Getting started on medicine is a relatively easy decision. When folks come in to see me, things are not going well. Be it depression or anxiety or an out of control kid who is going to fail third grade, they want help . . . like NOW. I will be the first to admit that medication is not the be-all-and-end-all of what should be done to address any mental health issue, but when life is going down the tubes, it can provide a quick safety net and help people dramatically. Once the dust settles and life gets back to some reasonable order, however, people forget . . . aaaaahhhhhh human nature! How quickly we forget the bad stuff!!! It is important to remember, however, that part of STAYING well is continuing to take the medication as prescribed and going off the medicine too quickly or too early in the recovery process can increase your chances for difficulties and relapse. While most of my patients feel totally competent to make the decisions regarding their mental health medications without my input, I put here my STRONGEST urging that no medication change be done without discussing it with your doctor. After all, the doctor does have some training you do not and some patient experience that you do not and advice is always a good thing when making potential life changing decisions, no? If you feel unable to talk to your doctor, you need a new doctor. But that is the subject for a different blarticle . . .
ANTIDEPRESSANTS–for some reason, these are the medicines that most people like to tinker with. Part of it comes from the side effects that are typical for many people and part comes from the “stigma” of having to use a medication to boost your mood. People don’t like them, overall, unless they have gotten to the point where they KNOW in their heart of hearts that they are mandatory for survival. In the early phases of treatment for someone with a relatively new mood disorder, Goal # 2 (getting off the medicines) becomes Goal #1 about thirty seconds after someone feels better after starting the medicine. It is imperative, however, for people to understand that most people who get relief from their symptoms with the start of an antidepressant will suffer significant relapse with a too-soon discontinuation of the medicine. The conventional wisdom is for people to stay on a medicine for 6-months to a year after feeling better (not after starting . . . after feeling better). To go off too soon risks relapse. And relapse sucks.
BENZODIAZEPINES–These are the anti-anxiety tranquilizers. Wonderful medicines but you are playing with fire if you mess with these yourself. This is especially true if you are taking multiple daily doses of a short acting benzo like Xanax, but caution is also key if you are taking a moderate or higher dose of long acting agents like Klonopin. Coming off these medications can result in two distinct issues: (1) return of anxiety, and (2) withdrawal symptoms. First, the return of anxiety. Like most psychiatric medications, benzos are not curative but are palliative. They help to relieve the pattern of symptoms but do not change any underlying biochemistry that would lead to your not needing them. Life events may change . . . your ability to manage life stress may change . . . and maybe you won’t need a benzo forever . . . but the medicines themselves do not play a specific role in changing your underlying biochemistry. If you went on a benzo to help your anxiety, your anxiety may come back if you go off them. Plain and simple. And no one . . . not you . . . not me . . . not no one . . . is able to predict. Second, the potential for withdrawal symptoms. This is not an issue with low doses that are used for short term or infrequent use of short acting agents. Still, the process of getting of benzos should be discussed with the prescribing physician because of the potential for life-threatening withdrawal symptoms if it is not done correctly. When the body gets used to the presence of a benzo, it goes BONKERS when it stops being available. Your body can go on overdrive . . . a very uncomfortable and unpleasant overdrive . . . and you could have dangerous elevations in your heart rate and blood pressure which could lead to heart attack or stroke, or you could have a seizure. Because of these risks, you MUST talk to your doctor about reducing the dose BEFORE you reduce your dose. There are ways of doing it very safely. It might take a while and you might need to be patient. But there are ways of doing it very safely.
MOOD STABILIZERS–There are so many different mood stabilizers and so many potential issues for which they are helpful, it is imperative that you talk to your doctor about changes in these. Complicating the picture, of course, is that they can cause so many side effect difficulties that people generally do not like being on them. Because the conditions that they are used for can be quite serious, AND because they (like the benzos) are not curative, going off them at the wrong time and in the wrong way risks disaster. Generally speaking they are not physically difficult to get off of. The psychiatric complications of coming off mood stabilizers may cause significant issues for you and for your loved ones.
STIMULANTS–These medicines are used for the treatment of ADHD. They are the one of the few medicines that can be skipped without significant difficulty for most people (there are always exceptions, of course). Generally given in the morning, they provide for 8-12 hours of improved focus and concentration for kids and adults with focus and concentration issues. Since they wear off at the end of the day, each day is a new day. The medicine does not HAVE to be given every day. There are times where I specifically encourage the daily use of stimulants, however. If they make a big impact on family life (by helping to control negative behaviors) then they should be used daily and though the summer. If the child needs the medicine to catch up on school work or if they are going to an academically based summer program . . . they should continue on the medicines. For strict inattentive kids, they may do fine with weekends and summers off the medicine. BUT PLEASE TALK TO YOUR DOCTOR ABOUT THIS. And, again, if you doctor is not amenable to the discussion, get a new doctor.
So, in summary, please don’t decide to change your medicines without discussing it with your doctor. We are at the beginning of summer and you are looking forward to some rest, relaxation and fun. Adding a significant psychiatric decompensation onto the season is going to create a complication for you and for your family that should be avoided if at all possible. It is not unreasonable to change medicine in the season where you feel your best (which many people do in summer). Make sure that your doctor is kept in the loop and is allowed to guide your actions. It might make all the difference in the world for you.
–Dan Hartman, MD
