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Within the past 6 decades, a large and diverse assortment of medications has become available for the treatment of various mental disorders. Given what is available, how should a clinician decide which medication(s) to try for any particular patient? In this article, I discuss eight questions that should be considered when selecting medication for a patient.
What is the Medication Being Used for?
The first step in selecting medication is to have a clear understanding about what the medication is to be used for in the treatment of a patient. All marketed medications have labeled indications approved by the U.S. Food and Drug Administration, but many psychotropic and some non-psychotropic drugs can also be considered appropriate for off-label use in the management of mental disorders.
Medications are prescribed for five main reasons. Medications typically are selected as the principal treatment for major diagnostic syndromes (i.e., schizophrenia, major depression, and other mental disorders). Medications can also be added to target residual symptoms when the principal treatment is only partially effective. They can be co-prescribed initially along with principal treatments to target particular symptoms associated with the main condition (e.g., anxiety, insomnia). Similarly, additional medications might be instituted during particular phases of a disorder. Examples of this would include a patient with bipolar disorder being treated with a mood-stabilizing agent who becomes depressed or a patient with recurrent major depression being treated with an antidepressant agent who develops a psychotic episode. Finally, medications can be used to treat the adverse effects caused by other drug treatments, such as tremors or parkinsonian side effects.
Although the importance of an accurate characterization of the patient's diagnosis or diagnoses, as well as associated symptom patterns, is intuitively obvious, it is not always easily accomplished in clinical practice. Patients can have multiple diagnoses. Symptoms or symptom clusters are not necessarily unique to a particular disorder and can cut across diagnostic boundaries. Signs or symptoms attributed to the disorder could be medication side effects and vice versa. Often, medications can be used for more than one reason, and symptoms or syndromes can often be treated by different types of medications. These issues can be exemplified by three common examples. The selection of medication(s) for a patient with depression will depend in part...