Different Piano Keys, Produce Different Sounds

What Do Piano Keys have to do with Med Management?

A typical modern piano has 88 keys, 52 white keys and 36 black keys. Each key provides a different sound. When a pianist is playing a song, they understand that pressing the same key twice will result in the same sound being played two times. Because of this, a pianist will utilize different keys to produce different sounds, each of which work together to create a beautiful piece.

Interestingly, psychopharmacology is an art that can be likened to playing the piano. In the same way that individual piano keys produce separate sounds, individual medications work on various neurotransmitters. The difference is that unlike the piano where each key produces a slightly different sound, some medications work on the same neurotransmitters.

So while a pianist would have to literally press the same key twice to recreate the same sound, a psychiatric provider could utilize any number of medications and expect a similar effect.

When we prescribe medication, we rightfully expect the medication to produce a positive effect in the same way that a pianist expects the various keys they play to produce a beautiful melody.

In order to actually do this, we must deeply understand the various neurotransmitters that each medication interacts with. We won’t be getting too deeply into that today.

Instead, let’s consider a medication naive adult male who has recently been diagnosed with MDD.

We know from the literature that there are a variety of medications to choose from, each of which is indicated for MDD. However, SSRIs have largely become the first line option and would be considered best practice for this patient.

We would perhaps start this patient on Lexapro or Zoloft, after a few weeks we may increase the dose appropriately. It’s important to note that individual patients respond to different SSRIs well.. differently, but they all work to inhibit the reuptake of serotonin, so for the purposes of today, they should be viewed as different medications that press the same key.

Because of this, you wouldn’t expect this adult male to be treated with both lexapro AND Zoloft. It wouldn’t make any sense. If he tolerated the lexapro and experienced somewhat of an improvement, but needed a boost, you wouldn’t add another SSRI. Instead, you would maximize the dose and maybe look into adding an adjunct. Same could be said if he tolerated the Zoloft. Simply maximize dose and consider adding an adjunct.

What is an adjunct? An adjunct is a medication that works on a separate neurotransmitter to produce a separate effect. In this case wellbutrin or abilify could both be appropriate adjuncts, depending on what you are looking to accomplish.

The big lesson or takeaway from today’s post is to be intentional with your prescribing. It is especially applicable when adding 2nd or 3rd medications to a regimen, rather than replacing one SSRI with another or titrating from one SGA to another. Think of the medications as piano keys. When adding a medication, you should be looking to contribute in a new way & not just produce the same sound all over again.

For those of you that are practicing, consider the most successful med combos that you have seen. Odds are, the medications complimented one another in different ways and utilized separate mechanisms of action. If you don’t mind share some of your most commonly utilized medication combos in the comments.

DISCLAIMER

This is not Medical Advice and while the writer believes what he has shared, substack dot com does not equate to strong evidence. Please do not treat patients based on what is read in this post, these are opinions of an internet stranger. Instead use these posts as a starting point for furthering your own study & education.