Am I on the right medication? How do I know if it is working?
These are among the most common questions I get asked by patients. Naturally it stems from people wanting to learn more about their medications, including how they work. I try to set up realistic expectations for medication and of me as their treating psychiatrist.
I try to educate my patients about what medications can do and what they do not do. For example, the SSRI antidepressants such as Prozac, Zoloft and Lexapro are commonly used to address anxious ruminations that are often characteristic of anxiety and depression. I emphasize that while such medications may take the edge off the severity or reduce the frequency of worrying, they cannot erase the habit of worrying that they been experiencing. That part is best addressed in therapy where thinking errors are explored and healthier patterns are established.
Psychiatrists prescribe medications in order to treat what is clinically referred to as the target symptom. This is what makes people seek help. These commonly include insomnia, depressed or anxious mood, depressive or anxious thinking, physical symptoms of anxiety, mood swings, irritability, difficulty in concentrating, and low energy or motivation. The choice of medication will be determined by which symptoms are most troublesome and for which the patient is seeking the most immediate relief. Medication treatment is both a science as well as an art because there are different combinations of medications that could be used.
In general, physicians are usually trained to avoid polypharmacy— the simultaneous prescription of several medications. This can increase or worsen the impact of existing medications. Medications can also interact with one another to produce unpleasant or even dangerous side effects. Patients may inadvertently do this if they add an over the counter medication to an existing prescription, so I specifically ask about this. I try to minimize polypharmacy as much as I can. If I can use one medication to treat sleep problems as well as anxiety, I will try hard do so rather than have two medications that target each symptom separately.
Do I a) Increase the dose? b) Add in another medication? or c) Switch to another medication?
This is where practicing principled prescribing is important. All too often polypharmacy has occurred because a person has seen several doctors and a new prescription sometimes gets added to an old one. This is one way that prescriptions can become inadvertently complicated.
The simplest, and safest, approach is usually to increase the dose of what medication the patient is already taking. This is important because oftentimes patients will tell me a particular medication didn’t work. When I ask what dose they were on or how long they were on it, I am frequently told that either the dose was much less than the maximum or that they did not try the maximum dose of medication for at least four to six weeks. This would be called an adequate trial of medication, and it is this technical term that formally tells you if the medication has truly worked or not.
If the medication is nearly maxed out at its ceiling dose, then there may be a value in adding another medication on top that specifically targets residual symptoms (such as tiredness, poor concentration or insomnia) and that in combination with the current medication will enhance its effectiveness. This strategy is called augmentation and is frequently used for inadequately treated symptoms.
Switching to another medication altogether is simpler when the medication is in the same family (class) of medications, Examples of these would be switching from Prozac to Zoloft or Paxil as these are all SSRI medications. This can be useful as often people respond better to one rather than the other medication in the same class. Based upon genetics, if a biological family member responded to that same medication, chances are that you will too.
Switching to another class may be necessary if an adequate trial of one to two members of the same class of medications is simply not working for anysymptoms. In such cases, the physician would not usually abruptly stop one medication and start another. The pharmacological principle used here is: Start low. Go slow so the brain receptors can get used to a reduced dose of the old medication and slowly introduce a new medication. Over time, the old medication is stopped and the new medication dose increased. This is called cross titrating and is common when switching antidepressants, antianxiety and even mood stabilizing medications.
The most common reason why a medication does not work or why symptoms return may surprise you: it is that people simply stop taking their medication! This can come as a surprise to the physician also, unless one specifically asks them if they are taking their medications, at the right dose, and how consistently. The reasons are common— ranging from side effects to feeling like they were doing fine and didn’t need them anymore. This is why I don’t make assumptions of whether my patients have taken their medications. I will usually ask to check in that the medication is tolerated, effective, and affordable. Most medications need to be taken at least six months to a year, after complete resolution of all symptoms, otherwise the risk of returning symptoms is much higher. This can be hard for many patients to accept until the science of brain receptors is fully explained to them, which I make a point to have informed consumers. It’s your brain and body after all!
The other common reason why medication may not work is substance use, namely alcohol and marijuana. These drugs can not only undermine the effectiveness of medications, but over the longer term worsen the very psychiatric symptoms that need to be treated. As a result, I ask my patients in such cases: What symptom(s) are you trying to medicate with drugs or alcohol? That way we can treat the symptom using the properly prescribed medication.
As they say in the television advertisements: “Talk to your doctor.” Make sure your specific questions are answered. That way you will know the answer to the often-asked questions: “Am I on the right medication and how do I know it is working?”