In Step 2 of your Take-Charge program, you considered your need for medication. Perhaps you decided that it’s a crucial piece of your healing plan, or you think that it might help. In this step, you’ll learn some guidelines to follow when taking medicine. They’re found in the answers to the following questions:
1. How do medicines work for anxiety, depression, and ADD?
2. How well do drugs work for these problems?
3. How much is enough?
4. What about side effects?
5. How do I pick the right one(s)?
6. How long should I take a medicine?
7. What is involved in starting and stopping?
8. Could I need medication even if I don’t have a diagnosis?
Let’s take a look at the answers to these questions. For each one, I’ve included important guidelines for you to follow if a prescription is part of your Take-Charge program.
HOW DO MEDICATIONS WORK
FOR ANXIETY, DEPRESSION, AND ADD?
The simple answer, and the most truthful one, is that we don’t know. We have some pretty good ideas about how different drugs affect brain chemistry and neurotransmitter levels, and we think that some of these actions on nerve cells and chemicals in the brain lead to the benefits or improvement in symptoms that we see. But the human body is extremely complex, and we aren’t very sophisticated in deciphering its many secrets.
That said, we do know some important things about how different pharmaceuticals work, and you need to learn some of that information to be your own best advocate! Here’s a fundamental fact: Different classes of medications work differently. Some have a direct effect on the brain, while others are indirect. This concept explains how quickly a drug can begin to work, and how you’ll need to use it.
A medication that has a direct effect binds or attaches itself to a receptor on a nerve cell and causes an immediate change by being there. Substances that work in this way cause a rapid (within minutes to hours) change in symptoms. To understand what I mean, think about alcohol for a moment. Like some other drugs, it has a direct effect on the nerve cells in the brain. So within 30 minutes of drinking some wine or beer, you might feel calmer, giddier, or more relaxed.
Another property of this type of drugs is that once they’re metabolized, and thus removed from their receptor spots on the nerves, their benefit disappears and symptoms return. Think about wine or beer again: When you have a couple of drinks, you may feel calm or giddy for a while. But within an hour or two (the length of time depends on your rate of metabolism), you’ll be back to your baseline or usual self. To feel different again, you’ll need to have another drink or two.
What about drugs that have an indirect effect? These substances work by causing a series of things to happen. They, too, bind to receptors on the nerve cell. But unlike direct-effect medications, their presence begins a cascade of changes that ultimately shifts the neurochemical balance. Think of a superlong row of dominos, falling in very slow motion as each piece hits the one next to it. Eventually they all fall down, and the landscape shifts.
Indirect-effect drugs cause all sorts of cellular changes before their ultimate result is seen. They often alter the levels of chemical messengers that are being produced and released into the space between the nerve cells in the brain. These shifts in chemical balance are probably responsible for the improvement in symptoms, but it can take weeks to see this result.
So how does this lesson about direct- and indirect-effect drugs relate to the treatment of depression, anxiety, and ADD? Well, many of the medications used to treat anxiety problems, and almost all of the medications used to treat ADD, are direct-effect drugs. That means they work quickly but don’t last long. To achieve a consistent benefit, you have to keep taking them.
By contrast, all the medications used to treat depression—some of which are also used to treat anxiety problems—are indirect drugs. That means they can take days or weeks to bring about a noticeable change, but the benefit isn’t short-lived.
This difference in the mechanism of action in various drugs is very important. It explains why the antidepressant you were prescribed last week may not have changed your symptoms yet, whereas the Ativan or Valium you were prescribed to take the edge off your anxiety is working like a dream. This is also the reason why the Ritalin or Adderall prescribed for your ADD, which you take with breakfast each day, works well to improve your focus, concentration, and memory throughout the morning but does nothing for you at the dinner table if you forget your afternoon dose.
So the take-home message in answer to the first question, How do medicines work? is that some of them act directly and quickly but don’t last that long. Others function indirectly by creating an ongoing shift in neurochemistry and take a while to improve symptoms. Their effect is more lasting.
Important guidelines: Once you’ve identified the diagnosis or reason that you need medication and have a prescription to address it, be sure you know the answers to these questions:
1. How quickly is the drug meant to work?
2. How often do I need to take it?
3. Do the time frame and mechanism of action fit with my need for relief?
If the answer to the third question is no, please request a different or additional prescription! You may need to take both a direct- and an indirect-effect drug together until the latter starts to work, or even indefinitely to cover a mix of symptoms. Your need depends on your story. Use your knowledge of yourself as you partner with your care provider to create your optimal and unique Take-Charge medication plan.
HOW WELL DO DRUGS WORK
FOR ANXIETY, DEPRESSION, AND ADD?
This is a crucial question. Medications can be lifesavers for lots of people, but they aren’t magic bullets. Even the best antidepressants, for example, don’t work for everyone. Studies comparing them to placebos in individuals with clinical depression show that the real thing works only modestly better than a fake. Not everyone responds to medication, and some individuals respond to sugar pills when they think they’re getting a drug!
Furthermore, even when patients respond, all of their symptoms may not go away completely. Often people get somewhat better. That said, 18 or 19 million Americans suffer from depression each year. If just 60 percent of them take medication and partially respond to it, that’s more than 10 million who have changed for the better. And depression is one of the greatest causes of morbidity and mortality in the world, so a lot of lives would be transformed or saved. In fact, a huge study of 65,000 individuals that was published in The American Journal of Psychiatry in January 2006 found that treatment with antidepressant drugs did reduce the risk of suicide in depressed teenagers and adults. Just remember that this treatment option can be a lifesaver, but it’s not a miracle cure. It’s simply a piece of the puzzle.
The same goes for anxiety disorders: Medication is a godsend for many folks and somewhat helpful for others. Most sufferers get some benefit from short-acting medicines, but these are bad choices if your condition is ongoing and long lasting. You’ll get rebound anxiety, or an increase in those feelings, when the drug wears off.
Many anxious people do well on what we call antidepressants. These are good choices for chronic, ongoing anxiety. In fact, there’s really no good reason for the drugs to be linked only to depression. Although most were first created to treat mood problems, studies have shown them to help a lot of other troubles, too. For example, they’re beneficial for obsessive-compulsive disorder (an anxiety condition), panic disorder, and social phobia.
What about medication for ADD? Well, again, popping a pill isn’t the whole answer. The vast majority (over 90 percent) of sufferers will get some benefit from stimulants such as Ritalin and Dexedrine; occasionally other types of medication are helpful, too. While drugs don’t eliminate all the symptoms, most patients can focus better and control their impulsivity more easily when they take something.
How does medication do in treating manic-depressive illness? Although bipolar disorder involves periods of depression, it’s different from what we call unipolar depression. Because it’s cyclical in nature, we often need to use several substances together and adjust them over time to treat this illness. While drugs don’t prevent depression or mania, they surely decrease the severity and frequency of symptoms. Remember, this illness has a high risk for suicide. Many people suffering from it need to take a mood stabilizer such as lithium in addition to their antidepressant. While medicine isn’t the whole story, it’s usually critical.
So the take-home message in the answer to the second question: How well do drugs work? is “Pretty well.” Medication can make a huge difference in the symptomatic relief of the mood and anxiety disorders and ADD. It can also decrease the frequency of episodes of mania and depression, although it isn’t a panacea. Using this treatment option may make a huge or moderate difference in your life.
Important guidelines: Once you’ve identified your target symptoms, evaluate each drug and dose you try with the rating scale entitled “My Progress Including Drug, Dose, and Side Effects” that you’ll find later in this chapter. If you don’t see adequate improvement on your rating scale with the proper dose of medication over the appropriate period of time, you may need to try something else or to add another treatment to your plan. Talk to your care provider about your observations and experiences as you use your rating scale to take charge of your emotional life.
HOW MUCH MEDICATION IS ENOUGH?
This may seem like a silly answer, but the right dose is however much you need to feel better. By and large, your level of response will be dose dependent. In other words, the more you take, the greater the benefit you’ll experience. But since all medicines have side effects and these are dose dependent, too, you don’t want to overshoot your need. If you take more than necessary and feel too ill from side effects, you may not be able to continue using that medication. So you want to “start low and go slow.” You’ll progressively move the amount up until you see enough improvement without too much fallout.
Although there are recommended starting levels for all medications, these are only useful to a point. Each person has a unique sensitivity to each drug’s benefits and set of side effects. Your profile is based on your genetics, biology, and metabolic processes, and there’s a great deal of difference from one person to the next. There’s no way to predict your response in advance, so finding your right dose will involve trial and error.
Years ago I was treating two tiny, depressed 95-pound women (who didn’t know each other) at the same time. Both were taking Prozac when it was only available in a 20-mg capsule. One woman needed four pills or 80 mg a day to treat her depression, and she had no side effects. The other patient had dramatic side effects on a 20-mg dose, but actually needed only 2 mg a day to treat her illness. How could she get such a tiny amount? She’d open the capsule and dump out the granules. Then she’d lick her finger, dip it into the grains, and lick her finger again. She tolerated that amount well and felt she was back to being herself after several weeks.
So how much medication is enough? It all depends on your story. Think of my two tiny ladies: They were the same size, had the same diagnosis, and were taking the same medicine. But one needed 40 times as much Prozac as the other did for healing. It’s all about your unique story and body chemistry.
Important guidelines: Once you’ve begun a medication trial, keep track of your dosage level as you evaluate your improvement in target symptoms. Use the expanded rating scale following the next question to evaluate your improvement and your level of side effects. As you work the Take-Charge program, share your rating scale with your treatment provider. This will help you and your doctor find your best drug and dose.
WHAT ABOUT SIDE EFFECTS?
Every single drug has side effects, but what does that really mean? Remember that each medication is designed to hit a target or decrease certain “target symptoms.” But we haven’t gotten sophisticated enough in our drug development to create agents that only affect the cells and symptoms we want to change. Therefore, whenever you take a pill—even an aspirin or Tylenol—it will travel throughout your body and touch billions of cells and many metabolic processes. It can cause many upsets as a result of its actions all over the body, and these unintended disturbances are what we call side effects.
If you look at any print advertisement for a drug or open the Physicians’ Desk Reference (PDR) and look up any medicine, you’ll see hundreds of possible side effects, risks, and cautions listed. In current times, this downside is inevitable, because we haven’t gotten sophisticated enough to avoid it.
All medications have a bunch of common side effects and a myriad of not-so-common ones. Before you start taking anything, ask your doctor to review the former. Be sure you’re comfortable with what you hear before starting the pill, and then keep track of your responses, both positive and negative. You may develop a common side effect, a rare one, or one that’s never even been reported. Most of these tend to decrease in severity over time, so if you can tolerate them early on, try to hang in there with your plan. The problems will probably become less prominent.
So the answer to the question: What about side effects? is that they’re unavoidable and sometimes problematic.
Important guidelines: Use the following rating scale to evaluate your symptom response and side-effect profile with various medication doses. Make as many copies of the chart as you need to document your ongoing experience. Use it to partner with your treatment provider in finding your best course of action as you take charge of your emotional life.
MY PROGRESS: INCLUDING DRUG, DOSE, AND SIDE- EFFECTS RATING SCALE
Use a scale from 1 to 10, where 1 = Almost Never and 10 = Always, for target symptoms. List the side effects you experience in each week, and rate them on a scale of 1 to 10, where 1 = Very Mild and 10 = Intolerable.
HOW DO I PICK THE RIGHT MEDICINE(S)?
Unfortunately, the answer to this question is similar to the others. Although we doctors have some idea of what to try, we aren’t very advanced in this area.
Of course, whatever medication we choose must be one that’s effective for your diagnosis. But there will probably be several drugs like that, so what guidelines do we use? Well, first and foremost is your past history. If you formerly responded well to something, there’s a good chance that you’ll respond to that agent again. By contrast, if you didn’t respond positively to a particular medicine before, it’s unlikely that you will now.
If your personal past doesn’t help, family history sometimes does. You may do well on a drug that’s helped a biological relative with similar problems, or do poorly on one that someone you’re related to couldn’t tolerate.
Many researchers and clinicians are trying to find ways to match symptoms to the best treatment option. Some of their techniques may ultimately be highly effective. But for now, the answer to the question: How do I pick the right medicine? is largely diagnosis, history, and hunch.
Important guidelines: Get as much historical data as you can to partner effectively with your doctor, and then vigorously evaluate your progress and problems with every intervention. You can take charge of finding your best fit here, and it’s crucial that you do so.
HOW LONG SHOULD I TAKE A MEDICINE?
The duration of a prescription depends on the type, length, and severity of the problem you’re being treated for. If you have a chronic or recurrent problem, it may make sense for you to remain on medication indefinitely. This is often the case for people with anxiety disorders, depression, bipolar disorder, and ADD. On the other hand, if you’re experiencing a first-time episode of crippling anxiety and depression, then a six-month to one-year course may be appropriate for you.
In another scenario, if you’ve been prescribed medicine for a brief increase in some ongoing symptoms that are usually tolerable, it might make sense for you to take the drug for an even shorter time. That said, antidepressant medications are rarely meant to be used for less than six months. Remember that they’re indirect-effect drugs. They take a while to work, and therefore they only make sense for challenges that are somewhat ongoing.
So the answer to the question: How long should I take a medicine? depends on the diagnosis, length, and severity of your problem.
Important guidelines: Be sure that your story and experience of trouble jibes with your treatment provider’s recommendations. Your history dictates the type and length of interventions in your TakeCharge program.
WHAT’S INVOLVED IN STARTING AND STOPPING A MEDICATION?
Well, we’ve covered beginning treatment (start low, go slow) but not the stopping part. This is when you need to know about withdrawal syndromes and reemergence of symptoms.
Medicines that you take episodically (or as needed) for anxiety or sleep can usually be stopped without tapering off. This applies to pills that you don’t take every few hours or every day. Similarly, stimulants for ADD can almost always be cut off at any point.
Most drugs that are regular and ongoing, however, shouldn’t be stopped abruptly. You might have a withdrawal syndrome or a return of your symptoms if you don’t go off slowly. If it’s time for you to try stopping a medication, work with your prescribing doctor to do so at an appropriate rate. You may discover that you need the drug more than you realized, or that you have to cut your dose much more slowly than you had anticipated.
So the answer to the question, What’s involved in starting and stopping a medicine? is that it depends on what drug you’re taking, and what problem you’re trying to treat. There’s no one-size-fits-all solution to this process, but there is a perfectly right answer for you.
Important guideline: Include your doctor, and make sure your plan to stop medication fits your story and experience with the drug.
COULD I NEED MEDICATION EVEN
IF I DON’T HAVE A DIAGNOSIS?
The answer is a qualified yes. Remember my story: I occasionally take a tiny dose of Valium when my system is too revved up to settle down and sleep. I don’t meet diagnostic criteria for an anxiety disorder or anything else, but I do benefit from a pinch of periodic intervention. That could be the case for you, too. However, the answer to this question is a qualified yes, because before treating your symptom, you need to rule out a medical or psychiatric condition as its cause. Don’t assume that you don’t have one. Even when no diagnosis fits, you’ll need to identify a specific set of target symptoms to guide your medication use. And of course, you must always evaluate your risk, benefit, and response.
Important guidelines: Make sure you know what symptoms you’re treating with the drug. Monitor your need and response just as you would in treating a formal disorder. Just keep in mind that even if you lack a diagnosis, medication might still be a crucial piece of your Take-Charge program.
Congratulations! You’ve just completed Steps 1, 2, and 3, an intensive course in evaluating your need for medication and learning guidelines for its use. Although you aren’t ready to be your own treatment provider, you’re highly qualified to partner with your doctor in taking charge of your emotional life.
You’ve learned how to use four principles to assess your medication requirement. You now know how to include diagnoses, target symptoms, and risk-benefit concerns in finding the right path. You even understand a lot about how medicines work, how much is enough, how to start and stop drugs, and when it makes sense to include pharmacological interventions even if you don’t have a diagnosis.
Before moving on to Step 4, please take a moment to respond to the statements on the next page either on the lines provided or on a separate piece of paper.
1. When I evaluated my need for medication with the four principles, I realized that:
2. When I review the eight questions and answers in Step 3, my take-home lessons and guidelines are:
You’ve just taken stock of where you are with diagnostic and pharmacological issues. Without further ado, let’s move into Step 4 and see what you can add to your Take-Charge plan!
