During the first twenty years of my therapy practice, I spent a significant portion of my time persuading patients to start psychiatric medication. But over the last five years, more and more of my practice has become taken up with giving patients permission to take less medication. With increasing frequency, I see patients with Bipolar Disorder, Depression and Borderline Personality Disorder (BPD) on high doses of multiple medications who complain of deleterious side effects that leave them sedated, cognitively and emotionally dulled, overweight, sexually dysfunctional, unmotivated and depressed. It’s not that medication can’t be helpful—I’m not anti-medication– but often the problem is quantity. Too much of a good thing is a bad thing. The natural tendency, as patient spend more time in therapy and still have symptoms is to increase the number of medicines and their dosages However, inevitably, this produces more side effects. With medicines, less can be more.
Since the publication of my book, The Hypomanic Edge, larger numbers of bipolar patients from around the country seek out my consultation, and the stories I hear are shockingly similar. First, patients often report psychiatrists who are overly aggressive in pushing them to add mood stabilizers and anti-psychotics to their mix, without adequately explaining either the possible or the probable side effects. A colleague of mine conducted a patient satisfaction survey for a large multi-state hospital system (I can’t mention which one). He found that the number one cause of patients’ dissatisfaction was: “Doctor didn’t explain the possible side effects of my medication.”
Given that side effects are dose dependent, one obvious solution to the side effect problem is to be judicious in using the smallest dose possible, to titrate up only if needed, and then very gradually. Yet, it seems psychiatrists often follow a lock step march, ramping up to the “therapeutic dose,” as quickly as possible. Yet, in truth, there is no such thing as an objective therapeutic dose of any psychiatric medication common to all patients. The therapeutic dose of a psychiatric medication is the one that works for you, while giving you the lowest amount of side effects.
The reasons psychiatrists err in this direction say a lot about how psychiatry has evolved over the last two decades. First, big Pharma has assumed more and more control over psychiatry, as I’ve written about in my blog on Psychology Today, and it is their clinical trials, their marketing materials and their marketing reps that “standardize” the dose they say patients should be on. Second, psychiatrists are spending less and less time with patients, as it has become economically more efficient to see patients for medication monitoring only, rather than seeing patients in therapy. Thus they have fifteen minutes every month, or often every three months, to make a clinical judgment. With such brief intermittent visits the psychiatrist has only a very limited chance to observe the patient directly, and thus what they have to go on is the standard clinical protocol. Of course they also what the patient tells them to guide their decisions, but especially if the patient is bipolar or borderline, there is a strong index of suspicion that the patient may be trying to resist treatment. Patients with bipolar disorder want to get high by avoiding their medicine, we are told in our training. And sometimes this is true. But I’ve found that more often bipolar patients are seeking balance, trying to find that golden mean between being out of control and being overly sedated. And the same is true of patients with Borderline Personality Disorder (BPD), who also have impulse control problems, and often have concurrent mood disorders like depression or bipolar disorder. For a doctor and patient to find that golden mean requires a mutually trusting therapeutic alliance, which is hard to achieve when you meet with a patient for only a few minutes a month.
My less-is-more method involves starting a new medicine at a very small dose, and then reevaluating after a few weeks. With bipolar, depressed, and BPD patients, unless the patient is in an acute episode, we have the luxury of time to get the dose right. If we do, the patient is more likely to comply with their medication regimen in the long run, which will provide more long-term stability. When we ramp up patients too high to fast they are far more likely to stop taking the medicine all together. Or, alternately, we see patients who suffer from bipolar disorder, depression or BPD who comply with their doctor’s recommendations, who function at a sub-optimal level because the side effects of their medication can leave them sedated, dulled, depressed and overweight.
So for example, I often suggest that patients with impulse control problems or rapidly shifting moods, as is often the case for bipolar, depressed and borderline patients, that they try Lamictal, the mildest of the mood stabilizers. Typically, the psychiatrist will give them a starter pack provided free from the manufacturer that contains: five 25 mg. pills, five 50 mg. pills, five 100 mg pills and five 200 mg. tablets. The expectation is that the patient will ramp up to 200 as quickly as it is safe to do so moving in 5 pill increments. The psychiatrist is often surprised when I suggest staying at 25 mg for a couple of weeks. Moving at that slow pace most of my patients find something in the 50-75 mg range is right for them, though I have some on doses as small a 12.5 (breaking the smallest pill in half). I’ve has psychiatrists tell me that these medicines cannot be effective at these doses—that it must be a placebo effect. But they are wrong, and I ask them: Have you ever taken 25 mg of Lamctal? If not, how can you know whether it has an appreciable effect. In the meantime, friends, relatives, partners and colleagues tell the patient he is noticeably calmer and more in control. Why should we force more medicine on the patient if he is experiencing benefit from the dose he is on, and doesn’t feel the need for more?
Patients want a doctor who will listen to them. Is that asking too much?