That was a question posed by a recent paper in Academic Psychiatry (1). The focus was on psychopharmacology agents from the perspective of older agents like lithium, monoamine oxidase inhibitors (MAOIs), and tricyclic antidepressants (TCAs). Every few years, the debate about these drugs is rekindled – almost like the stereotypical old man shouting: “Hey you kids – get off my lawn.” Should psychiatrists know how to prescribe older agents – of course they should. First off, the age of the agent has nothing to do with efficacy. Lithium is the best example there and it continues to have the best efficacy for bipolar disorder relative to new agents. TCAs and MAOIs have comparable efficacy to newer antidepressants like selective serotonin reuptake inhibitors (SSRIs) but given the span of clinical trials – a strict comparison is not possible. Some authors do make unequivocal statements about both TCAs and MAOIs having superior efficacy to SSRIs. But in my opinion meta-analyses does not eliminate the differences in clinical trials technology over the past 50 years.
The authors make some of these arguments and suggest a number
of biases that may be operating against prescribing these medications. Some of
those biases originate in risk perception. In general, newer medications do
tend to be safer. They are certainly not
without risk. Serotonin syndrome and
neuroleptic malignant syndrome are the typical rare but high-risk complications of prescribing
psychiatric medications but there are many more. The rational discussion of
risk involves knowing the pharmacology, knowing any risk mitigation strategies,
knowing to what extent your patient can co-manage that risk with you, and the
explicit informed consent discussion outlining the risks.
In my experience about 15-20% of outpatients do not
tolerate modern antidepressants well at all. I have always encouraged people in
that situation to try something different. TCAs and MAOIs are certainly not
devoid of side effects but it is possible to change to one of those medications
and the patient notices immediately that the drug is well tolerated and
eventually effective. Clinical trial
data will show that as a group SSRIs are safer and better tolerated than either
TCAs or MAOIs but in the clinic we are treating individuals and not
groups. On an individual basis, people
are selected based on whether they tolerate a class of medications or not and
that does not mean that they will not tolerate all medications. With lithium, MAOIs, and TCAs – the informed
consent discussion needs to include the potential toxicities with reassurances
that the goal is to avoid side effects and complications.
That has been my approach to psychopharmacology for 35
years. It was easier for me to have this perspective because when I started out
back in 1986, the only antidepressants available were TCAs and MAOIs. I also
trained with two psychiatrists, James Jefferson and John Greist who wrote the Lithium
Encyclopedia and ran the Lithium Information Center. In the days prior to the internet, it was
a repository of all known hard copy references to lithium in the medical
literature. There were additional formative experiences, most notable 22 years
on acute care units where you are the person responsible for the total medical
and psychiatric care of the patient. It was common to see patients on multiple
psychiatric and nonpsychiatric medications with varying levels of adherence and
instability. In some cases, they were accompanied by several shopping bags of
medications and it was impossible to determine what medication was being taken
and what was not. In many cases the medical providers and the
psychiatric providers had never communicated and there was redundancy and
drug interactions. My job in that situation was to make the best estimate of
what medications could be safely started and to follow the patient closely so
that they could be adjusted. That requires a good knowledge of medications that
are used to treat endocrine/metabolic conditions, infectious diseases,
rheumatic disorders, gastrointestinal disorders, cardiac conditions,
dermatology conditions, chronic pain and neurological conditions.
In other words, most medications that are commonly used.
And why wouldn’t psychiatrists prescribe everything both inside and outside of
the specialty? I have been fortunate
enough to work with many Internal Medicine specialists and subspecialists. I
have witnessed what happens when they encounter a medication that they do not
routinely prescribe. They ask the patient about why it was prescribed and their
experience with it. They read the
package insert and decide whether to prescribe it or not. The idea that each specialty has limited
knowledge about prescribing medications outside of that specialty seems like an
erroneous assumption to me. It is even
clearer now that we have nonphysician prescribers with less basic science and
pharmacology knowledge and less supervised prescribing training not restricted
to any set group of medications. Physicians have been trained in all classes of
pharmacology and should have worked out a general approach on how to safely
prescribe any medication encountered.
Physicians also need to know about the range of medications in the
population they are working with. Adapting to the medications utilized by different populations is all part of the practice of medicine. Today and in the future it is conceivable that a typical psychiatrist may cycle through 4 or 5 different practice scenarios, each one requiring unique a unique knowledge of pharmacology.
That does not mean that I am going to start diagnosing and
treating arrhythmias like a cardiologist.
But it does mean that if I get a patient admitted to my inpatient service
who is taking an antiarrhythmic that I should be able to decide to continue or
restart it, what monitoring needs to be done, whether an ECG needs to be
ordered, whether to get a Cardiology consultation or contact the patient’s
cardiologist (stat or electively), and whether any medication I want to start
or change will affect either the antiarrhythmic or the patient’s underlying
cardiac condition. The same process is true for every medication on their list.
The typical argument I encounter with that suggestion is:
“Well most psychiatrists don’t practice in that kind of intense medical
environment.” My answer is – open your
eyes. It is not enough to look at a typical list of medications in an
electronic health record (EHR) and focus only on the ones that psychiatrists
should prescribe. It is not enough to
assume that your patient’s list of medical problems is being adequately
addressed. Psychiatry from my
perspective still means that the psychiatrist has some responsibility for the
total medical care of the patient. In today’s fragmented medical care
environment, the psychiatrist may be the only physician the patient is seeing. When
asked who their doctor is – many people will name their psychiatrist.
That opinion is bound to make some psychiatrists nervous. They
may have the thought; “How can I provide that level of care when I am being
reimbursed less and have to spend most of my time doing clerical work for the
EHR?” That is a fair question and one without an obvious answer. If
administrators were really interested in quality care, they would give primary
care physicians and psychiatrists enough time for that level of analysis.
Psychiatrists need more time to establish and attend to their relationship with
the patient. But the medical stability
of the patient and assuring that they are not experiencing adverse effects and
that treatment is effective is an absolute priority.
Psychiatrists need to be trained to make these assessments
and they need to be able to prescribe and modify a significant pharmacopeia
extending well beyond what exists in a psychopharmacology text. That skill is predicated on the extensive content in basic science and clinical literature on pharmacology and also the process of learning about new drugs and how to safely prescribe them. That learning process is largely implicit and not discussed enough. If it was, it could be applied to older medications as well.
George Dawson, MD, DFAPA
References:
1: Balon R, Morreale
MK, Aggarwal R, Coverdale J, Beresin EV, Louie AK, Guerrero APS, Brenner AM.
Responding to the Shrinking Scope of Psychiatrists' Prescribing Practices. Acad
Psychiatry. 2022 Dec;46(6):679-682. doi: 10.1007/s40596-022-01705-1. PMID: 36123516.
Photo Credit:
Eduardo Colon, MD. - many thanks.
