Decisions to Stop Medication

People stop medication; that’s a fact of life. I want to show how this impacts the physician or therapist. What swirls through my mind/brain when a patient tells me he or she is thinking about stopping a medicine? First, has she already stopped it and is just giving me a heads up? Second, what will happen, what are the consequences? Will there be withdrawal (discontinuation) symptoms-such as the “electric shocks” or “tingles” often described? Will there be a return of previous symptoms which had improved?  Will nothing happen, or will she feel better off the medicine (with the implication that we should have stopped it sooner, or perhaps it was not the right thing in the first place)?

I’m usually very interested in the reasoning: why this decision? Perhaps it was related to cost; perhaps a significant other was opposed; maybe she ran out of pills and decided to experiment; possibly there was a problem such as weight gain, emotional flatness, sexuality- which was considered a medication side effect; perhaps potential pregnancy was at issue. People often feel an unspoken guilt or stigma, or family disapproval (which can be very subtle). I clearly remember my own embarassed agony about having to wear braces, or when I cheated on a 3rd grade eye exam so I wouldn’t have to wear glasses. Miss Flanagan was suspicious and caught me, by the way, because I had only thought to memorize the eye chart forwards and she tested me backwards.

So, in trying to be therapeutic, I have to be aware of these transference and countertransference themes as they arise in my brain and keep a focus on my patient’s brain. It’s best not to repeat the advice that every patient has received multiple times  (“Please don’t change your medication without discussing it with me first”) because everyone already has heard this and there are too many exceptions.

Let’s take the example of Stephanie P., an attorney, who has decided she will stop Lamictal (lamotrigine), a medication she has taken for eight months, which we started because of irritable, angry, and unhappy moods which had not responded to several antidepressants or to psychotherapy. She continues to suffer from premenstrual dysphoria (PMDD) and wants to try an herbal combination recommended by a friend. This is a brief visit and I would like her to leave the session with a reasonable plan. I ascertain that this accomplished and assertive person is beginning to doubt that Lamictal is helping that much, wants to focus on PMDD, and would like to be free of medication in general. We reach the point where she knows I understand her position. We briefly differentiate the symptoms of the two conditions, mood problems and premenstrual dysphoria. I suggest this can be treated as a trial experiment on the effects of stopping one thing (which she has already done) and starting another, and that keeping a daily mood or symptom diary or chart can help us gather objective evidence for future decisions.

We now have a story and a plan and will proceed to the next episode in a month or two. Could there have been another story in which the conclusion is “We’ve looked at some evidence together and I strongly advise you to restart the Lamictal”? Of course.

Details have been altered to protect patient privacy.