Antidepressant medication management

Dr. Rhoda Beltran

An interview with Rhoda Beltran, M.D., Grand Rapids

What are some of the challenges you face with keeping patients on antidepressant medication long term and how do you overcome them?

First, we realize that depression is getting to be a common problem. Research has shown that this is something we have to be diligent in recognizing, especially in patients with chronic medical conditions. As a primary care provider, we face many challenges in taking care of these patients, such as having the patients comply with taking their medications as prescribed. That is why education is very important. These patients need to understand why treatment is necessary, what these medications are, possible side effects and what to expect with their treatment plan.

We make sure that cost is not going to be a hindrance in getting their prescriptions. We try to follow up with these patients on a regular basis, checking if they are taking their medication and if they are having any problems with it.

I also recommend therapy in conjunction with medication. Medication and counseling work best together. This also helps them understand what depression is and what coping skills they can develop to get better. Coverage for counseling can be a challenge for some patients. They may not have the copay or even transportation or child care to go to their therapy sessions.

How do you deal with medication cost as a challenge?

A lot of antidepressants are available in a generic. I try to choose the ones I know insurance will cover. Our electronic medical records give me some idea of what’s covered by a specific formulary. If medication is costing the patient more than they can afford, I encourage them to call me right away so I can work with them and their insurance to find a suitable alternative drug.

You mentioned education. How important is that to keeping patients on their medications long term?

I tell them antidepressants aren’t short-term medications and I give them timelines. I encourage patients to take their medication for at least six months, preferably one year. I reassure them that these medications are safe to take for long periods of time. I tell patients that antidepressants may take a while to take effect. It’s not like a cold pill. Some patients may see improvement of symptoms right away, but for some it may take a few weeks to get the full effect of the medication.

I also tell patients that it’s not a good idea to stop their medication once they start feeling better. They may have worse symptoms if they stop abruptly, and we discuss withdrawal symptoms. I emphasize the need to wean themselves from most of these medications.

Side effects are a frequent challenge to keeping patients on medications long term. How do you deal with that issue?

I have one patient who I’ve been seeing for 20 years. Last April, I diagnosed her with diabetes. She had episodes where she felt down and didn’t go to work for days. She wasn’t getting out of bed. Her family was getting concerned about the change in her behavior. We realized that the diabetes diagnosis was causing her depression. So, I had to explain to her why we needed to start her on medication and that her depression was starting to affect her work and relationships.

The patient is overweight, so she was concerned about weight gain associated with antidepressants. When she agreed to be treated for depression, I prescribed Wellbutrin, which was once thought of as a weight loss medication. Choosing the right medication for the patient is important for them to improve their compliance and allow them to take it for a longer period of time.

We now have more choices for treating depression. Choosing the right drug for the right patient most often can minimize the side effects. We try to start slow with a low dose and slowly increase the dose until we reach the desired effect. The good thing about the antidepressants we now have is that the goal is complete remission. We want these patients to go back to their baseline.

I encourage my patients to call the office for any side effects they may be having. We try to make recommendations. For example, if they have nausea, we have them take their medication with food; if the drug causes them sleepiness, we have them take it at night.

Side effects of antidepressants can be as simple as nausea, dizziness, to as serious as seizures and suicidal thoughts.

We make sure we’re available to answer questions. We try to provide office visits for those who need to be seen face to face. We have same-day appointments for those patients who are having more challenges. Ten percent of our visits are for same-day appointments.

Let’s talk about follow up. How often do you want to see patients on medication?

I usually want to see a patient after four weeks, and then follow up every three months after that. If I’m concerned about their progress, I’ll see them in two weeks instead of four and then more frequent follow-up, if needed.

Is there anything unique in the way your office treats patients with depression?

The good thing about my office is our teamwork. We have care managers who call patients the day after being prescribed new medication to check on how they’re doing.

The care managers make sure patients have filled their prescription and taken the medication. Depending on how that conversation goes, we decide if they need to be called again the next day or the next week.

These care managers meet once a week with a group of providers, including a psychiatrist. The care managers present difficult cases during these meetings. They discuss these patients and bring back recommendations to me. It is up to me then to decide if these recommendations are appropriate for the patients. More often than not, I find their suggestions very helpful.

Our phone nurses are also trained to handle calls when patients have worsening symptoms of depression, reactions to medications or problems getting their medications filled.

The nurses have resources that they can go to in order to answer patients’ concerns.

We also have a nurse practitioner who works side by side with me and is available for urgent visits if I don’t have openings. She knows my patients well. We are fortunate to have an in-house psychologist who is available for urgent consults. If there’s a patient who I think needs counseling services right away, I can have the counselor see that patient the same day he or she is in the office.

We also have a social worker who is available to address social determinants of health, that is, a patient’s ability to get his or her medication or help with transportation for their office visits. We are aware that depression is very much impacted by what is happening in our daily life. We worry about finances, job and taking care of our family. The social worker gives our patients resources to help them take care of some of these things.