Here's how to help your patients separate fact from fiction and make an informed decision.
Fam Pract Manag. 2009 May-June;16(3):15-17.
Patients are free to decide which of the treatment options offered to them best fit their preferences, beliefs and values. This is as true for treatment of depression as for other conditions. However, sometimes a patient's non-adherence or refusal of depression treatment is based on false information. In such cases, brief patient education may lead to adherence and, ultimately, relief from the debilitating symptoms of depression.
It is not the intent of this article to address pragmatic reasons for treatment refusal (such as cost) or to delve into concepts that explain a patient's readiness to accept a depression diagnosis. Instead, this article explains how to respond when patients reveal misinformation about antidepressant use. What follows are 11 common patient concerns and suggested physician responses:
1. “I tried antidepressants in the past, and they didn't work.”
Physician response: There could be a number of reasons why antidepressants did not work for you. It is possible that the dose you were given was too low to effectively treat your depression, or perhaps you weren't treated long enough to prevent a relapse or a reoccurrence of symptoms.
Misinformation can play a role in medicine failure as well. Some patients stop taking antidepressants after only a couple of weeks because they do not feel an improvement in their mood, when in fact it takes four to six weeks before the benefits of the medication are felt. Some patients think they only need to take the medication when they feel bad, but antidepressants have to be taken every day. It can take a month to tell if a dose increase is necessary or if a switch in medications is needed. Treatment requires a lot of patience. Sometimes several medications have to be tried before finding the one that works for you. I know you have little faith in antidepressants, but I hope you will give them one more try under my close watch.
2. “I won't take mood-altering drugs.”
Physician response: I understand your concern, but anti-depressants are not like street drugs. Antidepressants do not make you feel high, change your sensory experiences or result in ups and downs. Most important, they are not addictive.
Antidepressants work by correcting a problem in the brain that stops you from being your normal self and feeling your best. Taking an antidepressant to correct a chemical problem in the brain is no different than taking a medication for diabetes or hypothyroidism. You are simply returning the body to proper functioning. You are not making the body do something it was not intended to do, which is the case with street drugs.
3. “My friend took an antidepressant, and it made her crazy.”
Physician response: I understand how your friend's experience with antidepressants could affect your decision to take a similar medication, but I want you to know that the most commonly used antidepressants have been around for many years, and they are generally safe and effective. As with all medications, there are potential risks and side effects. For example, if a person has an undiagnosed bipolar disorder and he or she takes an antidepressant without the bipolar medication, it may increase the likelihood of a manic episode. Maybe this is what happened to your friend. I am going to complete a thorough interview with you to ensure that you do not have any symptoms of bipolar disorder. If you begin taking an antidepressant medication, I will monitor you closely.
More common side effects that may occur within the first few weeks include light-head-edness, nausea, upset stomach, dry mouth, nightmares and changes in sleep. Weight loss, weight gain and sexual side effects may occur a bit later in the course of treatment. Be assured that I would never try to persuade you to stay on a medication that makes you feel uncomfortable. There are many different antidepressants available, and I think we have a good chance of finding one that will work for you without making you feel bad.
4. “I've heard that antidepressants make you suicidal.”
Physician response: It must be scary to hear this. I know you feel horrible already, and you certainly don't want to take a medication that will make you feel worse. Some studies have shown an increase in suicidal thinking and behavior while taking antidepressants, but this side effect is more common for teenagers than for adults and the vast majority of people do not experience it. If this side effect does occur, it will typically happen during the first few months of starting the medication, and I will be meeting with you regularly to see how you're doing during that time. (Note: When speaking to a teenager, emphasize the importance of weekly or biweekly therapy to monitor mood changes in addition to medical follow-up.) It's really important to remember that antidepressants typically help people feel better, not worse, and that is why I am recommending this medication for you.
5. “I don't want to lose my sex drive. Now that would depress me!”
Physician response: I understand that this is important to you, and I will do my best to find a medication that will not inhibit you. Sexual side effects are a relatively common problem with a group of antidepressants called selective serotonin reuptake inhibitors (SSRIs). These side effects include difficulty ejaculating or maintaining erection for men, difficulty achieving orgasm for women and loss of interest in sex for both men and women. It may be best to start you on a different kind of antidepressant that is less likely to cause this side effect.
Depression can also cause sexual problems. Some people find that their sex life improves once the medication is started. If you do experience a sexual side effect from the medication, we have two options: We can wait it out, because sometimes this side effect resolves on its own, or we can switch to another medication. I want you to know that any potential sexual side effects will go away once the medication is out of your system. I recommend that you try the medication. You probably will not experience any sexual side effects. If you do, we will address it promptly because I know how important it is to you to have a healthy sex life.
6. “I've heard that antidepressants cause weight gain.”
Physician response: I understand why this is of concern to you, and I will be careful to select a medication that does not have this side effect. It is also important to consider that weight gain might simply be a symptom of your depression, especially if you have struggled with your weight in the past. If so, you may find that fully treating your depression actually helps you lose weight.
7. “If I go to counseling, do I have to take the medication?”
Physician response: I understand the reason for your question, and I want you to know that you don't have to go to counseling or take the medication. It's your body and your choice. The reason many doctors recommend that patients who are depressed see a therapist and take an antidepressant is that research suggests that counseling and medication together are more effective than either of the two alone. For example, if you had a thorn stuck in your arm and it got infected, I would take the thorn out and give you an antibiotic. The antibiotic treats the infection, and removing the thorn prevents reinfection. Likewise, antidepressants treat your infected mood and counseling removes emotional thorns that may contribute to your depression.
8. “My wife will think I'm crazy if she finds out that I'm taking an antidepressant.”
Physician response: I understand that you're worried about what your wife will think of you, but taking an antidepressant doesn't mean you're crazy. In fact, deciding to take an antidepressant is a very sane decision that will better your life. Depression is a disease, and like any disease it makes sense to catch it early and treat it fully. Admitting that you feel depressed is the first step toward becoming healthy.
It's up to you whether to share information about your treatment with anyone. Your medical record is confidential, and no one, including your spouse, has access to it without your permission.
9. “I'm really more anxious than depressed. Why do you want to give me an antidepressant?”
Physician response: I can see why this is confusing. Let me try to explain: There is a fine line between anxiety and depression. We used to treat anxious people with anti-anxiety medicines, but we discovered that antidepressants work as well or better for some people. No one can say exactly why this is true, but we do know that some of the same chemicals that play a role in anxiety also play a role in depression. I would rather treat you with antidepressants than anti-anxiety drugs because antidepressants have less serious side effects, and they aren't addictive. For these reasons, it has become common practice to start with antidepressants when treating certain anxiety problems.
10. “I can fight this without an antidepressant.”
Physician response: You can fight this alone, but you don't have to. There is risk associated with untreated depression, and depression is episodic. If you wait it out, the depression will pass and you will feel better again. Unfortunately, people who have one depressive episode are more likely to have a second episode. When depressive episodes occur again and again, they tend to increase in severity and frequency. Treatment with medicine, counseling or both can help to prevent this downward spiral.
11. “I don't need medication because I believe in prayer.”
Physician response: I understand that your spirituality is immensely important to you and is a great source of strength for you. I'm sure it will help you battle this disease. Is there a chance that antidepressants and counseling might be part of the answer you've been praying for? It may help you to discuss this with a therapist. If you are interested, I can locate someone for you.
Enabling an informed decision
When patients refuse depression treatment, it is important not to dismiss their reasons as irrational or illogical. Instead, respect the patient's decision to accept or reject treatment, listen to the patient's concerns and enable him or her to make a knowledgeable decision. When treating a stigmatizing diagnosis like depression, you can play a vital role in dispelling myths and misinformation and illuminating your patients' decision making.
About the Author
Dr. Dohrenwend is assistant program director and director of behavioral medicine for the Internal Medicine Residency Program at McLaren Regional Medical Center in Flint, Mich. She is a board-certified health psychologist. Author disclosure: nothing to disclose.
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