In psychiatry, the use of psychotropic drugs is very often essential. These molecules include several drug classes. In addition to neuroleptics, which occupy an essential place in the therapeutic arsenal of many pathologies, antidepressants, antiepileptics used as mood stabilizers, central stimulants and benzodiazepines are not left out. All these drugs are likely to cause undesirable effects that can alter patients’ quality of life and compromise their management. Through the accounts of three patients from the GRAAP (Reception and Psychiatric Action Group) foundation, adverse effects will be addressed. What these people have in common is the long duration of their respective psychiatric illness,
PATIENT RIGHTS AND INFORMED CONSENT: WHAT ABOUT PSYCHIATRY?
Mrs. D: “I have had this diagnosis for a long time, more than 30 years. I had several hospitalizations, and I remember going through many drugs; we tried several neuroleptics. I was not in a state to react and be consenting. They [the doctors] introduced the drug more or less without dialogue. Maybe they told me about the side effects, but I can’t remember. I was in a state of crisis. “
Whether it is in a hospital or an outpatient setting, the patient has rights. One of them is the one with information. The doctor is required to inform him of his state of health, the planned treatments, their costs, and any negative consequences to allowing him to give his free and informed consent. Without the latter, no care should be provided. The patient must be capable of discernment. In other words, he should be able to assess a situation and make a decision accordingly.
In the psychiatric field, this ability is very often questioned, particularly during crises requiring hospitalization. In these situations, if the person concerned loses his judgment, a legal framework is defined, allowing doctors to override this right and act in the patient’s best interests, taking into account his wishes to the extent possible. The rules concerning treatment without consent vary from one canton to another. It is therefore recommended to consult the various cantonal laws for details.
However, note that a person suffering from mental disorders, under guardianship, minor or elderly, is not necessarily incapable of discernment.
Significance of side effects
It is a proven fact that in severe psychiatric illnesses, drug nonadherence very often results, in part at least, from the presence of bothersome, or even disabling, side effects. The direct consequences are the risk of relapses and re-hospitalizations. For a patient with a long psychopharmacological history, negative experiences experience is likely, increasing the potential reluctance to introduce a new medication. By approaching the side effects as it is supposed to, the doctor runs the risk of generating additional anxiety in his patient and being confronted with his refusal.
Mr. K: “The first time we introduced a neuroleptic, I was very distressed when I heard about side effects. I had to take it because I was in the hospital; they [the doctors] should have explained better. “
It is therefore essential to establish a climate of trust around the drug. The practitioner’s attitude towards the medication is just as important as the communication and therapeutic alliance with the patient.
IS THERE AN IDEAL METHOD FOR DISCUSSING SIDE EFFECTS WITH PATIENTS?
Mrs. D .: “After the discharge, no one spoke about the side effects. I think we often have to ask for them. At a hospitalization where I was offered a neuroleptic, I asked about the side effects, they [the doctors] showed me the compendium, and I refused because it had too much for me. They agreed with my refusal. So that might have been a good choice, but we didn’t chat about it. “
For the novice hospital doctor or the experienced psychiatrist, the skills required are the same. Beyond the qualities of communication desirable for any practitioner, good bases in psychopharmacology are necessary. The doctor should explain to his patient, in popularized terms, why his choice fell on a given molecule, what are the expected benefits, and approximately in what time frame. This first step is a source of hope. When it comes to undesirable effects, transparency does not necessarily mean completeness. Indeed, it seems more judicious to focus on the side effects most likely to occur in a particular patient, taking into account, in particular, the properties of the drug, the person’s history as well as existing co-morbidities. Just listing them would risk generating excessive anxiety. It would be advisable to announce possible strategies to prevent them and remedy them if necessary. This approach is intended to be reassuring and is part of the context of the therapeutic alliance.
Of course, there is no one optimal and unique way to approach the issue of adverse reactions. However, favoring an open dialogue and adopting a proactive attitude by developing therapeutic strategies in concert with the patient promotes drug adherence, thus increasing success chances.
Mr. K.: “I’ve been in the psychiatric community for 15 years. I find that there has been a marked improvement over the past five years. Doctors at the hospital explain better than before. “
A teaching method
During his university studies, although basic notions in psychopharmacology are provided to him, the doctor is generally not trained in a specific way to address the issue of adverse effects with the patient. A recent American publication shows a new teaching approach for this subject, which ultimately constitutes only one psychiatry branch. Originally, the method was designed at Yale University in 2010, then implemented and developed over other sites, notably at Columbia University. Its goal is to deepen knowledge in psychopharmacology and develop the skills necessary to prescribe psychotropic drugs and their introduction to patients. The method consists of working sessions organized in the form of workshops lasting approximately 75 minutes. The first quarter of an hour is dedicated to consolidating knowledge already acquired on a therapeutic class or a given drug;
The course conducted at Columbia also included viewing interviews about medication between a seasoned psychiatrist and a fictitious patient and supervision by a psychopharmacologist and more experienced residents during the sessions. Job.
These examples illustrate that training can help overcome a lack of confidence in young psychiatrists while waiting for the experience to be acquired.
HOW TO MONITOR AND MANAGE SIDE EFFECTS?
Mr. K.: “I was previously on Amisulpride, and I immediately gained a lot of weight. I went from 80 to 130 kg in a few years. Then we changed the drug to aripiprazole. Currently, I am down to 90 kg. “
The adverse effects of psychotropic drugs are well documented and fairly studied. Due to their impact on patients’ quality of life and their morbid potential, it is commonly accepted that they should be monitored.
Metabolic disorders occupy a predominant place in the monitoring and managing of the side effects of psychotropic drugs in general and particularly neuroleptics. With the advent of atypical neuroleptics, they are the subject of numerous studies. However, they are also manifested with certain conventional neuroleptics, for which extrapyramidal side effects are often in the foreground.
Recommendations exist for the monitoring and management of metabolic side effects. Before introducing the drug, routine examinations are recommended with follow-up at one, three, and six months, then quarterly or six-monthly 6 ( Table 1). It is recommended to define each patient’s metabolic risk profile and take it into account in the neuroleptic choice, some being more at risk than others. They should be checked at least monthly for the first three months as for weight and waist circumference. Weight gain is not limited to a purely aesthetic consideration. It worsens the mental state by altering patients’ image and self-esteem, whose self-confidence is already damaged by their condition. Abdominal fat is particularly harmful in terms of cardiovascular risks.
HOW TO ASSESS THE SIDE EFFECTS AS EXPERIENCED BY THE PATIENT?
Mrs. D .: “In the past, a private doctor wanted to introduce quetiapine. He told me about the negative effect of the drug, which canceled the feeling of fullness. I felt it, and it was something terrible. We are not hungry, but as soon as we eat, we can not stop. I gained over 20 kg in a short time. Maybe he told me about restricting myself or following a different lifestyle, but it just wasn’t possible. I will not have been able to follow any dietary measures; at one point, it was bulimia. I couldn’t take it anymore and wanted to stop. It’s already painful looking at yourself because of the disease, it gave me one more problem, and I had enough already. “
The clinician has a theoretical knowledge of what the adverse effects of psychotropic drugs might be. A recent review of the literature demonstrated that, among the side effects, neurological and metabolic symptoms and sedation problems were more systematically reported and monitored than affective, various cognitive, hormonal, or skin complications. But in the patient’s reality, an undesirable effect usually relegated to the doctor’s background could hinder his routine and compromise his management. He may not necessarily have the opportunity to discuss this with his therapist, depending on how the interviews are conducted; it is not always possible to cover all the desired topics. For this reason, documentation of subjective adverse effects experienced by the patient could prove to be a good communication tool.
An Australian study was carried out on developing a questionnaire intended for patients concerning their psychotropic medication’s adverse effects. The involvement of patients and groups of professionals (psychiatrists, general practitioners, pharmacists, psychiatric nurses, and other caregivers) made it possible to improve the questionnaire and to assess the ergonomics and acceptability of the completed version “My Medicines and Me” or “M3Q”. Each of the participants recognized its usefulness.
The M3Q is a combination of closed (like a checklist) and open-ended questions. A questionnaire for each drug should ideally be completed by the patient beforehand, before the doctor’s scheduled interview to discuss it. Such a session would indeed be beneficial because prescribers do not always realize the extent of the impact of the adverse effects of psychotropic drugs on the daily life of their patients.
THE FINAL WORD
A good explanation of the possible side effects, apart from the disease’s acute attack, decreases anxiety and alleviates the reluctance to take a new treatment. However, the benefits must ultimately outweigh the disadvantages, especially from the patient’s perspective. Proper medication therapy management is a significant aspect of successful outpatient treatment programs. Otherwise, treatment failure can be feared.