Medication choice and managing problems

Medication can play a key role in treating mental illness. Unfortunately, sometimes people have problems with taking this medication that make them feel that it’s not right for them. This section considers ways of trying to resolve problems with medication. Here, the word ‘doctor’ means psychiatrists and general practitioners (GPs).
•Medication is a key part of the treatment of mental illness, but it is not the only treatment. A lot of people find ‘talking treatments’, self-help and complementary therapies helpful.
•People with schizophrenia, bipolar disorder, depression and anxiety disorders are normally offered medication by their doctor. However, not all illnesses are treated this way. For example, people with a sole diagnosis of personality disorder are not normally offered medication.
•Your doctor should explain the risks and benefits of taking your medication before you start taking it.
•You can expect to be given an opportunity to ask questions about your medication and to have these questions answered.
•Unfortunately, all medications carry a risk of side effects. It is important to try to find the right balance between reducing symptoms and managing side effects.
•If you have a problem with your medication, talk to your doctor about it. If you find this difficult, you might wish to ask a friend, relative or advocate to help you.
•You may have to try a few different medicines before you find the one that is right for you.
•If you cannot resolve disputes informally with your doctor you could try writing them a letter about our concerns or making a complaint.

DECIDING

What things should my doctor take into account when prescribing medication for me?

Your doctor will consider a number of things when deciding which medication to offer you and what the dose should be. This may include:
•Evidence about which drugs work to treat your condition
•Which medications you have tried before, if any
•Your physical health
•How much you smoke, drink alcohol or take recreational drugs
•Any ‘interactions’ that might happen with other medication you are currently taking
•The side effects associated with the medication
•Your opinion e.g. about what side effects are tolerable for you
•Guidance produced by the National Institute for Health and Clinical Excellence (NICE)

A doctor might recommend a particular type of treatment based on their knowledge and experience. However, they should not put pressure on you to accept a particular drug or treatment. You should be able to negotiate which, if any, medications you want to try.

Some people worry that if they decide not to take the medication that a doctor recommends, they will be detained under the Mental Health Act 1983 (‘sectioned’). This is unlikely, and you must not be threatened with sectioning just because you will not accept a particular treatment. However, if your illness puts you or others at risk of serious harm and if you do not accept any appropriate treatment, you may be assessed for detention under the Act.

What should my doctor tell me before I take my medication?

Your doctor is under a legal duty to ensure that you consent to treatment and that they are fulfilling their ‘duty of care’ to you. In order to meet these duties, your doctor should explain the benefits and risks involved in taking medication. Your doctor should tell you why you are being offered the medication and what the common or severe side effects are. You should also read the patient information leaflet that comes with your medication, which will go into more detail about possible side effects. The doctor will not be able to predict whether your medication will work for you or what side effects it may cause, because this will differ from person to person.

The way that the doctor provides you with information about medication will depend on:
•What information you want and need
•The nature of your illness
•The kind of medication being offered

When providing information, the doctor should not make assumptions about:
•What you would like information about
•What you think is important
•Your level of knowledge or understanding

The doctor should check that you have understood the information that they have told you about the medication, invite any questions from you and answer questions honestly. As long as you have the capacity to consent to treatment, your doctor should not withhold any important information from you unless there is a risk of serious harm to you. Serious harm means more than just a risk of you refusing treatment and it is quite rare for doctors to withhold information for this reason. If your doctor does withhold any information from you, they should state clear reasons for this in your medical notes.

You can ask your doctor questions about your medication during any appointment. You may wish to put together a list of questions to ask before you go to your appointment. An example set of questions can be found at the end of this section.

What if my medication doesn’t seem to be working yet?

Medication sometimes takes a while to work. A doctor would expect to see some effect within the first three weeks of treatment with an antidepressant or antipsychotic drug . However, they will often wait until up to 4-6 weeks of your medication having little or no effect before changing it, depending on the drug and whether there are urgent reasons for changing it.

If you feel as though your medication should have taken effect sooner than it has, talk to your doctor about whether a change needs to be made. If there are urgent reasons why you think the medication needs to be changed, make sure your doctor knows about these.

Your doctor might think it is necessary to increase your dose or try a different medication at this point. Remember that you have the right to ask questions and choose your medication based on what you think is right for you

What things should my doctor take into account when prescribing medication for me?

Your doctor will consider a number of things when deciding which medication to offer you and what the dose should be. This may include:
•Evidence about which drugs work to treat your condition
•Which medications you have tried before, if any
•Your physical health
•How much you smoke, drink alcohol or take recreational drugs
•Any ‘interactions’ that might happen with other medication you are currently taking
•The side effects associated with the medication
•Your opinion e.g. about what side effects are tolerable for you
•Guidance produced by the National Institute for Health and Clinical Excellence (NICE)

A doctor might recommend a particular type of treatment based on their knowledge and experience. However, they should not put pressure on you to accept a particular drug or treatment. You should be able to negotiate which, if any, medications you want to try.

Some people worry that if they decide not to take the medication that a doctor recommends, they will be detained under the Mental Health Act 1983 (‘sectioned’). This is unlikely, and you must not be threatened with sectioning just because you will not accept a particular treatment. However, if your illness puts you or others at risk of serious harm and if you do not accept any appropriate treatment, you may be assessed for detention under the Act.

What should my doctor tell me before I take my medication?

Your doctor is under a legal duty to ensure that you consent to treatment and that they are fulfilling their ‘duty of care’ to you. In order to meet these duties, your doctor should explain the benefits and risks involved in taking medication. Your doctor should tell you why you are being offered the medication and what the common or severe side effects are. You should also read the patient information leaflet that comes with your medication, which will go into more detail about possible side effects. The doctor will not be able to predict whether your medication will work for you or what side effects it may cause, because this will differ from person to person.

The way that the doctor provides you with information about medication will depend on:
•What information you want and need
•The nature of your illness
•The kind of medication being offered

When providing information, the doctor should not make assumptions about:
•What you would like information about
•What you think is important
•Your level of knowledge or understanding

The doctor should check that you have understood the information that they have told you about the medication, invite any questions from you and answer questions honestly. As long as you have the capacity to consent to treatment, your doctor should not withhold any important information from you unless there is a risk of serious harm to you. Serious harm means more than just a risk of you refusing treatment and it is quite rare for doctors to withhold information for this reason. If your doctor does withhold any information from you, they should state clear reasons for this in your medical notes.

You can ask your doctor questions about your medication during any appointment. You may wish to put together a list of questions to ask before you go to your appointment. An example set of questions can be found at the end of this section.

What if my medication doesn’t seem to be working yet?

Medication sometimes takes a while to work. A doctor would expect to see some effect within the first three weeks of treatment with an antidepressant or antipsychotic drug . However, they will often wait until up to 4-6 weeks of your medication having little or no effect before changing it, depending on the drug and whether there are urgent reasons for changing it.

If you feel as though your medication should have taken effect sooner than it has, talk to your doctor about whether a change needs to be made. If there are urgent reasons why you think the medication needs to be changed, make sure your doctor knows about these.

Your doctor might think it is necessary to increase your dose or try a different medication at this point. Remember that you have the right to ask questions and choose your medication based on what you think is right for you

SIDE EFFECTS

My medication is working, but the side effects are difficult for me to deal with. What do I do?

The first thing to do is talk the situation through with your doctor. It might be that something can be done to help to reduce the side effects. For example, your doctor could change your dose or type of medication, or offer you other drugs to help with the side effects. When deciding what to do, it is important to take into account that another medication may not work for you and that all medication carries a risk of side effects. Lifestyle changes may also help you.

Some side effects are particularly common with certain medications and there are some ways you could try to improve the situation if you are affected:

Tiredness / Sedation
Talk to your doctor about whether you can take your medication in the evening in order to reduce how tired you feel in the daytime. Making sure that you are on the right dose of your medication might also be helpful, to make sure that you are not taking more than you need to be.

Sexual side effects
Some people might find sexual problems embarrassing to talk about. Sometimes these are caused by medication, and sometimes they are caused by a physical or psychological issue. Talk to your doctor about what might be causing your problems and how you can try to resolve them. Although you might find it difficult, doctors will have discussed this sort of problem many times before.

Weight gain
Medication, especially antipsychotic drugs, can cause weight gain. The reasons for this are not clear, but it is thought that some antipsychotics can cause people to become hungrier. It is important to try to eat well and ensure that you have healthy snacks available so that you are not tempted to eat junk food. Also, talk to your doctor about what can be done to lessen the weight gain. Your doctor may refer you to a dietitian or offer you an ‘exercise prescription’, for example.

Clinical guidance states that people with bipolar disorder and schizophrenia should receive an annual physical health check.

The side effects of my medication are unbearable. Can I stop taking it?

You should be very careful about this because there can be severe consequences if you stop taking your medication suddenly without taking the advice of a doctor. For most medications, withdrawal of the medication should be done slowly. In some cases, the process will take months in order to be done safely. In other cases, side effects will be very serious and so the medication will have to be withdrawn more quickly than usual.

If you are having serious side effects, contact your doctor and make an appointment to discuss the problem as soon as possible.

CHALLENGING

What are the first steps towards challenging my doctor about a medication decision?

Guidance produced by the General Medical Council (GMC) states that doctors should be open and honest about why they have made a decision. They should listen to your concerns and take any reasonable requests into account. Sometimes, however, a doctor and a patient can disagree about what should happen during treatment, or mistakes can be made.

It is best if possible to try to resolve any disputes informally at first. If you have regular appointments, you could use your next one to discuss this. If you have not got an appointment coming up, then you can make one. Prepare for your appointment with questions you would like to ask and a list of your concerns. You may wish to write some of these things down to help you remember them. Perhaps you could ask a carer, friend or relative to go to the appointment with you if you think that it will help. You could also see whether there is an advocate in your area who can help. If you have a care coordinator, perhaps they could support you at an appointment.

Negotiate with the doctor and try to find out the reasons why they have made their decision. If the doctor seems to be refusing to negotiate about a particular issue, find out whether there are good reasons for this.

More formal ways of trying to resolve an issue include writing a letter to your doctor asking for your concerns to be taken into account, possibly by making reference to guidance produced by a governing body such as the GMC or the National Institute for Health and Clinical Excellence (NICE).

It is best, wherever possible, to keep a good relationship between you and your doctor. So it may be best to try the least antagonistic way of resolving a problem to begin with and to be diplomatic when raising issues. If your doctor is obstructive or will not listen to your concerns, then you can try more formal ways of resolving the problem.

What can I do if my doctor won’t help to resolve my problem?

If your dispute with your doctor is about your diagnosis or treatment, you may wish to ask whether you could be referred for a second opinion.

Ultimately, if your relationship with your doctor has broken down completely, a dispute cannot be resolved or if you feel as though you have been treated badly, you could use the NHS complaints procedure.

If you think your doctor has seriously breached his or her professional code of conduct, you could also consider reporting them to their governing body, the GMC. This option is only appropriate where a doctor has acted very badly by, for example, committing a criminal offence, making serious mistakes repeatedly or being dishonest. It is not a way of resolving simple disagreements about medication.

I believe I have been treated negligently by my doctor, what can I do?

If you feel that you have suffered loss because your doctor has acted in a way that no reasonable doctor would act, you may wish to consider taking legal action.

Our sections on clinical negligence and getting legal advice and assistance will provide you with further information.

My doctor says that the treatment I want isn’t available on the NHS, what can I do?

Unfortunately, due to limited resources, the NHS may not always be able to make all treatment options available in your area. If your local NHS services do not offer a type of medication that you would like to try, you could try making an ‘Individual Funding Request’ in order to get this funded by the NHS. You can find further information on this in our Rights in Relation to NHS Treatment section.

MENTAL HEALTH ACT

When you are detained under certain sections of the Mental Health Act 1983 (MHA), you can be treated without your consent using a medication that your doctor thinks is most appropriate for you. However, you should still be asked whether you consent to treatment before it is given to you. It is important that your doctor asks you questions and looks over your medical notes so that the right medication can be chosen for you.

You can try to resolve disputes about medication in the ways set out in this section. However, your ability to stop medication is affected by your status under the MHA. You should have access to an Independent Mental Health Advocacy (IMHA) scheme if you would like an advocate to help you to discuss medication problems with your doctor. Your friends and family could also help you if you are willing for them to be involved with your care.

CHECKLIST

•What is my diagnosis and what does this mean?
•Why have you chosen this particular medication for me?
•What is the usual dose of this medication?
•Which symptoms should this medication help with?
•Are there treatment options that I could try that don’t involve drugs?
•What are the likely side effects? Will they be short-term or long-term?
•What are the chances of experiencing a particular side effect? E.g. weight gain, sexual side effects.
•Are there any other medications that I could try instead if I wanted to?
•How long will it take to work?
•How long will I have to take it for?
•Will I be offered a repeat prescription?
•What should I do if it doesn’t work for me?
•What should I do if I get bad side-effects?
•How often will my medication be reviewed?
•(If applicable) Can I drink / smoke when taking this medication?
•(If applicable) Will the medication interact with any other drugs I am being prescribed or herbal remediesI am taking?
•(If applicable) Can I drive while taking this medication?
•How does the medication work?

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