Recognizing and Avoiding Common Pitfalls in Clinical Psychopharmacology

Because psychiatrists are not trained or experienced in pain management, they put themselves at grave risk if they do prescribe narcotic analgesics. One way a psychiatrist can manage the risk of prescribing pain medication is to be part of a multidisciplinary team that includes primary care physicians, neurologists, pharmacists and, if available, pain specialists. If that is not feasible, then ongoing consultation with a primary care physician should be standard practice. Substance misuse is not going to be eliminated by multidisciplinary teams or consultation²²; however, working with such a team dilutes the risk to the physician.

Primarily prescribed for children and adolescents with attention deficit disorder with or without hyperactivity (ADD/ADHD), psychostimulants can produce a "high" or feeling of elation, followed by withdrawal/depression, which can initiate a reward cycle of abuse and addiction. Moreover, these medications tend to reduce the appetite and promote weight loss. The adventuresome tendencies of adolescents, combined with the near-epidemic prev-alence of obesity, sets the stage for a slippery slope of attraction, abuse, and addiction.

ADHD is considered the most common neurobehavioral disorder in children, affecting an estimated 4% to 12% of children aged 6 to 12 years.²³ Approximately one third to one half of all pediatric mental health referrals are for treatment of ADHD,²⁴ and it is unwise to withhold medication when clinical experience has demonstrated that 70% to 90% of children will respond favorably to at least 1 psychostimulant if the dosage is titrated properly.²⁵

In managing the risk of prescribing psychostimulant medication it is essential for the prescribing physician to collaborate with parents, guardians, and teachers. Problem behavior may not be observable during the office visit, so collateral contacts are very important.

With all abusable prescription medication, managing the double-edged sword of denying needed treatment versus unintentionally abetting abuse need not be exceptionally difficult, if good practice standards are followed. Recommended steps for reducing the overall risk of abuse, overuse, or addiction are listed in Table 1.

The effect ofchlorpromazine on agitation and psychosis was serendipitously discovered by a Parisian surgeon, Henri Laborit, in 1952, who was using it to reduce the amount of anesthesia needed to sedate surgical patients. He was so impressed that he passed it along to psychiatrists: "The results were stunning. Patients who had stood in one spot without moving for weeks, patients who had to be restrained . . . could now make contact with others and be left without supervision."²⁶ Another psychiatrist reported, "For the first time we could see that they were sick individuals to whom we could now talk."²⁶ Chlorpromazine(Drug information on chlorpromazine) and the newer antipsychotics that followed may be bona fide miracle drugs and should always be considered for psychotic patients, but they have a considerable downside.

First-generation antipsychotics (FGAs) have been notorious for producing extrapyramidal syndrome (EPS) and tardive dyskinesia (TD). Second-generation antipsychotics (SGAs) were touted as having little or no risk for causing EPS or TD, but these adverse effects have been observed.²⁷ Moreover, the SGAs have been associated with a metabolic syndrome of abdominal weight gain, dyslipidemia, and insulin resistance.²⁸ The FGAs have also been known to increase insulin resistance and foster new cases of diabetes but to a lesser extent.²⁹

Adverse drug reactions are the fifth most common cause of death in the United States, following heart disease, cancer, stroke, and pulmonary disease.^30,31 Psychotropics are often associated with adverse effects, including cardiac toxicity, confusion, and unwanted sedation. People taking psychotropics for mental illnesses may be especially susceptible,³² and not surprisingly, the elderly are the most susceptible.³³ Finally, one of the most confounding problems in psychopharmacology is the paradoxical potential of antidepressants to promotesuicidal ideation.³⁴

The risk of adverse effects may be minimized by:

• Taking a good medication history, including over-the-counter drugs and medications ordered by other physcians.
• Ordering, monitoring, and following up on appropriate laboratory studies, including weight and vital signs, especially in patients with a personal or family history of diabetes.
• Avoiding the SGAs that may increase the risk for insulin resistance in patients with a personal or family history of diabetes, obesity, and dyslipidemia.
• Observing and asking patient about movement irregularities at each visit.

Informed consent is the sine qua non of risk management and possibly the most sticky wicket in the realm of psychopharmacology. Since the psychiatric disorders themselves often compromise the patient's ability to give informed consent,³⁵ it presents a formidable concern not just for psychiatrists, but for physicians of all disciplines.³⁶ Every psychiatrist who has ever tried to get a patient with paranoia to take psychotropic medication has experienced this conundrum. Off-label use of psychotropic medication is quite common, yet fewer than one third of patients are informed when their prescriptions are for off-label uses.³⁷ It is of utmost importance that patients clearly understand the risks and benefits of the treatment being proposed, the risks and benefits of any available alternative treatments, and the risks and benefits of no treatment.³⁸