28. Evolving Your Medication Regime

In the previous few chapters, we’ve described how psychotropic medications work, how they can help, and why they are used. We’ve highlighted essential information about the major classes of medications and explained how to manage side effects.

You may have a pretty good idea which medications will meet your needs. You may have even talked with your doctor and started taking one. Every once in a while, the initial dose of the first medication you try will be all you need to thoroughly treat your symptoms without causing side effects. In mental health, that is most definitely the exception and not the rule, but it can happen.

Assuming you didn’t 100% succeed on your first try, you should work with your doctor to make changes. You’ll consider questions such as these:

• Should you increase the dose?

• If so, by how much?

• How long should you wait before increasing?

• Should you try something else?

• Is the new medication in addition to or replacing what you’re taking?

• How do you decrease a medication that isn’t working?

• If you have side effects, what then?

Why So Difficult?

Because everyone reacts differently to mental health medications, there are no universal answers to these questions. It will take trial and error to find the right combination of medication(s) and dose(s) for you.

We’ve emphasized the importance of giving a medication a proper trial. You don’t want to reject a medication that actually could help. Unfortunately, this happens far too often. A proper medication trial requires both you and your doctor to have realistic expectations about what effects you hope to see and when you hope to see them. What you see and when may be very different from others on the same medication.

Common missteps with medication trials include these:

• You don’t wait long enough to see an effect.

• You stop at the initial dose, even if it’s below the target dose (the dose that helps most people who benefit from the medication).

• You immediately stop when you first experience any uncomfortable side effect.

• You and your doctor make incorrect assumptions. For example, your doctor assumes you took your medication as and when prescribed. Instead, you took less and started later than planned.

• You try a standard dose that is too high (or increases too fast) for you to tolerate, but don’t try again lower and slower.

• You discount other health problems or life stressors and blame how you feel entirely on the medication.

It’s easy to end a promising trial prematurely, particularly if your doctor doesn’t prescribe a medication often or if they don’t know you well.

Document the Process

While you and your doctor work to find the right medication regime, document the process. Use your living treatment plan to keep track:

• Understand why you’re trying each medication, i.e., what problem will this medication hopefully solve? How does it fit into the big picture?

• Describe what each step of the trial looks like. What are the doses? How long do you need to wait?

• Measure the extent to which the medication helps or not.

As you begin trying anything new, add it to your living treatment plan. Every time you make a change, e.g., start a medication or increase the dose, make a note. If what you tried doesn’t work, whether the medication doesn’t help or you can’t tolerate it, record it as an unsuccessful treatment. Write down why it didn’t work.

Ideally, you should make one change at a time. But as we said, sometimes it makes sense to try several things at once. Starting several medications at once is not common, but it happens. Adjusting doses of several medications is more common.

Expectations and Evaluation

At each new step, find out what to expect. Ask your doctor what effect you could see and how long it might take. This determines how long to spend on a given step.

You’ll recall that antidepressants require several weeks before they take full effect. You need to increase them slowly, and you may not even expect any improvement at lower doses. These first steps help you adjust to and tolerate the medication. Evaluating the benefits will happen later.

When making any medication change, expect some side effects. Most side effects happen when first starting a medication or changing its dose. Many go away quickly, often in days, sometimes weeks. Most are not dangerous, though they may be uncomfortable or annoying.

When you evaluate a medication change, ask yourself if other factors played a part. Recent events, good or bad, can affect your mood and overall mental health. The last thing you want is to make medication changes based on a quick snapshot of how you feel at your doctor’s appointment. Consider how you’ve been feeling over several days or weeks and if any events or stressors influenced your mood. Plan what you want to tell your doctor ahead of the appointment. Ask family and friends for their input.

Adjustments

At each appointment, you’ll evaluate how well your medication is working and consult your treatment plan. Then you and your doctor will figure out the next step. The next step may include not making any change at all. Instead, you may decide to wait a bit longer on your current medication regime. In effect, you’re extending the timeframe of the current step.

You may decide to keep your medication as-is for the long term. Your next step then is to do nothing. No more tweaks, no more trials. Your current medication regime has treated your symptoms and helped you meet your goals. In other words, it worked!

Another reason to not make a change is that the medication partly helped, and you figure that’s good enough for now. It’s okay to adjust your goals. Perhaps you don’t want to make any more changes right now, but you’ll come back to it later. Sometimes you just need a break from always feeling like a patient. But long term, you should aim for full remission of your symptoms.

Then, of course, there are the changes you can make to your medications to see what effect they will have: changing the dose, adding another medication, or discontinuing the medication.

Change Dosage

Increasing or decreasing the dose of a medication is the most common type of change you’ll make. You and your doctor may decide to increase your dose if you’ve tolerated your current dose, notice some benefit, but think that a higher dose may give a better result.

Similarly, you may decrease your dose if the higher dose you tried didn’t work. Maybe you had no added benefit, in which case why take more medication when less will do? Maybe a side effect became worse, or you couldn’t tolerate the increase. Perhaps the higher dose worsened your initial mental health symptoms. For example, venlafaxine helps anxiety at low doses because it affects serotonin. As you increase the dose, it also boosts norepinephrine and dopamine, which may increase anxiety.

Sometimes psychotropic medications are increased too quickly. By making slower increases, your body has time to get used to the medication. If you are sensitive to medications, consider starting at half the typical starting dose and waiting twice as long between dose increases.

Sometimes the smallest size pill available is the usual starting dose. If so, ask your doctor or pharmacist if it can be split, which some medications can. Others, however, should never be divided. Splitting many extended-release pills will cause you to absorb a large amount of medication at once, instead of over time as intended. If they can be split, divide tablets with an X-acto knife or similar precision blade, or a dedicated pill splitter. Many capsules can be opened, and their contents divided.

You can also enlist the help of a compounding pharmacy to produce any dose of most medications. Because this takes time and manpower, these are unfortunately more expensive than standard commercial doses.

Medication changes might also involve keeping the total dosage the same but changing when you take it. If a medication is too sedating when taken in the morning, try taking it in the evening instead. Or, if a particular dose taken once a day causes a bad side effect, splitting the dose and taking it at two different times might help. Sometimes even changing to the same medication made by a different company may make a difference. Some people react to the colourings, fillers, and other non-medicinal ingredients. Compounding pharmacies can come in handy here, too.

Add Another Medication

You could add a new medication to what you’re already taking. It may boost or augment the effectiveness of your existing medication, as when adding low doses of antipsychotics to antidepressants. Alternatively, it may treat other symptoms or manage side effects of your current medications. Adding bupropion to an SSRI may increase energy or reduce sexual side effects.

Keep track of why you’re trying to add another medication. That’s where your living treatment plan shines. You don’t want to add a second medication to treat the side effects of one that isn’t providing any benefit.

Discontinue

Stopping a medication is another action you and your doctor might decide to take. You may find the medication isn’t helpful or the side effects are more annoying or intolerable than you expected. Maybe you’ve been on the medication for a long time and want to see if you can get by without it. Occasionally, medications simply stop working after a few years, usually referred to as pooping out.

If you stop your medications as soon as you no longer have any symptoms, your symptoms are likely to return. As we mentioned in the Antidepressants chapter, guidelines recommend how long you should continue a medication to minimize the chance of relapse.

Most medications need to be gradually reduced to prevent significant withdrawal symptoms. Again, everyone reacts differently.

If you plan to stop your current medication and try another, your doctor might ask you to slowly add the new one as you’re reducing the old one. You can cross-taper only some pairs of medications this way. It can both save time and minimize withdrawal as it keeps a roughly even amount of medication in your system.

Special Situations

There are several special situations such as overseas travel, surgery, and pregnancy, that may require changes to your psychotropic medication regime. A trip to your prescribing doctor is usually advisable. In this section, we’ll quickly note some of the most common situations that arise, and then introduce some strategies to deal with them.

Pregnancy

Whether to continue your psychotropic medications during pregnancy can be a difficult choice. Can they pose a risk to fetal growth and development? Can they cause pre-term delivery or birth defects? While we can’t begin to do justice to this issue here, consider the following:

• Up to 3% of healthy mothers, doing everything right and not taking any medications, can have a child with a congenital defect. Statistics on individual defects are also available.2

• Some psychotropic medications can increase these risks. Some are associated with one or more specific defects. Other medications have been well studied, and no risks to the fetus or related to the pregnancy itself have been found. Still others have not been studied much so there’s less known about their risks.

• Consider the total size of the risk, not just how much a medication increases it. A three times greater risk for a defect that otherwise is present in 1 of every 5,000 births (0.06% versus 0.02%) may or may not be important to you. Put that into context of other risks. For example, the effect of smoking on low birth weight is 9.1% versus 4.5% for non-smokers.3 The risk may be (only) two times greater but compare the actual size of the risk.

• There are ways to decrease some risks. For instance, some mood stabilizers increase the risk of neural tube defects. Folic acid supplements can decrease this risk.

• Untreated mental illnesses can themselves significantly raise the risk of negative birth outcomes including premature birth and low birth weight. Pregnancy complications and increased emotional and developmental problems in children are also increased. Untreated mental illness is associated with poorer nutrition, riskier behaviours, and decreased compliance with prenatal care recommendations.

There is no risk-free pregnancy. You can’t control everything. Your challenge is to find the right balance. The odds of most risks are still very small. With these considerations in mind, we recommend the following:

• Pregnancies should be planned. Some congenital defects appear in the initial weeks of pregnancy. Planning allows you to work with your doctor to change any medications ahead of time.

• If you become pregnant, do not suddenly stop taking medications. This can cause severe physical and psychological withdrawal and a relapse of your illness. This, in turn, raises risks to you and the fetus.4

• Seek advice from reputable organizations that provide information on pregnancy, e.g., OTIS.5 They can help you understand the risks associated with your illness as well as medications and natural substances you take. Review what you have learned with your doctor.

• Be aware of your risk of becoming unwell in the postpartum period. Depression and psychosis are common. Make plans so that any problems are caught early.

• If you plan to breastfeed, there is good information available through OTIS about which medications cross into breast milk, which do not, and how this affects infants.

Hormonal Changes

Your mental health is affected by hormonal changes. Significant changes occur during puberty, during pregnancy, in the postnatal period, and during perimenopause. Hormonal changes are part of the regular menstrual cycle. Some illnesses cause hormonal changes, and many medications are either hormones themselves or affect hormone levels. Some intrauterine devices (IUDs) release hormones that negatively affect mood in a small proportion of women.

Be mindful of your mental health during times when hormone changes occur. Watch your ongoing symptoms closely and look out for any new ones. If you notice changes, be proactive and address them with your treatment team. Make sure they know about your hormonal changes. Your medications may need adjustments.

Many women who experience significant physical and mental premenstrual symptoms benefit from the addition of an SSRI. The symptoms include mood swings, marked irritability or anger, hopelessness, self-criticism, feeling overwhelmed, tension or anxiety, decreased interest and concentration, fatigue, and changes in sleep patterns and appetite. Strategies to manage this differ. SSRIs can be used either daily or only during part of the menstrual cycle. They may be started during the luteal phase (typically 10-14 days before menstruation) or only in the latter portion of that phase, coinciding with the onset of symptoms. If not used continually, they are usually discontinued at or just after the start of menstruation. Medication choice and dosage varies. As always, be careful with SSRIs if you have a bipolar disorder.

Overseas Travel

Overseas air travel can be challenging when you take psychotropic medications. Here are some things to consider before you fly:

• To minimize mental health symptoms, make sure you have adequate sleep, especially when taking long overnight flights. Ask your doctor if a temporary sleep aid would help.

• Plan ahead so you know when you will take your medications, factoring in time zone changes. Depending on the length of your trip, you might adhere to either your home or destination time zone or plan a short transition at either end.

• Research your destination ahead of time. Some countries require letters from your doctor describing what medications you take for what condition. Some may prohibit or tightly restrict certain medications, including stimulants, opioids, or benzodiazepines.

• It may not be easy or possible to obtain replacement prescriptions abroad. Keep your medications close when travelling, not in checked luggage. If two people are travelling, consider splitting the medication between you. Bring a few extras days’ worth in case of travel delays.

• Always bring your medications in their original bottles. Your pharmacy can give you properly labelled small bottles sized for your trip.

Hospitalization or Surgery

If you will be having surgery, other medical procedures, or are being admitted to hospital, make sure your entire treatment team knows what medications you’re taking. Speak with the doctor who will be taking care of you in the hospital, the doctor at the pre-admission clinic, and the doctor who prescribed your medications. Find out if you will need to stop any medications or alter your schedule. This could result in significant withdrawal symptoms. Find out if the medications you are taking are available on the hospital formulary (i.e., are they stocked, or should you bring them yourself?). Planning is key.