My sister isn’t prescribed a lot of medication, relatively speaking. Every morning she takes Sertraline (anti-depressant, which helps take the edge off of her agitation) and Lorazepam (to reduce anxiety). Every evening she takes Olanzapine (anti-psychotic). She has been using these medications for a few months now and has been generally doing well, with relatively few incidents of extreme agitation/aggression (and those tend to happen when she skips her medication).
I accompanied my sister for her latest visit to the psychiatrist, who said that Lorazepam is not something he usually recommends taking daily, but rather only as-needed. He explained that the effectiveness of the drug goes down when it’s used frequently, and that each pill is really only effective for the 4 hours after it is ingested, rather than for the whole day. My sister, of course, was only too happy to agree to remove it from her list of daily meds and to only take it as-needed.
So she did.
One or two days later she screamed at me while we were talking on the phone, after weeks of not being this agitated. At the time I thought perhaps the circumstances were stressful for her–she had been complaining about a sore throat and asked if we could schedule another botox injection for her vocal cords–and let it go. But the following day she screamed at me again over the phone, and again on the third day (at which point I blocked her, which turned out to be a very good decision).
The coinciding of her stopping with the morning Lorazepam and her becoming much more agitated was hard to ignore. And even though correlation does not equal causation, it was still very suggestive. And of course the causality of the Lorazepam was testable, if my sister were willing, by having her start taking it again.
I called my sister’s psychiatrist to consult with him and to task if it’s reasonable to go back to having my sister take the Lorazepam daily (during our first visit to the psychiatrist, we all agreed that it’s okay for me to communicate directly with the psychiatrist if I have any concerns). He reiterated that the pill should only work for a few hours after it’s ingested, but that if I see such a clear shift in behavior then it’s okay to go back to a regimen that was working, if my sister is willing.
I emailed my sister’s personal helper, who noticed my sister was more agitated, and asked that she discuss it with my sister and suggest adding the Lorazepam back to the daily meds. After they met, the helper said that my sister agreed to take it every other day, which was a good enough start.
I met with my sister a few days later and, after spending a nice hour together (we went out to pick up her medication, went to Five Guys for veggie sandwich and French fries), we went back to her place to arrange meds for the week. We were adding one more medication that my sister has been waiting to receive for a while (Amitriptyline, a daily pill that my sister’s primary care physician prescribed with the hope that it will prevent my sister’s frequent and severe headaches), and I suggested that my sister resume taking the Lorazepam daily. I pointed out that my sister seemed more agitated since she stopped taking it, has been driven to shouting on multiple days, and seems more tense in general. i was in a pretty good place emotionally during the conversation, and I think I was able to communicate this from a place of caring, rather than being accusatory or condescending, A little to my surprise, my sister agreed almost immediately, and arranged her medication accordingly.
It’s been over a week since then, and my sister seems well. I learned two things:
1) Even though the effect of each Lorazepam pill is supposed to be fairly brief, it seems to change the entire day for my sister. Maybe it’s because she starts days with less agitation. Maybe she metabolizes the drug differently than the drug companies (and the psychiatrist) think. Either way, the evidence seems pretty clear.
2) There was no reason to change the medication regimen, since it was working. I’m all for using the least amount of medication possible, but in this case dropping the daily Lorazepam resulted in a significant deterioration in the quality of life for both my sister and people around her. I don’t fault the psychiatrist for suggesting to switch to as-needed, but I’m glad we got it back to daily.