When is it time to go off the meds?

Joelle writes in with a common question:

I am on 600 mg of Lamictal and was prescribed this medication a year ago. My doctor increased my dose from 50mg slowly taking me to 600mg over a period of 4 months. It took this much to feel less suicidal and even balanced in my mind. Recently I have felt concerned about this amount even though I feel completely normal and funtioning. How in the world do I begin to come down? I am not certain why I feel it necessary to begin taking significantly less, perhaps because there was a major power outage in my area and realized how the pharmacies were closed and I ran out. I hallucinated when trying to fall asleep and the paranoia I was suffering from frightened me. I know I should speak with my doctor and have him guide me. But he is of the strong impression I should remain on this dose. I am only trying to seek a second opinion. Thank you for your time.

Forget the power outage . . . when to go off the medicine is ALWAYS question number one for most people.  It can be very frightening to want to be on the medicine and not to be able to get it.  This can happen for reasons such as yours or just not having the money to pay for the medicine.  It often leads to a heightened desire to limit or eliminate the medicine.  There are several issues here, tho’, so lets separate them out . . .

First, lets think clinically.  Now that we are firmly entrenched in the 21st century, we can think of psychiatric illness as biologically based and not a personality flaw or an impairment in our upbringing.  Under certain circumstances, medication is clearly indicated to assist in the management of the illnesses.  From your description, the medication has made an important difference.  To be able to achieve a period of stability after feeling un-balanced and suicidal is nothing short of a life-saving miracle.  Now, I do not know much about your history, but use of this medication in such a high dose is unusual and would suggest that other medications have failed.  It would also indicate to me that this is part of a long standing illness and not just a single event in a younger person (sorry if my assumptions are wrong).  So from a clinical standpoint . . . is it time to come off the medicine.  I would guess not.  It sounds like you have had this discussion with your doc and he/she is also of the opinion that you should hold tight.  If you trust this doc, I suggest you listen to him/her.  You don’t hire a doc to tell you what you want to hear, you hire a doc to tell you what you need to hear.  If it is the doc’s clinical opinion that you should continue with this medicine, stick with it.  It is ALWAYS acceptable to have the “get off the meds” conversation with your doc.  Lowering the dose or getting off should be re-considered every three to six months for most people.  The decision to change the dose or the medicine should be clinically based whenever possible and not based on life circumstance (whenever possible).  Issues such as duration of illness, pattern of re-occurrence, response to the medicine, side effects of the medicine should take precedence when possible in the decision making process.

Now . . . lets think “real world” . . . 

I will be the first to admit that, far too often, us shrink-types don’t recognize or act in a way that is sensitive to a patient’s life circumstance.  Issues such as paying for the medicine, family pressures to get off the medicine, a person’s embarrassment about being on medicine, and, such as in your case, fear of catastrophic inability to get the medicine, can all lead to a feeling that you must get off medicine.  I don’t discount these factors as important, but consider them issues that must be dealt with.  Sometimes they DO lead to a decision to get off the medicine.  When these issues outweigh the clinical recommendation to stay on the medicine, however, the patient is at higher risk of relapse when the medicine is stopped.  Relapse of symptoms can have a devastating impact on work, relationships and self-esteem so the risk of relapse should . . . must . . . be carefully managed.  In my work with patients, I try to approach these issues in a thoughtful and methodical manner.  If it is a financial issue . . . I try to find patient assistance programs or use samples to offset overall cost.  If it is a family member that is pushing for a change . . . get the family member in to discuss the issue with me.  Usually it is just a matter of increasing their understanding of the issues at hand.  If it is an access issue (such as a repeat of a power failure), I would get a 7 day supply of the medicine as a buffer in case access is restricted (you can pay out of pocket or use samples to get the medicine).  Keep the week’s supply on the side but remember to rotate it with new medicine every few months when you get your usual prescription.  That way, your rescue stash is not expired when you need it sometime next year.

In any case, remember to use your doc as a sounding board and a consultant.  If you have a doc you trust, use them to work through these medication related issues.  If you don’t trust your doc . . . you need a new doc.  Non-clinically related medication issues can usually be resolved with a little extra communication or some ingenuity and problem-solving.

–Dan Hartman, MD

1 comment to When is it time to go off the meds?

  • “To be able to achieve a period of stability after feeling un-balanced and suicidal is nothing short of a life-saving miracle.”

    That sentence really struck me. Almost 2 years ago Wellbutrin saved my life. But after a year of therapy with a psychiatrist I really connected with, a peak experience involving my brain and quantum theory, and an experience with hallucinogenic mushrooms, I felt like I was mentally in a place that would allow me to go off Wellbutrin without crashing. Of course I consulted my doctor, but in the end it was up to me. It’s been a couple of months now without Wellbutrin and I am feeling much better than I anticipated. There are so many factors for each individual, it seems hard to give advice about whether or not to stick with a medication—like you said, is it an episode or a life-long pattern?

    And what are the effects of the expected outcome when someone goes off their meds? In my case, I have the option of going back on Wellbutrin, but it’s my mindset that has changed, my outlook on the world and my place in it. I truly believe that a lot of the depression in our society is rooted in the lack of connection to nature and our true nature as human being, interacting in a meaningful way with each other. I don’t think that someone can “think” their way out of depression, but I do believe that a combination of insights I had over the last year made it possible for me to be med-free.