Is the present treatment working?
One view is that the physician's priority should be to help the patient overcome the illness. Others may decide that the priority must be to not harm the patient. This is a value decision. To help guide the physician's course of action, we must remember the rule: do everything possible to help the patient. When putting effectiveness first, the present illness status and, more important, the course of the current treatment has to be taken into account. If the current treatment has led to some progress, it should be continued unchanged.
Whatever the treatment strategy may have been—older or newer antipsychotics, low or high dosage, 1 drug or multiple medications—if it works, it is okay. No theoretical reason should make a physician change a successful treatment. If there is no convincing progress, the next step is to make sure that the medication is being taken as prescribed. One cannot argue that a drug did not work if it has not been used correctly. Double-check and correct dosages (ie, are they too high or too low), treatment duration, and patient adherence. If the present illness status has not improved in spite of an appropriate antipsychotic medication, do not wait, test something else and switch to another medication.
Is the current treatment tolerated?
Physicians should not harm patients (nil nocere). Negative drug effects have to be taken seriously and should be minimized as much as possible. Look for and ask about signs and symptoms of known adverse effects. Inquiring about adverse effects does not increase their prevalence, nor does it lead to nonadherence. Instead, the patient gets the feeling that the physician cares about his progress and well-being.
If there are adverse effects, the question is whether something can or must be done. Serious adverse effects that can cause severe harm (eg, tardive dyskinesia) must lead to a change in treatment, whether the patient likes the change or not. Subjective burdensome side effects should not be played down but should lead to a change in treatment whenever it is medically possible. Medical considerations should come first but don't forget to empathize with your patient.
Which drug should be selected next?
After the decision has been made that a change in medication is needed, the physician must decide which drug should be tried next. Factors listed in the RTSQ8 that should be considered include patient preferences, pharmacological profiles, drug interactions, potential side-effect profiles, costs, application modes, illness status, special drug effects, social and occupational status of the patient, recommendations by superiors, colleagues or others, and experience with the drug. Again, value judgments are necessary to determine what factors are most important. We think that in most cases the decision should start with consideration of the side effects.
This leads us to another rule:use rehabilitation pharmacotherapy and support participation. By and large, all antipsychotic medications are equally effective.30-33 However, there are relevant differences in respect to their side-effect profiles. Adverse effects are not only a medical problem, they also have consequences for participation in social or occupational life. For instance, sedation impairs working ability, impotence impairs connubial life, emotional flattening impairs social interaction, and weight gain impairs general health and self-confidence. All patients have special needs and individual problems. Rehabilitation pharmacotherapy,34 a new way of prescribing that aims to increase participation in social life in addition to (and perhaps even more than) reducing illness symptoms, takes all these factors into consideration.
Another important aspect is the patient's cooperation. Like most physicians, most patients have their own preconceived notions about certain drugs. They may also prefer different modes of application. The general rule should be to fulfill the patient's wishes whenever medically possible (treat your patient as if he were your client).
Pharmaceutical companies and scientists love to point to new developments, and it is their job to do so. They thus recommend new drugs more vigorously than older ones. They highlight their new pharmacological, side-effect, or efficacy profiles. They bring new literature to every physician desk and stimulate scientific debates on special aspects of new drugs. They even include these discussions in treatment guidelines.
Experienced physicians know that medical progress in antipsychotics has moved at a snail's pace and that many promises turn out to be empty or simply wishes and good intentions. Therefore, it is wise to stay with well-known drugs and not hop on the bandwagon of every new drug. It is also wise to use the same drug in most patients instead of using different drugs in each patient. Only by repeated prescribing is it possible to become thoroughly acquainted with a drug. Thus, it is wise to choose the drug that you have prescribed most often and with which you are most familiar.
Last but not least, physicians should be aware that they spend the money of other persons. Whenever possible they should help to reduce costs.