Imagine this client walks into your office…
Susan complains that she feels exhausted, but you can’t help but notice that she’s also been experiencing anhedonia, difficulty concentrating, lack of appetite, bouts of crying, an overwhelming sense of guilt, and trouble falling asleep.
Based on this constellation of symptoms, the diagnosis is probably clear to you...
Susan is depressed.
But you’re not the first professional Susan has visited. Before you, she saw her primary care physician, who decided to give her something to help her sleep and prescribed a benzodiazepine.
It’s a situation you’ve likely encountered before: your client’s presentation doesn’t match the prescription they have.
And it’s not that Susan’s prescriber was negligent or made a mistake.
The bulk of antidepressant and benzodiazepine medications are written by non-psychiatrists, and the average primary care visit is only 8 minutes long. In that time, the physician needs to take a history, make a diagnosis, prescribe treatment, educate the patient, and answer questions.
In that 8 minutes, your client may not have been able to get all their questions answered. Additionally, they may have been too nervous to bring up all their symptoms or simply thought their mental health concerns weren’t appropriate for their primary care physician.
It’s also very common for clients to present in very different ways to different professionals.
As a non-prescriber, you may be wondering what you’re ethically able to tell your clients. What advice are you able to give within the scope of your practice?
Because of our role in our clients’ lives, it’s important to be proactive in speaking with both clients and prescribers. Here are eight ways that we can help clients succeed on their medication.
1. We can help our clients have realistic expectations of their medications.
Many clients may have unrealistic hopes for what their medication will do and how quickly it’ll begin to work. Early conversations with clients to establish their expectations for their medication can help us align them with reality.
Often, clients with depression will say something to the effect of, “I don’t think my medication’s working. I don’t feel happy.” My response to this is that there’s a big difference between feeling not depressed and happy.
This is the metaphor I often use with my clients. Think about the pool noodles that kids like to play with. If you want to get from one side of the pool to the other, that pool noodle isn’t going to get you all the way there. It’s going to assist you, and then you still need to figure out where you want to go and what resources you need to get there.
Medications are the same way. They’ll assist and help relieve some symptoms, but they won’t do everything.
2. We observe or are told about potential side effects that may interfere with compliance.
One barrier that prevents clients from following through on a treatment program is the side effects of their medication. For example, sexual dysfunction is a common side effect of SSRIs.
When I want to give clients information about side effects, I encourage them to speak to their pharmacist. Think of the pharmacist as your healthcare partner. They have so much information about side effects and may even know OTC treatments to address them.
3. We know information clients may be too embarrassed to tell their prescribers.
Trouble affording medication. A history of substance abuse. Sexual dysfunction. These are all issues a client may tell their therapist before their prescriber.
Reasons to withhold information from a prescriber can be complex and varied. A survey done by USA Today found that many clients were too embarrassed, didn’t want to be lectured, didn’t think it was the doctor’s business, or even forgot to mention things during their appointment.
If you learn something that you believe the prescriber should know, this can be the right time to get a release of information (ROI) from your client. To preserve the therapeutic relationship, make sure your client knows what you want to communicate with their provider and why you find it important.
4. We are aware when clients aren’t taking their medications as prescribed or have stopped.
Prescribers often assume a client is no longer taking their medication when they stop calling in for refills. Because of this, prescribers can be the last to know a client has stopped taking their information.
If you know or suspect a client has stopped taking their medication and you have a release of information, this is important information to pass along.
5. We are on the front line at witnessing the emergence of late-onset side effects.
Some side effects like nausea, heartburn, and insomnia are typically seen early on, but there are side effects that don’t emerge until much later. Muscle spasms or tardive dyskinesia are examples of late-onset symptoms that show up months later.
Knowing the late-onset symptoms associated with your client’s medication can help you know what to continue to watch for.
6. We can recognize breakthrough symptoms.
A common breakthrough symptom that can happen with some antidepressants is the depression coming back. It doesn’t mean that the medication has stopped working, but it is time for the client to check in with their prescriber.
But the prescriber won’t know that the client is having a breakthrough depression in the first place unless you help your client identify what’s going on and encourage them to see their provider.
7. We can encourage clients to discuss substance use with prescribers.
Whether it’s alcohol or other substances, I encourage clients to disclose to prescribers anything they’re taking that can affect their mood, energy, or body chemistry.
As a clinician, I want to know if a client is feeling less tired because their antidepressant is working or because they’ve doubled down on energy drinks. Are meditation techniques helping reduce their anxiety, or have they starting using marijuana?
8. We can recognize inadequate medication response which may warrant dosage adjustments or augmentation.
You may be wondering how you can recognize this as a non-prescriber, but you can be very helpful because you’re seeing your clients on a regular basis. Consider using a rating scale to monitor changes in mood, like the Beck Depression Inventory or even a mobile app. Your client can then share this information with their prescriber at follow-up appointments.