This month's issue of Psychiatric Annals, guest edited by David Osser, MD, deals with treatment algorithms. When algorithms are adapted to varying clinical situations seen in practice, as is done in the ones presented here, we have a useful clinical tool for incorporating developing, upto-date, evidence-based treatment. These algorithms also make it clear where more data and better treatments are needed. I especially salute these algorithms that adapt to differing clinical contexts within diagnostic classes, rather than the more mechanical, cookiecutter approach of earlier attempts. When it comes to treatment, the clinical situation, partially defined in terms of pathologic behavioral dimensions, becomes the target as much as the diagnostic category being addressed. The contextual aspect of these algorithms makes for more applicability and adaptability to real-world practice, and encourages the clinician to make important clinical observations and distinctions - just like a good consultation should. The algorithms presented tend to broaden one's clinical thinking and acumen, not oversimplify the process. This is the direction of development that makes algorithms increasingly useful and powerful.
This algorithm issue provides an opening to address one of my growing concerns. As I have the opportunity to meet with and talk to residents at home and in other training centers, I become concerned that we may be forgetting some of the valuable experience we have accumulated with "older" agents. For example, many trainees I talk with have little or no experience with tricyclics and monoamine oxidase inhibitors - as if the introduction of the safer and more user-friendly selective serotonin reuptake inhibitors (SSRIs) has solved all of our patients' problems. I constantly "preach" to residents about the importance of getting experience with these more difficult to use, but often more effective medications. Algorithms will incorporate these treatments (sometimes even in combinations) as alternatives when the simple solutions do not do the job for the patient. As we are challenged to see increasing proportions of patients with treatmentresistant and refractory illness, we need to keep in mind all the knowledge we have and make it available to our patients. Primary care physicians, and God only knows who else, will be prescribing SSRIs to most of the uncomplicated patients who have good responses to a first or second treatment course. It increasingly becomes the psychiatrist's job to deal with the many patients who have more difficult clinical situations - who need both clinical skills and often sophisticated psychopharmacologic treatment to recover, and sometimes to survive.
Although algorithms may prove to be a readily accessible source of very useful clinical consultations, they cannot always completely address important issues of how suggested medications or therapies are most effectively and safely used. It is up to the teachers among us to be sure that we all know how to safely and effectively apply this knowledge in the relevant clinical context.