Medications are a cornerstone of effective treatment, and the psychiatrist should uphold the medical model as an essential perspective. Diagnosis of pathology directs treatment and permits risk assessment. It can also delay premature labeling. For example, staff members may interpret an act as proof of a personality disorder, but they should consider mania, paranoia, stimulant use, akathisia, or hyperthyroidism as possible causes.
Paranoia blocks alliance. Psychosis impairs attention and learning. Anxiety and insomnia exhaust. Depression impedes hope. Cravings and compulsion twist willpower. Medications can alleviate all these problems. Multiple and overlapping diagnoses are the rule, and the evidence base is scant when it comes to such complicated cases. It is sometimes necessary to treat symptomatically, until diminished drug use and time permit greater diagnostic certainty. Medications with strong supporting evidence that are still underused include the following:
• Opioid replacement therapies
• Agents that affect craving and cue responsivity, such as naltrexone(Drug information on naltrexone)
• Smoking cessation therapies
• Clozapine(Drug information on clozapine), which works for many treatment-resistant psychoses and appears to reduce illicit drug use19-22
Physicians also need to recognize and treat common medical and iatrogenic disorders (eg, sleep apnea, diabetes, movement disorders).
Patients resist medications because of fear of losing control, concern about adverse effects, and stigma of having a mental illness. Willpower and autonomy are revered in our culture and medications are often discouraged. This is particularly relevant in the realm of addictions where recovery is somehow seen as soiled if someone is taking medications, especially an opiate replacement, despite decades of evidence of efficacy.23
The psychiatrist needs to be collaborative and respect the participant’s priorities and worries rather than targeting a symptom. For example, an antipsychotic drug might be deemed unacceptable by the patient if it is recommended for delusions but accepted if it is prescribed to ease associated insomnia or anxiety. The full effect of a medication might be explained in a later phase of recovery when there is sufficient insight or alliance.
Prescribers should use the fewest number of medicines and discuss with the patient why they are choosing a particular drug, as well as its limitations and potential adverse effects. In this way, the patient becomes an active participant who knows his concerns will be listened to.
Education, symptom management, and skills training
Education (individually or in groups or via the Internet, books, and meetings with peers) helps families understand why the clinician is making a particular treatment choice. This knowledge can reduce shame and anger, and it can begin to unite families. Evidence-based practices often use cognitive and behavioral interventions in group or individual formats. The framework of interrupting automatic responses by reviewing triggers, thoughts, and feelings can be applied broadly. Manualized, time-limited applications are available for many disorders, including substance use, psychosis, and mood and anxiety disorders.24-26