Teaching the STEPs of clinical psychopharmacology
Teaching medical students and psychiatry residents the principles of safe, effective clinical psychopharmacology can be challenging. Psychotropic agents from the same category often possess different mechanisms of action, cause various side effects, and have distinct safety profiles. Moreover, similar agents can be differentiated by the amount of evidence supporting their efficacy in treating particular disorders.
To help, I encourage prescribers to add a “STEP”—Safety, Tolerability, Efficacy, and Practicality—to their clinical decision-making. This is an invaluable “pearl” I learned nearly a decade ago and present here in a slightly modified form.1
Safety. Know the psychotropic’s safety profile, especially regarding comorbid medical illness and potential drug-drug interactions. Bupropion, for instance, may be an excellent choice for a depressed patient who recently had a myocardial infarction, but research shows the drug is risky for a person with a comorbid seizure disorder.
Tolerability. Evaluate the short- and long-term effects of each medication. Haloperidol, for example, is a reasonable choice for acute treatment of psychotic agitation in the emergency department, but a young woman struggling to manage her schizophrenia may not tolerate the drug as a maintenance therapy.
Efficacy. Familiarize yourself with the clinical evidence supporting a drug’s use for a particular disorder. Evidence strongly supports lithium carbonate for treating bipolar affective disorder, but current evidence-based clinical guidelines do not endorse gabapentin as a first choice for mood stabilization.
Practicality. Consider cost, adherence, and monitoring issues. A medication will certainly fail if the patient never fills the prescription because of cost or cannot adhere to a multiple daily dosing regimen or routine serum chemistries. This aspect may be the most essential to dispensing psychotropics because the student or resident must have a thoughtful grasp of the patient’s life circumstances, deficits, strengths, and motivation. Such understanding can be achieved only through careful, empathic listening and active involvement in the patient’s care and well-being.
1. Preskorn SH. Selection of an antidepressant: mirtazapine. J Clin Psychiatry 1997;58(suppl 6):3-8.
Dr. Christensen is associate professor of psychiatry, University of Florida College of Medicine, Jacksonville, and director of the university’s community psychiatry program.