In our country, mental health treatment increasingly emphasizes the use of psychotropic medications. As we’ve searched for the magic bullet for these complex conditions, we’ve moved away from other forms of support, like psychotherapy. This shift has occurred despite evidence that medication is most effective when it is coupled with therapy. From the outsider’s perspective, the solution to someone’s mental health problems can appear simple: “Just take your meds”. Too often, we believe that medicine is completely safe and effective because it was prescribed by a doctor. This can be a dangerous assumption. Psychotropic medications are drugs—they can positively affect a person’s mood or state of mind but they also have the capacity to harm. Providers can use a harm reduction approach to engaging with participants about psychotropic medications to ensure that they are used in the most beneficial way possible.
Our participants have the right to choose whether or not they use psychotropic medications. We should acknowledge their experience and autonomy. Nobody is better equipped to describe the effects, good or bad, of a medication than they are. Just like the decision to use drugs must be respected, sometimes our participants will decide that their best option is to not use psychotropic medication altogether.
A harm reduction approach to psychotropic medication means it is not framed as a requirement for mental health treatment and recovery. Instead, medication is presented as an option to be considered. The job of a case manager is to help participants make an informed choice. Participants have legitimate reasons not to use psychotropic medications, often based on previous negative experiences. We should ask about these reasons and take them seriously, refraining from judgement. Harm reduction workers provide space for participants to discuss how their choices are working out and regularly engage with them about the risks and benefits of their choices. But, these conversations can be challenging. This article offers some information and resources to help guide you. The two issues we’ll focus on are medication adherence (i.e., the extent to which people follow a health care provider’s advice about a medication and how to use it) and how to come off of psychotropic medications.
Non-adherence, or not taking medicine as prescribed, can be risky. Research links non-adherence to psychotropic medication with poor outcomes like hospital admissions and suicide. However, non-adherence is not unique to people with a mental illness. Rates of non-adherence to psychotropic medication are comparable to those for physical medications. A lot of things can factor into whether or not a person takes medication as prescribed: the information or understanding the person has about the medication; the degree of improvement or side effects they experience; their ability to afford the cost of the medication; their ability to remember to take the medication or refill their prescription when needed; and the approach of the health care provider prescribing it to name a few. Exploring the barriers to adherence can help them identify strategies to overcome them.
Some effective options to improve adherence include the use of long-acting injections of antipsychotic medications or medication monitoring through community support. However, a relapse of mental health symptoms is still possible while remaining adherent. So, we should talk to participants about their medications and how they are working for them. Even if a medication has been useful in the past, it’s important for participants to continue regular follow up with the prescribing provider to keep an eye out for unwanted side effects. Rxisk is a website dedicated to making medications safer by educating people about the risks and side effects associated with them. Among other resources, it provides a checklist of questions for patients to ask providers about the medication they are prescribing. Case managers should also research and be aware of potential side effects of the medications that the people they work with are taking, so that they can educate, monitor, and check in with them regularly.
When participants choose to stop taking psychotropic medication, case managers should aim to be involved in the conversation and encourage people to involve their psychiatrist in the process as well. The potential for withdrawal with many medications is real. As with other drugs, like heroin or alcohol, our bodies can get used to the presence of certain chemicals which makes it difficult to adjust when they are no longer there. Sometimes the symptoms of withdrawal (e.g. anxiety or sleep problems) can mirror the symptoms of a mental illness or exacerbate them. Remember that even when withdrawal symptoms are present, it is possible to successfully come off of psychiatric medication altogether. For an in-depth guide on this process, check out the Harm Reduction Guide to Coming Off Psychiatric Drugs and Withdrawal from the Icarus Project and Freedom Center. In general, tapering off of these medications is safer. A guiding principle to keep in mind is that the longer someone has taken a medication, the longer it will take to safely get off of it. As with taking medication, the process of coming off of them is one that we should engage with our participants about to review their progress and help them revise their plan as needed.
Medication can help or hurt people’s efforts to manage their mental health. Open-minded conversations about the pros and cons of using psychotropic medications encourage honesty from our participants about their level of adherence to a medication or their ultimate desire to stop using it. In a future blog post, we’ll address other strategies for managing mental health. With or without medication, recovery is possible.