But in Primary Care, It's Not That Simple
Dr. Culpepper: Dr. Ghaemi and I agree on most aspects of these discussions. Use of the atypicals on a symptom basis is not good medicine. Recognition, and then diagnosis is critical. And for bipolar disorder, seeking corollary input from those close to the patient can provide critical information. We also agree that for many patients mood stabilizers are a preferred treatment option.
However, I do not agree that since our studies on the atypicals are for the most part only of 2-months (or 6-weeks) duration, that that means these drugs only work for 2 months, and not 2 months and a day or longer. The reality is that in primary care (as well as many other areas of medicine) a large majority (perhaps 80%) of what we do for patients is not evidence based, simply because the evidence, pro or con, is not available. We do agree that a key value for the profession is "do no harm." However, harm can accrue from withdrawal of a medication that is working when the evidence-based warrantee on its effectiveness runs out just as it can from the uncritical use in individual patients of medications based on group data of effectiveness.
In primary care, a common saying is that many situations require the physician to "know the patient's name" to be able to be of benefit. By this we mean that our role is to get to know the individual deeply, and use this knowledge in creating a treatment recipe that is truly individualized. The role of the physician is to blend an understanding of best evidence from group (eg, RCT [randomized controlled trial]) data with this deep understanding of the patient.
Another fundamental in primary care relates to the use of time in the doctor-patient relationship. The primary care relationship is one that is ongoing; we continue to monitor, fine tune, educate, and encourage our patients. A third fundamental is that we come to know and treat our patients in context – that is within their family, social, and work environment – and build on their resources and minimize the liabilities inherent. Within this framework, if a patient has benefited from short-term use of an atypical, I do try to reduce or withdraw it periodically. However, if the medication does continue to provide benefit, I will continue its use – again with close monitoring, education, and work translating the symptom and possibly disease control gained into improvements in the patient's relationships and resources. I believe this approach has more potential to "do no harm" than one based on the time limits explored in studies.
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Cite this: Are Antipsychotics Overprescribed? - Medscape - Feb 18, 2011.