Archive for February, 2012



If you find yourself prescribing neuroleptics for a mood disorder, mood stabilizers for a psychotic disorder and antidepressants left and right for all sort of NOS diagnoses it’s not a bad idea to take a deep breath and a hard look at your diagnoses.

Not that we never prescribe mood stabilizers for schizophrenia, or (in this brave new age of second generation everything) atypicals for mood disorders. We do.

However, even during these times of a relaxed psycho-pharmacology, an understanding of first versus second line, switching and augmenting is still a sine qua non of good doctoring.  Which implies that when your psychotropic does not closely match your patient’s diagnosis you’d better have a good explanation of why that is.

And it wouldn’t hurt either to document it accurately so that the next doctor in line or yourself looking at your old notes will understand your rationale for prescribing outside the standard of care.

You should consider also reviewing and/or appropriately documenting your drug dispensing habits for your patients on major poly-pharmacy type of cocktails. Remember that the evidence base for most poly-pharmacy type of strategies is rather flimsy, while the evidence base for compounded toxicity is gaining momentum.Bottom line: prescribing more than one medication for an indication is not the best charted territory, which by the way includes the unclear evidence-based realm of augmentation strategies.

Red flag combinations? Two or more similar agents prescribed together. This includes , going from rather non-nonsensical to somewhat explainable combinations (and I list here only combinations that I’ve actually seen): two SSRIs, tow SNRIs, SSRI + SNRI, two stimulants, two TCAs, two typical neuroleptics, two atypical neuroleptics, typical + atypical neuroleptic, two mood stabilizers (other than lithium).

Make sure that your medications match your diagnosis and that you have a good rationale for each medication you dispense to a patient.

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Consider the following:

Decreased sleep: as in I “can’t sleep” versus “don’t need to sleep”.

Ruminative thinking versus racing thoughts.  “Can’t turn off my thinking” versus “thinking too fast to put it in words”.  Remember: the speed of thought is essential.

Distractibility versus tangentiality.  “Mind going blank, cant remember what I was thinking/talking about” versus “thoughts just pop up, one after another”.

Psychomotor agitation: the patient reports feeling exhausted but restless as in “I can’t stop worrying” versus hyperenergetic.

Impulsivity: as in “I wanted to kill myself as I can no longer stand feeling this way” or “I don’t think much about what to do next.”

Same or different?

Details matter.

When it comes to psychiatric history and review of systems the context is what makes or brakes your diagnosis.

Which, in the cases above, should be depression versus mania.

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