Words to the wise: 4 secrets of successful pharmacotherapy

Participatory pharmacotherapy

Many patients seek ownership in making decisions about their treatment and medications. In participatory pharmacotherapy, patients provide you with data and valuable information—such as family history, personal medical history, and experience with treatment—and inform you about which medications worked best and which did not work. You invite patients to predict how they see themselves getting better and into recovery.

Based on this information and your knowledge, training, and experience, you and the patient create a treatment plan that includes pharmacotherapy tailored to the patient’s specific needs. The following case illustrates the use of participatory pharmacotherapy to enhance treatment

CASE REPORT: All in the family

Mr. A, age 28 and single, has been diagnosed with a bipolar mood disorder. As part of a detailed family history, he reports that his maternal grandfather, mother, and a maternal uncle were diagnosed with mood swings and were successfully treated with medications, specifically lithium. He states that he believes he has the same condition.

I compliment Mr. A for being so well informed about his grandfather and uncle and educate him about mood stabilizers’ benefits in bipolar disorder. I tell him about the finding that if lithium has helped his relatives, it will probably help him as well.

I also reassure Mr. A that, in deciding what medications to avoid and what medications to use, I will consider his experience with specific antidepressants that did not help him. He thanks me for considering his suggestion about what medication to use for him.

Inviting patients to be partners in diagnosing their illnesses and formulating treatment plans improves the likelihood of:

• a successful therapeutic alliance
  
• adherence with prescribed medications
  
• the best possible outcome with pharmacotherapy.
  

Not all patients are candidates for participatory pharmacotherapy (Table 3), but many respond well to it. One key is to avoid medications the patient has experienced as unhelpful, ineffective, or associated with side effects. Whenever possible, choose medications the patient associates with a positive experience or expectation, based on family and personal history.

In patients with a defiant-oppositional personality, consider framing the treatment decision as a choice between 2 equally efficacious medications. This gives the patient the sense of control in choosing his or her own medication, which is jointly monitored.

Table 3

Choosing patients for participatory pharmacotherapy

Good candidates	Exclusionary qualities
Adults	Children, adolescents, and prison inmates
No history of alcoholism or drug addiction	Alcohol dependence or drug addiction
Average and above intelligence	Below-average intelligence
Intact cognitive function	Cognitive deficits, such as dementia
Not psychotic	Actively psychotic
Good comprehension of diagnosis and treatment	Poor comprehension of diagnosis and treatment
Therapeutic alliance is present	Therapeutic alliance is absent
Personality style or disorder with a need to be in control of treatment, such as obsessive-compulsive personality	Passive, dependent personality style or disorder; these patients may view a participatory approach as the doctor’s lack of confidence

Related resources

• Brody H. The placebo response: how you can release the body’s inner pharmacy for better health. New York, NY: HarperCollins Publishers; 2000.
  
• Spiro H. The power of hope: a doctor’s perspective. New Haven, CT: Yale University Press; 1998.
  
• Ernst E. Placebo: new insights into an old enigma. Drug Discov Today 2007;12:413-8.
  

Drug brand names

• Lithium • Eskalith, Lithobid
  
• Mirtazapine • Remeron
  
• Quetiapine • Seroquel
  
• Sertraline • Zoloft
  

Disclosure

Dr. Torem reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.