There comes a time in my work with some of my patients that I have to stand back and say . . . “what are you doing???” When patients come in with a cascade of difficult problems, the knee jerk reaction is to change the medicine. Initially, this might be adding an antidepressant (say . . . Zoloft). Then, there seems to be a lot of anxiety. So I add in a benzo (say . . . Klonopin). Then, the depression continues to muddle along and we think about adding a complementary antidepressant (say . . . Wellbutrin). Then, there are some sleep problems, so a sleeping aid (say . . . trazedone) gets added. Then there is some breakthrough anxiety and we need a ‘once in a while’ antianxiety agent, so we add a short acting benzo to address these times (say . . . Xanax). Next thing you know, I take a look at the list of medicines, and . . . YIKES!!! . . . this nice person who came to me for depression is on five different medicines . . . and not necessarily doing too well. Or, there might be dramatic improvements, only to be followed by a gradual return of symptoms over the course of weeks or months.
I’m glad to say that this is more the exception than the rule. Most of my patients do not end up with this type of extensive medication cocktail, but it is far too easy for this to happen (easier than I’d like to admit) and I’m sure many of you can relate. It seems that a doctor’s natural reaction to a patient coming in with a difficulty is to prescribe more medicine. Let it be known that, it is also the natural reaction of the patient to EXPECT that the doctor prescribe more medicine. When someone comes in feeling depressed or anxious, my attempts to get them to make changes to their life-style (diet, exercise, meditation etc) or, to just experience the mood and talk about it in therapy, is rarely greeted with enthusiasm. While there are certainly a great many situations where the pattern of symptoms are spiraling out of control, there can also be cyclical patterns to some people’s experience of mood and anxiety symptoms. Things are ok for a while and gradually become worse, then gradually become better, then gradually become worse, etc, etc. If you come to the doctor at a time when things are not good, and the doctor prescribes a medicine and things get better, the doc looks like a wizard! Truth is, often times, if we just sit on our hands and do nothing, things might get better too. When you see your doctor, keep your mind open to the option of doing nothing with the medicine and seeking life-style and therapy options that may be more beneficial in the long run.
But anyway, I digress. The original point of this blarticle was to discuss the need at times of getting off the medicine and seeing what happens. How many of you have experienced feeling lousy off the medicine and, honestly, not feeling that much better on it. There does come a time where, when multiple medications have been tried, it seems best to admit you just aren’t sure what is going on, and it is time to try a little bit of nothing. Now, when multiple medications are being used, the titration down for each of them must be carefully planned and the patient MUST adhere to the plan very closely. Slowly tapering the medicines minimizes the risk for rebound symptoms or discontinuation symptoms. In addition to the gradual decrease in the doses, there must be support people in place to keep an eye on the patient so that, if the crap hits the fan, there is someone there to help. Decreases in the medicine should (of course) be accompanied by all of the usual stuff that helps people’s mood be better (detailed in other blarticles). Back in the day, we used to be able to do this in the hospital. It was almost a standard practice to get someone off medicine, and observe them for a few weeks, and, once reassessed, re-apply medications as needed. Unfortunately, this was overused, and, now, is simply not available (unless you have deep pockets and can pay cash–no one I know!). It is still a method that can be used in the out-patient world, but everyone must communicate well and everyone must be careful. There is always the distinct possibility that things could get worse–much worse–off the medicine.
Anyone want to share their story about being on too much medicine and then coming off?????
–Dan Hartman, MD
I remember at one point being on three medicines at once. Turns out they made it worse.
I find being on so many medications made everything worse- not all- but most. The side effects where at times unbearable. But when I was on so many…it made me so doped up to the point of almost being high. When my doctor took me off of them I felt much more normal and more relaxed. But while being on so many, it almost gave me a sense of unreal, and I grew use to that. Now off the meds I feel like drugs are the way to bring back the “unreal subdued” feeling which I was feeling 24/7…now that everything else is under control– but me…
I went through that. As a teenager, I had some issues with depression. Between the ages of fifteen and 21, I was on 37 different psychiatric medications – with a record high of six at once. As it turns out, I am one of those people who has a paradoxical reaction to the reuptake inhibitors as a class. But 15 years ago, people hadn’t recognized that as a problem – so the response to worsening depression and suicidal thoughts was hospitalization and more drugs. When I was 21, I stopped the meds cold turkey – not intending for that to be permanent, only for a couple of weeks so I could drink at a party. My life changed that night – three days later, I woke up and realized my world had color in it for the first time in six years. It was stunning. 9 years later, I am starting to have some recurrences of depression – but I will never take an SSRI again. The drug-train isn’t worth it, for me.
This is for K and silenced–Thanks for your comments. I have written about this in a main blarticle.
–DH MD