How to become a better psychopharmacologist?

[Psychresy]

Resident here, really wanting to be better about knowing the ins and outs of all of our drugs. I review drugs in Stahl's but I find I often forget all of the receptor interactions and other nuances. It seems no matter how much I review I can't keep it in my head unless I'm looking at it daily. Any tips, other resources, etc to get this information down? Feeling somewhat down that I'm more than half way through residency and still having trouble here.

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[hamstergang]

I'm 5 years out of residency and am still learning/re-learning things. Don't set unrealistic expectations for yourself.

That said, repetition is a big key, so continuing residency should certainly help.

 

[comp1]

Yeah, I'd second the recommendation above about completing residency. I don't know if this is something that you can really get from a book or articles long term since it's not going to stick with you like patient experiences. Also...pharma companies are LOATHE to fund head to head trials.

 

[Nudexta]

CME, practicing and doing question banks

 

[Psychresy]

CME, practicing and doing question banks

Any specific banks you recommend?

 

[MacDonaldTriad]

Many people suggest up to date as texts are out of date by the time they are printed, but Janicak or Schatzberg are reasonable alternatives to Stahl if your are disappointed.

 

[romanticscience]

When I was in residency, I used Maudsley as a map for my reading. Now as an attending, I refine my knowledge by reviewing successive editions with updated citations, package inserts, and searching clinical trials on pubmed.

 

[Nudexta]

Any specific banks you recommend?

I liked the psychopharmacology section of www.mypsychboard.com

 

[robellis]

To be honest a lot of it I have found really isn’t clinically relevant with experience you have hone your knowledge base

 

[Dr.MONO]

You will learn more with clinical practice. I like simple and practical mental health as they send an email daily so it is a quick tip and mypsychboard

 

[Monocles]

I think having practice is helpful. I never read any of the big books and just learned from watching my attendings and getting experience.

In some ways psych is nice in that there's only a handful of meds, and once you've used the same half-dozen over and over again you get pretty comfortable. of course there are always complex cases where I get stumped and end up doing some lit search on review articles, etc.

 

[calvnandhobbs68]

To be honest a lot of it I have found really isn’t clinically relevant with experience you have hone your knowledge base

Yeah I mean specific binding affinities for the 5 different receptors a med hits isn't really super super relevant day to day...it's useful information certainly but not very clinically helpful day to day. Generally having knowledge of this is relevant but knowing the Kd for every receptor for every med is just unrealistic.

 

[robellis]

Yeah I mean specific binding affinities for the 5 different receptors a med hits isn't really super super relevant day to day...it's useful information certainly but not very clinically helpful day to day. Generally having knowledge of this is relevant but knowing the Kd for every receptor for every med is just unrealistic.

I wish it was 5 more like 20 it’s a bit ridiculous especially since who even knows what’s clinically relevant and where the effect is even coming from, is it one of the 20? Something we don’t even know about? A combination? Who knows

 

[clozareal]

1. I think going back to basics in terms of physiology is helpful. The psychotropic medications affect not only the brain and you'd become a better psychopharmacologist if you can learn which receptors are on which parts of the body and what effect it has physiologically.
   • In addition to pharmacodynamics, it's also helpful to understand pharmacokinetics to know how slow and how fast to titrate medications with regards to steady state concentration. I often see people who go way too slow in increasing a medication and thus delaying a person's treatment into remission. I also see people go too fast (especially on inpatient settings) and then have adverse side effects and then the patient will forever be averse to a medication that may have been effective if they were titrated a bit slower.
   • The most comprehensive textbook that I've used that explains this physiology well is Silverthorn's Human Physiology.
2. For example, knowing that alpha-1 receptors are on arterioles and blocking the receptor causes smooth muscle relaxation (in fact, all Gq secondary messenger receptor on smooth muscles have action on contraction) can help you understand why clozapine/quetiapine/risperidone needs to be titrated to decrease orthostatic hypotension risk.
   • It's also helpful to know how long it takes for those receptors to regulate themselves.
   • Alpha receptors are also on the radial dilator muscle of the eye, GI tract, bladder sphincters, pregnant uterus and are involved in smooth muscle contraction so the aforementioned drugs can also have an effect on those organ systems as well.
   • Binding affinities are most helpful in medications that start hitting different receptors at different dosages: quetiapine, doxepin, etc.
3. Once you understand the underlying physiology, you can then have a better understanding of the drug's mechanism of action and side effect profile.
4. With regards to serotonin physiology, I really enjoyed Carhart-Harris's paper on this.
5. This has no bearing on the understanding of evidence-based medicine though since many of the medications we use that we think may be effective theoretically do not pan out in clinical research.
   • Reading the landmark studies and knowing the effect sizes of each medication and keeping in mind what medications have been shown NOT to work for certain indications is also helpful.
6. Learning how to use as many medications that could be considered psychotropic medications increases the armamentarium of tools you can use to help patients with their symptoms. Stahl's has 143 medications in his 2017 prescriber's guide and there have been dozens more approved since then.
   • I find that some psychiatrists are averse to use certain classes of medications and therefore, a patient who may benefit from them would never have the opportunity to try them. I've heard some psychiatrists say they would never prescribe benzos, non-benzo sedative hypnotics, TCAs, MAO-Is, clozapine, lithium, LAI's, and even FGAs for one reason or another (lack of experience in training is a huge one).

 

[splik]

It's easy to learn the ins and outs of drugs but you really need to get experience with using a wide range of drugs and managing their complications. This is the skill. It is also really important not to forget the psychological aspects (contextual healing, placebo effects, expectancy effects, transference issues) as relate to prescribing.

As a resident I would strongly recommend getting good experience with lithium, clozapine, TCAs (a range of them), MAOIs, deprescribing (i.e. getting people off polypharmacy, and tapering off antidepressants, antipsychotics and benzos), and rotating in a TRD and bipolar clinic and also do a reproductive psych rotation so you get comfortable with prescribing in pregnancy and breast feeding and preconception counseling. If you can do a behavioral neurology or neuropsych rotation that would be helpful too as there is complexity to prescribing for behavioral and psychological symptoms of dementia, in movement disorders and epilepsy, and work with medically complex patients (during C-L and in outpatient settings with medically complex pts) then you will be off to a great start. There are various charts and tables that may help as aide-memoirs. You don't have to know all the receptor profiles off by heart to be a good psychopharmacologist.

 

[jbomba]

It's easy to learn the ins and outs of drugs but you really need to get experience with using a wide range of drugs and managing their complications. This is the skill. It is also really important not to forget the psychological aspects (contextual healing, placebo effects, expectancy effects, transference issues) as relate to prescribing.

As a resident I would strongly recommend getting good experience with lithium, clozapine, TCAs (a range of them), MAOIs, deprescribing (i.e. getting people off polypharmacy, and tapering off antidepressants, antipsychotics and benzos), and rotating in a TRD and bipolar clinic and also do a reproductive psych rotation so you get comfortable with prescribing in pregnancy and breast feeding and preconception counseling. If you can do a behavioral neurology or neuropsych rotation that would be helpful too as there is complexity to prescribing for behavioral and psychological symptoms of dementia, in movement disorders and epilepsy, and work with medically complex patients (during C-L and in outpatient settings with medically complex pts) then you will be off to a great start. There are various charts and tables that may help as aide-memoirs. You don't have to know all the receptor profiles off by heart to be a good psychopharmacologist.

Can you share or point to any of these charts you recommend?