Overmedicated or undermedicated?
Thanks for all your warm comments and interesting questions over the last two months I can’t answer them all, and I can’t safely comment on individual treatment plans, but I will continue to answer your questions in this column and use them as a way to start further discussions. As a follow-up to my last column discussing psychotic symptoms, I’ll discuss some related reader questions.
Several readers have asked me to comment further on the issues of overmedication raised in that column. Patients and their doctors may at times be pushing in different directions when it comes to medication management, with physicians trying to achieve maximal symptom resolution, and patients trying to achieve minimal side effects. For example, a psychiatrist may feel strongly that a patient should continue taking a maximal dose of a medication in order to avoid a recurrence of mania. At the same time, the patient may be suffering severe sedation that interferes with work, driving, and their interpersonal relationships, and would like to try a lower dose to improve the quality of their life.
Some readers have likely sensed this patient/physician friction when discussing dose changes. Psychiatrists are primarily motivated to use their knowledge and experience to maximize patients’ outcomes. Unfortunately, fear of lawsuits may encourage some psychiatrists to err on the side of overmedication. Maximizing benefit and minimizing side effects often requires intensive cooperation between patients and physicians and long amounts of time spent understanding the patient’s unique symptoms and response to treatment.
If you find yourself or someone you care about becoming frustrated when "negotiating" dosing adjustments, I would recommend considering the following points:
How long has the illness been stable on the current medication regimen? If the answer is never, or only a few months, then I would tend to argue that it is not the right time to consider a dose reduction.
What happens during a typical manic episode? The dangerousness of the manic symptoms will help determine the stakes involved in taking the risk of a medication reduction. For example, a person who has injured or endangered others or themselves in the midst of a manic episode poses a future risk for similar behavior if a dose reduction leads to mania. On the other hand, someone whose relapses have tended to include poor sleep and inability to control their own thoughts, but who is feeling oversedated and unable to function satisfactorily stands to benefit more and risk less from a dose reduction.
Using the points discussed above, with time it becomes easier for psychiatrists to become comfortable with endorsing a dose reduction. However, if you feel that your doctor is unwilling to help you assume what you feel to be an acceptable level of risk, then a second opinion may be well worth the time and money, and could lead to the identification of a better patient/physician match.