The pills aren’t working

“I’m never trying this again, it was awful. I thought you said this thing was supposed to make me feel better?”

“I’m sorry that happened to you. As we discussed, some side effects like nausea and headache are quite common when you start–“

“Start?! I took this thing for four whole days, doctor. I need a different pill. Will my depression and anxiety every go away?”

Medication selection can be a painful time for patients. As with our diagnoses, often times there is trial and error in selecting the right medication that works for you. When it gets to the fourth, fifth, and sixth medications in some cases, it can be demoralizing, not only to the struggling person, but to their doctor. The fact is the science isn’t the most clear to the researchers in the laboratory, let alone a doctor in the office, and for that reason arriving at a suitable psychiatric treatment regimen can take some time.

Don’t despair – the medications work! Not only often, but usually. I see and help people recover every single day in my office, and it can be refreshing. However, that’s not always the case. Sometimes, struggling lasts a little longer than we would like it to. Sometimes, people lose faith in the system and look elsewhere for help. These cases can be tough; but there’s an upside! In my opinion, the majority of these treatment failures are actually preventable. So what am I talking about?

There are many reasons a particular medication regimen does not work. First and foremost, the most common reason I see, as described in the example above, is a misunderstanding of the expectations of an antidepressant or anti-anxiety medication.

Anti-depressants take time to work.

The textbooks would tell you that you need six weeks at a suitable dose to have a full effect. What does this mean? Here’s an example;

Week 1 – Sertraline (Zoloft) 25mg, oral, daily
Week 2 – Sertraline 50mg, oral, daily
Week 3 – Sertraline 75mg oral, daily
Week 4 – Sertraline 100mg, oral, daily
…
…
Week 9 – Sertraline 100mg, oral, daily
FULL EFFECT
Week 10 and onwards – Sertraline 100mg, oral, daily

The dose this person required was 100mg, and not until 100mg was achieved for six weeks do we see full effect.

What if 100mg isn’t enough? Well, a further increase may be required. The maximum recommended dose of sertraline is 200mg. You and your doctor may ultimately try a 100mg dose for a few weeks, decide it is sub therapeutic, and titrate further. Yes, this means we can be talking week 15, 16 in some case. But remember – this is for full effect. In reality, a skilled clinician and a patient can often tell after the first four weeks of a treatment whether there may be a significant benefit from a particular medication. That’s what the doctor’s are for!

Side effects are expected and will happen.

And they aren’t permanent. Like anything, your body takes time to adjust to anti-depressants and anti-anxiety medications. In fact, the presence of side effects shows that the medications are getting to the brain and having some kind of effect! It’s important to appreciate that this is a normal part of the journey, not only with starting, but with significant dose increases.

Side effects suck and the last thing your doctor wants to do is make you feel worse – like all things in mental health, trust me, it’s an investment! Side effects like nausea and headache and anxiety tend to go away after the first half week-full week of therapy (yes, anti-depressants and anti-anxiety medications can cause transient anxiety – it’s your brain adjusting to the changes). Doctor’s are also all about safety, and don’t worry, the side effects are reversible with dose decrease.

What is considered a true treatment failure?

Part of my job when you come see me for a mental health problem is to take a detailed medication history; people have often tried multiple medications over time, and if something hasn’t worked in the past, it’s unlikely to help in the future. But what constitutes “doesn’t work?”

Not the above example. For a course of an SSRI to be considered a treatment failure, you need to have completed at least six weeks on an appropriate dose of that medication. A rough estimate of an “appropriate dose” is half the maximum dose.

***

The moral of the story? The medications work, they take time, and they can be a nuisance. Careful time, understanding, and collaboration with your physician is the best way to work through a mental health disturbance. With patience, I promise we’ll help you.

Dr. Travis Barron is a resident physician in Toronto, Canada.