so well.

Dr. Laura Roberts (03:34):

That's wonderful. And you trained, was it at Medical University of South Carolina?

Dr. Paul Putman (03:41):

I did. Late McCurdy had just left when I arrived. In fact, his departing grand rounds was on scholarship, which really impressed me. And then James Ballenger came and I was the chairman while I was there. I really benefited from their pluralistic approach, which at the time was rare. Again, a very rational and scholarly approach.

Dr. Laura Roberts (04:11):

So let's think about your book. It's got a dozen chapters and they range from thinking thoroughly and methodically and evidence-based medicine assessment techniques, which I thought was a fantastic chapter. The risks of jumping from molecule to mind are sometimes fantastic ideas. So just tell me about and tell our listeners about just the structure, how you built the architecture of this book.

Dr. Paul Putman (04:42):

Well, there are many different areas to cover and many different things as clinicians that we have to accomplish. And so the challenge was to link it all together in a coherent theme. And so I wanted to begin with how we think, what is the history of rational thought? Why have we used rational thought as human beings? How has it evolved through deductive and inductive and towards abductive reasoning? And to describe that as a foundation and then to talk about the nature of data. What is information, what is noise? How do we approach that? How do we model, how do we try to predict how do we use probability? Because really in, in, in clinical psychopharmacology, we're using probability and modeling so predictably.

Dr. Paul Putman (05:38):

So I wanted to cover that area thoroughly, and then I thought it was appropriate to utilize those skills at looking at evaluating the scientific literature. Because if we're going to be rational clinicians, we've got to have the best database that we can have, of course, and it falls upon individual practitioner to make those decisions about what we're going to consider evidence when we practice evidence-based medicine. There's never enough evidence, so we have to make judgment calls every day about what we're going to consider evidence and how we're going to apply that to our modeling and our treatment planning.

Dr. Paul Putman (06:16):

So I thought it was very important to cover that. And then I wanted to talk about the, as you said, not jumping from molecule to symptom or mind because you see that's so often in practice is our wonderful friends at the pharmaceutical industry are very helpful by providing tools that we need to treat our patients, but sometimes as they squabble over market share, they'll stress some unimportant features.

Dr. Paul Putman (06:42):

And so I think it's very important that that clinicians be aware of the cognitive errors that we can make, even with the best intentions. I mean, we know to only read peer review journals and we know not to just pay attention to anecdotal evidence. We know even about confirmation bias and while we do double blind studies. Maybe we're not as aware however that as we learn scientific information, it's been documented that we pick up just as many incorrect facts as we do correct facts.

Dr. Paul Putman (07:17):

And recently demonstrated interestingly enough that when we learn an incorrect fact, even when we learned the correct information, our brain doesn't erase the incorrect information that in fact, it takes active process of suppressing it for years to the rate that it's measurable. So I think the more awareness clinicians have of the struggles that we're having internally to remain rational, that would serve us well as well.

Dr. Paul Putman (07:47):

So after all that, I moved into treatment planning and how you would rationally approach the treatment planning with abductive reasoning, starting with partial information, developing a hypothesis, testing it, and then modeling using Bayesian inference where you use your prior information and prior probabilities and you then test and you gather more information, and then you move to what are called posterior probabilities, where you alter your model.

Dr. Paul Putman (08:20):

Whenever there's an unfortunate or unexpected or disappointing outcome from a treatment plan, one of the most important things to do is to examine your model, not just pick another medication. So I included chapters on understanding those issues and then became the big challenge, which is what am I going to do about talking about medicines? Because of course there are myriad fabulous books on psychopharmacology from the very best people in the field that I don't need to compete with or recreate.

Dr. Paul Putman (08:54):

So I decided that the best approach and discussing the medications rather than just leaving them out altogether, was to take a historical approach because I really believe context is essential. If I'm going to pick a medication for a patient to offer them, I really feel like I need to understand the entire landscape. I need to know what came before and what might've come afterwards. I need to know why that medication was used in the first place, how it was demonstrated. I need to know all the comparisons to that, so that I'll be making the most informed decisions and rational decisions for my patients.

Dr. Paul Putman (09:31):

So that's the approach that I took with each of the commonly used medicines in psychopharmacology. And I also applied that to supplements because supplements are something many patients want. And if there's a lot of misinformation about on the internet. So I tried to review the supplements, what we know, what we don't know, what we like, what we don't like and put that alongside the medications for consideration. And then equally important to me is as an everyday practicing clinician is lifestyle issues. They're just huge.

Dr. Paul Putman (10:06):

You've got to pay attention to sleep. You've got to pay attention to of course, alcohol and drugs. You've got to pay attention to caffeine, even exercise. If a patient wants to have exercise, be the number one intervention for their psychiatric problem, how valid is that? How can you approach it? So the book covers that information, and then of course discusses how you would approach any adverse events, which of course occur more than we would like, but should be anticipated. And so there's a thorough discussion of how to approach that.

Dr. Paul Putman (10:39):

And then the book wraps up by talking about, once you come up with this rational plan, how do you monitor it and how does it evolve over time? And I hope also hope I've stressed in the book, the process of working with your patients during this process. It's not just an internal process, but you have to reach out and work in cooperation with the therapeutic alliance. So that's the decisions I made and how I structured the book. And it's my hope that it came through as a coherent message and theme at the end.

Dr. Laura Roberts (11:14):

It really did. Working with a lot of different book manuscripts, sole author book is a rare gift because there is a kind of coherence, kind of logic that is really evident in the book. And sometimes you don't have that as much in edited volumes. And then what you value there is almost the different perspectives that come through. But what I really appreciated about was your book and it's the flow and the logic and the coherence of the message. But let me ask you a little bit, because some people, I think it's a false dichotomy myself, but some people might think that by emphasizing rational, you're taking out the heart and you did talk about the therapeutic alliance.

Dr. Laura Roberts (12:02):

And just actually just speaking with you for a few minutes, I can tell the patients will feel how much you care and how conscientious and you only want what's good. It comes across from your demeanor and your way, but what would you say to the critics who suggests that emphasizing the rational cuts out a part of the therapeutic alliance, the heart of the interaction between the clinician and the patient.

Dr. Paul Putman (12:31):

I mentioned this in the book a bit, but when I was in training, Thomas [Steel 00:12:39], one of my best psychotherapy supervisors used to say that our job as a clinician was not to be [inaudible 00:12:45] detectives of psychopathology, but to use our common sense, goodwill and undivided attention. And that really impressed me. And I tried to apply those skills throughout my time, and I think if you're really giving goodwill and undivided attention and it even as little as common sense, which of course when you're starting is mostly what you have to give, I really think that you do develop an emotional connection with your patients.

Dr. Paul Putman (13:17):

I mean, your patients invite you in at the most vulnerable times of their lives when they are not necessarily functioning at their best. And it's an invitation to honor them and to honor that relationship. And I don't think you can escape that by being rational. I think by being rational, you're giving them your best. You are telling them that you are there trying as hard as you possibly can, working with them to understand what information is useful, what information is not useful.

Dr. Paul Putman (13:54):

I mean, I've of course had patients over the years that are sick and tired of me asking about caffeine, or that will say, "You worked with me for 20 years. Do you really need to ask me about suicidal thoughts at absolutely every visit?" But I think most patients understand that you're concerned and that it's important. Every now and then I may leave out one question by mistake, and then my long-term patients will say, "You forgot to ask me about [inaudible 00:14:26]"

Dr. Paul Putman (14:27):

And I think they feel really nurtured by the fact that I am being thorough and many have commented on it. They'll say, "Wow, that was really thorough." And they feel like they're getting a good evaluation or money's worth, and then I'm paying attention and that it matters. Another issue is head injuries, head trauma. I have a very low threshold for being worried about head trauma. And many people are stigmatized by it. They think I mean brain damage when I'm really just trying to figure out how it could be affecting their underlying medical condition and our treatments and their safety.

Dr. Paul Putman (15:10):

And so there's a struggle at the beginning sometimes as we talk about that, but I think the more you persist about something, if you do it in of course a kind and friendly way, the more your patients are alerted to the fact that this is important. That this guy thinks this is important, you come and ask him your opinion so I'm going to go along with it. I think the caring comes across by the diligence. I really do.

Dr. Laura Roberts (15:38):

Yeah. Yeah. And so let me pose a question to you. When you think about a trainee or someone in private practice who picks up your book and after they read your book, what will be different about a new patient visit from one week, till the week after they've read your book? What do you hope might be a little bit different?

Dr. Paul Putman (16:08):

The three words I keep stressing in the book over and over are to be thorough and to be methodical and to do it every time to be consistent. So my hope is that the clinicians having just read the book will apply those skills, that they won't cut corners. They don't want to say I've only got 15 minutes, 20 minutes, I really don't have time to go into that.

Dr. Paul Putman (16:40):

That they'll put off making important clinical decisions or recommendations until they gathered the data. That there'll be much more diligent and insistent on themselves for being thorough and consistent. And that they will ask the questions every time, even though they probably know the answers. I'm hoping for consistency and thoroughness more than anything else. I think that improves the practice of psychopharmacology immensely.

Dr. Laura Roberts (17:10):

And have you seen a difference in patient outcomes?

Dr. Paul Putman (17:15):

I have. I also mentor other clinicians at times and I'll use their experience rather than mine. And what they tell me is that when they start paying attention to the details more and more, when they go into a deeper discussion of other medical issues, when they ask more questions than they're used to asking, when they spend more time thinking about the complexity that they are seeing that patients that one time they would have considered treatment resistance or no longer treatment resistance. They're finding the answers in the keys for each patient by being more thorough.

Dr. Laura Roberts (17:55):

Yeah, that's phenomenal. That's phenomenal. Let's shift gears a little bit. One of the things that I'm most worried about with COVID, I mean, and there's a long list of things to worry about, but it's the neuropsychiatric equality of COVID infection that we're just beginning to appreciate now. And so I'm wondering if you have any observations about how psychiatrists should bring in questions about COVID to their psychiatric practice as we move forward.

Dr. Paul Putman (18:31):

I'm a strong believer and I hope this came through in the book that we are physicians first and specialists second. That you can't really be the best psychiatrist or psychopharmacologist you can be, unless you are a thorough physician. You've got to approach the patient with a thorough medical evaluation. I think I even say in the book that the general medical history is every bit as important as the mental status examination, which I know might sound like heresy, but I really believe it because there are so many other non psychiatric medical problems that could be contributing to your patient's symptoms, it's easy to miss those. You don't want to go off on a tangent.

Dr. Paul Putman (19:12):

So I firmly believe that the COVID symptoms, as you were alluding to we're realizing are impacting a significant number of COVID patients with mental health and neurological symptoms, you must ask those questions. Just like you would ask about head trauma, now we need to be asking about this infectious exposure. I think it should be part of the routine initial assessment, and it should be part of the review of symptoms at every visit.

Dr. Paul Putman (19:41):

Again, I've had patients who were 55 years old, nice family, people who I ask every week, and yeah, they did try marijuana last week for the first time in their lives. I think it's important to ask that. It's important to ask, "Have you had any exposure to COVID? Have you had any exposure to any other important illnesses that you know are going to impact your mental health. So again, being up on the literature is going to alert us to every question we should be asking about their medical.

Dr. Laura Roberts (20:14):

And that's great. And let me ask you. I'm going to anticipate part of your answer, which is that it was that you planned it well, but what was it like to write a book? And what did you learn about yourself in that process?

Dr. Paul Putman (20:29):

I am fortunate my father was in journalism, and so I got the rare experience during summers in high school and college to get to write for a small town newspaper. And I only got that because of my father. I would never have had that job otherwise.

Dr. Laura Roberts (20:47):

Amazing. Yeah.

Dr. Paul Putman (20:48):

And I always wanted to be a physician, so I didn't want to give that up and not get to be a physician to be a journalist. And as I said at the time, I can be a physician and still write, I can't really write and, and do physician in our dark times. So I went ahead with that. I've always wanted to write and, so it, I enjoy writing very much. So it comes to me naturally.

Dr. Paul Putman (21:15):

I had written a book for my patients that I self published, just so that they could get it 15 years earlier about bipolar disorder because I wasn't finding anything that I really wanted to recommend. Everything was too technical or too watered down. And so I had gone through the discipline of finishing a book before, and so I really welcomed the opportunity to write this one. I've I've thoroughly enjoyed it. I liked the process of finding the right words.

Dr. Paul Putman (21:48):

Mathematicians will talk about the pure joy of finding the right equation. I think finding the right words is a joy. It's just like communicating with your patients. You've got to find the right way to say it, the most efficient way to say it. So it was a very enjoyable process for me. I don't know if I'm answering your question, but that-

Dr. Laura Roberts (22:09):

No. That's great. No, that's great. And I would say that your sense of beauty in language really comes through. And again, to reinforce what I thought was really special and quite distinctive about this book is you're walking the clinician through the process of thinking about caring for patients and the use of psychopharmacological agents. So as you described, it, wasn't a book about different medications or the parameters of their use. It was more about engaging with your patient, learning about your patient and using your knowledge and wisdom to try and serve them well.

Dr. Laura Roberts (22:55):

And so it really is a different book and I felt like that intention came through really beautifully. So I want to thank you for doing this book with us. And I also want to talk to you about your next book so I'm going to set up a call.

Dr. Paul Putman (23:12):

Thank you. That would be great.

Dr. Laura Roberts (23:14):

Yeah. That's great. Is there anything else you'd like to tell our listeners about the book or your reflections on the writing of the book or your hopes for the field?

Dr. Paul Putman (23:26):

My hopes for the field is that everyone who goes into the field, of course, we're hoping has the best intentions and very good abilities. I'm just hoping that the book helps us organize that and focus that and fine tune it. And if that can happen, everybody talks about memes today, using the evolutionary biology, meaning of meme, not the social media meaning of meme, it's my hope that as we work more rationally in this field, that it will be observed and it will be mimicked, it will be copied and it will be passed on and it can reverberate and hopefully improve the outcome for all of our patients. That that's what I hope most.

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