As a practicing psychiatrist, I am often asked this question both by patients as well as family members. The answer is: it depends. It depends on several important factors that patients need to be aware of, especially when they agree to trying a medication for the first time. So, what are these factors?
- It depends on what the medication is used for and what the evidence-base suggests
Both the patient and the physician need to be clear on whya medication is being added. It could be to treat a psychiatric disorder such as ADHD, Depressive Disorder, Bipolar Disorder or an Anxiety Disorder. Many antidepressants such as Zoloft® aka Sertraline are also used to treat anxiety disorders. Newer antipsychotics are also excellent mood stabilizers because they target the same brain neurotransmitters in the brain (serotonin). In fact, at low doses, many antipsychotic/mood stabilizing medications have proven anti-anxiety properties (e.g. Gabapentin, or Seroquel® aka Quetiapine), even if the package insert doesn’t say so. This is called off label prescribing. In addition, not all antidepressants work in the same way. Some are more activating, such as Wellbutrin XL® aka Bupropion while some are more sedating such as Remeron® aka Mirtazapine). Depending on the accuracy of the evaluation completed by the medical professional, symptoms may prove to be even more important than the diagnosis. In turn, these symptoms can then be targeted. For example, if a patient tells me he/she is having a hard time falling asleep or staying asleep as part of their depression, I would not want to add an activating medication, especially at the end of the day. I would, instead, choose a sedating medication at the appropriate dose. When chosen properly, the right medication can either provide complete relief of symptoms or have a significant impact on what were previously unbearable or chronic symptoms.
Studies vary as to how effective whole classes of medication, like SSRI antidepressants, are. Oftentimes, various internet threads will trash a particular medication or class of medications. I would ask individuals turning to Dr. Google for advice to be wary of applying any such studies/websites to their own situation, and instead to discuss their individual concerns with their treating provider. It is also a good idea to ask what evidence-based studies there are that support the use of a medication for a particular symptom or a particular disorder. As a practicing psychiatrist, I can say I have regularly seen improvements in patients’ depressed moods, mood swings, anxiety, distractibility, sleep, energy and even zest for life, as a result of choosing the medication that targeted the relevant brain neurotransmitter(s)that was/were actually at the root of such a symptom. Hence, discussion with your physician as to the likely effectiveness as well as possible side effects can/should be expected, so that you know what symptoms are going to be treated, as well as realistic expectations as to what the medication is designed to actually do.
- It depends on the dosage
One of the most common questions I ask a patient who tells me a medication I mention didn’t work is: Do you remember what dose you were on? This is because underdosing of psychiatric medications is far more common than is realized. Frequently people stay stuck at what is known as a subtherapeutic dose. By the time I inherit such a patient, I typically increase the medication, sometimes doubling the dose, in order to see more rapid or effective recovery from their disabling symptoms. I also then educate the patient on how an effective and proper dosage is key to being able to ascertain whether or not a medication works. There is also established evidence that indicates the more rapidly psychiatric disorders are treated, the better the overall outcome, including quality of life and day to day functionality. Conversely, the longer a psychiatric disorder remains untreated/undertreated, the harder it can be to treat. Because psychiatrists are trained as physicians to know how brain receptors and medications work, they can therefore gauge how fast to increase the medication dose.
- It depends on the duration of treatment
Most psychiatric medications do not work on mood or anxiety symptoms immediately. While there are some medications that can rapidly relieve ADHD symptoms or anxiety, they also come with the risk of physical dependence including stimulants like Adderall® or benzodiazepines such as Xanax®, Valium® and Klonopin®. As long as realistic time frames are discussed from the outset, people can know when the medication will kick in. Essentially, the longer the duration of treatment, the more effective and lasting the recovery is likely. The brain’s biology is such that it tends to respond to consistent medications that act on those receptors. In fact, it is the brain’s adapting to chronic medication treatment, that is known to be the keybehind the effectiveness of antidepressants.
- It depends on whether the medication is actually taken
Yes, that may sound obvious, but you would be surprised how many patients either fail to fill the prescription, take less than recommended dose, skip doses, or stop their medication altogether, all without the prescribing physician being even aware of what happened. Medication nonadherence is the number one reason for worsening or persistence of symptoms and even hospitalization. I emphasize the importance of being absolutely consistent with taking medication, in order to better gauge how effective it actually is.
- It depends on your tolerance to medication
Patients naturally vary in their tolerance to medication or susceptibility to side effects. This can be related to genetics, age, sex, height and weight, as well as how physically active they are. Having a history of drinking or smoking regularly also plays into the kind of doses they may need because their liver may be faster at metabolizing doses that might seem high for others. That is why your doctor needs to be made aware of these factors when choosing a particular starting dose, in deciding how rapidly the dose is increased, and even the maximum dose for your particular situation/disorder. Genetic testing can also identify whether you are a fast or slow metabolizer of medication.
- It depends on whether side effects were experienced or were hard to tolerate
Side effects matter. In fact, they are the number one reason why people stop medications and say that they didn’t work. There is enormous variation among patients as to which side effects are likely to be experienced, and, if so, whether they are mild, moderate, severe, or just simply intolerable. There are differences in the genetics of the enzymes in the liver that metabolize medications and other factors that make some patients more susceptible to the effects of medication than others (akin to different people having different tolerance for alcohol). I educate my patient as to which side effects are common, whether they are likely to wear off, and whether antidote medication, reduction in dosage or a switch to another medication is recommended. In any case, the final decision would be the result of a mutually informed discussion where the patient provides me as much relevant information in order for me to give an appropriate recommendation. As you can see above, it really does depend on a number of factors as to whether a medication does or does not work. While there are a number of medications that may not work for psychiatric symptoms, it would also be important to consider the above factors before writing off a medication altogether. As the old adage promotes on television, please talk to your doctor, so you can be best informed as to which medication is right for you.