Words to the wise: 4 secrets of successful pharmacotherapy

CASE 2: A soothing drink

Ms. L. G. is a 24-year-old single college student who complains of irritability, short temper, and anxiety associated with obsessive worries about her health and her studies. Her symptoms become significantly worse before her menstrual period. Repeated diagnostic workups and pelvic examinations by her ObGyn have all been unremarkable.

At the beginning of this visit, Ms. L. G. is short of breath and looks anxious and worried. The nurse offers her a cup of tea; she asks for water instead, and is asked to bring it into the consultation-therapy room.

After a comprehensive interview and mental status examination, I recommend treatment with a combination of cognitive behavior therapy (CBT) and medication. Considering Ms. L. G.’s history of treatment with other medications, we agree to start treatment with sertraline. We review the potential benefits and therapeutic expectations of alleviating her symptoms of anxiety and obsessive worries. She is also told that she can expect an improvement in mood.

I then give her a sample of 50-mg sertraline and ask her to take it right there in the office, sipping from the glass of water. As she swallows, I compliment her on her wise decision to start treatment. She thanks me for being attentive to her needs. She is instructed to call me in 1 week, even if she feels better, and report changes in her condition.

Seven days later, Ms. L. G. calls to report significant improvement in her symptoms. 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, they swallow and incorporate the liquid into their body. 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 again experiences the positive therapeutic effect that was internalized in the physician’s office.

The power of suggestion

It has been shown that the power of suggestion can positively—or negatively—affect treatment outcome.^12,13 In practice, most clinicians give unintentional suggestions by how and what they communicate to the patient.

We make predictions about the patient’s disease in terms of progress, severity of symptoms, and expected treatment outcomes, including possible side effects. The patient consciously and subconsciously internalizes these predictions, and then exhibits the outcome predicted by the medical expert. This is compatible with Watzlawick’s principle that the prediction of an event may lead to events fulfilling the prediction.¹⁴ In practice, be aware of the power in your words and body language and learn to use them wisely to enhance the positive outcome of pharmacotherapy.

CASE 3: Predicting improvement

Mrs. J. C., 48 years old, has had premenstrual dysphoric disorder (PMDD) and fibromyalgia for many years. She describes to me how specialists have tried to alleviate her depression and chronic pain. Follow-up questioning reveals 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. C. would call as instructed and describe side effects she developed with the new medication. Often, the physician would discontinue the medication, depriving her of benefits she might have obtained later.

My approach is different. Although I answer all of Mrs. J. C.’s questions about potential side effects, I also emphasize this prescription’s potential benefits—improved sleep, appetite, thoughts, and mood. I tell her she may experience improved sleep before improved mood. I then make a request: “Promise to call me by Tuesday next week, even if you begin to feel better?”

When Mrs. J. C. calls to report her status, she mentions that she is sleeping better and has begun to feel better during the day.

This vignette illustrates the importance of suggesting to the patient a positive outcome of pharmacotherapy associated with a particular action (calling the physician’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. Contrast that with saying to her: “Call me if you have a problem with any of these side effects,” which gives her a suggestion to 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 (see “Using suggestion to reframe initial side effects as positive signs”).