Managing medication compliance helps patients with depression

Dr. Shelley Drew with patient Kristin Hogeterp

It’s generally accepted that discontinuing antidepressant medication before six months is associated with a higher rate of recurrence. The key to helping patients accept long-term medication is communicating with patients, setting expectations and lending support through follow‑up visits, says Shelley Drew, D.O., who practices in Walker.

“It’s important during the initial phase to get the patient past that first two weeks,” says Dr. Drew. “One of the things I talk about for the long‑term is to set expectations and let the patient know that this is going to be a long‑term medication – anywhere from eight months to a year,” she says.

“A lot of times they don’t want to take the medication that long,” continues Dr. Drew. “At that point, I talk about the idea of serotonin in the brain and the fact that you have to adjust those levels. I tell them it’s just like a diabetic who requires insulin.”

Frank discussions about medication are also necessary. “I also talk to them about not stopping their medication in the winter,” says Dr. Drew. “I let them know that at the end of the summer they will feel much improved due to medication and increased light and they will think they no longer need meds. If they stop medication in October, they feel terrible by February or March. I encourage them to stay on medication until spring when we can wean them off medication,” she says.

Dr. Drew helps patients come to terms with the fact that depression is a chemical imbalance. “I ask patients when they started feeling this way,” she explains.

“Sometimes they say they have been depressed since their teen years. It’s sometimes hard to start those patients on medication because they think they way they feel is normal. They are reluctant to start medication because they think it will make them feel worse.

“I let them know we can always wean them off the medication if it does,” continues Dr. Drew. "They often want to use lifestyle changes alone to treat their depression, but have been trying for years to make those changes without success. I let them know medication may help them feel good enough to start making those changes.”

Followup is critical to keeping patients on medication over the long term. “If a patient is severely depressed, I might see him or her the next week and make the patient commit to not hurting themselves,” says Dr. Drew. “I explain to everyone that these medications take time to work.”

Dr. Drew also gives patients the option of contacting her between visits if they can’t tolerate the medication. “I tell them if you can’t stand the side effects for two weeks, email me through the patient portal or call me. If they have a severe reaction, I will change the medication before their follow‑up visit. In the past, patients would just stop their medication and return to the office feeling no better. They then would have to start all over with a new medication and new side effects.”

For more stable patients, Dr. Drew sets a follow‑up visit for four to six weeks out. At that time, she also gives patients another PHQ9 depression assessment to get an objective look at how they’re doing. “If the patient is doing well, we can wait three months,” she says. “If not, I will see the patient in a month.”

Challenges

There are challenges to keeping patients on antidepressant medications that go beyond side effects. “There’s the stigma of being depressed,” says Dr. Drew. “The patient may be afraid they’re going to be a different person with the medication. I tell them we want to fix the underlying problem so you can be yourself.”

The most important thing for women is the effect of their depression on their families, says Dr. Drew. “Studies show anxious moms have anxious babies,” says Dr. Drew. “For patients who are reluctant to stay on medication, that’s made a huge difference to them. When we say, ‘Look what you’re doing for your family,’ mothers respond to that,” she adds.

For men, there’s more anxiety after a major illness. Dr. Drew talks to them about how depression affects their job performance. “If you’re better at your job, it makes you more secure,” she said.

It’s more difficult to treat those who don’t come in for depression, admits Dr. Drew. "For the patient who comes in with multiple physical complaints but scores high on the PHQ9, I let them know right away that I think depression is contributing to their symptoms,” says Dr. Drew. “I do not wait until we have ruled out everything else, then blame it on depression. But I also don’t ignore their physical symptoms and let them know their concerns will be addressed if they do not resolve.”

A lot of patients with depression have comorbidities. “If you’re in pain constantly, you’re going to be depressed. People with COPD can’t breathe well enough to participate in the activities they enjoyed previously,” she says. “Divorce, job loss, aging — there are many contributing factors,” explains Dr. Drew. “So it’s important to individualize care. But it is also important to explain to patients that for whatever reason they have depression the medication can help them feel able to deal with life’s issues.”

“And always, I let patients know that once life has settled down and they have made significant lifestyle changes, that we will work on weaning them off their medications. But if those medications help them function well at work, relate better to their spouses and children and enjoy our beautiful state, then they should not feel bad about taking them long term.”