Muddled Medication Management Often Equals Suboptimal Outcomes

A woman called me recently regarding her 25-year-old son. Her reason for calling went like this: Michael (the son), had been prescribed the following: Celexa, Lexapro, Effexor, Pristiq, Cymbalta, Lamictal, and the newest kid on the block of antidepressant dwellers — Brintellix. These drugs were prescribed by a family medicine physician and a couple of psychiatrists over a time frame of a few years. With no equivocation, she stated that Michael showed sparks of improvement vis-à-vis these medications — which eventually slowed and has now ceased. Her question for me was simple and straightforward enough: “Joe, what would you suggest as a next step, really, how should I proceed?” I recommended she contact the psychiatrist who has most recently treated her son and start a dialogue with this: “Would you please explain the rationale for switching from drug to drug in treating Michael’s depression? I see no evidence that it is working to his advantage so I’d like to bring him in to discuss other ways we might proceed to help him.”

medicationsSwitching from antidepressant to antidepressant, along with concocting one drug cocktail after another for treating depression, serves as a catalyst for more medication resistance going forward; and increasingly, I’m being referred patients who have experienced such strategies. Proceeding with medication management in this manner is like trying to push a rock uphill. Resistance is much less as the roll uphill begins, but as the trajectory and incline get steeper and steeper, the pushback accelerates and becomes overwhelming. Flood the brain with chemical after chemical as well as combination after combination, and it doesn’t know what to make of it or how to act, so it fights back by bucking the intended effect of the drugs. This results in the user reacting to the drugs instead of responding to them.

I’ve repeatedly stated in blog posts that antidepressants have helped millions of people jumpstart the process of digging out from under the weight of depression. Their usefulness in this regard is irrefutable.

My concern here is the reality of diminishing returns associated with antidepressant prescribing that provides false hope, keeping users trapped in a belief system that relief is forthcoming with the next medication change or addition. It often isn’t, as is the case with Michael described above and with hundreds of others referred to me in a similar situation.

Clearly there are instances (severe, intractable depression where danger to self is a bona fide concern, bipolarity and psychotic spectrum disorders) where medication and even polypharmacy takes center stage. But even in these instances, the complexity of many of these drug regimens points to psychiatry’s proficiency at adding medications and deficiency at taking them away. The field really needs to get better at evaluating how a patient is responding to a trial or course of medication management, and if response is lagging, discontinue some of them or even all of them periodically and reevaluate. And do a better job of determining whether any given patient is taking the medication at all, I might add.

man_thinkingMedication doesn’t teach people how to feel better or do better, this is something they have to learn for themselves. As is the case with managing diabetes, hypertension or any other syndrome, physical or mental, medication alone is not and never will be enough. Affected people must be willing to go deeper into the core of what’s troubling them. Then they have to make a commitment to clawing themselves out. When the meter on drug efficacy runs out, personal accountability has to take center stage, and taking oneself to task never goes out of style.

Prescribers though should be active participants in the patient’s care and guide the course and direction of that care — medication and otherwise — particularly when a “Michael-like” situation arises.

If not, they’d just as soon tell the patient “I have nothing else for you.”


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Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.

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