too_many_medicationsJoe, I am 69 years old and live in San Francisco. I was on Prozac for over 20 years. In 2012, while on an African Safari, a trip of a lifetime, I noticed that I was disinterested and bored. Actually, I realized that I was depressed. I got a recommendation for a psychiatrist to get a new antidepressant. Here is a list of them that I’ve tried: Brintellix, Symbyax, Lamictal, Lexapro, Viibryd and Pristiq. Also in the past I tried Wellbutrin. I am too anxious to know if I am depressed or not. During the last 2 years I have also been prescribed Valium, gabapentin and Remeron for sleep. I was on trazodone for many years, as well as Abilify, Librium and Ambien. I felt strongly that my body was rebelling and I wanted off all these meds. My psychiatrist didn’t think it was a good idea. I put myself in a psychiatric hospital last year. I didn’t want to live anymore. I was so uncomfortable in my body. Nowadays I suffer from panic attacks. I can’t smile, laugh or cry and I have no affect. My life has become a steady stream of going of going from doctor to doctor. I have a psychologist too. I’ve lost 13 pounds. I have acute anxiety all the time. I have no energy or enthusiasm for anything. Joe, can you help me?

I receive messages like this one at least once a week — only the names of the senders and their circumstances are a bit different. The common thread among all of these scenarios is the pursuit to solve problems, relieve suffering and improve mental health through medication as a primary treatment modality — a process so often devoid of clear rationale, it amounts to no more than throwing drug after drug a patient’s way in hope that something works. So why and how does this happen? Here’s the anatomy of what can be described as a potential medication mess waiting to happen.

  1. Patients are affected by what I refer to as “white coat intimidation.” I know this because they tell me they are afraid to challenge their prescriber’s authority, thus they ask few if any questions regarding their medication regimen because they trust that their prescriber has their best interest in mind. I don’t at all quibble with the “best interest” issue, but after a trial of medication for 3-6 months with little or no improvement or even feeling worse, it’s time for the patient to speak up. Yet many don’t, clinging instead to the false hope that keeps them trapped in the belief system that relief is forthcoming with the next medication change or addition. Also, many prescribers make it pretty clear — either verbally or non-verbally — that they don’t want their judgment challenged or questioned.
  2. As patients shuffle themselves from provider to provider, they wind up with a veritable grab bag of diagnoses, which many prescribers then attempt to treat all at the same time. Such a strategy often fails to deliver positive results because each diagnosis is often micromanaged via a different medication, in spite of the fact that many of the criteria for these diagnoses overlap. With so much going on at once, there’s no time to evaluate what’s working for what diagnosis, and if response is lagging, discontinue some of the drugs periodically and reevaluate.
  3. Some prescribers cling to “evidence-based” practices for prescribing medication as if such strategies are a patient’s life preserver ring. But the paradox of some evidence-based pharmacological practices is that many patients aren’t getting better on medications, particularly antidepressants and anxiolytics. This is because switching from antidepressant to antidepressant or anxiolytic to anxiolytic serves as a catalyst for even more medication resistance going forward. Flood the brain with chemical upon chemical and it doesn’t know how to behave, so it fights back by bucking the intended effect of the drugs. This results in the user reacting to the drugs instead of responding to them.

So why would any prescriber continue down what becomes a blind alley of prescribing one drug after another for the patient described above, who is clearly not responding and is seemingly getting worse? Because psychotropic medication prescribing can mimic what happens to a moving freight train — once it gains momentum, it’s really hard to stop and difficult to turn around. Although this patient described herself as not wanting to live anymore, lacking energy and enthusiasm and wanting off some of the drugs, the treating psychiatrist didn’t think it a good idea. In other words, the risks of discontinuation outweigh the possible benefits of taking some of these agents away.

The example cited above ended with the question, “Joe, can you help me?” I conducted a consultation session by phone with this individual, and the good news is she has weaned herself off many of these drugs. I recommended she get connected with a competent, licensed psychotherapist in the San Francisco area because she is numb, confused and amotivational; and her current psychologist doesn’t seem to be serving her well. Also, of the bevy of intervention strategies and behavioral change recommendations I could have offered her, I zeroed in on these two:

  1. yogaSign up for a yoga class. Increasingly, yoga is finding its place as a very effective “treatment” for the unrelenting anxiety she is experiencing — more effective than any medication ever studied. This is because very anxious people have increased adrenal activity, which continues to flood through them — keeping them in a perpetual state of anxiety. So developing a relationship with the body, opening it up to breathe and to feel it is very important.
  2. Pursue mindfulness and self-compassion techniques. These techniques, as with yoga, are excellent for dealing with difficult emotions. In fact, a lack of self-compassion is one of the strongest predictors for anxiety and depression. Both strategies teach anxious, depressed people how to be aware in the present moment, and how sitting with and gradually accepting difficult feelings and emotions can result in significant healing that transforms suffering into love, joy and positive inner dialogue.