Meticulous diagnosis and close monitoring are the essence of good psychiatric treatment. This requires very close attention to the patient’s early development and illness history. Before being seen, patients are asked to write or call all previous psychological and medical care-givers, to authorize and request release of records: laboratory tests, computerized pharmacy prescriptions records, summaries of diagnosis, treatment and course—to be sent promptly to Donald Klein MD—1051 Riverside Drive, Box 22, NYC, 10032. Release forms are provided to fill out and send.

Hospitals often respond slowly but eventually provide essential information. Therapists may not reply to information requests unless repeatedly asked and given the date of oncoming evaluation.

Prospective patients are also sent forms inquiring about history, demographics, treatments, doses, responses, current and previous symptoms, etc. Particularly important are patients’ own narrative summaries of their lives, illnesses, symptoms and treatment responses. Patients are also asked to bring the person who knows them best, usually a spouse or parent, to the initial evaluation . This often provides crucial information. Of course, the patient’s information is held confidential.

Unfortunately, many doctors avoid family contact.

The initial 90 minute evaluation is set by my appointment secretary (212-543-6249), usually in one or two weeks. At the start of this session, all submitted information is reviewed to keep it freshly in mind. This may take about 15 minutes.

I then meet the patient and others and often jointly review what brings the patient to me. The informant and patient often have differing perspectives. Then we review the prior history. Regarding the patient’s symptoms, difficulties and treatment responses the relative’s views are often invaluable. Parents are particularly helpful with a detailed developmental history of early life. This often proves illuminating since patients usually have no recollection of early life problems. In addition, this helps to make the significant others therapeutic allies, rather than critics.

I then talk to the patient alone (and at times, talk alone with the significant others), which increases the yield of information about "secrets" and behaviors with legal and disruptive consequences.

I then identify the treatments that did not work. If ineffective treatments were previously prescribed at high enough dosages, for long enough durations, I can then confidently decide to avoid them. However this is often difficult to determine because of multiple concurrent drugs or co-morbid illnesses.

Often, this evaluation results in slowly weaning from the current regimen (usually a mix of medications piled up over the years). I monitor my recommendations frequently enough to accurately assess effectiveness and tolerability and ‘fine-tune' dosage and timing .

The standard goal is to get patients well. With difficult illnesses, that may not be achievable- but usually it is possible to significantly decrease symptoms and enhance functioning.

I believe that failing to see patients frequently enough or for long enough early in treatment is the most common failing in psychopharmacologic practice. Giving patients a fixed prescription and telling them to return in two months is inadequate monitoring.

If you want to detect problems and titrate dosage adequately, patients must usually be seen 1-2 times/week. Premature medication changes because of symptom fluctuations must be avoided. Most psychotropic drugs only produce clear effects after several weeks.

My experience has been that it is better to develop a long term strategy, explain it to the patient, and have the patient keep a fairly sparse daily diary about good and bad days, to be carefully reviewed each visit. (Unless emphasized as necessary, most patients will not do this.)

A consistent substantial improvement over a long period is the goal. Changing drugs too quickly, may lead to stopping highly effective treatments, if they were prescribed over a longer duration. Also, changing multiple drugs simultaneously often does more harm than good, and is more likely to obfuscate than clarify. This tactic is sometimes necessary, but generally it is important to avoid pressing more than one ‘button’ at a time. Patients often want to change several things simultaneously. While it is not difficult to explain the rationale for not doing so, it may be very hard for patients to accept.

They may say, "I'm taking four different drugs and you are only going to change one?" Conveying that changing several drugs at the same time will be that much more difficult to interpret if they feel worse or do not improve usually succeeds. Many clinicians do not agree and do not hesitate to simultaneously change multiple drugs, but my experience indicates that is usually poor practice.

The patients that I see are typically taking multiple medications and doing poorly when they walk through the door. It often turns out that they are doing poorly because of prolonged use of multiple ineffective or even toxic medications. Multiple drugs often have a point—but shouldn't simply be allowed to persist despite ineffectiveness.

A widely ignored issue that almost never comes up in drug safety discussions is the extent of the perfectly legal "off-label" use of drugs. The law prohibits the FDA from interfering with medical practice, although that is the clear intent of much of their language supposedly addressing drug toxicity. If a physician decides to use a drug for an illness (indication) that no drug manufacturer has submitted to the FDA as an indication, nothing prohibits this practice and it often makes clinical sense.

For instance, in 1961 I reported that imipramine blocked panic attacks in agoraphobia, following this report with a series of controlled trials, published in leading journals.

However, it took about 17 years until my work was independently shown to be true. Further, the FDA never approved a tricyclic antidepressant for panic disorders, even though it was the most widely used panic disorder treatment for many years.

A related problem is the existence of drugs, widely used in advanced countries as safe and effective, but have not received US FDA approval so that the FDA still considers them experimental. This does not usually mean that the drug was rejected by the FDA. Rather, often foreign industries have a good product that is nearing the end of patent protection. They may calculate that the expenses of US clinical trials (hundreds of millions of $) may outweigh their shortened patent protected period of marketing profitability.

In a nut shell they will lose money in an attempt to get into the US market-so they don’t try.

Therefore, at times the doctor must consider whether it would be wise to import, for the patient’s personal use, drugs available abroad. Unfortunately this is a chaotic area of law and practice mixed with public and insurance concerns about both safety and profits—requiring much experienced judgment. Since many malpractice companies declare that they will only defend the use of FDA acceptable drugs—any such treatment incurs financial risks for the doctor.

Nonetheless, given extensive explanation and the patient written consent, such use of attested medications may be uniquely helpful.

Please note that surgery, psychotherapy and “natural” food supplements have no legal requirement for demonstrating either safety or benefit.