Front Matter

Introduction

Acknowledgments

1 Thinking Thoroughly and Methodically

2 Evidence-Based Medicine in an Era of Sparse Evidence: Assessment of Data

3 Thorough Assessment Techniques

4 Rational and Methodical Treatment Planning

5 Risks of Jumping From Molecule to Mind or Symptom

6 Pharmacokinetics, Pharmacodynamics, and Pharmacogenomics

7 Categories of Medication Used in Clinical Psychopharmacology

8 Supplements: Their Role in Helping and Not Helping

9 Critical Lifestyle Supports to Successful Clinical Psychopharmacology

10 Nonpharmacological Somatic Treatments in Current Use

11 Adverse Events

12 Rational and Methodical Treatment Monitoring

Answer Key

Index

Many books about psychopharmacology have been published. Most focus heavily on the basic science involved and describe the currently available medications, including brief rationales for their use as well as their dosages and their side effects. Others are more for the general public, intended to help them understand how psychopharmacology might be helpful. This book is different.

What I hope to achieve is not only to teach you, the reader, what medicines are available and what their characteristics are but also to teach very valuable skills: how to think thoroughly and methodically when assessing a patient, when reviewing research data (both basic and clinical), and when thinking through, developing, and monitoring the most effective clinical recommendations for patients. Rather than a lesson in elementary patient assessment, this book is an attempt to help you identify weaknesses in your practice style and improve them where psychopharmacology is involved. Medicines will come and go, but these skills, applied alongside regular literature reviews, should keep you on the cutting edge for the length of your career, helping each patient to the greatest degree possible and enjoying high professional satisfaction for decades to come.

“Wait!” you may protest. “I understand how to identify a good research study and to analyze data. I had to demonstrate these abilities to get into medical school and then again while in medical school, residencies, and fellowships.” I am certain that you did. You certainly also witnessed, however, the human tendency to not use these skills on a daily basis; to give in to hearsay, anecdotal evidence, and yes, even advertising; to not really understand the study design or statistical analysis in journals and to read non-peer-reviewed articles; and even to be lazy about asking enough questions to understand our patients.

Clinical psychopharmacology is best practiced through a routine process of ongoing thorough and complete assessments of our knowledge base and our patients. This discipline is attached to conscious application of abductive and Bayesian logic in formulating and adjusting treatment plans until they produce outcomes desired by both patient and practitioner. This text attempts to explicate the necessary techniques, in detail, in the hope of elevating clinical practice. Participation in a therapeutic alliance with a patient is a privilege practitioners honor by providing only their very best—time, patience, safety, undivided attention, and goodwill—plus the rational steps stressed in this book.

Therefore, should you embark on this process, please read the entire book, even if it seems elementary in some cases. Chapter 1 begins with a description of the various methods humans have used to structure rational thought, ultimately defining the most useful practices for the medical field. Chapter 2 explores the nature of data and outlines tools for the best analysis of basic and clinical research. Chapter 3 is a detailed discussion of what information is necessary to obtain from patients and the skills for eliciting it. Chapter 4 demonstrates how combining the lessons from the first three chapters can help physicians structure optimal treatment planning sessions with their patients.

Chapter 5 explores how errors in learning and thinking across scales can affect medication selection. Chapter 6 quickly reviews pharmacokinetics, pharmacodynamics, and pharmacogenomics, before plunging into a historical and broad review of psychotropic medications in Chapter 7 and commonly used supplements in Chapter 8. Essential patient lifestyle elements necessary for good pharmacological outcome are covered in Chapter 9. Although this is a book on pharmacology, Chapter 10 provides an update on somatic treatments that are also available to patients. Very importantly, Chapter 11 discusses adverse event awareness, assessment, and response. The final chapter, Chapter 12, focuses on effective techniques for the ongoing assessment of patients and treatment plans and how any necessary alterations may be formulated and best approached.

Self-assessment questions are included at the end of each chapter, as are topics to consider individually or to discuss in seminars or journal clubs. Suggestions for additional reading are provided. I encourage you to use the description of statistical methods covered in Chapter 2 to evaluate the references included with each chapter. Remember, this process is both thorough and methodical; skipping around is neither. That is where many would-be clinicians begin to fail. Commitment to a standardized routine is the beginning of success. If you work through each chapter completely, my hope is that you will be rewarded with not only new insights but also a commitment to return to best practices learned from others that may have been forgotten, devalued, or discarded during busy and hectic practice. With effort, we not only may “do no harm”—we also may do some good.

My career in psychiatry has been stimulated and nurtured by many generous teachers and colleagues; I thank them and those who encouraged my idea of writing this book. Mr. Joe Wood, my high school government teacher, and Professor Shelton Williams, Ph.D., at Austin College (AC) most impressed in me the process of thinking rationally. Professor Henry Gorman, Ph.D., let me into his AC January term course in psychopharmacology, although I was a sophomore, and followed it with “The Physiological Basis of Behavior.” Obviously, it stuck. During my residency at the Medical University of South Carolina, Thomas Steele, M.D., stressed the importance of avoiding “chronic undifferentiated therapy,” while Alberto B. Santos Jr, M.D.; James C. Ballenger, M.D.; Raymond F. Anton, M.D.; and Charles Kellner, M.D., also took me under wing and imparted their best. Thanks also to Bruce Lydiard, M.D., Ph.D., who was kind enough to treat a lowly resident as a friend and colleague. I was fortunate to benefit early in my career from association with many at the American Psychiatric Association (APA) but particularly from the wisdom, knowledge, and guidance of Carolyn B. Rabinowitz, M.D.

I want to thank my early teachers and eventual colleagues in psychiatry, Albert Singleton, M.D.; Ahmed Zein-Eldin, M.D., Ph.D.; and William Bondurant III, M.D., a fellow AC grad. My colleagues in Austin, James Kreisle, M.D.; Simone Scumpia, M.D.; and Rex Wier, M.D., supported the proposal for this book to the APA. Special thanks to John McDuffie, publisher; Laura Roberts, M.D., M.A., editor-in-chief; and Erika Parker, acquisitions editor, of APA Publishing for their belief in and acceptance of this project. Thank you to Greg Kuny, managing editor; Jennifer Gilbreath, senior editor; Susan Westrate, production manager; and Zoe Boyd, marketing associate, all at APA Publishing, for shepherding me through the publication process. Your guidance and suggestions were invaluable.

I mostly thank, however, my family: particularly my wife, Meg, whose love and support made devoting a year to this project possible. I thank my computer scientist sons, Houston and Alex, for their advice on the future of computerized scientific publishing, and my daughters, Bonnie and Charlotte, for their love and encouragement. I also thank the patients who, during my 35 years in psychiatry, allowed me to participate in their lives at vulnerable moments and satisfy my dream of becoming a practicing physician.