Saturday, March 21, 2015

On Combining Antipsychotics, Top-Performing Therapists, and Procrastination

I woke up this morning and realized that I've allowed myself to become a victim of BPS--Blog Procrastination Syndrome. It happens to the best of us. We write a post, and days and weeks and months go by. "My next post has to be really, really good," we think.

Forget that. I'm just going to dive back in beginning today. "Done is better than perfect," someone once told me.

At The Carlat Psychiatry Report, we are busy planning future issues, and here are a couple of upcoming topics that I'm fired up about.

Combining Antipsychotics. 

Psychiatrists have gotten plenty of bad PR about our use of antipsychotics. And some of that bad PR is justified. We overuse Seroquel as a sleeping pill. We add too much Abilify to antidepressants because patients come into our office having been hypnotized by ads telling them that this is the drug that will finally help them kick their blues.

But sometimes the criticism is misguided. Lately, guidelines have been published discouraging us from combining antipsychotics. "That's not evidence-based practice," we're told. Fair enough. But when your patient on risperidone is still digging through the snowbanks looking for the transmitter that he's convinced is causing the world to hurtle toward oblivion, you need to something. You can increase the dose, you can switch, you can add, etc....

So I'm working with psychiatric pharmacist Kelly Gable on an article that says, "Look, we understand that combining antipsychotics can increase side effects and is not supported by randomized controlled trials. But sometimes we do it anyway, because our patients our suffering."

We're collecting a list of scenarios that typically lead to antipsychotic polypharmacy, and we're going to evaluate how reasonable these scenarios are. If you have any experience, positive or negative, with antipsychotic polypharmacy, please let me know by email or by commenting to this post.

Top Performing Therapists. 

I interviewed Scott Miller, PhD, the other day for our April issue on psychotherapy. Dr. Miller believes that the real key to improving our clinical success is systematically getting feedback from our patients on how well therapy is going (or medication treatment, or combined treatment, etc....).

He's also found that top performing clinicians spend three to four and a half times as many hours per week than others engaging in "deliberate practice". What does that mean?  You'll have to read about it in the issue. I'm still editing the interview and really enjoying it.

Phew. Feels good to clear out some of the blog-webs that have developed over the months. See you again soon. Really.


Bernard Carroll said...

Welcome back, Danny... we missed you. Barney Carroll.

David Upton MD said...

The therapeutic alliance, including the doctor-patient match, has always been the key to good outcomes in mental health care and in health care of all kinds.