Common Mistakes in Medication Management
Why Am I Getting Worse and Not Better?
Most Common Medication Errors
From the series” I want you to know what I know.”
Mental Health Problems that Shouldn’t be Missed and their Treatments
The first three are examples of diagnostic errors, the last five have to do with medication management.
1. Similar Symptoms With Very Different Brain Chemistry: Using Antidepressants of the SSRI/NRI category for depressive symptoms, that are misdiagnosed as Unipolar Major Depression, when in fact the symptoms and history indicated symptoms of Bipolar Depression. This may result in a temporary improvement of the symptoms that is not sustained, and as the medication is increased, not only don’t the symptoms get better, but they intensify, and there is fueling of the underlying Bipolar process with mood swings, increased irritability, anger and rage, possible Mania, Psychosis, with increased risk of violence to self and others including homicidal and suicidal behavior. Correct treatment is one of the mood stabilizing medications.
2. Confusing Symptoms for Diagnosis: Using stimulants for the symptom cluster of over activity , inattention and impulsivity, mistaking this cluster for ADHD, when in fact they represent an Atypical Mood Disorder, Bipolar Disorder, Anxiety Disorder such as Generalized Anxiety Disorder, Unipolar Depression or Tourette’s Disorder. Initially there may be some improvement but eventually the core symptoms will get worse, and as the stimulant is increased the symptoms of the underlying disorder will be aggravated. Correct treatment is treating the underlying diagnosis with the appropriate medication.
3. Symptom Severity Change Brain Chemistry: Using SSRI/NRI category for Anxiety & Unipolar Depressive Disorders when the symptoms are very severe, of long duration, with severe agitation & or complicated by thinking problems such as thought blocking, mild looseness or derailment, with flight of ideas, & dissociation of thinking from feelings. Some example would be severe agitated Depression, Generalized Anxiety, Panic, Obsessive Compulsive& Post Traumatic Stress Disorder. The symptoms are worsened by the activating effects. Correct treatment is using a low dose of an Atypical Neuroleptic with or without SSRI/NRI.
4. Insufficient Dose: Using the right medication for the right diagnosis but not getting complete symptom relief because of not pushing the dose to its therapeutic limits because the patient is feeling much better, though not symptom free and there still is clinically significant impairment. Examples are the Panic Disordered person who can has few panic attacks but still have much phobic avoidance, or the ADHD person who is 80% better at school or work; both can do better. Problem besides the poorer quality of life with residual impairment is that incomplete treatment allows symptom re occurrences with increased severity of remaining symptoms and especially in anxiety and depressive disorders the possibility of fueling relapses and not preventing complications like psychosomatic equivalents, drug and alcohol misuse. The solution is to use either formally or as a guide a tool like Global Assessment of Functioning [GAF] Scale, which considers symptom severity, personal social and family distress and impairment of functioning across domains like work, school and in the family to assess initial functioning and effectiveness of treatment. History from the patient, and their family asking simple questions as is there room for improvement and are you back to your self will asses treatment adequacy.
5. Inadequate Duration: Using the right medication for the right diagnosis but there is symptom breakthrough, relapse of the entire syndrome, and the beginnings of complications, because of inadequate duration of treatment. The person with Panic attacks is doing so well the medication is stopped after 6 months, and the they get generally anxious with trouble sleeping, with some anxiety attacks not full blown panic, and begin to avoid situations, and start to drink alcohol more frequently socially. Solution is to have continued treatment for 9 to 12 months if not longer to prevent relapses and complications.
6. Multiple Meds From Same Class: Using the right medication, right dose, for sufficient duration, but symptoms and impairment continue, or complications occur because of failure to use a second medicine from the same class. In the Panic person, the panic is much better, but there is much generalized anxiety with somatic complaints like muscular tension, sleep difficulties, and headaches. A SSNRI is added to the SSRI with symptomatic improvement.
7. Adding Med From Another Class: Symptoms, impairment, and complications though doses are correct for multiple medications, and the duration of treatment is adequate, due to not adding a medication from another class. A person with Unipolar Major Depression has re occurrences, and relapses after one year, on two antidepressant medications in adequate doses, Lithium is added for relapse prevention.
8. Side Effect Management: Medications are terminated or lowered prematurely because of negative or side effects. Person with depression is depression free, but has trouble concentrating , with short term memory problems, and feels emotionally flat, all symptoms of too much serotonin. The serotonin agent is either reduced, or discontinued and medication working on norepinephrine of dopamine is used . Another with Bipolar Disorder that is very Lithium Carbonate responsive is doing extremely well but has a tremor which adds to social anxiety, and is more restless than usual, possibly Akathisia, and lowers the Lithium, with a relapse of the disorder. The solution is adding Inderal for tremor, anxiety and the Akathisia.