Empiric medicine in psychiatry

[Anasazi23]

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I know I'm not purpledoc, but felt compelled to respond to this question posed in the other thread. Psychiatry, like ALL branches of medicine (trust me), does indeed employ a lot of empiric medicine. It's an issue not related solely, by any means, to psychiatry (not that I was implying that you felt this way). Infectious disease, anyone?

I treat my patients, psychiatrically or otherwise, empirically very often. This is not to say, however, that evidence-based takes a back seat in the psychiatric floors I've worked on in New York. We are forever going over the latest research in the orange journal, and employing strategies given credence through research. We are always reviewing current treatment guidelines from the American Psychiatric Association and American Medical Association (especially for those with complex medical comorbidities), which of course are research-based.

Many empiric strategies that were found to be effective and "passed on" through residency training are now enjoying validity through controlled studies. Other strategies, however, have fallen out of favor and for good reason. There are a lot of medications on the market. Doctors tend to use the ones that they're familiar with. Unlike many who think that prescribing is nothing more than buying epocrates pro and thinking you're covered through the "multicheck," physicians are reluctant to start their patients on newer medications, despite promoting research, until it has gained empiric acceptance. Except for patients with certain medical comorbidities (DM, etc), many psychiatrists do not see aripiprazole as a first line neuroleptic, despite its "cleaner" side effect profile than many other antipsychotics.

To close, psychiatry, like all branches of medicine, takes a lot from both empiric and evidence-based medicine. And, like all branches of medicine, is moving over to a more evidenced-based protocol. IMO, however, to ignore personal successes with various strategies or to ignore your clinical judgement or intuition based on your experiences medically and psychiatrically, could be foolish.

 

[purpledoc]

Aripiprazole? First line? Anasazi, we have to talk, girlfriend. 🙄

Leaving that aside, I do plan to respond to the issue of empiric medicine -- I just don't have time right now, sorry. Look for some sort of cogent response tomorrow, I hope...

 

[Svas]

I think that your recognition of aripiprazole as a first-line choice is top drawer! I use it this way & have been rewarded repeatedly (and, no, not by the pharmaceutical company).

Good choice and good thinking (from my vantage point)!

Svas

Except for patients with certain medical comorbidities (DM, etc), many psychiatrists do not see aripiprazole as a first line neuroleptic, despite its "cleaner" side effect profile than many other antipsychotics.

QUOTE]

 

[JRB]

Psychiatry, like ALL branches of medicine (trust me), does indeed employ a lot of empiric medicine. It's an issue not related solely, by any means, to psychiatry (not that I was implying that you felt this way).

I wasn't intending to imply that the issue of empiric medicine is restricted to psychiatry practice. My query in this area stems from 2 interests or issues.

One, that is related the other post, is to what degree this can be taught didactically. I've experienced team teaching with pharmacology faculty on psychiatric topics (anxiety disorders, for example), when we were absent psychiatry faculty. These used to be team taught with a psychologist and psychiatrist, owing to the research on combining approaches to treat many of these disorders. The blatant difference was the disconnect between the material presented by the pharm faculty versus the psychiatry faculty with regard to pharmacologically managing these disorders. [I found myself having to politely disagree with the pharm. faculty in front of the class; uncomfortable position to be placed in, and very tricky to do I might add].

I don't want to misconstrue what you've written but, I gather that empiric medicine is the part of the "art" of psychiatric medicine. My experience in working with family practice physicians in managing psychiatric disorders is that they are weak in being able to utilize an empiric approach (training vs confidence, I'm not sure). This then points to possible training issues that may need to be addressed for FPs and nonphysicians in treating psychiatric disorders.

One of my research interests is in finding ways to teach FP physicians to become more effective providers. I am interested in developing a training program for our FP residents and am starting to conceptualize what kind of exposure they will need.

My second reason for asking about the practice of empiric medicine is my interest in the nature of idiosyncratic responses to various biologicals.

Regards,
JRB

 

[Anasazi23]

My second reason for asking about the practice of empiric medicine is my interest in the nature of idiosyncratic responses to various biologicals.

Regards,
JRB

The concept of idiosyncratic biology indeed an interesting one. Medical students are taught this within their first few months. For example, we all remember dissecting cadavers and making the discovery that not every human has even the same gross anatomy! One particular muscle of the hand, (palmaris longis? - it's been a while) and various vessels, including certain brances of the radial artery do not exist in ceratain people at all and vice versa.

Likewise, idiosyncratic responses to [psychiatric]medication are varied as well. I still find much of the most useful information give to me by psychiatrists in the hospital the sort of "off the record" prediction of responses of patients to various medications. While we all know that SSRIs have similar chemical structures, why would one patient respond wonderfully to escitalopram and not to paroxetine? Of course, one could always make the argument, at least for SSRIs, that you prescribe based on the side-effect profile. Amazingly, well-versed psychiatrists often seem to know who will respond better to different agents....and I'm only now beginning to pick up this skill myself. This concept seems to occur even more so with neuroleptics. The other psychiatrists on this board would be better able to attest to this, I'm sure, as they have much more experience than I.

 

[purpledoc]

I wasn't intending to imply that the issue of empiric medicine is restricted to psychiatry practice. My query in this area stems from 2 interests or issues.

One, that is related the other post, is to what degree this can be taught didactically. I've experienced team teaching with pharmacology faculty on psychiatric topics (anxiety disorders, for example), when we were absent psychiatry faculty. These used to be team taught with a psychologist and psychiatrist, owing to the research on combining approaches to treat many of these disorders. The blatant difference was the disconnect between the material presented by the pharm faculty versus the psychiatry faculty with regard to pharmacologically managing these disorders. [I found myself having to politely disagree with the pharm. faculty in front of the class; uncomfortable position to be placed in, and very tricky to do I might add].

I can identify with this one -- case discussion, mixed group of MDs, PhDs, CSWs, etc. Patient with inappropriate sexual behavior. Psychodynamic-minded types talking about narcissism and personality development. Biologically-minded types (including yours truly) pointing out the symptoms characteristic of Asperger's. But back to the main point...

I don't want to misconstrue what you've written but, I gather that empiric medicine is the part of the "art" of psychiatric medicine. My experience in working with family practice physicians in managing psychiatric disorders is that they are weak in being able to utilize an empiric approach (training vs confidence, I'm not sure). This then points to possible training issues that may need to be addressed for FPs and nonphysicians in treating psychiatric disorders.

One of my research interests is in finding ways to teach FP physicians to become more effective providers. I am interested in developing a training program for our FP residents and am starting to conceptualize what kind of exposure they will need.

This is a very important issue. I used to teach and supervise FP residents (a great group of folks, by the way.) I also worked on a project designed to teach medical students about psychiatry with "model patients," who were actors. Great fun!

The problem I see is that FPs simply do not have the time to make a proper diagnosis, even when they're caring and really, really want to. They can ask the screening questions to determine if someone has a mood disorder, but most of the time, they don't have that extra hour to parse out depression from bipolar disorder from anxiety. They give an antidepressant to the person, and often that works, but sometimes it doesn't work or doesn't work completely, and they don't know what to do.

I think that the most important thing to teach FPs is how to distinguish those three illnesses (MDD, GAD, bipolar) correctly, and how to treat GAD vs. panic disorder. If they can do those things, they can at least begin to treat at least 90% of patients with psychiatric issues. After that, they need to learn about the medication options, how to choose one vs. the other, how to use them properly (e.g., don't give benzos "prn") and about important medication interactions. Finally, some additional information about treating elderly patients with psychiatric issues.

Out in the "real world," most of the referrals to me from IM or FP docs of non-psychotic or non-acutely-suicidal patients are simply the result of incomplete diagnosing, and another bunch from undertreating. Every once in a while I get someone whose doc put them on something totally ludicrous, and I catch a heck of a lot of sleep apnea, but usually it's one of the two things above.

Does this jibe with your own experience, JRB?

 

[JRB]

Does this jibe with your own experience, JRB?

My experience (and I work in Family Practice) is that even when the education (per your description) is provided, it doesn't get translated into routine practice. They have not adopted the mindset. FPs get very good continuing education presentations, organized materials including screening instruments, updated prescribing information, resources, and patient handouts. Plus, drug reps presentations and materials. I see it as simply just not incorporating the mindset to conceptualize the patient in that way. It's just a different focus. I don't perceive this as any kind of conscious resistance, and I don't think its as simple as an issue of efficiency.

I'm interested in what happens when they begin to utilize pharmacologic interventions to manage psychiatric disorders. What I've experienced is consistent with what has been reported in the literature; monitoring is not frequent enough, they are hesitant to increase dosages so that patients are often not given an adequate therapeutic trial before the patient discontinues the meds or is changed to another, and the patients don't tend to stay on the medications for a long enough time period. These things could be probably be addressed through the implementation of quality improvement/risk management projects for facilities that are JCAHO accredited.

However, as I've become more interested in empiric medicine I'm beginning to see another perhaps more critical issue emerge. I'm not certain that FPs have had the kind of "mentoring" that Anasazi alluded to or the experience needed to have an empiric approach to treating the many patients that don't respond to a simple psychotropic medication regimen.

In terms of being able to treat psychiatric disorders in patients who have complex medical problems and patients who do not have a straightforward response to the pharmacological intervention, the lack of training in an empiric approach seems problematic. This issue I see as pertinent to various training issues that are being discussed, not only for FPs but also for physician extenders who are supervised by FPs.

For the few FPs that I've had a discussion with on the topic of empiric medicine in psychiatry, it was not perceived in a positive light. (mind you, it's only a few) But for these few, there is an obvious lack of understanding for the rationale.

Just my thoughts.

JRB