Question: I have been on the same four medications for years. I am happy to say that I have been doing well and am back to work.  I hardly even think about my symptoms unless it’s time to see my psychiatrist once every 6 months, or go and get a refill.

My girlfriend and I are getting pretty serious. I felt I had to tell her about my meds and why I take them. I am on two antidepressants and two medicines for anxiety.  She was OK with it.  She called it a “medication cocktail.” I’ve heard that before, and I figured it just means a combination of medicines that works well together.  But then I started wondering why I have two of the same kind of medicine? Wouldn’t one of each be enough?

Anne Fenton, MD: My patients often ask me this question, and it is an excellent one.  There are several reasons that people are given more than one medication for the same condition.

Sometimes, people respond only partially to one medication and need to enhance it with another of the same kind. Sometimes, they might have a partial response to a certain medication at a certain dose but can’t tolerate the side effects of a higher dose. Adding a different medicine helps achieve a better response without added side effects.

We often try after a while to streamline the “cocktail” by eliminating apparent duplications. However, this is easier said than done. One reason is that, even though more than one medication, (like your antidepressants), treat the same condition, it does not mean that they treat it in exactly the same way.  And even medications which are in the same “family” have differences in chemical structure which offer different benefits.

We tend to “lump together” a variety of symptoms into one word that describes the overall condition, like “depression”.  We forget that behind the general condition may be several different mechanisms that are going on in the brain.   You can see how one medication alone may not always provide the best treatment for a condition that represents more than one symptom, or is caused by more than one change in the brain’s chemistry.

In many cases, the balance created by a combination of medications in the system seems to provide a benefit beyond that of any individual medication.  This may be akin to the adage that “the sum is greater than its parts”.  If we tamper with that balance,  we often find that symptoms recur.  It appears that the balance itself is an important factor not only for achieving, but also maintaining emotional stability.

Question: I have been seeing a psychopharmacologist.   He prescribed some medicine for me a few months ago.  It helped a lot, and now I feel fine.  I would like to stop taking my medication.  I think I’m ready. But whenever I bring it up with him, he talks me out of it, or changes the subject. I’d like to do it the right way.  Can you help?

Anne Fenton, MD: People often ask why they should be on a medication once they are feeling better.

You are right to bring this up with your prescriber. Part of his job is to explain how, when,and whether you should go off your medication.  Part of your job is to communicate your thoughts about it, as well as your interest in his guiding you safely through the process.

Generally speaking, the protocol for discontinuing medication varies with the particular type of medication, the response of the individual, the onset and duration of the original symptoms, the persistence or recurrence of symptoms over the period of treatment, and many other factors.

There are also standard treatment guidelines for suggested length of treatment based on research studies.  Researchers study the treatment outcomes of thousands of patients who have been on a particular medication.  They continue to monitor these patients for symptom recurrence after they have discontinued their medicine.  Researchers may review the results for groups of patients who were treated, say, for 6 months, a year, a year and a half, and two years.  Then the patients are monitored after discontinuing their medications for 6 months, a year, a year and a half, and two.  The recommended optimal length of treatment is based on which group had the lowest rate of recurrence over the longest period of time after discontinuing treatment.

Not everyone is able to discontinue medications indefinitely without recurrent symptoms.  There are many people whose symptoms simply require continued, lifelong treatment.  This is similar to any chronic medical condition.

Sometimes, people go off their medications and feel fine for a little while, but start to experience symptoms after a few months.  It can often take that long before the effect of the medicine wears off, even though it is out of the system within a few days after discontinuing.

It is thought that the initial and rapid positive response a person may experience within the first few weeks of treatment represents positive changes in brain chemistry mediated by the medication.  The longer, more stable positive changes result from physiological and anatomical changes in the brain that occur later as the brain recovers and returns to normal.

As you can see, your question does not have a simple answer.

When you and your prescriber feel the time is right to discontinue medication, it should be done carefully. You and your prescriber should work together closely to observe for any symptoms of withdrawal from the medication, or any recurrence of your original condition. The best and safest way to ensure your successful “medicine taper” is to do it slowly and carefully. Regular follow up even after discontinuation is recommended to monitor the possibility of recurrence and resume treatment if indicated.

It is also important to follow up with your prescriber at specified intervals over the two years following discontinuation.  If you do have recurrent symptoms, you will be in a good position to get help before your symptoms take hold.