A difficult point to get across to someone, especially a young person, is that they may have to take medicine forever. I know from my own personal experience with health issues that it is not MY first choice! My cholesterol is chronically high and for years I swore I would not take medicine and would adjust my diet and exercise and would not need to take medicine because . . . well . . . because I AM BETTER THAN THAT!!!! WOW. What a medically egotistical jerk I was! I’ll do unto others (prescribe) but wanted no parts of it for myself. Well, those days be done. I have now realized that life is just so much better when I take my cholesterol medicine. Sure I watch my diet . . . somewhat. Sure I exercise . . . somewhat. But, quite frankly, I love cheeseburgers and ribs and can have them guilt free if I take my cholesterol medicine.
We mental health people use these (stupid) medical analogies all the time . . . much to the irritation of our patients. The analogies are correct. It just sucks to be told that you might have to take any medicine all the time forever. You hand over such control of your life when you do that. Or so it seems. Nobody wants to be dependent on someone or something too much. You have been raised to take care of yourself . . . to be independent . . . that use of medicine (especially psychiatric medicine) is a crutch that needs to be avoided. Now some shrink is telling you that you need some medicine everyday for the rest of your life to have any chance of being happy? Not a happy message to give or to receive. There are times, however, when it is the appropriate message. When, exactly, is medicine forever the right message to give?
Every depressed patient has a first episode. Depending on life circumstance and genetics, some have their first episode when they’re five, some when they are fifteen, and some when they are fifty. Let’s assume that you get depressed and you get into treatment and get placed on medicine. You tolerate the medicine well and get better–like, all better–back to where you want to be. The conventional wisdom is that you stay on that medicine for six months to a year and then taper off and see what happens. If you get depressed again, back on medicine. Get you better, and keep you on the medicine for another six months to a year. You taper off the medicine and then . . . and then . . . you get depressed again. You go back on the medicine, you get all better, you stay on it for six months to a year. And then what? Do you go off? Do you stay on? Do you try to lower the dose and see if you can get by on a maintenance dose? The answers to these questions are very individual so that I would have to write out a hypothetical decision tree with multiple individualized contingencies. It is always a balancing act between factors that make me want to take the medicine away, and factors that make me want to keep it in place. Since everyone’s life is a mish-mosh of competing potentialities, it is impossible to be complete in a blarticle like this. My thought process goes something like this, however. If someone really, really wants to get off the medicine, I am more likely to try to get them off. If their life is calm, get them off. If their life is way hectic and stressful, keep them on. If every biologically related member of their family has required antidepressants to keep them OK, keep them on. If they are the only one in their family to ever get depressed, try them off. If it is the middle of the winter, keep them on. If it is spring or summer, try them off. If they have terrible side effects that they hate, try them off. If they don’t even notice that they are on medicine, try to get them off. Etc., etc., etc. I could go on and on. I think you get the idea. The ultimate decision to taper off involves factoring in all of these many life factors. No mater what, the risk is always there that the mood disorder will come back once the medicine has been stopped. The more relapses you have had, the more likely you are going to relapse again if you go off the medicine. You, as the patient, must be aware of that. It is irritatingly like treating high blood pressure, type II diabetes, angina, migraines, etc. Even if you do all the right things (such as diet, exercise, nutritional enhancements, stress reduction) you might have a relapse of symptoms if you go on the medicine.
It is just one of the many irritating features of being human.
What can you do?
If the medicine makes a difference when nothing else does, take it. And be glad it is around to make your life better.
Then, go have a cheeseburger. That ALWAYS seems to make life better.
–Dan Hartman, MD
A few years ago, it would make me sad knowing I might be on anti-depressants and/or mood stabilizers for the rest of my life. (I have been diagnosed with major depression, but several psychiatrists, including my current one, have suspected bipolar II disorder.) Because I had previously had several recurrent episodes of depression for years before I sought medical help, it seemed likely that I wouldn’t just “wake up” one day and be free from depression or bipolar disorder forever as I had always hoped. I think it’s a hard thing to be in your early 20s and realize you’ll be taking pills everyday for possibly the rest of your life.
Right now, though not thrilled with taking pills daily, what worries me more is not that I’ll be taking a pill for the rest of my life, but instead that I might have to try new medications every few years when my current medication stops working. It is the fear that my worst depression will come back despite being on drugs and trying to take care of myself. I can deal with being on the same medication for the rest of my life; it is having to experiment with different kinds that is the worst. I experienced this in the spring of 2007 after several years of taking a medication that had been effective, and my psychiatrist and I are still working on finding the right medication for me.