Shirah Vollmer MD

The Musings of Dr. Vollmer


Posted by Dr. Vollmer on November 17, 2010

Jack,  was feeling quite depressed for a sustained period, months. I started him on Wellbutrin, along with twice a week psychotherapy, but he was still tearful, he had concentration problems, he lacked motivation to see his friends, he felt pessimistic about his future. I proposed adding Zoloft, at very low dose to his regimen. He was desperate; he agreed. The next week, I asked him “how is the Zoloft going?” He looked at me as though that were a strange question. “Gee, I have not thought about it. What am I supposed to look for? ” “Well, are you feeling worse? Are you more agitated?” I ask, trying to see if there are negative effects. “I don’t think so,” he responds with some hesitation and surprise at those questions. The following week he comes in and immediately says “I stopped that Zoloft. After you asked me the question, I have been thinking about it. I noticed that I was so agitated and even more depressed. Of course, I did not attribute those feelings to the medication, but then after our last appointment I realize that the timing was such that I was feeling more depressed and more agitated since starting the Zoloft and now that I stopped it I feel much better.” Jack says with relief that he took action which improved his mental state, at least temporarily.

Monitoring of medication is one of the most important jobs of any prescribing physician. Checking in allows both the doctor and the patient to decide if they are on the right course. Too often, medications, particularly psychotropic medications, are prescribed with multiple refills, such that the expectation is that the medication either helps or it does not help, but that observing closely for side effects is not a critical part of the intervention. Of course, when the patient and the doctor pause, observing how the medication interacts with each person’s biochemistry is going to be a unique experience and as such, no generalizations can be made. To some, Zoloft is like it says in my picture; it makes some folks more tolerable. To others, like Jack, Zoloft might be exacerbating his already disturbed mental state. The level of distress is the target; Zoloft, like all psychotropics can help, do nothing, or make it worse. It is that simple. It is also mandatory.  Checking in involves spending time and attention to the patient’s change in mental state. That is not simple, nor is it done as often as it needs to be.

2 Responses to “Zoloft”

  1. Shelly said

    How can you tell which drug to start with? Why didn’t you start with Zoloft instead of Wellbutrin? In the figure, the woman’s comment, “Zoloft has made me so much less of a bit__,” sounds like that is what somebody else has told her, but that is not what she feels. Likewise, Jack had not evaluated how he felt on the Zoloft until you raised the issue with him. My point is, how do patients know if they are better (and I understand that you will say that that is the role of twice a week psychotherapy sessions)?

    • First, there is an art to psychopharmacology. Second, Zoloft is a particularly good SSRI in that it tends to help a lot of people, without the likelihood of weight gain, withdrawal symptoms or major drug interactions. I started with Wellbutrin because his main complaint was concentration difficulties and Wellbutrin increases Dopamine which helps with focus. He did benefit from the Wellbutrin in that way, but his mood remained low. Zoloft can make other people around the individual feel better. Zoloft can decrease irritability which may be out of the patient’s awareness, but those living with him/her can certainly appreciate the difference. Getting better is clearly subjective. That is NOT the role of twice a week psychotherapy. Patients determine when they are better, not the mental health professional. The role of twice a week psychotherapy is to have an opportunity for a more in-depth exploration of one’s inner world. Thanks, as always for your comments.

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