I thought it would be helpful to share some of my thoughts on what is involved in the prescription of medications for psychiatric disorders. Many individuals are fearful of psychiatric medications because of concerns about:

1. side effects
2. the belief that medication may permanently alter their personality
3. that they will develop physical dependence and need to stay on the medication forever
4. that some medical harm will come from taking medications for mood disorders
5. that taking a psychiatric medication will label them as “crazy”

On the other hand, it has been my experience that some patients want a “quick fix” and only want to take a pill that will immediately remove their symptoms.

Needless to say, both sets of beliefs require discussion and education. As I have indicated previously, one of the major role responsibilities of the psychiatrist is that of a teacher, providing clear and concise information about the rationale, risks and benefits of the medication(s) recommended for treatment of psychological disorders. It has been my impression over the years that the anxieties and false beliefs about  medication therapy for mood disorders are based on both lack of knowledge and the continuation of stigma present among the lay public. Only an adequate discussion about the nature of treatment will allow a patient to express concerns, fears and beliefs and eventually lead to an alleviation of such concerns. For a patient to know that their doctor respects their fears and worries and is willing to address them with pertinent facts and dialog goes a long way toward reducing stigma. Such a dialog is also essential in promoting compliance since many of the medications utilized in mood disorders require daily use.

So, what are some of the “ground rules” implicit in medication therapy of psychiatric disorders? Firstly, the choice of medication requires that a diagnosis is derived from the clinical information provided by the patient. For the most part, psychiatry has yet to be able to rely on formal laboratory or radiologic testing to delineate etiology. As I have said before, the more information that I can gather from my patient and support system the easier it is for me to formulate a diagnosis and treatment plan.

To complicate matters there is no simple cookbook-like formula to determine medication choice for mood disorders. It is the nature of the patient’s underlying symptoms that become central to an accurate diagnosis. For example, a depression with significant agitation may require a different antidepressant than a depression with marked fatigue and lethargy. The other important variables in the choice of medication include, but are not limited to, past history or psychiatric medication usage, complicating medical problems and drug interactions with the medications used in treatment of these problems, age, presence of cognitive difficulties and whether the individual would have difficulty remembering to take a medication more than once daily.

Once the biological nature of the disorder has been clarified and the family of medications has been clarified (antidepressant, antipsychotic, mood stabilizer, anti-anxiety) it is time to write the prescription.  I have already outlined some of the factors in medication choice in treating psychiatric disorders. The side effect profile of medication becomes pivotal. Weight gain, sedation, dry mouth/constipation, Parkinson-like side effects, excessive activation, potential for abuse and dependence, sexual side effects, cardiac rhythm disturbance are some of the medication effects to consider. In addition, drug interactions may occur as medications can interact in a negative way with each other and/or influence their metabolism in the liver. To make this discussion even more complicated is the finding that an individual can report lack of positive response to medication X years ago only to currently demonstrate an excellent response to the same medication! I have also found that how rapidly one starts and ramps up the dosage of medication can influence the presence or absence of medication-related problematic side effects. Even though it may delay the time to positive medication response, I have found that a “low and slow” approach to medication institution works best. It seems that giving the brain and body a chance to slowly adjust to the new medication is beneficial.

After all is said and done, the next two critical issues in evaluating psychiatric medication response are time and dosage. In my opinion, despite the Federal Drug Administration (FDA) medication dosage guidelines, there is no “one size fits all” formula when it comes to prescribing medication for mood disorders. Each patient in my opinion is a unique pharmacologic test case and will ultimately require their own specific dosage. Brain sensitivity and not bodily size becomes an important variable. I have had rather large individuals who respond to a very low dose of antidepressants while a very small patient may need a large dose of the same medication.

Hopefully this helps to clarify some of the questions implicit in prescribing for treatment of psychiatric disorders. To find out more about how our psychatric services can help you or someone you love, please contact Dr. David A. Gross in the Delray Beach, FL area at 561-865-6734 or email Dr. Gross today.