Cases presented to me recently at another medical school and within my own department highlight a common clinical problem: picking up (“inheriting”) a patient previously under another doctor’s care. In resident clinics, it is commonplace, as residents advance through their training.
I shudder at how often I see complex pharmacologic “cocktails,” with at least one agent from every psychiatric drug category—sometimes two or three in a category. Truly there are some patients who benefit from polypharmaceutical regimens—as they do in hypertension treatment and other medical specialties. But more often, no one can say why the patient is taking these medicines at these doses: not the chart, the patient, the family, or other caregivers. Commonly, providers inheriting such patients go into “autopilot”—continuing the regimen without understanding it. It’s quicker and has less hassle. A resident recently told me how she worked to understand, then disentangle a complicated multi-drug regimen, then explain it to the patient, family, and other staff. By the end of the session, she was exhausted!
When a physician assumes care of a new patient on a complex treatment regimen, I recommend slow and cautious but methodical diligence. Ask everyone for input on the regimen, review the clinical record, and try to contact previous clinicians. At an initial visit, put confidence building and establishing trust first, but mention that the regimen is complex and might conceivably be less than optimal. Suggest future conversations toward simplifying the regimen, and document the discussion. And over time, consider cautious tapers—one drug at a time—with careful observation for adverse outcomes.
It is time consuming. And emotionally draining. And when a patient or family is adamant against change, I take their wishes seriously. But if I assume medical responsibility for care, I am responsible—not the doctor or doctors who created the regimen in days past.
-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry