Principles of Med Management
General Principles Of Medication Management
Cyril M J Puhalla M.D.
Board Certified in Child, Adolescent and Adult Psychiatry
Below are some of my rules and principles of using medications that affect the mind. I believe that using psychotropic medications, that is those that have mind effects require a higher standard of care because we are dealing with the most precious and sensitive and important organ system of your body and deserves extra special care and management. Though there a many side effects of psychotropic medication the most important ones for our purposes are the psychiatric effects good and bad which is the whole point of medication management. If one start very low and goes very slow and is vigilant and paying attention to the medication effects any serious problems can be anticipated found early and fixed before they do more harm than good. Look for effects that change how you think, feel, change your mood, sleep, energy level, concentration, memory, speed up or slow down your mind, make the symptoms you came into treatment for worse rather than better. If anything new or unexpected happens to your mental functioning or body symptoms that seems to be making matter worse, stop the medicine, or lower the dose until you can discuss it with your prescriber. See General Principles of Psychiatric Medication Q and A for more of a discussion or these principles.
1. You/your child has a mental health problem that in part has a biological, hereditary, genetic, chemical imbalance basis/cause, that may be helped with medication management.
2. When you are sufficiently educated and comfortable on a medication approach you may want to consider a carefully managed medication trial, in which you will have ultimate say and control.
3. I call it a trial because brain chemistry is very unique, and even in identical twins who are bio chemical “clones” that at is a least theoretically should have very similar brain chemistry, yet they don’t have the same responses to medications that effect the mind. If there are such differences in twins one can expect unique responses in all individuals even when one has the correct diagnosis and has history of medication responses of the individual and the family when it is available.
4. A medication trial is not only a therapeutic process but the response to trial aids and often helps confirms and fine tune the diagnosis. A group of symptoms with a specific history in the individual and the family make up two parts of the diagnostic process, the third part is the expected treatment response.
5. I may know more about the medication then you, but you know your child and yourself better than I do when it comes to things like their appearance, thinking, feeling states, moods, physical signs like sleep, appetite, sensitivities to foods, dyes, and other kinds of internal and external environmental stimulations and stresses good and bad. Therefore I will almost always defer to your opinion and judgment about the medication effects and will be only a phone call away if you have questions or problems.
6. On the right medication with the right dose strength and schedule and properly adjusted , you should be your normal self, but relieved of the target symptoms, not looking or feeling drugged, medicated, numbed out, zombied like, high or low You should not have to suffer through negative effects to get positive effects. The medicine should be neutral or helpful, as we adjust the dose, never should the bad effects outweigh the good effects.
7. We will start with the safest simplest medication with the best tack record, and start with the lowest dose. It may necessary at the beginning to use more than one medication depending on the number of problems that need to be addressed and how severe they are. In cases of multiple diagnoses more than one medication may be needed for adequate treatment and control, but even here the goal is to use one medication if it will do the job or the fewest number needed for the shortest length of time.
8. Why lowest dose? for at least two reasons to find low end responders that people who only need smaller doses to get helpful effects, and where starting at the “normal” even a low dose may be too much to start and secondly to minimize any negative effects.
9. Because we are starting with a very low dose, the initial response may be neutral or only mildly helpful. This is normal and is too be expected. We can always increase both the dose strength and the rapidity at which we increase the dose if the symptoms warrant such.
10. If the medication is doing more bad then good, making matters worse stop the medicine and call me.
11. The dose will be slowly increased on a scheduled determined by your need and your response.
12. Correct dosage of the medication is very individual specific, based on your unique brain chemistry.
13. Dosage is based more on your unique brain chemistry, rather than age, weight, or symptom severity though all of these play a part in picking the medication, its dosage and how rapidly it will be increased or adjusted.
14. Remember more medications or higher doses are not necessarily better, your unique response is the final determining factor. In fact lower doses, or less medicine or no medicine may in fact be in your best interest. It all depends on your unique brain chemistry and its response to an adequate and carefully managed medications trial.
15. Specific targets such as behavior, concentration, moods, anxieties, thinking, physical symptoms i.e. headaches, sleep, etc, with level of improved functioning will be used to assess the effectiveness of medication adjustment.
16. Improvement in targets must always be balance with your needs and possible negative effects both short and long term.
17. As the dose is increased, if the lower dose was better, return to the lower dose, if not sure call me.
18. If unexpected bad effects occur, go back to the lower dose, or stop the medication, if your not sure call me.
19. Medication effects may be seen a soon as 3 to 7 days once the right medicine and dose is found though one my see initial effects as sooner. With stimulants for ADHD, effects may be seen within an hour, lasting up to 12 hours.
20. Long term and long lasting effects depend more on the type of problem you have and the course of the disorder than the individual effects of a medication.
21. Duration of treatment depends on diagnosis, for ADHD, 50% of people after treatment find they do fine without medication, others may need the medicine for 6 to 12 months, hardly anyone needs it forever. Longer treatment is necessary if there is a personal or family history of re-occurring biologically based mental health disorder.
22. The shortest duration of treatment is best guaranteed by treatment beginning at the earliest age, with the proper dose of medication being used for the appropriate length of time to ensure adequate treatment.
23. Treatment is adequate when it not only addresses symptom relief, but prevents relapses, and complications.