My roommate's psychiatrist prescribes 6 mg. daily of an antipsychotic for her to take. She takes 2 mg. instead each day, and she's really doing better. She tells me she's afraid to tell the doctor. What should we do?
(Column: Ask the Doctor)
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It is quite interesting for me to respond to the same question Steve Kauffman, RPH, the Pharmacy Editor, answered in the March/April 1999 NYC Voices. I had -- to keep the record straight -- prepared this answer prior to reading his column. The differences in our answers reflect, I suppose, the differences in our training and roles.

This question poses issues on many levels. First, there is, of course, the issue of dosages of medications, how they are selected, and who should do the selecting: the doctor or the person being treated. There's the question of why your friend is taking only a third of the amount prescribed, and what she means by "really doing better." Finally, there is for me what is the most important question. Why would your friend be afraid to tell her doctor what she's doing?

The question of dosage selection was covered in a previous issue of Voices, but let me expand a bit on Steve's answer. Too often, both physicians and patients collide in what I sometimes think of as "the dance of medication prescribing." The doctor pretends that, as might be the case with antibiotics, there is an exact dose of medication that is perfectly right for YOU. You pretend that you are taking exactly that dose, and each med visit, each of you does another step in the dance.

"So Sally, are you taking the medication I gave you last time? Any side effects?"

"Yes, I'm taking it just as you ordered. I guess I feel a little tired, but otherwise I'm doing fine."

"Great! See you next month."

Physicians are often reluctant to take the time, and give up the "power," that would be involved if they honestly worked together with those they treat in deciding which medication to use, and at what dose. Since many of the medications we have available are pretty much equally effective in treating the illnesses for which they are used, selecting a medication is often as much an issue of choosing which side effects are less disturbing to each individual. Often, we can increase the extent to which a medication does what we want it to do, but only by increasing the dose, which often makes the unwelcome, unpleasant side effects worse. All to frequently, however, clinicians see this as a unilateral issue rather than as a decision they should be sharing with their patients. In my experience, although such an approach takes more time initially, its benefits are enormous-creating trust, fostering a general collaborative stance and improving adherence to these mutually selected medication regimens.

So, is your friend only taking 2 mg. because when she takes more, the side effects are worse? Is she, in fact, compromising getting the best treatment of her psychosis? Does she find the side effects so unpleasant that she prefers continuing to have some symptoms of her illness? Often, I've found that patients will cut down on their medications to relieve the stiffness, or drowsiness, or sexual side effects, rather then ask if another medication might be available which has fewer side effects they, personally, find most noxious. Working together, we can often come up with choices, or combinations, of drugs that are both maximally helpful and minimally distressing.

Finally, why is your friend afraid to tell her doctor the truth? What has her doctor done that makes her afraid, or is she worrying without cause about what will happen if she's honest? Has the "system" so beaten down your friend that she believes telling the truth is useless, or worse, threatening? Is your friend afraid of being chastised, or threatened with hospitalization, or rejection? Is the doctor so rushed and preoccupied that he or she gives your friend the sense that there is no time for her to talk about such issues? Openness and honesty are the hallmarks of a therapeutic relationship, yet all too often, this cornerstone of treatment is undermined by one, or both, sides of the relationship.Tell your friend to share her concerns, her rationale and her responses with her psychiatrist. Tell her to bring this column along with her. Even if their work together has strayed from the ideal, perhaps, together, they can rescue it!
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