4 Secrets of Successful Pharmacotherapy
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Words to the wise: 4 secrets of successful pharmacotherapy Put to good use the placebo eff ect, conditioned responses, and the power of suggestion ® Dowden Health Media ny medication’s therapeutic success depends on the interaction between its specifi c biochemical A effects and nonspecifiCopyright c factors.For1 Thus, personal clinical use only trial designers may view the placebo effect as undesir- able, but it can be a valuable response that improves treatment outcomes in clinical practice. As Freud stat- ed, “Expectation colored by hope and faith is an effec- tive force with which we have to reckon … in all our attempts at treatment and cure.”2 This article describes how experienced clinicians make use of the placebo effect and 3 other powerful, nonspecifi c elements of successful pharmacotherapy. VEER The placebo eff ect 2008 © The placebo effect is any effect attributable to a pill or potion that does not originate from its specifi c pharma- Moshe S. Torem, MD, DFAPA cologic properties.3 Its clinical value has been trivialized, Chief, Integrative medicine Akron General Medical Center in part because of misconceptions (Table 1, page 20). For Medical director, Center for Mind-Body Medicine example, the placebo effect is commonly believed to be Professor of psychiatry short-lived, whereas in fact it can last a long time.4 Northeast Ohio Universities College of Medicine Rootstown, OH In clinical practice, our goal is to enhance the place- bo effect to maximize a desirable therapeutic outcome (Table 2, page 20).5 Therefore, before I prescribe a medi- cation, I tell my patient that I have selected a particular medication because I have had good results with it in many other patients and I believe it will work well for him or her, too. Too often, doctors feel pessimistic about a medica- tion’s potential therapeutic result and communicate Current Psychiatry this pessimism. What the patient hears is, “There’s Vol. 7, No. 12 19 For mass reproduction, content licensing and permissions contact Dowden Health Media. 19_CPSY1208 19 11/14/08 8:40:39 AM Table 1 Correcting misconceptions about the placebo eff ect Misconception What the evidence shows Placebo effects are short-lived The placebo effect has been documented to last for a long time Only complaints that are psychologically Changes after placebo have been documented 4 secrets of originated respond to placebo for most symptoms, including those originating from pharmacotherapy somatic diseases Placebo responders are distinctly There is no difference between placebo responders different from nonresponders and nonresponders The placebo effect is only about The placebo effect can be up to 100% of the total one-third of the total therapeutic effect therapeutic effect Only about one-third of the The placebo response is context-dependent population responds to placebo and may include >90% of the patient population Clinical Point Source: Reference 4 Experienced Table 2 gest that he be treated with cognitive-be- clinicians understand Clinical strategies to enhance havioral therapy (CBT) and mirtazapine. the placebo eff ect’s the placebo eff ect I tell Mr. B this antidepressant has excel- power and harness lent potential to help him recover from de- • Develop a sustained therapeutic partnership pression. I also inform him that improved it to benefi t their with the patient patients sleep and appetite may be the fi rst eff ects he • Listen effectively and verify that the patient experiences. I give Mr. B an appointment for 1 feels listened to week later, and when he comes in he reports • Provide comprehensible explanations improved sleep and appetite, as expected. of health problems therapeutically tailored for each patient’s needs and personality style Even though studies of antidepressants • Show empathy, care, and concern for the rarely show mood improvements within patient as a person the fi rst 7 days, it is not unusual to hear pa- • Enhance patients’ sense of control tients report feeling less depressed within and mastery over their predicament days after they start a new antidepressant. Source: Reference 5 Although the drug’s specifi c chemical ef- fects on the brain may not be suffi cient to nothing else I can do for you; why not explain this phenomenon, the explanation try this medication, even though I don’t probably lies in nonspecifi c effects—such as believe it’s going to work.” This may cre- the patient expecting that this medication ate a negative placebo effect6—termed the will make him feel better. “nocebo” effect—which gives the patient a The placebo effect can occur as soon as negative expectation about the treatment’s a patient starts a medication. Experienced outcome. The patient internalizes the doc- clinicians understand the placebo effect’s tor’s words and lives out this negative ex- power and harness it to benefi t their pectation. patients. CASE REPORT Predicting positive results Conditioned responses Mr. B, age 42, has a history of recurrent de- Many biological responses can be associ- pression associated with severe insomnia, ated with visual, auditory, tactile, olfac- poor appetite, signifi cant weight loss, and tory, or gustatory stimuli. Nonconditioned psychosocial withdrawal with feelings of physiologic responses paired with condi- hopelessness. After I take a detailed history tioned stimuli induce the same biological Current Psychiatry 20 December 2008 and do a mental status examination, I sug- effects of a drug. Evidence supporting this 20_CPSY1208 20 11/14/08 8:40:46 AM phenomenon includes successful condition- Often patients come to my offi ce feeling ing of the immune system.7-10 Conditioned thirsty. My staff or I offer them a glass of responses—as demonstrated in glycemia water or a cup of tea. As patients sip from regulation10 and with psychopharmacolo- the cup, they swallow and incorporate the gy11—also can enhance the desirable results liquid into their bodies. At the same time, I of pharmacotherapy. use verbal interventions to make them feel listened to and understood. They internal- CASE REPORT ize this emotional experience in connection A soothing drink with swallowing the liquid. Ms. L, a 22-year-old college student, suff ers Later, when swallowing the new medi- from obsessive-compulsive disorder associ- cation as instructed, the patient re-experi- ated with anxiety and depression. She arrives at ences the positive therapeutic effect that the appointment hurried and worried that she was internalized in the doctor’s offi ce. might be late. She is short of breath and looks stressed. The nurse off ers Ms. L a cup of tea or water. She chooses a glass of water and is asked The power of suggestion to bring it into her session. The power of suggestion has been shown Clinical Point Following a comprehensive interview and to positively or negatively affect treatment Learn to wisely use mental status examination, I recommend CBT 12,13 outcomes. In practice, most clinicians the power of your plus medication. Considering Ms. L’s medica- give unintentional suggestions by how and tion history, we agree to start treatment with what they communicate to the patient. words and body sertraline. We review its potential benefi ts and We make predictions about the patient’s language to enhance expectations that it will reduce her anxiety, al- disease in terms of progress, severity of the positive outcome leviate her ruminating obsessive worries, and symptoms, and expected treatment out- of pharmacotherapy improve her mood. I give her a 50-mg sample comes, including possible side effects. The and inform her that some patients experience patient consciously and subconsciously positive eff ects soon after taking the medica- internalizes these predictions, and then ex- tion. I then ask her to take the fi rst pill, using her hibits the outcome predicted by the medical glass of water. She does so and thanks me for expert. This is compatible with Watzlawick’s being attentive to her needs. principle14 that the prediction of an event I instruct her to call within 1 week and report may lead to events fulfi lling the prediction. on her condition, even if she feels better. Seven In clinical practice, be aware of the power in days later she reports that she is feeling better your words and body language and learn to and is looking forward to her next appoint- use them wisely to enhance the positive out- ment. She reports no side eff ects. come of pharmacotherapy. continued Read today’s psychiatric news on CurrentPsychiatry.com Staying current just got easier! Through the reporting services of Physician’s Briefi ng, CurrentPsychiatry.com now provides 24/7 access to: Ñ 15 or more news stories related to psychiatric practice Ñ Brief summaries with links to details and primary sources Ñ Twice-daily updates Ñ News and alerts from NIH, FDA, CDC, and other government agencies Ñ 2-year searchable archives of psychiatry news. Too busy to attend psychiatric conferences? Read credible, timely summaries of proceedings. Current Psychiatry Timely, clinically relevant, in one searchable location. Vol. 7, No. 12 21 Check it out on CurrentPsychiatry.com 21_CPSY1208 21 11/14/08 8:40:50 AM Box Using suggestion to reframe initial side eff ects as positive signs s. M, age 32 and single, has an anxiety Discussion. In pharmacotherapy, side effects Mdisorder associated with bipolar may appear before patients experience a depression. She has discontinued several medication’s benefi cial/therapeutic effects. psychotropics because of uncomfortable side Patients’ initial experience often determines 4 secrets of effects, such as constipation. whether or not they will continue taking a pharmacotherapy After taking a detailed history, I decide prescribed medication. I know Ms. M may to prescribe quetiapine. I tell Ms. M about stop taking quetiapine—as she has done this medication’s potential benefi ts and side with other medications—if she initially has effects.