Taking a psychotropic medication history and assessing current motivation for treatment
Miranda is a 52 yo woman with a history of recurrent major depressive disorder (MDD). Her regular PCP is on parental leave, and you are meeting Miranda for the first time. Miranda’s PHQ9 is 24, with trouble sleeping most nights, 10 pounds of unintentional weight loss over the last 6 weeks, and frequent suicidal thoughts without plan or intent. These symptoms started about 2 months ago and are familiar from prior depressive episodes. Miranda is having trouble functioning at her job and at home. She sees her long-time therapist weekly but is not taking any psychotropic medications. Clinic notes list prior trials of fluoxetine, sertraline, bupropion, and most recently escitalopram. It is unclear why any of these medications were stopped.
What do you prescribe for Miranda?
- Start vortioxetine. It doesn’t look like she has tried that antidepressant before.
- Ask her if escitalopram was helpful. If it was, restart escitalopram.
- Ask her if fluoxetine was helpful. If it was, restart fluoxetine.
- I need more information about her experience with these medications.
Answer: 4. I need more information
Once you have made a diagnosis of major depression or generalized anxiety disorder and decide that the patient may benefit from an antidepressant, what medication do you choose? What dose do you start? Do you titrate the medication? How fast? When do you stop?
This 3-part PsychSnap dives into the art of prescribing antidepressants for MDD and GAD. In Part 1, I focus on understanding a patient’s prior experiences with psychotropic medications and assessing current motivation for treatment. Part 2 will focus on individualizing the initial dosing and support. Part 3 will focus on individualizing future dose changes.
How to take a psychotropic medication history
| Start with a general question | What has it been like for you to take medications for [depression/anxiety]? (Mintz 2012) |
| Ask about prior medication trials | What medications for [depression/anxiety] have you taken?* |
| Ask a general question about each medication | Can you tell me more about your experience with each of those medications? What was your experience like with [sertraline]? |
| Ask specific questions about each medication | What was the maximum dose you took? How long did you take it for (approximately)? What did the medication help with, if anything? What side effects did it cause? Why was it stopped? |
*If a patient has previously taken multiple medications but is having difficulty recalling the details, ask about specific times in their life. What was the first medication that you took for [depression/anxiety]? Did you take any medications in graduate school? After your daughter was born? When you were living in Florida?
Listing medications by name can also help patients remember prior trials. Have you ever taken fluoxetine or Prozac? Sertraline or Zoloft?
If patients can’t recall important details, consider requesting and reviewing their prior medical records. A full antidepressant trial typically takes 2–3 months, so a delay of 1–2 weeks to obtain records may be worthwhile if it increases the likelihood of selecting an effective treatment from the outset.
You may learn that antidepressants were helpful in the past, but that they were stopped as soon as the patient felt better. Maybe the patient stopped the antidepressant because they were worried about getting addicted, or due to pressure from a partner who didn’t like the sexual side effects. Maybe they’ve started 4 different medications for anxiety in the last 6 months but have never taken any of them for more than a couple of days due to nausea.
Understanding the patient’s prior experiences allows you to individualize your prescribing – pick the right medication, the right starting dose, and the right titration for this person. One additional question prevents you from writing prescriptions that patients are unlikely to fill.
| Ask about motivation for trying another medication. | If I were to recommend another medication for your [depression/anxiety], how likely are you to start it before our next visit? |
If the answer is unlikely or suggests significant ambivalence, don’t write a prescription. Spend your remaining appointment time learning more about the patient’s ambivalence (cue your motivational interviewing skills!).
Back to Miranda:
You ask, “How has it been for you to take medications for depression?” Miranda explains that overall, it’s been ok. They generally seem to work for her, but long-term side effects have been problematic.
After speaking with Miranda, you rewrite the medication history in the chart:
3 prior episodes of major depression.
- Fluoxetine 40 mg daily, took for ~8 months, helpful for depression in early 20s, no side effects, stopped because her depression was in remission
- Sertraline 100mg, took for ~2 months – no benefit for postpartum depression at age 32, no side effects, multiple serious stressors, switched to bupropion due to lack of efficacy
- Bupropion – dose unknown (1 pill daily; possibly 100-300mg) – helpful (in combination with 4 weeks of an intensive outpatient program (IOP) and significant decrease in stressors), no side effects, stopped after 2 years
- Escitalopram – ineffective at 10mg after her mom’s death at age 52, effective at 20mg for depression but with emotional blunting/sexual side effects, stopped after 4 months due to severity of side effects at 20mg.
Miranda shares that she is hoping to start a medication now and will definitely start it if you prescribe one.
You interpret her medication history. Miranda had clear benefit from adequate trials of 2 prior SSRIs (fluoxetine 40mg, escitalopram 20mg), but the side effects from escitalopram 20mg caused her to stop taking it. She had no benefit from an adequate trial of a moderate dose of sertraline. She may have benefited from bupropion (dose unclear, 1 pill daily, no side effects), but her recovery from depression at that time was also was supported by an intensive outpatient program and a decrease in stressors, so the specific impact of the bupropion is less clear.
You remember the first rule of choosing an antidepressant, “Use what worked before” and recommend restarting fluoxetine.
Stay tuned for Part 2 of this PsychSnap: individualizing the initial prescription.
Key Points
- To individualize the antidepressant choice, learn about the patients’ prior experiences with psychotropic medications including the maximum dose, how long they took it, what it helped with, what side effects it caused, and why it was stopped.
- Ask explicitly about a patient’s current motivation for taking medication before writing a prescription.
Related PsychSnaps:
“How do you choose an antidepressant?” Emma Samelson-Jones, May 2023.
“How do you manage the side effects of SSRIs?” Zoë Kopp, January 2024.
References:
Mintz, David L., and David F. Flynn. “How (not what) to prescribe: nonpharmacologic aspects of psychopharmacology.” Psychiatric Clinics 35.1 (2012): 143-163.