Medications – Expectations of Treatment

There is no doubt that psychiatric medications have the potential to provide tremendous relief for many individuals.  Whatever the nature of the distress, a positive response to medications can not only help to survive, but more importantly, to thrive.

It is critical from the outset to ensure that one’s expectations about the medication are both clear and realistic.  The view that one’s response to treatment is analogous to, for example, taking Tylenol or Advil for a headache doesn’t directly apply.  The axiom of “Symptom -> Medication -> Immediate Resolution” is not appropriate in this context.  So then what can an individual expect from treatment with a psychiatric medication?

Choice of Medication

No matter which condition is present, there is a wide variety of medications that can be used.  The specific treatment will depend on many factors including but not limited to:

  • the exact nature of the condition
  • the symptoms present and their duration
  • other co-existing medical conditions
  • response to prior medications
  • medications currently being taken for other medical problems
  • the “fit” of a medication with an individual’s lifestyle

Short-term Relief

For some, symptoms are so severe that they are profoundly affecting the person’s ability to function, in addition to causing overwhelming distress.  It is then obviously critical to employ a medication (or medications) that can significantly ameliorate that suffering in the very short term.  This medication may not be the best choice in the long run, but it is exigent until there is a significant reduction in these overwhelming symptoms.  Depending on the condition, the short-term relief may be immediate; in other cases it may take somewhat longer.  However acute stabilization can nearly always be achieved within weeks with day-to-day improvement a realistic goal within the first one to two weeks.

Long-term Treatment

In nearly all cases, the appropriate medication for long-term treatment is initiated at the outset.  Certain medications for certain conditions can take up to one to two months to exert their full effect.  While it’s important to be comfortable during this period, it’s equally important to stay the course even if there is no discernible improvement within just a few weeks.  If a medication that has the potential to be the “perfect” one for you is stopped prematurely, we will never know that it was a missed opportunity.

Combinations

In psychiatry, adequate treatment not infrequently may require the use of more than one medication on an on-going basis.  It is always best to treat any condition with as few medications as possible however treatment with one medication (called mono-therapy) is not always sufficient.  Furthermore, at times, the use of multiple medications is necessary for reasons of safety.  Here are some examples:

  • An individual has significant mood instability (such as in bipolar disorder) and is currently in a depressed state  Treatment with an antidepressant alone can actually trigger a devastating manic episode.  In this case, this individual would require both an antidepressant as well as another medication to stabilize the mood and prevent the onset of mania.
  • A number of conditions are associated with insomnia.  It is been clearly established that disrupted sleep on its own can cause, worsen and/or perpetuate psychiatric conditions.  And although behavioral interventions for insomnia are superior to pharmacologic treatment, at times it is necessary to use medications to regulate sleep in addition to the medications being used to treat the initial problem.

Side Effects

Every medication has potential side effects.  Most side effects are usually seen at the beginning of treatment.  It is important though to keep in mind the following:

  • Many side effects are transient and disappear over time.
  • Although it is important and helpful for patients to do their own research, what you read needs to be put into context.  The list of side effects of any medication, including over-the-counter preparations, is mind-bogglingly long and at times frightening.  At the same time, the lists do not tell you how frequently the side effect appears, how often the side effect has another cause or if the side effect is transient.  Of course a patient should always contact his/her physician if a side effect is suspected.  However this doesn’t mean that a medication should necessarily be discontinued.
  • Ironically, some medications have welcome side effects.  For example, a mild antidepressant, mirtazapine (Remeron), is quite sedating and increases appetite for those with trouble sleeping and/or low appetite.

The Unexpected Consequences of Successful Treatment

It is extremely rare that psychiatric medications result in 100% alleviation of symptoms.  They almost are never a “cure.”  A more realistic goal is up to 70% improvement.

Individuals are very pleased to finally experience relief from their symptoms.  However it is just at this time that the challenge begins.  Human nature is such that we can acclimate and accommodate to even the most unpleasant things because we are so adaptable.  An example is an individual who has had depression over many years but did not identify it as such and was never treated.  Over the period of time, many such individuals develop a relatively more negative and pessimistic view on life.  This view colors their thoughts, goals, aspirations and choices.  Once the depression is significantly lifted, it is very common that these individuals report feeling somewhat lost and confused.  They must now readjust their entire view of life and of themselves.

Take another example – someone who has had panic attacks for a long period of time.  These attacks frequently come out of nowhere.  Over time this person becomes very vigilant, always on guard in order to not be caught by surprise by another attack.  This stance magnifies to the point that the person increasingly avoids situations that can cause anxiety resulting in isolation, avoidance and despair.  Once these panic attacks are suppressed in treatment, it can take the person literally years to un-learn these protective attitudes and behaviors and re-learn how to approach life’s challenges without the fear that the anxiety incumbent in growth will not deteriorate into a terrifying panic attack.

Thus, although it is critical for treatment to alleviate acute suffering and distress, that treatment goal is actually just a beginning of a much longer process by which medications help individuals become the person they always wanted to be.  As you can see, medication treatment is not merely taking medicine to alleviate a symptom.  Consider this analogy.

In the midst of terrible or distressing symptoms, you are in a dark room and cannot get out.  You cannot find an exit.  Shortly after treatment begins, suddenly a previously hidden door appears before you.  It is open just a notch.  Effortlessly you push the door open and find yourself standing in the sun.  You feel such relief to be out of that room and out of the darkness.  You smile and catch your breath.  Then you notice that there is path in front of you.  You intuitively know that this path is there just for you and that it leads you to the destiny you have always known is yours.  Now you must begin your journey on your path.  In order to continue on this path you must rid yourself of the memories of that dark room – not an easy task.  But the more determined you are in your choice to walk that path, the more distant become the memories of that room until you are singularly focused on your path and your destination.

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