Medications Play a Key Role in Treatment
Prescribed medications play a key role in the treatment of co-occurring disorders. They can reduce symptoms and prevent relapses of a psychiatric disorder. Medications can also help patients minimize cravings and maintain abstinence from addictive substances.
In order to get the most out of medication, patients must make an informed choice about taking medications, and understand the potential benefits and costs associated with medication use. In addition, they must take the medication as prescribed by a mental health professional.
Taking medication is not substance abuse. Some people in recovery for a substance use disorder may think it is wrong to take any medications. However, a medication that manages one's mood is very different from a drug that alters one's mood.
Prescription medications have been developed and tested for all of the Axis I psychiatric disorders. Effective medication options exist for the treatment of most of the major disorders, including mood disorders such as major depression and bipolar disorder; anxiety disorders, such as post-traumatic stress disorder, panic disorder, social anxiety disorder, and generalized anxiety disorder; and schizophrenia and other psychotic disorders.
Placebo-controlled trials have demonstrated that medications for mental health disorders reduce or eliminate symptoms. For example, antidepressant medications such as the selective serotonin reuptake inhibitors (SSRIs) consistently reduce symptoms of depression by 30 percent to 60 percent overall and lead to complete remission in a significant proportion of patients. Effective psychotherapies have also been developed and tested for many mental health disorders and can be utilized without medications for patients with mild or moderate disorders. However, medication is an important mainstay of treatment for patients with more severe and/or long-standing mental illness symptoms.
Many patients do not take medication as prescribed. Some simply forget medications, but often "forgetting" is really related to an underlying concern. Prescribers should assume that a patient will sometimes failt to take his or her medications. In these cases, they should ask about the missed medication in a nonjudgmental way. When patients are not adherent to the medication plan, modifications to the medication prescription or to the plan should be based on the patients' unique reasons for not taking them.
Nonadherence to the medication plan is often found in a patient who experiences the following:
medication-releted side effects
concern about the interactions between substances and the medication (a patient may not take his or her medication if a return to substance use occurs)
belief that the medication isn't working
feeling better, which leads the patient to believe that the medication is no longer needed
misattribution of the mental health disorder symptoms to the use of the medication
disorganization or apathy related to the ongoing substance use disorder or mental health disorder
lack of family support for medication taking
Addressing side effects
If a patient reports side effects, or changes the way he or she takes medications due to side effects, prescribers should do their best to address the problem. Full empathic attention to the difficulty and reassurance that it will subside is sometimes enough to reduce the concern. Serious side effects or ones that interfere with functioning should be addressed by changing the timing or dose of the medication, by taking the medication with or without food, or by using another medication to alleviate the problem. At times, a medication switch will be required to address nonadherence.
Medication use and the active use of substances
Prescribers should avoid prescribing medications that are known to interact with the patient’s preferred substances of abuse. Psychotropic medications that are safe in the context of substance use should be utilized with the following advise:
“Please take this medication every day, even if you are using substances. The medication won’t help your problem with depression if you don’t take it every day, even after you are feeling better. As we have discussed, your goal is to avoid using substances, but if you do use, take the medication anyway.”
Admonitions to the patient not to use substances because he or she is on a medication often result in the patient using substances and not taking the medication.
Medication use and mental health disorder symptoms
Some patients may misattribute mental health disorder symptoms to medication use. A careful documentation of mental health disorder symptoms prior to prescribing medication is helpful in this situation. Patients with psychosis, for example, may say the medication causes hallucinations. Patients with depression and fatigue may attribute the fatigue to the medication. Education and reminders can be helpful, but if a patient is fully convinced that the medication is causing mental health disorder symptoms, switching medications may be an option to address this problem.
Medication use and family support
Sometimes a patient is willing to take medication as prescribed, but the attitude of a family member interferes. Inquiring about how family and friends perceive the use of medication is important. If a spouse has concerns, it’s vital to include him or her in the educational process. It's important for clinicians to provide education to all concerned family members. This education should include information about mental health and substance use disorders and their treatment. (Read more about family support.)
Medication use and peer support groups
While the official stance of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) is that taking medications prescribed by a medical professional is compatible with recovery, some individuals in peer support groups may still view psychotropic medications as potentially addictive substances that should be avoided by people with addiction or substance use issues. This perception may be due to the fact that benzodiazepines and other tranquilizers, which can indeed be addictive, were commonly prescribed in the past to patients with substance use disorders. Many effective, nonaddictive alternatives to these medications are now available.
Patients may run into particular individuals in peer support groups, or even entire groups, who are not supportive of medication use. It’s important to remind people that medication is one important tool they can use in their own personal recovery path. The patient may want to shop around for other peer support groups that are more supportive of people with co-occurring disorders.
Medication tapering and discontinuation
The effects of medication for mental health disorders can take several days to several weeks to take place, and it can take several months for their full effects to be felt by a patient. Once the mental health disorder is stabilized over a period of months, the medication should be continued for approximately six months. Patients with mood and anxiety disorders may consider tapering and discontinuing medication, depending on how chronic and severe the mental health disorder symptoms are. Patients with bipolar disorder and psychotic disorders may benefit from remaining on medication for a much longer period of time, often for life. Reseearch suggests that relapse of symptoms occurs within a year of discontinuation of medication in these types of disorders.