Why are your psych meds not working?
Often people get frustrated with their mental health treatment and decide to quit, saying “I have tried everything and it just doesn’t seem to work for me.” I have also heard people saying “I just don’t do well on those medications, they make me feel worse” and refuse other recommendations for treatment. I see it every day in my practice, patients refusing treatment because they have lost hope, they feel defeated, and have given up. There also other patients that get frustrated with the process “ I feel like a guinea pig, doctors keep experimenting with me.” Most of the time they don’t understand how the medications work, don’t comprehend their diagnosis, and are not aware of the course treatment with psychotropic medications. Many medications work right away, doses are standard, but that is not the case for psychotropic medications. But, I can’t blame them, for most people it has been years of trying and trying and failing and not experiencing relief in their symptoms. Years of depression, anxiety, hospitalizations, side effects etc, etc.
If you are reading this, you may be that patient, or you may know someone in this situation. Here I explain some of the factors that negative affect treatment and may lead to poor outcomes.
1. WRONG DIAGNOSIS
To treat patients we must be able to identify the problem and the diagnosis. We do this by performing a thorough assessment or diagnostic interview, usually done in the first visit, and takes 45 to 90 minutes. We go through current symptoms, duration, severity, how they affect ability to function. We also assess history, prior trials of medication, history of psychiatric hospitalization, suicidal ideation, family history, medical history, and psychosocial history. During this interview we are also assessing affect, appearance, demeanor, verbal communication, level of insight, intelligence or ability to learn and understand, among many other things. After this extensive interview we feel more comfortable providing a diagnosis that will determine the type of treatment needed. We then establish goals for treatment and determine how often we need to meet with the patient to assess for progress. Assessment is also ongoing, and the diagnosis may change if other symptoms present later.
However, if you are receiving your care from a primary care doctor/practitioner, they do not always have the time to complete such thorough interview with you. They are qualified to treat mild symptoms and might feel comfortable prescribing antidepressants. Not knowing your full history, past medication trials, family history etc, limits their assessment of you and your symptoms, therefore missing key elements that would differentiate a diagnosis of anxiety vs trauma, depression vs bipolar, panic attacks vs panic disorder. They may also diagnose you with an emotional issue related to a medical problem and recommend treatment for mental health, when probably the issue is more physiological.
And please don’t get me wrong, we have amazing primary care providers that go far and beyond for their patients, but being aware of these issues could give you another perspective and help you determine if this is someone getting on the way of your progress. Great doctors usually refer out when realizing that the issue goes beyond their scope of practice, or request help from other providers. Please ask your PCP to refer you to a behavioral health specialist if your symptoms are not improving, you may need further assessment and evaluation to determine the right diagnosis and treatment for you.
2. YOU MAY BE TAKING THE WRONG MEDICATIONS
If you are anxious and depressed because an underlying bipolar disorder, SSRIs might trigger manic symptoms or worsen your depression. If you are given medication for anxiety such as Benzodiazepines to address situational anxiety or panic attacks, but not put on a medication to treat the actual diagnosis, the anxiety could actually worsen, making it more difficult to treat with recommended treatment. Benzos are very effective for as needed situations, but usually panic attacks are related to a much bigger issue such as trauma, generalized anxiety disorder or PTSD. Overlooking the diagnosis and not using the recommended treatment can lead to long lasting symptoms, and increases the chances for developing addiction to the medication and/or other substances.
3. WRONG DOSE
Psychotropic medications have a dose range of efficacy, and not everyone will respond to the same dose. For example, Prozac (fluoxetine) has a dose range of 20-80mg daily for its therapeutic effects. Some people are hesitant on going up on the dose because of they fear side effects, when very often it doesn’t have anything to do with dosing, but with how your body tolerates the medication. People often think that they are “crazier” if they need a higher dose, so they refuse medication changes even though their symptoms continue active and not responding to treatment. The way you metabolize medications depend on your DNA, age and other factors that vary from person to person. Higher dose does not mean you are “crazier” than other people, you just need enough of it so it can work. Adjusting doses will also provide information that will determine if that is the right medication for you. After adjusting the dose couple of times your provider may recommend something else and consider that a successful trial of the medication that was not effective.
4. FAILED TRIAL-INCOMPLETE TRIAL
Taking your medication for short time, not enough dose, or inconsistently, is considered a failed or incomplete trial. Sometimes mild side effects and poor understanding about how the medications work may discourage people from taking their medications, failing a potential good option for them. Most psychotropic medications require weeks before you notice improvement in symptoms, and very often you will need to adjust the dose and allow more time for the medication to work. Psychotropic medications are also associated with transient side effects, which means short lasting or temporary side effects. Transient side effects tend to be mild and may include nausea, diarrhea, mild anxiety, loss of appetite. Your provider may offer medication to counteract the temporary side effects. Medications are often prescribed for daily use, morning time or night time. Sometimes they are recommended to take with food or after meals. Failing to take medication as prescribe can cause side effects, poor efficacy, and increases the chances of failing the medication trial, therefore giving the impression that the medication is not working.
5. LACK OF CONSISTENCY
Are you cancelling or not showing to your follow up visits? Being consistent with your care is up to you entirely, but if your provider is not available, often cancels visits you may want to find a different provider. Having that connection and communication with your doctor is essential for success when taking psychotropic medications. Follow up visits allow your provider to assess whether or not medications are working, suggest new treatment options, update your diagnosis if new symptoms come up, assess for other environmental factors that may be contributing to your symptoms. It is also there where you have the opportunity to talk about side effects, what you like or don’t like about the medications, issues with affordability, questions about how to improve tolerability or efficacy of the medication.
6. OTHER HEALTH RELATED ISSUES
It is so often that people think that medical issues are unrelated to mental issues forgetting that the body is one and the head is connected with the rest of the body. Issues such as diabetes, hypertension, vitamins deficiencies, anemias or blood disorders, COPD, asthma and more can cause and contribute to mental health issues. If you have been taking medications for mental health but they don’t seem to work despite of being consistent, taking the right dose, trying different medication and medication combinations, you may have an underlying health issue that needs to be addressed, evaluated and treated. People with COPD and Asthma often struggle with anxiety, people with heart disease or history of heart attacks struggle with depression, people with hypertension struggle with anger, and so on and on….
7. SUBSTANCE USE
Drugs in general can cause major cognitive issues as well as psychosocial struggles, but people often rely on them as a way of self-medication for their mental health. Acknowledging the issues simultaneously has proven to be more effective. Be hones with your practitioner and let them know about your substance use history even if they dont as you. Let them know if you have been drinking heavily, smoking marihuana, or struggling other drugs. Caffeine is often overlooked as normal, but often leads to anxiety, agitation, anger, insomnia when taken in high quantities. People with caffeine addiction may be struggling with underlying ADHD symptoms, or bipolar disorder. Drugs, whether illegal or legal like caffeine and nicotine can hinder efficacy of the medications, therefore making you feel again like “they dont work.”
Now that you know how many things can get on the way of your mental health treatment with medications, take the opportunity to think about your experience with providers, medications, and regain the hope that there may be more that can be done or tried for you to have success in your treatment and get to where you need to be. Feel free to write your questions, email us, we are always happy to help.
