Reply To: Psychiatric medicines

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Hi Team,
An interesting conversation, where PATIENT BUY IN (and not simply the search for a prescriber) continues to be the lynchpin, in this, a patient group that is often very cynical, critical, angry, desperate and even litigious. The novel (especially after years and decades of sx persistence, disappointment, unnecessary meds, tests, procedures, surgeries, and diminished hope) and essential ingredients we might offer are time, patience, and this new approach… to the management of a significant proportion of GP patient complaints…that our teachers have developed and refined. This new treatment model sadly does not fit into the piece work payment schedule in current use in Canada. My strategy has been to take on a manageable number of such patients, allow more time than usual, and stick to that agenda. By logging time with the patient at the outset, and in fact establishing credibility through a different type of exchange than has been previously experienced (eg hand on the doorknob), trust grows, and an action plan can emerge, with a careful and complete history, rock solid (minimum essential) diagnostics, careful recording and a plan forward that moves slowly and sensitively. In other words, we co-invent a plan that can turn off the Danger Signal. I appreciate Alicia’s candour re going too fast with a new patient and seeing them walk away. Yep, been there. A wise psychiatrist once told me, “if you are working harder than the patient, its time to back off and re-evaluate”. I have (painfully) learned more to be a guide than Mr Fix It, where the rate limiting step is determined by the patient, not by me. I am excited about learning new treatment strategies here, to engage a challenging and despairing patient group. Often on the meds list is a mix of psychotropics (SSRIs, SNRIs, TCAs, BDZs, atypical antipsychotics, etc) and narcotics, such that the role of each of these in the pill salad is confusing (and certainly numbing) at best, requiring a very slow and shrewd meds reduction plan. Yes, patients (with coexisting anxiety and dependent traits) become very invested in the notion that this pill salad is what is keeping them going, and any disruption in that list will cause them to topple. If Trust in our Program can be carefully cultivated and maintained, then careful meds reduction can occur, but I think the care giver-patient relationship must be sound before one starts. If the picture is further complicated by age related cognitive impairment, then we must modify our patient expectations and support/share that reality with the caregivers. The pharmacologists (depending on the meds and doses and pt comorbid conditions) typically guide us in weaning off the narcs first. I have no doubt that a pattern of positive interactions between doc and patient can boost the placebo effect of meds like SSRIs (longer term) and BDZ (short term) as we await the onset of effect of SSRS’s, while continuing to pitch the idea that the patient understanding, housecleaning and rebuilding is the more powerful and enduring stuff for the longer term. Where I live, the community supports for patients like this are woefully lacking. The belief-fear-chronic pain loop joins the mood disorders/anxiety and addictions loops where often all 3 coexist in these patients. There can be no doubt that providing a solid grounding in psychoeducation, ruling out structural/tissue damage, ruling in MBS, based on circumstantial and confirmatory testing/clinical assessment offers more than these patients have ever known in understanding and reversing conditioned response behaviours. Attitude is everything (Gordon) goes so well with seeing sx relapses/flares as opportunities, to harness the power of the prefrontal cortex to calm the and limbic system. But only when the danger signal has become contained and the slope of the line becomes positive.