Comments on Treatment Conundrums
Sir William Osler
Clinical medicine is an art and as medical pioneer Sir William Osler declared, often involves “skillful use of combinations.” As the risks of inadequately treated illness increase, use of drugs with inadequately delineated benefit-to-risk ratios may be increasingly justified, such as in the case of memantine as recommended by Koukopoulos.
One should start early, effective, preventive pharmacological treatment of the recurrent unipolar and bipolar disorders. When this is not accomplished, an increasing number of unknowns enter the treatment equation, and as these illnesses enter more serious stages of recurrence, progression, and treatment resistance, the path to remission and wellness becomes increasingly complicated and relies on skillful management, guesswork, and good data from patients.
Given the multiple unknowns, patients can play an important role. They can be intimately involved in the decision-making, and provide precise feedback in the formal or informal longitudinal monitoring of mood, sleep, other symptoms, and side effects so that whatever is tried can be accurately assessed. A treatment with known efficacy is only worthwhile if it is effective in a given patient. When evidence of efficacy in the literature is more questionable, the evidence of effectiveness of a given treatment regimen in a given individual becomes all the more important to discern. We recommend that patients chart their mood and medications using the National Institute of Mental Health’s Life Charting Method (NIMH-LCM) or another type of personal calendar (we offer several on our Lifecharting page–see the gray horizontal menu above this article). This type of careful longitudinal monitoring method can help in the quest for an optimal treatment result.
Our old recommendation would appear particularly appropriate for this discussion. When things are going well (in the treatment of recurrent mood disorders), be conservative and stay the course. Conversely, when mood is not stabilized, be more radical and continue to explore new options until stability is achieved.
