Words to the wise: 4 secrets of successful pharmacotherapy
Put to good use the placebo effect, conditioned responses, and the power of suggestion
Following a comprehensive interview and mental status examination, I recommend CBT plus medication. Considering Ms. L’s medication history, we agree to start treatment with sertraline. We review its potential benefits and expectations that it will reduce her anxiety, alleviate her ruminating obsessive worries, and improve her mood. I give her a 50-mg sample and inform her that some patients experience positive effects soon after taking the medication. I then ask her to take the first pill, using her glass of water. She does so and thanks me for being attentive to her needs.
I instruct her to call within 1 week and report on her condition, even if she feels better. Seven days later she reports that she is feeling better and is looking forward to her next appointment. She reports no side effects.
Often patients come to my office feeling thirsty. My staff or I offer them a glass of water or a cup of tea. As patients sip from the cup, they swallow and incorporate the liquid into their bodies. At the same time, I use verbal interventions to make them feel listened to and understood. They internalize this emotional experience in connection with swallowing the liquid.
Later, when swallowing the new medication as instructed, the patient re-experiences the positive therapeutic effect that was internalized in the doctor’s office.
The power of suggestion
The power of suggestion has been shown to positively or negatively affect treatment outcomes.12,13 In practice, most clinicians give unintentional suggestions by how and what they communicate to the patient.
CASE REPORT: Predicting improvement
Mrs. J, age 48, has had dysthymic disorder and fibromyalgia for many years. She describes how various specialists have tried to alleviate her depression and chronic pain. Follow-up questions reveal that whenever she received a new prescription the physician would alert her to all the possible side effects and instruct her to call the office if she developed a problem with the new medication.
Invariably, Mrs. J would call as instructed and describe side effects she developed with the new medication. Often the doctor would discontinue the medication, depriving Mrs. J of benefits she might have derived later.
When Mrs. J calls to report on her status, she mentions that she is sleeping better and has begun to feel better during the day. She says that her husband told her she has started to smile again.
This vignette illustrates the importance of suggesting to the patient a positive outcome of pharmacotherapy associated with a particular action (calling the doctor’s office to report results). When the patient promised to call, she internalized the suggestion that calling would be associated with feeling better—and that is what happened. This intervention contrasts with saying to the patient, “Call me if you have a problem with any of these side effects,” which gives the patient a suggestion to call and report a problem.
The suggestion effect also can be used to reframe a predictable side effect as a positive sign that indicates the beginning of change leading to recovery (Box).
Ms. M, age 32 and single, has an anxiety disorder associated with bipolar depression. She has discontinued several psychotropics because of uncomfortable side effects, such as constipation.
After taking a detailed history, I decide to prescribe quetiapine. I tell Ms. M about this medication’s potential benefits and side effects. One common side effect is dry mouth, which often occurs before patients experience therapeutic effects.
I inform Ms. M that a dry mouth will be her sign that the medication has begun to work, and beneficial effects—such as improved sleep, reduced anxiety, and improved mood—will soon follow. I then instruct her to call my office and report when she experiences a dry mouth.
Discussion. In pharmacotherapy, side effects may appear before patients experience a medication’s beneficial/therapeutic effects. Patients’ initial experience often determines whether or not they will continue taking a prescribed medication. I know Ms. M may stop taking quetiapine—as she has done with other medications—if she initially has uncomfortable side effects.
Instructing patients to expect a specific side effect (such as a dry mouth with quetiapine) and associating it with a future therapeutic benefit sets up a road map of expectations. They know their experience is compatible with the doctor’s predictions. For Ms. M, I reframed the side effect as a positive sign that recovery has begun, with more positive changes to come.
