This week a reader wrote me, “Jack could you give some pointers on this – many of my patients don’t take their meds regularly. They skip doses, forget doses, stop meds when they feel better. I think I do a good job explaining how to take the meds. But the problems persist.”
I’m not sure what I’m writing today will be helpful or not. It’s mostly common sense. Perhaps there is something here that will help you hone your own statements to patients. So I’ll take a chance. And please let me know if I’m target or not, and if you’d like more of these types of posts.
Also, note that the statements I wrote out below are long and it would be rare that in real life I’d go into as much detail, and certainly not in a single session – it’s too much info for a patient to absorb at once.
Patient Question: “Doc, how long will I have to take this med?”
When a patient asks me this question, it occurs at the end of an initial evaluation. So I already know – or suspect – if the patient will need antidepressant maintenance treatment. For patients I suspect do NOT, I say the following:
At this point we can’t know how long you’ll have to take this med. To treat depression, you’ll have to be on an antidepressant at least for several months. Let me step back and explain why I can’t give you a more specific answer.
The treatment of depression with a medication is divided into parts. The first part we call active treatment. This part continues as long as it takes until your depressive symptoms are essentially gone. Often a medication can’t do this all on its own and we’ll need to discuss the option of “talk therapy.” When a person has been depressed for a while, it can be hard to get back into the swing of things even when a medication works. We’ll talk about this psychotherapy option a little later.
The issue with active medication treatment is that it takes different people differing amounts of time to respond to the antidepressant. Some patients respond to the first medication they take while other patients don’t. If a person doesn’t respond to the first med we have to add a second medication – if the first medication is helping but not enough – or we have to switch to another medication while stopping the first one – if the first one is not helping at all. For some patients, this process of finding the right medication or combination of medications that both helps and is well tolerated can take a long time.
There is a second part of treatment and it’s called continuation treatment. So, even when you recover from the depression, you’ll need to take the medication for at least half a year longer. That’s because the brain and the body need more time to reset into their non-depressed state even after the depressive symptoms lift. If you were to stop the antidepressant too soon, it increases the risk of the depression returning, often rather quickly.
Also, when it is time to stop the medication, we’ll work together to do it gradually; and we do that over a period of about 3 months. It’s not a good idea to stop an antidepressant abruptly. We’ll discuss that in detail when the time comes.
For patients who are candidates for maintenance treatment, I add:
There is also a third part of treatment with an antidepressant. Some people, such as yourself, who have had several previous episodes of depression, benefit from staying on their meds for the long term. To summarize, active and continuation treatment are designed to treat your current episode of depression. This third part, called maintenance treatment, is designed to decrease the risk of getting hit with a future episode of depression. Staying on the medications that got you out of the depression for the long term cuts the risk of a future depression to half. We can discuss details about this when you’re out of your current depression.
Question: “What happens if I stop my med or forget to take it?”
Thanks for thinking about this. First, it is important to take your medication as prescribed. If you forget a dose – and we’ll shortly talk about how best to remember to take every dose – then take it as soon as you remember you missed it. Skip the dose if it is almost time for your next dose. Do not take extra medication to make up the skipped dose.
Now, let’s put this into perspective. Skipping a dose will not kill you. We’re not talking about a life or death situation. Skipping a dose makes the level of the medication drop in your system, and that abrupt change can lead to some unpleasant effects, what we call discontinuation effects. For the antidepressant you’re taking, you may experience some stomach upset, dizziness, headache, changes in your sleep, including having vivid dreams for a while. Emotionally, you may notice feeling irritable, fatigued, drowsy or just out of sorts. These discontinuation symptoms occur soon after stopping a medication, perhaps as soon as the second missed dose and can increase over the first few days.
If you miss 1-4 days of medicine, you can restart your medicine right at the dose you left off. If you’ve been off your medicine for longer than that, it would be better to start back up at a lower dose, just as if we were restarting from the beginning. Of course, if you run into a situation of missing several days of your medicine, call me and we’ll figure it out together.
Now, let me shift to another possible problem when stopping medications. If you stop your medicine, not only will your body need to adjust to being off of it, like we just talked about, but also your depression can come back. It may come back in a week or two, or perhaps longer. The point is if you stop the medication before the active and continuation treatment parts are complete, you’re at increased risk of the depression returning.
Let me end by stressing this: I’m on your team. If you don’t want to be on a med, if it isn’t working or causing you side effects, let me know. We can discuss all kinds of alternatives. As I’ve said before, there is no guarantee that any one medication will work for you. Some can even make you feel worse! If you want to make a change, let’s make it together. You won’t hurt my feelings by telling me a certain medication doesn’t work like you hoped it would. It’s not like I invented it!
Patient Question: “Can I drink alcohol on this medication?”
What I’m about to write below is my opinion only. Different authorities have different views on this. I try to avoid being dogmatic about not drinking alcohol because I’ve had too many patients stop their meds because they want to have a drink at a graduation or to return to drinking because they have alcohol use disorder. So, use your judgment, taking the risk-benefits for each individual patient. Given that, this is what I commonly say:
Before I give you a straight answer let me explain. The antidepressant medication you’re taking works – or should work – because it causes changes to your neurotransmitters in your brain. And when you drink alcohol and you get buzzed or drunk, it’s because the alcohol changes how your brain works too. So, when you combine an antidepressant with alcohol, both cause effects on the brain and those changes can be unpredictable.
So, I request that during the time when we’re getting you on the full dose of the medication, and when your brain and body are getting used to the medication, you avoid alcohol. Once you’re on track, having a small amount of alcohol will probably be ok. But you have to test it out in a safe way. Like have a glass of wine with dinner at home when you don’t need to drive … or operate heavy machinery that evening – haha! What can happen is that the antidepressant may make the effects of the alcohol stronger. You may become less alert. You may feel more tired or drowsy. You may feel more irritable or sad. It’s better to play it safe, especially during these initial stages.
Other Concerns: Poor Adherence
In my experience the five main reasons for poor adherence are:
• Patient unclear on the benefits of taking the medication. This problem may only crop up during continuation or maintenance treatment when the patient no longer has depressive symptoms. It’s hard to take a medication, which may still exert some adverse effects, such as interfering with sexual function, when the benefit is the prevention of symptoms which are currently absent. Continued patient education and clinician support are crucial during these treatment phases.
• Patient doesn’t understand the frequent non-response or delayed response to adequate treatment. At the start of treatment I take pains to explain that only some patients respond to the first medication. For some, the path to response may be more complicated and take a long time. Then, in order to minimize discouragement, I point out that we have “dozens of options” and that “I have never run out of options” and that as long as the patient is motivated and in treatment “I will continue to keep trying new things until we find the right medication or combination.”
• Patient experiences adverse effects or fears possible adverse effects of the medication. We know that everything is available on the internet. If a patient reviews the adverse effect list of any medication, no matter how generally safe, that patient will find plenty of scary info. There is no way around this other than educating the patient on the context and probability of the adverse effects AND encouraging them to voice their concerns. They have concerns and will act on them irrespective whether or not they talk to you about them.
• Patient misses doses because they are forgetful or disorganized. One of the greatest inventions of all time is available to patients for a buck or three, or for free. And that is a pill box. If your patients don’t have funds to buy their own, maybe you or your clinic can buy them in bulk and hand them out to every new patient receiving a prescription. I went on Alibaba.com and found offers of 1000 one-week pill boxes available for $330 – or 33 cents a piece. Once your patient has a pill box, show them how to use it. Have the patient bring it in to the appointment and discuss how it’s working for them. Check also if it is filled with meds that should have been taken.
• Patient is influenced by friend or family member who is skeptical about or explicitly hostile towards psychotropic. Probe for this scenario specifically in any patient who shows poor adherence. Then graciously invite the influencer to accompany the patient to their appointment with you and allow both patient and influencer to voice their concerns. Approach the influencer, who may even show some hostility towards you personally, with respect for their motivation, which undoubtedly is to protect the patient. They may be misguided in terms of their approach but not in terms of what they hope for the patient – which is the best.
Until next time,
“Medicine is a science of uncertainty and an art of probability”– Sir William Osler
“I think that when we know that we actually do live in uncertainty, then we ought to admit it; it is of great value to realize that we do not know the answers to different questions.”– Richard Feynman
“I spent a lot of years trying to outrun or outsmart vulnerability by making things certain and definite, black and white, good and bad. My inability to lean into the discomfort of vulnerability limited the fullness of those important experiences that are wrought with uncertainty: love, belonging, trust, joy, and creativity…”– Brene Brown