Words to the wise: 4 secrets of successful pharmacotherapy
Put these all to good use: the placebo effect, conditioned responses, the power of suggestion, and participatory pharmacotherapy
IN THIS ARTICLE
Ms. M. K. is 34 years old and unmarried. She suffers chronic tension headaches associated with anxiety, depression, and insomnia. Numerous diagnostic workups have been negative.
After taking a detailed history, I decide to prescribe amitriptyline. I tell Ms. M. K. about this medication’s potential benefits and side effects, including the common one of dry mouth, which often occurs before a patient experiences a therapeutic effect. I tell Ms. M .K. that dry mouth will be a sign for her that the medication has begun to work, and the beneficial effect will soon follow. I instruct her to call my office and report when the sensation of dry mouth has begun.
In pharmacotherapy, side effects may appear before patients experience a medication’s beneficial or therapeutic effects. Patients’ initial experience often determines whether or not they will continue taking a prescribed medication. I know that Ms. M. K. may stop taking amitriptyline—as she has done with other medications—if she has uncomfortable side effects at the outset.
Instructing a patient to expect a specific side effect (such as dry mouth with amitriptyline) and associating it with a future therapeutic benefit sets up a roadmap of expectations: She knows that her experience is compatible with the physician’s prediction. For Ms. M. K., I reframed the side effect as a positive sign that recovery has begun, with more positive changes to come.
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—family history, personal medical history, experience with treatment—and inform you about which medications worked best. 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 jointly create a treatment plan that includes tailored pharmacotherapy. The next case illustrates the use of participatory pharmacotherapy to enhance treatment.
CASE 4: All in the family
Mrs. B. R., age 52, suffers from diabetic polyneuropathy, with tingling, numbness, and pain in her legs, feet, and hands. These symptoms are associated with anxiety, sadness, and worry. A detailed history reveals that these symptoms persist even though her blood glucose level has been in the target range and she has already achieved her goal of weight control with proper diet and exercise.
Mrs. B. R. then reports to me that her cousin, who has the same diagnosis, recently started to take venlafaxine with very good results. She asks me if we can consider this medication as part of her treatment.
I compliment Mrs. B. R. for her knowledge of her condition and her cousin’s treatment results. She responds by elaborating on her readings about venlafaxine on the Web and how convinced she is that this medication will help her as it helped her cousin.
I also reassure Mrs. B. R. that, together, we will make decisions about what medications to use and what to avoid based on her experiences. Her input into this process of choosing the best medications for her is valuable and will also be considered in future situations. She smiles and thanks me for considering her suggestions.
Inviting patients to be partners in diagnosing their illness and formulating a treatment plan improves the likelihood of a successful therapeutic alliance; adherence with prescribed medication; and the best possible outcome of pharmacotherapy.
Not all patients are candidates for participatory pharmacotherapy (TABLE 3), but many respond well. Avoid medications that the patient has already found unhelpful, ineffective, or associated with intolerable side effects. If possible, choose medications that 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 two equally efficacious medications. This gives the patient the sense of control in choosing her medication, which is jointly monitored.
Related resources See Dr. Torem’s accompanying reading list
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 or above-average 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 reflecting the physician’s lack of confidence) |
Benedetti F. Placebo Effects: Understanding the Mechanisms in Health and Disease. New York, NY: Oxford University Press; 2009.
Brody H. The Placebo Response: How You Can Release the Body’s Inner Pharmacy for Better Health. New York, NY: HarperCollins Publishers; 2000.
Ernst E. Placebo: new insights into an old enigma. Drug Discov Today. 2007;12:413–418.
Kradin R. The Placebo Response and the Power of Unconscious Healing. New York, NY: Routledge, Taylor & Francis Group; 2008.
Raz A, Raikhel E, Anbar RD. Placebos in medicine: knowledge, beliefs, and patterns of use. McGill J Med. 2008;11:206–211.
Spiro H. The Power of Hope: A Doctor’s Perspective. New Haven, Conn: Yale University Press; 1998.
Thompson WG. The Placebo Effect and Health: Combining Science & Compassionate Care. Amherst, NY: Prometheus Books; 2005.
Torem MS. Hypnotherapeutic techniques in the treatment of hyperemesis gravidarum. Am J Clin Hypn. 1994;37:1–11.
Torem MS. Psychopharmacology for office gynecology. In: Curtis MG, Hopkins MP, eds. Glass’s Office Gynecology. Baltimore, Md: Williams & Wilkins; 1999:519–548.
