Non-adherence to psychiatric medications: They are often curious

This excerpt is from a chapter in the book Dosed: The Medication Generation Grows Up that deals with teenagers’ “rebellions” against their psychiatric medications. People of all ages sometimes fail to take their meds in the manner their doctors have prescribed, but young people with psychiatric conditions are especially likely to experiment with what doctors call “non-adherence" to their prescriptions. Because drugs for psychiatric disorders change moods, behavior and even personality, and because young people are in such a state of flux, constantly growing, developing and changing, children and teens are often curious to see whether they still need their medications or what they would be like without them. Even a few months in an altered state can seem like an eternity when you’re young.

But quitting psychiatric medications rapidly and without a doctor’s supervision can have serious consequences, either in the form of withdrawal symptoms, relapses, or new symptoms cropping up. This young woman, Elizabeth, began taking Prozac and Ritalin at the beginning of ninth grade and let her prescription for Prozac run out a year later because she had trouble gauging whether the antidepressant was doing anything for her depression symptoms.

Although Elizabeth told her mother during the fall of tenth grade that she no longer wanted to take Prozac, she blanched at the prospect of confessing to her psychiatrist.  The regular fifteen-minute med-check appointments were agonizing enough.  though she had made more friends during ninth and tenth grade, becoming more socially adroit, once she entered a therapist or psychiatrist's office she'd just stare at the books and knickknacks and clam up completely.  She felt like she couldn't force words out of her mouth even if she'd wanted to.  Now embarrassed at having failed to follow the psychiatrist's prescription and unable to explain why, even to herself, she wanted to open up even less.  If this was  rebellion against anything  against her medication, against psychiatry, against her parents, against who-knows-what - it wasn't a rebellion she wanted to acknowledge, let alone be forced to discuss and defend.  The prospect of telling the psychiatrist was so daunting, in fact, that she threatened her mother with ditching the Ritalin, too, unless her mom found her a new doctor.  As usual, her mother capitulated.  When Liz saw the new doctor, she casually mentioned she'd previously taken Prozac, but that she was fine without it.

Liz wasn't necessarily rejecting antidepressants for good when she let them run out during the fall of tenth grade, but as time went on she simply didn't seek a refill, even as she bean to sink into a deep depression.  Around the same time, she befriended a circle of classmates who, even more than her pals at camp, thrived on interpersonal drama and embraced their identity as "fucked-up kids."  Several of them had taken to cutting themselves in secret, which, as Liz gleaned, helped put their emotional pain into something tangible.  In theory, she found the practice disturbing, but a few months after she went off Prozac, she took to cutting herself occasionally, too.  It turned out to be an effective way of calming herself.

So-called "cutting," otherwise variously referred to ask self-injury, self-harm, and self-mutilation, was by no means a new phenomenon in the 1990s, although it was undergoing increasing scrutiny:  Johnny Depp and Princess Diana had both admitted to self-injury, a psychotherapist published a young adult novel about the subject called The Luckiest Girl in the World, and the New York Times Magazine ran a lengthy article on the topic in 1997.  The article profiled a girl who had begun cutting herself, been treated with Prozac for depression and improved, but had gone off the medication after a few months and resumed the practice.

Liz didn't cut frequently, just when the tension built up to a point she couldn't bear.  She was careful to cut only when it was cold enough to wear long-sleeved shirts to cover the wounds.  But her despair during  this time, in tenth and eleventh grad, wasn't unrelenting  At times when she felt more cheerful, she couldn't remember quite how it felt to be depressed, but nevertheless felt a twinge, as though her past unhappiness were calling her back.  "I realized I still want to be depressed," sh wrote in a diary entry from her junior year.  "Like if you are, it proves you're a real person and if I' always happy, it means I don't really feel things.  Anyway I guess I romanticize depression.  Which is funny, because I don't enjoy it when I am. More like the idea of it."

Only in retrospect, many years later, did it occur to Elizabeth that quitting Prozac may have played a role in the urges she developed a couple of months later to begin cutting herself. But why had things come to such a pass?

There are certainly advantages to letting teenagers have a say in their care so that when they leave home, they are prepared to cope with any problems that emerge. Yet, Elizabeth felt that her mother hadn’t set enough boundaries or provided enough guidance, making Elizabeth responsible for her own refills and allowing her to stop seeing psychiatrists whenever she pleased.

Kaitlin Bell Barnett's Advice:  A more consistent and firm attitude from both her mother and her prescribing doctor, Elizabeth later concluded, would have helped stabilize her treatment and might even have prevented a relapse of her depression and the self-injurious behaviors that came with it.

Read a patient's drug compliance story on this blog.  Thanks to Kaitlin for this excerpt from her book, Dosed:  The Medication Generation Grows Up, and to Bethany Sales of Newman Communications for connecting us.