Goldilocks & the Three Bears...

- or, How to Talk To Patients About What You're Putting Them On and How You're Dosing It So That They Understand the Game Plan
(With a Focus on Psychiatry & Psychopharmacology) by Louis B. Cady, M.D. copyright, 1997 - may not be reproduced or disseminated in any form for commercial gain without express permission of the author.  It MAY be downloaded, copied, and printed, for the PERSONAL use of PATIENTS ON PSYCHOTROPIC MEDICATIONS. Links may be freely placed to this page by anyone, without permission.

for physicians-

1. Understand how to communicate better with your patients so that they understand what you are attempting to do, are aware of possible side effects and how to handle them.
2. Help cement a "working alliance" with the patient so that they are "partnering" collaboratively with you in their health care and so that you don't end up practicing "veterinary medicine" where you diagnoses and treat the patient by how they look and ignore what they might have to say.
3. Clue patients in, ahead of time, about side effects they may encounter, so that they will not be terrified should they occur and constantly be calling your office.  Hey, it's their right to do so if you're giving 'em side effects and haven't explained it to them!
   

Goldilocks & The Three Bears - the Cady version

"You remember the story about Goldilocks.  She was in the 3 Bears place.  She found three bowls of porridge.  One was too cold, one was too hot, and one was JUUUUUUUST RIGHT!"

"The medication I'm prescribing for you is like that.  We're going to start TOO COLD - which means we'll be starting at a REALLY low dose.  It will probably not help your condition one little bit.  But it shouldn't hurt you, and you shouldn't get side effects. 

"That's too cold - it won't help you, but it won't hurt you.  That's the first order of business... making sure that you can TOLERATE the medication.

"Then, we're going to start 'raising the temperature.'  That means we'll start increasing the dosage.  Hopefully, we'll get it to just right.  

'Just right' is defined as: it cures (or treats adequately) what's ailing you but doesn't give you side effects.  In the late 20th century, it is my opinion that NO PSYCHIATRIC PATIENT (except patients with schizophrenia or bipolar disorder) SHOULD HAVE TO BE ON A MEDICATION TO TREAT HIS/HER CONDITION THAT CAN'T DO IT WITHOUT SIDE EFFECTS."

" 'Just right,' then, means that you're going to LOVE this dosing because you'll be feeling absolutely normal with NO SIDE EFFECTS.  This should be like 'a vitamin pill for the head.'   We are going to push the dosage until I am SURE that you are at a good, solid therapeutic dose, or until we encounter side effects. 

The possible side effects of this medication are       (name the common ones) .  We don't want you to have to have those side effects.  Should you start getting side effects, this means the dosing is too hot . 

If that occurs, we're going to back the dosing down to a level that you can tolerate.  You can do this without calling my office.  The only time you must call me is if you ever feel you need MORE than I'm prescribing.  You ALWAYS have my permission to cut the dosage down if you're having side effects.  That' s good'ole common sense!

"It may be that in a few weeks, your condition will improve substantially or completely on that dose [patients: this is common for depression and anxiety disorders].

"If we still can't get it under control on a dosing of this medication which doesn't give you side effects, I'll probably add something, or we might try another medication which I think will work at the "just right" level and not give you side effects.

"Now, it will be very important for you to know that:
    (a) this medication is very safe;
    (b) if you encounter side effects they will GO AWAY when you drop the dosing down - realize that you will not "break your brain" if you start to have these [patients worry about this!]
    (c) if you have side effects that I haven't explained to you, or you feel really 'weird', or are afraid that  you're having a side effect that we haven't talked about... CALL ME.

"Unfortunately, for some medications, there isn't going to be a " just right " for you.  That is, you'll go from too cold - where you're not getting any benefits - to too hot .  Sometimes, the only dose that will benefit you from a medication is the too hot one.  That's not acceptable to me... it means we need to look at another one so that we can get you just right.

"I am flat-out confident that you and I are going to be able to determine a "just right" dose of medication for you that you'll hardly even know you're taking, except your  __________ is simply going to feel like it went away.

"Do you have any questions?"

Good luck!  I hope that mastering this parable has been helpful to you.

                                                                                                    Louis B. Cady, M.D.

The Three Deadly Sins in Prescribing Medications - according to Goldilocks...

DEADLY SIN # 1: STARTING TOO HIGH

Steven Stahl, M.D., Ph.D., in his book, Essential Psychopharmacology explains the pharmacodynamic rationale for the side effects that patients have with a "too-high" starting dose.  [This is the single best, most essential book on the use of psychotropics in clinical practice I've ever read.  You should have it.]

Most physicians reach for the sample cabinet and start with 10 mg of Lexapro, 50mg of Zoloft, etc.    Or for treating ADHD, they will start on 10 mg of Adderall or even 18 or 36 mg of Concerta. WRONG!  While the patient may ultimately be able to tolerate this dosing, the up-regulation of their post-synaptic receptors will typically result in almost immediate side effects if you start at the customary therapeutic dose.  My customary practice is to start patients at 1/4 to 1/2 the usual "therapeutic dose" and titrate up quickly over three to four days - [or a week to two weeks, depending on age of patient, severity of condition, and the usual "clinical variables"] - , as expeditiously as the patient can tolerate it, and then to make the "usual therapeutic dose" the first way station, "stopping over" point before continuing to push the dosage.

If a patient has "side effects to the medication" at too high of a starting dose, you have proved nothing.  You have certainly not proved that the patient "can't tolerate the medication."               

DEADLY SIN #2: NOT GOING HIGH ENOUGH, and for an adequate period of time.

I never consider a patient a medication failure until they have failed the absolute MAXIMUM dose after one month of whatever I'm titrating: - Maximum daily doses for commonly prescribed antidepressants -

Lexapro - 2o mg	Celexa - 60 mg	Zoloft - 200mg
Prozac - 80 mg		Paxil - 50 - 60 mg
Serzone - 600 mg	Effexor - 375 mg	Wellbutrin - 450 mg

DEADLY SIN #3 - BEING BULLHEADED AND STUBBORN!

If a patient is having legitimate side effects - and is not a neurotic, somatizing patient (who also needs therapy - but of a concomitantly psychotherapeutic nature), it means that the medication is too hot.  Period.  End of discussion.

Patients have told me that their doctors have told them, "You'll have to live with the side effects."  Rubbish!

Particularly if a patient has started to get SOME benefits from a medication, but isn't all the way there yet, and is tolerating the medication fine, the enlightened prescribeR should consider augmenting the medication with something else, rather than "throwing the baby out with the bath water" and starting all over again.  The use of Wellbutrin or Effexor, at low to medium doses, superimposed onto a partial SSRI responder, works quite well.  Particularly if there is a robust response, one should consider pushing the "augmenting" medication upward and seeing if the SSRI, for example, on which you have been "building" the patient's pharmacotherapy can be tapered and discontinued.  [For an optimum understanding of the pharmacodynamic actions of the various antidepressant, cf: Richelso, E. Pharmacology of antidepressants: characteristics of an ideal drug.  Mayo Clin Proc 1994;69:1069-1081]. 

Simplicity and monotherapy - with no side effects - should ultimately be the desiderata toward which we strive.

A common error in thought is that using two antidepressants together is somehow ill-conceived, indefensible, etc.  It's not as long as you think out loud to the patient and in your charting.  Telling the patient that what you are doing is not found in the PDR, but, in your clinical judgment, is the way to go - particularly if you have an excellent collaborative relationship with the patient evolving - will almost invariably enlist the patient as a "co-investigator" with you in determining their optimal pharmacotherapy.  [This is NOT a defense against ill-considered "combo therapy" where you put the patient at a lethal risk from a drug-drug interaction, e.g., "combining" a tricyclic and Prozac (or Paxil) at full therapeutic doses for both.*  You will be headed toward a severely bad outcome and a probably (and well-deserved) malpractice suit.
        [*cytochrome P450 2D6 interaction - Prozac or Paxil inhibits metabolic pathway of tricyclic, resulting in potentially fatal tricyclic levels... recall the relatively low therapeutic index of TCA's...]

One needs to recall that the use of Elavil (amitriptyline hydrochloride) was about as "polypharmacy" as you could get!  [cf: Preskorn, S. Outpatient management of depression .  Professional Communication, Inc.  Caddo, OK, 1994].

The final tip for docs is to reread the package inserts, or in-depth "detail pieces", periodically to reacquaint yourself with the mechanisms, rationale, potential drug-drug interactions, and range of common side-effects peculiar to each drug and class of drugs.

Good luck and happy prescribing!