In my work with patients who have anxiety and/or depression, I often recommend a consultation with a psychiatrist regarding medication. I believe in the value of psychotherapy; that’s why I became a (non-prescribing) psychologist. However, I find the careful use of psychiatric medications as a helpful aid to psychotherapy. For best results, you must communicate closely and assertively with your psychiatrist about your experience as you try new medications.
It is important to note that I am not a psychiatrist and do not prescribe medication, but I have worked closely alongside psychiatrists in many different settings. I continue to work with patients during the intervals between psychiatry visits. I am intimately familiar with the experiences they have when starting medication. I frequently coach my patients to communicate more with their psychiatrists.
Psychiatric Medicine: an Inexact Science
The selection of an appropriate psychiatric medication is a less exact science than is the choice of medications for other problems. If you have a particular bacterial infection, the specific antibiotic indicated for that infection should work for most people – for example, penicillin for strep throat. However, a medication that works well for one person’s depression may not work for another’s. Unfortunately, we don’t know why that is. Today, there is luckily a large arsenal of medication options from which to choose. Because some medications work for some and not others, often it takes trial and error to determine which medication works for a particular patient.
Furthermore, the classes of psychiatric medications that are most commonly used for anxiety and mood disorders do not take full effect immediately but rather build up to a therapeutic dose in one’s brain over time. There can be side effects that many people experience before the curative effects kick in. Often patients are started on a lower dose of medication to determine the lowest effective dose as well as to minimize the severity of potential side effects caused by the medication. Further complicating the process, some patients require a higher dosage than others to experience a therapeutic effect. For example, some may get a benefit from 20 mg of Prozac while others may need 60 mg.
When choosing specific medications, psychiatrists rely on information from drug manufacturers and research trials as well as their own clinical experience of how clients with diagnostic similarities responded to different medications. These doctors often try to match medication and its side effects with specific symptoms. For example, someone with depression who is very tired may be prescribed an antidepressant that is more energizing, while someone with depression who is more agitated may be prescribed an antidepressant that has the side effect of calming. The side effects often also determine at what time of day the medication should be taken. More activating agents are generally taken in the morning and more sedating medications at night.
Because of the trial-and-error process of matching patients to medications and the lag time it can take to build up to a therapeutic dose, it can take several months to find the right psychiatric medication for a patient. Unfortunately, I too often see clients stop taking medications before they reach a beneficial effect due to some annoying but mild side effects that would have gone away over time. I have seen patients giving up on medication altogether if the starting dosage of the first medication tried doesn’t help. It is disappointing when this happens because it might have worked.
If a client does not seem to respond to medication, psychiatrists will often first try increasing the dosage to see if a larger dosage produces a positive effect once it has built up, which can take another few weeks. Then if this seems to have no effect, they will usually recommend patients stop or taper the first medication and switch to a different medication, which will take several weeks to ramp up. And then, if necessary, raise that dosage… and so on. Sometimes patients require combinations of different medications, which multiplies the combinations that must be tested.
As you can see, this can be a slow and frustrating process. Due to the period of time it takes to test the effectiveness of each medication, this can be unavoidable.
What this Means for Patients
When moving to a new medication, it is critical to follow through with the medication plan and communicate closely with your psychiatrist about both the therapeutic effects and any side effects you experience. Your psychiatrist is not a mind-reader. I have seen many clients who notice no benefit from their medications, wait until the next appointment, which is sometimes months away, to report a lack of progress. In doing so, they can waste precious time.
Here are some suggestions for working with your psychiatrist and maximizing your chance of more quickly finding the medications(s) and dosages that work for you.
- Take the medication exactly as your psychiatrist recommends.
- Keep to the regular appointments requested by your psychiatrist. They typically time these to coincide with the opportune times to gauge whether your medication is working. However, do not hesitate to call them sooner.
- Take notes on your symptoms and any side effects so you can remember details.
- Report any severe side effects or suicidal thoughts to your psychiatrist right away (do not wait until the next appointment).
- Watch for signs of serotonin syndrome, a rare but potentially life-threatening side effect that can occur in response to psychiatric medications. If you experience these symptoms, call your doctor right away or go to the emergency room.
- Make note of mild side effects (headache, nausea, dry mouth) and try to wait it out. See if the side effects subside after a few days. If not, report to your psychiatrist.
- Understand how long your psychiatrist has told you it will take to notice the therapeutic effect of the medication. If it takes longer, report to them even if your appointment is still several weeks away. Psychiatrists can sometimes alter a prescription by phone before seeing you again, or they may suggest you come in sooner.
I hope that this information and tips have felt helpful to you. If you are considering medication, it may not be a cure-all, but it can be a beneficial recovery tool. The key is communication!
At Eating Disorder Therapy LA, we only provide psychotherapy (and not psychiatric medication management), but we can refer you to psychiatrists with whom we work.