Advances Bring Many Choices - and Many Challenges

April 1, 2007

Driven by a wave of neuroscientific advances, no area in the field of psychiatry has grown more explosively in the past few decades than psychopharmacological practice.

Driven by a wave of neuroscientific advances, no area in the field of psychiatry has grown more explosively in the past few decades than psychopharmacological practice. These advances, however, bring with them new problems and challenges that must be addressed. This Special Report section focuses on both sides of the changes in psychopharmacological practice: the benefits and the challenges.

Attending to some of the concerns raised by pharmacological advances, the articles by Preskorn, Kingsbury and colleagues, and Pyrkosch and Linden focus on problems and factors to consider in polypharmacy and in the decision to switch medications. The spread of polypharmacy in psychiatric practice has been driven by several forces, including the increasing sophistication of clinical research and better recognition of treatment resistance, all of which have led to approaches that combine several medications for difficult-to-treat or nonresponsive patients.

Pressures from managed care, which puts a premium on rapid intervention and brief treatment, also pushes many treating physicians to combine medications in patients for whom such a decision is not always clear from clinical indications alone. Finally, the advances in our diagnostic system and the revisions of DSM over the past several decades have led to a greater focus on specific symptoms or symptom clusters as targets for separate pharmacological intervention. The authors of the articles on polypharmacy caution us to be parsimonious in our decisions to prescribe multiple medications and to consider the hazards that polypharmacy entails.

Mitchell's article on medication discontinuation reminds us that there are several reasons why patients may miss doses or stop taking antidepressants-and that these reasons may be based on realistic factors that must be considered. He alerts us to the critically important role of the physician in fostering compliance.

The article by Horst on advances in the treatment of adult attention-deficit/hyperactivity disorder and the review by Ismail and associates on the early initiation of treatment for Alzheimer disease reflect the state of the art of pharmacotherapeutic practice as part of a comprehensive treatment plan.

The article by Osser emphasizes that the ideal is to follow a logical process in making decisions about prescribing psychopharmacological medications and urges us in the direction of thoughtfulness. He reminds us that there is an opportunity for substantial progress in the development of practice guidelines and treatment algorithms.

I feel confident that you will find these articles both enjoyable and rewarding. They provide the opportunity for us all to stay better informed about critical knowledge that we can incorporate into our daily practice.

Links to other articles:Why Do Psychiatrists Select or Switch an Antipsychotic?Benefits of Early Pharmacological Treatment in Alzheimer DiseaseThe Role of Guidelines and Algorithms for Psychopharmacology in 2007 Understanding Medication Discontinuation in Depression Psychiatric Polypharmacy: The Good, the Bad, and the Ugly Treating Adults With Attention-Deficit/ Hyperactivity Disorder A Precautionary Tale in Psychiatry