When prescribing medications, I’m confident that few of us behave unethically. But I’m also confident that none of us goes through a full day practicing only evidence-based medicine.
I would like to use medications only in ways that have been proven in double-blind, placebo-controlled studies—the gold standard of evidence-based medicine. However, most of my patients (and I’m sure most of yours) have too many psychiatric, chemical dependency, and medical diagnoses or are too young or too old to meet the inclusion criteria for most double-blind studies. And of those few patients with just one diagnosis, many do not achieve complete remission on the drugs that are supposed to work for them.
What do we do then? I usually try a single medication that has not been thoroughly researched for the diagnoses I’m treating, or I use multiple medications.
Yes, I am a polypharmacist, and Drs. Sheldon Preskorn and Steven Werder have become my new heroes. Their article in this issue reviews the literature on use of multiple medications and suggests general principles for going beyond the literature.
Maybe that’s a better way to think about it: going beyond the literature. Where there are good scientific studies to guide us, we should certainly follow them. But we need to admit that there are not studies to justify everything we do. The practice of medicine would be ineffectual if we had to tell suffering patients, “I’m sorry, you’ll have to come back in a few years when maybe we will have completed some more studies.”
The practice of medicine in psychiatry—and in all other specialties—combines proven treatments and those for which there is evidence but not proof. Frequently, we try treatments that lack solid evidence but whose potential for efficacy exceeds their potential for harm.
Most medical research arises from clinical practice. If we prescribed only what is proven, we would never generate—or test—new hypotheses. We would not be using all of the available evidence, and we would not be helping as many patients. The purpose of Current Psychiatry is to keep us informed of the latest evidence, so that we can use it—or go beyond it—as each case dictates.
I am proud to be a polypharmacist. There, I’ve said it, and I really do feel better.