Helping Clients Overcome Resistance to Psychotropic Medication: Strategy # 1

Why are some clients so resistant to the use of psychotropic medication? After all, it is a treatment strategy that has garnered rather widespread acceptance as an option for treating a vast array of mental health maladies isn’t it? Over my next four blog entries, I’ll address four common reasons why clients refuse or even downright resist medication, together with strategies you can utilize to assist them to better comprehend why medication just might be a viable alternative for their condition.

1. The Shame Factor.

Shame is often experienced as the voice in our clients’ head that judges what they do as wrong, inferior or somehow worthless. Clearly these shaming inner voices can do considerable damage to clients’ self esteem. For some clients, this critical judge is continuously providing a negative evaluation of what they are doing, moment-by-moment. If medication is mentioned as a treatment option, negative self-evaluation can kick into overdrive resulting in faulty, illogical conclusions. Two common conclusions that clients reach are: (a) they have failed themselves because their own attempts to remedy their condition haven’t worked, and (b) they must therefore be “really sick.”

How you can help: Work first with the client on the negative self-talk. Emphasize that resolution of their presenting problem is a journey that may include several different directional paths, and that medication is merely one of them. Explain that medications are not necessarily essential and that they are not demeaning or even redemptive. Medications are merely an option to possibly help kick-start symptom improvement, and that they can be discontinued – preferably after consultation with their therapist and the prescriber – if the client so wishes.

Latest News about ADD/ADHD

- ADD/ADHD is not being over-diagnosed. In fact, 50 percent of children that would meet diagnostic criteria for the disorder are NEVER diagnosed and will struggle with distractibility and inattention throughout their entire lives. - The most important telltale sign that a child may benefit from medication is when the child no longer feels accepted by peers, at school, or even at home. Social and academic impairment are important markers to take into consideration. In fact the American Academy of Pediatrics requires the impairment to be observed in more than one domain (social, home, school, playground, etc.) before medication treatment for ADD/ADHD is warranted.

- From a medication perspective, the latest advances are the first-ever transdermal patch, and a new oral medication. The transdermal patch goes by the brand name Daytrana. The patch is applied directly to the skin with frequent site rotation. It has proven to be very effective, assuming of course, that the child wears it continuously throughout the day. The newest oral medication goes by the brand name Vyvanse. This drug is essentially the same as Adderall XR, and “supposedly” has less abuse potential than Adderall XR. Adderall XR will soon be losing FDA patent protection.

- Advice for parents and caretakers: Don’t be too quick to conclude that a child should be treated for this disorder. Some parents, teachers and even treating clinicians are intolerant of unruly behavior and therefore are often too quick to assign this “diagnosis.” Parents should be sure that academic or social functioning is impaired and should also consider a variety of information sources to assist in diagnostic confirmation. Optimally, a child should be assessed in multiple settings (home, school, social). Extensive interviews should be conducted with the child and at least one parent. These interviews should thoroughly review the child’s medical history and family history of ADD/ADHD, and rating scales should be employed – particularly in instances where diagnostic uncertainty is an issue. Most importantly, if ADD/ADHD is suspected, the child should be assessed by a clinician experienced in treating pediatric disorders of childhood.

SAMe (S-adenosylmethionine) for Mild Depression

SAMe is considered by many to be one of the best natural antidepressants in the treatment of mild depression. This made SAMe headline news when it first hit the U.S. market in 1999. SAMe (S-adenosylmethionine) is a substance found in the body that helps in the production of neurotransmitters and hormones aided by the amino acid methionine. Ordinarily, the brain manufactures all the SAMe it needs, but in depression, methionine synthesis is impaired.

SAMe has been the subject of more than 100 trials around the world. Some of these studies show that it likely mimics the action of the selective serotonin reuptake inhibitors (SSRIs), which are instrumental in the treatment of depression. In some recent studies, SAMe has performed as well as the SSRIs. It is also used in the treatment of fibromyalgia, a chronic disorder characterized by widespread muscle pain accompanied by depression and anxiety. Although there is no standard dose, SAMe appears to be effective particularly in mild depression at doses of 400 mg per day.

In 2004, researchers from Harvard Medical School found that SAMe was beneficial in treatment-resistant depression when combined with conventional antidepressants for those whose symptoms had not responded to the antidepressant alone. The results of this study showed a positive response to the therapy, with improved scores on the Hamilton Depression scale and Montgomery-Asberg Depression Rating scale, two instruments that measure the severity of depression.

A 1994 report of 13 clinical trials concluded that the efficacy of SAMe in treating depressive syndromes and disorders is superior to that of placebo and comparable to that of standard tricyclic antidepressants. These findings were confirmed in a 2002 report presented by the Agency for Healthcare Research and Quality.

Due to its high cost, SAMe has never really taken off as a treatment for depression in the United States. A one-month supply in its oral form can run as high as $60.00. SAMe is contraindicated in bipolar disorder as it may possibly induce manic or hypomanic episodes. The most frequently reported side effects of SAMe are nausea, stomach upset, insomnia and anxiety.

Frequently Asked Questions Regarding Risk Factors for Developing Depression

What are some of the biggest risk factors for developing depression?

The three biggest risk factors for developing depression are: (1) Genetic predisposition. Many individuals that meet criteria for major depressive disorder have a significant family history for depression. Treating clinicians should always thoroughly examine the depressed client’s “family tree” for depression. (2) Environmental events. Individuals that have recently experienced situational factors such as the death of a loved one or close friend, a recent divorce or job loss are at risk for developing depression. (3) Physical illness. Physical illnesses such as diabetes and hypothyroidism are major contributors to depressive symptom emergence.

Are women more likely to develop depression than men? Why or why not?

Women are twice as likely to develop depression compared to men. It is a myth that this is primarily a hormonal issue. Instead, women are at twice the risk due to discrimination, poverty, oppression and the stresses of single parenthood.

Are there certain ethnicities that are more likely to be depressed than others?

Approximately 30 percent of Hispanics report suffering depression compared to 26 percent for whites, 20 percent for blacks, and 16 percent for Asians. However, approximately 75 percent of whites with self-reported depression go on to receive an official diagnosis vs. 62 percent for Hispanics, 58 percent for blacks and 47 percent for Asians.

If so, do we understand at all why this is?

Although a higher percentage of Hispanics REPORT suffering depression for example, they are less likely to be DIAGNOSED. This tells us that reporting symptoms does NOT correlate with recognizing depression and subsequently seeking a diagnosis. Factors impinging upon this lack of follow-up include: Poverty, lower socioeconomic status, low education attainment (less than an 8th grade education), and decreased access to mental health services.

What other issues seem to play a role in making one person more likely to be depressed than someone else?

Many people that eventually meet depression criteria take prescription medications that contribute to or even worsen the depression. Examples are medications for high blood pressure such as the “beta blockers.” Brand names of these drugs are Inderal and Tenormin. Medications used for the treatment of Parkinsons disease and corticosteroids for inflammatory conditions are other examples. Also, substance abuse complicates every aspect of both diagnosing and treating depression.

If you have any of these risk factors, is there anything you can do to protect yourself or minimize the effects of depression?

Nothing can be done about genetic predisposition other than recognizing family history and monitoring oneself for possible symptom development. If symptoms develop due to predisposition or environmental events, seeking the services of an experienced psychotherapist can be most helpful. Other ways to minimize the effects of depression are exercise (brisk walking three times per week), proper diet (high Omega-3 fatty acid consumption), and regular exposure to bright light.