Table 4
Strategies to build a therapeutic alliance with psychotic patients
| Enlist support of the patient’s family or loved ones |
| Do not argue with the patient’s delusions |
| Focus on what is bothering the patient most, and treat identified symptoms |
| Refer to the “stress” the patient suffers because of the unusual experiences he is describing |
| Commiserate with the anxiety he feels when others (such as his family) ridicule or reject his beliefs |
| Describe the medication as a “tranquilizer” rather than an antipsychotic. Use terms such as “nerves,” “stress,” “depression,” “anxiety,” or “insomnia,” which are often preferred by psychotic patients |
| Normalize treatment by suggesting “many of my patients with fatigue or lack of sleep find this medication very helpful” |
| Use medical terms to destigmatize the illness. Suggest that the patient suffers from a chemical disturbance that can be treated, similar to patients with diabetes who require insulin |
Monitoring. The primary care physician’s role after the patient begins antipsychotic therapy is to:
- assess his or her symptoms (particularly suicidality) and adherence to psychiatric visits and treatment
- monitor for adverse effects from medications.
Atypical antipsychotics have been associated with weight gain, hyperglycemia, and hyperlipidemia. Check fasting glucose and lipids quarterly for the first year of antipsychotic therapy and annually thereafter.5 Watch for drug-drug interactions whenever a new medication is added. Monitor for abnormal movements, even though the risk of extrapyramidal symptoms and tardive dyskinesia is lower with atypical antipsychotics than with traditional agents.
For Mr. J’s psychiatric symptoms, I would:
- assess his willingness to start medication to reduce or eliminate the voices
- suggest he accept psychiatric referral
- assure him that I will remain involved in his care and continue to evaluate his abdominal symptoms.
I would also request permission to discuss his case with his partner and a family member to gather pertinent history and enlist their support for treatment. I would then start Mr. J on any drug listed in Table 3.