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Share Difficult Decisions
Published in Scott A. Simpson, Anna K. McDowell, The Clinical Interview, 2019
Scott A. Simpson, Anna K. McDowell
In the sample dialogue, the clinician is firm in explaining the available options for decreasing a medication dose. The boundaries of the available options are set early—this medication needs to be discontinued, but within those parameters there are multiple ways to achieve this goal. When the patient is given options within these limits, they better engage in the decision-making process. The end goal of discontinuing a medication is implicitly accepted as inevitable, and the patient’s investment in the process generates acceptance of the ultimate decision. Although the overall goal of medication discontinuation may be undesirable, the patient’s preferences are reflected in the treatment plan.3 This technique works best when the upcoming decision is anticipated in preceding encounters. Groundwork helps the patient accept the upcoming change and makes clear the clinician’s commitment both to enforcing some end goal (e.g., medication discontinuation) and also to incorporating the patient’s preferences (e.g., the taper schedule). Discussing the change over at least two appointments is ideal.
Treatment Efficacy
Published in Melisa Robichaud, Naomi Koerner, Michel J. Dugas, Cognitive Behavioral Treatment for Generalized Anxiety Disorder, 2019
Melisa Robichaud, Naomi Koerner, Michel J. Dugas
Since developing our cognitive behavioral treatment (CBT) for GAD, we have tested its efficacy in different ways. We have compared our treatment to a passive control condition (waiting list) and to an active control condition (applied relaxation). We have also compared our treatment to a nonspecific active control condition (active listening) in terms of its ability to facilitate medication discontinuation.
Panic Disorder
Published in Stephen M. Stahl, Bret A. Moore, Anxiety Disorders: A Guide for Integrating Psychopharmacology and Psychotherapy, 2013
Meredith E. Charney, M. Alexandra Kredlow, Eric Bui, Naomi M. Simon
Recommendations for the duration of the treatment are at least 12–18 months, as studies have shown long-term therapeutic gains through maintaining pharmacotherapy (Rapaport et al., 2001). Such a time period allows patients sufficient time to experience potential triggers, learn safety, and return to previously avoided situations, and may decrease the risk of relapse with medication discontinuation. Regardless, slow medication discontinuation over weeks to months when possible is preferable and may decrease the likelihood of triggering a return of symptoms or intolerance of medication discontinuation due to medication withdrawal symptoms. It has been reported that combining benzodiazepine and antidepressants early in the treatment resulted in an accelerated response compared to antidepressants alone (Pollack et al., 2003). However, the absence of real long-term advantage of the association (i.e., an additive or synergistic effect) suggests that combination therapy may be best utilized during initiation to improve the speed of response and tolerability of antidepressants, but that benzodiazepines can be tapered after the initial weeks once maintenance antidepressant dosing is achieved.
Does antipsychotic combination therapy reduce the risk of hospitalization in schizophrenia?
Published in Expert Opinion on Pharmacotherapy, 2021
Justin Faden, Natasha Kiryankova-Dalseth, Ruby Barghini, Leslie Citrome
All-cause time to medication discontinuation has been accepted as a proxy of effectiveness, integrating aspects of medication adherence, efficacy, and tolerability. Intuitively, rehospitalization or time-to-rehospitalization can be considered as an alternative measure of effectiveness [75]. Although most guidelines either do not recommend antipsychotic combination treatment or fail to provide guidance on ‘rational’ polypharmacy, the global pooled median rate of antipsychotic combination therapy is approximately 20% [43,50]. For that reason, we systematically reviewed studies that compared antipsychotic monotherapy vs combination therapy with hospitalization as the outcome measure. A total of 15 reports were found that specifically addressed this question. The quality of the data varies and includes several large retrospective cohort studies as well as smaller studies and one survey, with the numbers of study participants ranging from four to 125,102. We did not find any randomized prospective controlled studies that addressed this outcome.
Factors associated with medication persistence among ischemic stroke patients: a systematic review
Published in Neurological Research, 2020
Dong Eun Jang, Julie Ann Zuñiga
This review has several limitations. First, because persistence does not measure the reason for medication discontinuation, there might have been some cases in which medication was discontinued at a doctor’s recommendation. Also, due to the included studies’ use of self-report or a regional/national stroke registry for secondary analysis and a lack of evidence for measurement validity, medication persistence might have been under- or overestimated or even a measure of something else. Furthermore, the included studies did not differentiate between community-dwelling patients and patients admitted to facilities such as rehabilitation hospitals and also did not consider the presence of caregivers. These might serve as confounders. To extend this study’s results with scientific rigor, further meta-analysis should be done. Moreover, results of future studies should be utilized as fundamental evidence for developing and testing interventions with various stroke patients.
A systematic review of clinical guidelines on choice, dose, and duration of antipsychotics treatment in first- and multi-episode schizophrenia
Published in International Review of Psychiatry, 2019
Christy L. M. Hui, Bertha S. T. Lam, Edwin H. M. Lee, Sherry K. W. Chan, Wing C. Chang, Y. N. Suen, Eric Y. H. Chen
The current trends shed light on future research directions. First, regarding the selection of AP, the use of a pragmatic criteria places less emphasis on the comparison between FGAs and SGAs. However, it neglected to mention criteria for choosing the most suitable form of AP administration. Future research should address the advantages and disadvantages of oral and injectables, not only in terms of compliance, but also of issues such as efficacy, insight, stigma, and management of side-effects. Moreover, despite general consensus over the recommended dose ranges, there is a need to assess the extent to which efficacy and side-effects are dose-dependent, and, if so, explore the methods to determine the optimal dose for each patient. Additionally, the durations of AP trials and of maintenance treatment are pertinent to the issue of medication discontinuation—which, for obvious reasons, is an ultimate goal for patients. It is, therefore, necessary to identify reliable factors that can distinguish between those who can and cannot withdraw from AP without relapsing (e.g. Hui et al., 2013, 2016).