About 4 years ago I started a blog for my psychiatry practice, entitled ‘Psychiatric Times.’ The web address for that blog was fdlpsych/blog, and when I eventually bought the ‘patienttimes’ domain name, I lost most of my posts during the migration process. I recently stumbled across the old posts at archive.org, a site that contains ‘snapshots’ of the internet that have been archived over the past twenty years. Remember Netscape?
I plan to reassemble the old posts over the next few weeks. Of all those old posts, the only one that stood out in my mind — a post about a certain conceptualization of psychiatric medication— was not part of the archives. Bummer… until I searched the web using parts of the post with Google. To my surprise, I found that old post, copied on several web pages belonging to other people, with no mention that I was the person who wrote the post in the first place. If imitation is the ‘sincerest form of flattery’…. Then I’m flattered.
I copied the post from one of the sites to reclaim it as my own. In case you’ve seen it before— I can assure you that it started here, at my blog!
The Warm Coat Theory of Psychiatric Prescribing
I sometimes envy scientists and physicians from 100 years ago who took credit for all of the easy discoveries and attached their names to them. The Bernoulli Principle, for example, describes how the pressure of an inviscid material decreases as the rate of flow of the material increases, i.e. why the disgusting shower drapes in cheap motels are pulled toward people taking showers. I’m sure I noticed that effect when I was about six years old, and had it not been already figured out (and named for Bernoulli), I would have come up with my own theory eventually! But life is harder now, and the days of just thinking real, real, hard and coming up with a ‘discovery’ are long gone.
Or are they? I have a theory about psychiatric prescribing that in my opinion is every bit as impressive as the Bernoulli thing. If you want to Facebook, tweet, or share this post, be my guest!
Junig’s Warm Coat Theory of Psychotropic Prescribing ( the title needs some work.)
Back when I was an anesthesiologist, surgeons sometimes used the phrase ‘better is the enemy of good.’ The point was that in some surgeries the best approach was to remove the infected or diseased tissue, stop the bleeding, close up ASAP and get the patient back to the ICU. Spending another 4 hours picking at the tissue to make everything pretty risked a drop in the patient’s body temperature, a decrease in clotting and immune function, and an increased stress response, all in turn increasing the odds of a bad surgical outcome. I have to give credit where credit is due, and note that the warm coat theory is similar in some ways to the ‘enemy of good’ phrase that I have heard recited over the years. In fact, it is entirely possible that the unconscious parts of my mind stole the phrase and adapted it to psychiatry. If that is the case, I’m sorry for the actions of my unconscious-and I plead ignorance to the entire affair!
When prescribing medication for psychiatric conditions– for example ADD or anxiety– the patient might note positive effects initially but then at some point ask ‘maybe I’d do better with a higher dose-should we try a little more?’ With any medication for any condition, there is a balance between positive effects of the medication and risks or side effects from the medication. Serotonin medications work well for depression and anxiety, but as their doses are increased they will eventually cause sexual side effects. At still higher doses they may cause drowsiness or nausea. The positive effects of a medication go up with dose, but the side effects increase as well.
The goal for the patient and physician is to find the proper balance is between positive effects and negative side effects. If the patient has no interest in sex (and doesn’t WANT an interest in sex), sexual side effects should not limit the dose. Nausea or sedation, on the other hand, may be barriers to dose increases. Different people have different concerns about risks and side effects, and different people have different needs for higher doses of medication. These differences, by the way, are why I maintain that psychiatrists should spend more time with patients than they do-but that’s another topic for another day.
When we Wisconsin folks go outside in January, we take a look at the Weather Channel and dress accordingly. But we don’t dress for 14 degrees F; we dress for ‘pretty darn cold.’ If I’m going to a Packer game, I’ll put on my long-johns (too much information?), jeans, and the snow-suit from Fleet Farm (that changed my life when I finally bought it, after suffering a few football seasons without it). I’ll also wear a stocking cap and maybe even a face mask, and of course a thick pair of gloves. At some point during the game, if the drunken guys squeezed in way-too-close on each side of me take off their shirts so their body heat radiates toward me and warms me up, I’ll take off my face mask and maybe my cap. By the end of the game I might even have my own shirt off if the sun is out. Of course the guys next to me might have enough of the game at some point and spend the rest of the game at the bar, just as the sun disappears behind a thick layer of clouds. Then I’ll put the heavy stuff back on, and maybe rub my hands together or do some jumping around to raise my body heat. If I get cold enough, I’ll go inside and warm up for a few possessions. The point is that I don’t bring along a spring jacket to change into when I’m warm, and I don’t bring extra coats for when I’m cold. Instead I change my activity, my location, or make minor adjustments to my wardrobe.
According to the warm coat approach, I suggest that patients think of their psychiatric medications in a way similar to how I think of dressing for a Packer game in January. At the time the person wonders about a higher dose, he/she is getting a good response from the medication, usually with a low amount of side effects. At this point, ‘better’ may be the enemy of ‘good.’ The person is essentially wearing a warm coat in January. There is no need to run home and pick up a few more coats; the better action is to change behavior to fine-tune the degree of symptom relief. If the target symptoms are attention problems and the current dose of stimulant has taken the person 85% of the way, the correct action is to adjust behavior. Find a quiet location for studying. Get enough sleep. Come up with reminders and plan ahead, to avoid time crunches that interfere with performance. These are better approaches than increasing the dose of stimulant, which might raise blood pressure or lead to addictive problems. If the target symptoms are anxiety-related, work on positive self-talk and try to gain insight into why the anxiety is there in the first place. Learn to relax using deep breaths or by taking a walk to get away from the stressful environment.
The medication should be like a warm coat in January; a way to make symptoms ‘good.’ Use behavioral or therapeutic interventions– approaches that don’t increase risks or side effects- to make things ‘better’.
If Junig’s Warm Coat Theory becomes big, someday you’ll tell your grandchildren about the day you first read it, before anyone was talking about it. They’ll look up at you, eyes wide, and say ‘Wow!’