Practices

A medicine that lifts drive is not the same as one that settles anxiety, and for some people the energising kind makes the worry louder.

Bupropion is the clearest example: often good for flatness and lack of motivation, often unhelpful on its own when anxiety and a racing, sleepless…

If the usual antidepressants have not reached you, there are treatments that work on an entirely different system in the brain. They are worth asking about.

Esketamine, given as a nasal spray in a clinic, acts on glutamate rather than on serotonin or noradrenaline, and the change it brings can arrive in…

The newer thinking about depression is less about topping up a missing chemical and more about connections that have thinned out being rebuilt. Recovery looks more like regrowth than refilling.

Long stretches of depression seem to leave parts of the brain less richly connected, and some treatments appear to work by helping those links form…

Before anyone concludes that nothing works, go back over the ordinary explanations: a dose that never went high enough, a trial that stopped after three weeks, doses missed on the hard days.

Treatment resistant has a technical meaning, which is that at least two proper trials at a proper dose and length have failed. A great deal of what…

Put something in before you take something out. Removing the only way a person has of coping leaves them with nothing, which is not safer.

In practice this looks like smaller steps than a promise to stop: cutting the frequency, changing what is used, agreeing to wait ten minutes and do…

When something has helped a little and then stalled, adding a different kind of help often does more than pushing harder on the first one.

That is the thinking behind adding a second medicine with a different action rather than only raising the dose of the first, and it is the same…

Six to eight weeks is what an antidepressant needs before it can be judged. The first fortnight will mostly tell you about side effects.

The transporter is blocked within hours, so the delay belongs to slower changes further down the line. In practice that means picking a date four to…

A few treatments are only given in a clinic, with someone sitting with you afterwards. The chair and the hours are part of the treatment rather than paperwork.

Esketamine is the current example. It is a nasal spray, given on site, with a monitoring period of about two hours afterwards because blood pressure,…

With the fast acting treatments, the plan for what happens afterwards matters as much as the treatment itself.

Electroconvulsive therapy can shift severe depression quickly, and without something in place afterwards the relapse rate is high, which is why…

Sometimes the honest answer is that there is nothing in your surroundings to feel good about. Changing them counts as treatment, not as running away.

A life with no friends nearby, no work that means anything and a steady drip of criticism will produce low mood in most people, and skills practised…

If sleep has gone since starting, look at what time the dose is being taken before deciding the medicine is the problem. A long acting dose swallowed at one in the afternoon is still working at bedtime.

Extended release preparations are built to cover eight to twelve hours from whenever they are taken, so a late start pushes the whole thing into the…

Count good days, not unbroken runs. Whatever yesterday was, brilliant or a write off, the only live question is what can be done with today.

Streaks make one slip cost everything, so the missed night turns into a missed week and then the whole effort gets quietly dropped. Aiming for more…

Debt, impulsive spending, an account that never quite recovers: this belongs in the conversation about attention rather than in a separate drawer marked shame.

People hide this part longer than anything else, which means it is usually the last thing to get any help. If you are the one struggling, saying it…

Where anxiety sits alongside the attention difficulty, a non-stimulant is sometimes the better first choice. Stimulants sharpen anxiety in some people, and that is a hard trade to live with.

The same holds when blood pressure rises on a stimulant that is otherwise working, since adding an alpha-2 agent can make it possible to keep the…

The stimulant shortage is not your pharmacy being disorganised. Regulators set a fixed annual quota of the raw material, and the ceiling has been too low to cover the prescriptions being written.

Knowing that changes what you do with your energy. Ringing round twenty chemists is exhausting and it creates no supply, so spend the effort on…

When a prescription cannot be filled, you can report it to the medicines regulator's shortage inbox, naming the medication and the pharmacy. Nobody writes back, and people often find their prescription turns up soon afterwards.

The value of this is partly practical and partly in not being stuck. Being told no at a counter, month after month, is what makes people quietly…

Waking your child at six to give the tablet so it has taken hold by breakfast, then letting them fall back to sleep, is not a strange thing you invented because you are failing. It is a reasonable answer to a real gap in how the medicine works.

Families quietly carry a lot of these. The early alarm, the switch to a faster product, the parent who does the whole morning alone because it goes…

Doing badly on one long acting product does not mean the medicine inside it was wrong for you. The same molecule in a different capsule can behave differently enough to be worth trying before anyone gives up on it.

What gets described as the medicine not working is often the shape of the day being wrong: too slow to start, too abrupt at the end, strongest at the…

People usually stop for one of three reasons: the side effects are not worth it, the price is too high, or the dose was never raised far enough to do anything. The last one is the saddest, because it makes a workable medicine look useless.

If a trial ended with the words nothing happened, it is worth going back over what dose was actually reached and for how long it was held there. A…

Before anyone concludes that medication does not work for you, check what dose was actually reached. Doses in general practice often stay lower than a specialist would use, and a fair share of so called non responders respond once the dose goes up.

You are allowed to ask this, gently and without any accusation in it: what was the highest dose tried, and how long did it stay there? A trial that…