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Pearls


Help ‘sensitive’ patients tolerate medication

Improving patients’ well-being rather than arriving at a predetermined therapeutic drug dose should guide treatment

Vol. 8, No. 11 / November 2009

Some psychiatric patients report intolerable side effects with almost every psychotropic one reasonably could prescribe. Their psychiatric disorders remain undertreated as treatment-emergent side effects lead again and again to medication nonadherence. These patients often are frustrated by their lack of progress and in turn exasperate practitioners, creating strong transference and countertransference reactions.

To keep the therapeutic relationship on track, consider that your patient’s physiologic response to medication may be the result of genetic or psychodynamic factors you can overcome.

Start low and go slow

One option is to initiate medication far below the recommended starting dose. For example, try starting a patient on 1, 2, or 5 mg/d of fluoxetine instead of the typical 20 mg/d. These small doses can be achieved with a pill cutter or by using a liquid formulation with a measuring spoon that allows for 1-mg increments.

Some patients may report significant amelioration of symptoms even if they do not reach what is considered a therapeutic dose. These clinical observations have been confirmed by pharmacogenetic research that demonstrates metabolic variation across the population. 1 Improving patients’ well-being rather than arriving at a predetermined therapeutic dose should guide treatment.

Patients who experience multiple side effects may need extra time to acclimate to a new medication. Try initiating medication changes or increases at longer intervals, such as over months rather than weeks.

Examine psychodynamic factors

Seek to understand dynamic factors that contribute to your patient’s pattern of intolerable side effects. For example, patients’ disappointing early experiences with parents may result in angry feelings toward authority figures and a desire to frustrate them. In traumatized patients, internalized object relations consisting of pain-inflicting authority figures may be acted out through medication matters.

By understanding patients’ dynamics, we can better understand our own countertransference reactions and devise interventions that are more likely to help patients tolerate medication.

Accept patients’ sensitivity

I often tell patients, “You happen to be sensitive to side effects of medication. We might have to try a number of different medications before we find one that works and is tolerable. Furthermore, we need to start at a very low dose and take things very slowly.” This statement:

  • recognizes and accepts patients’ sensitivity to psychotropics
  • allows for externalization of some responsibility for troublesome side effects to the medication
  • conveys a sense of therapeutic uncertainty
  • allows patients to undertake treatment at a comfortable pace.

Reference

1. DeVane CL. Principles of pharmacokinetics and pharmacodynamics. In: Schatzberg AF, Nemeroff CB, eds. The American Psychiatric Publishing textbook of psychopharmacology. 4th ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2009.

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