One of COVID's few silver linings has been a dramatic decrease in mental health stigma. But let's admit it, it's still hard to get patients to accept the idea of taking psychiatric medications. I've devised a powerful motivator to encourage patients to initiate meds, and I've dubbed it licking the spoon. But first, I have to qualify my remarks. I work in private practice where patients have insurance or are self-pay. I treat primarily mood, anxiety, and bipolar disorders. Still, my approach could work anywhere, with anyone. Even outside psychiatry.
Why? Because the first thing I do is solidly place medication control in the patient's hands. I insist they are the experts. "I am only the consultant here," I tell them. "You are the expert. And you're in the driver's seat. I can offer the benefit of psychiatry knowledge but ultimately, you decide what you're going to do." And then I do my best to walk the talk of respect and collaboration.
I learned to always aim for collaborative care, far before "patient-centered" became a buzzword, as an essential part of practicing as a certified nurse-midwife. If I could figure out how to convince a grown woman to push a baby out of her body while wide awake, often with no exogenous pain relief, initiating psych meds should have been easy. So why wasn't it?
To make it easier, I came up with licking the spoon. It sounds weird, even lurid as I write it, and I apologize for that. But it's the best name I've got.
I've had psychiatric patients whose therapeutic selective serotonin reuptake inhibitor (SSRI) doses have ranged from 2.5 mg of citalopram (Celexa), all the way up to 400 mg of sertraline (Zoloft) or 120 mg of fluoxetine (Prozac). But even with a patient with a severe diagnosis who I know will eventually need higher doses, they are often most reluctant. Before starting meds, when an antidepressant-naïve patient asks how soon they will be able to discontinue the medication, I know they are focused on -- or rather, against -- taking medication.
Luckily, virtually all SSRIs -- except for fluvoxamine (and who uses that as first-line therapy anymore anyway?) -- come in liquid form. Enter licking the spoon. I tell patients I am going to prescribe a liquid form of antidepressant, and at first all they have to do is open the bottle and touch, smell, or look at the solution.
From there, I suppose you could call my recommendation, "medication exposure and response prevention (MERP?)" therapy, if you wanted to get formal about it. But patients seem to prefer the name "licking the spoon." At the very least, it catches their attention and they listen 100% of the time. And they seem reassured that many patients have tried licking the spoon before them with good results, paving the way. Successfully, too.
You might predict what comes next in MERP. I ask patients to dip a spoon in the medication solution, and whenever they are ready, to barely lick the spoon. Just touch their tongue to it, on their own time, as their comfort level allows. They are the expert. When they realize nothing untoward happens (no horns grow, no immediate lack of libido or severe sexual side effects assert, no zombie-like lack of affect arises), I tell them to keep at it. Simply lick the spoon for a few days, or as long as they like. They gain confidence and are usually eager -- not just willing -- to increase their dose.
Patients set their own pace of upping their dose, up to a desired dose we've agreed to. I underscore that for fluoxetine, as an example, only 20 mg is contained in every 5 ml (an entire teaspoon). It's a long way from licking the spoon to an entire teaspoon. I reassure patients they probably aren't even getting one full milligram at the outset. They can take their time or increase their intake as quickly as comfortable for them before their next visit, staying within the maximum range prescribed. Soon, they're at a high enough dose that we can switch to the ease of tablets or capsules. They keep the liquid solution, and often use it for any future increase or decrease in dose over the course of treatment.
Licking the spoon offers new meaning to our old adage, "start low and go slow." I used to think everyone must do this with patients. But whenever I've mentioned it to other prescribers, speaking at conferences, or to students, everyone's eyes widen and they immediately start taking notes. It's an easy and low-risk trick -- and it works. And most importantly, it puts power to get well in the patients' hands, right where it belongs.
Diane N. Solomon, PhD, PMHNP-BC, runs a private psychiatry practice in Portland, Oregon, and is assistant professor at the Oregon Health & Sciences University School of Nursing. She is also a certified nurse-midwife, immediate past chair of Nurse Practitioners of Oregon, and on the executive committee of the Oregon Wellness Program, offering free mental healthcare to healthcare professionals in Oregon.