Treatment refusal is a difficult problem that’s somewhat different from simple non-compliance. The reasons may be numerous and they must be explored. Common reasons for not wanting to use antidepressants are the fear patients have that they will no longer be themselves or that they’ll become dependent on the drug. Many feel that this affects the core of who they are as people in a way that drugs for, say, hypertension do not. There’s a very strong double standard when it comes to psychiatry drugs. Many who wouldn’t question using an anti-hypertensive agent or one that provides glycemic control don’t want to take a psychiatric medication. They feel that they should be able to control their mood by sheer will power and that it’s a sign of weakness if they can’t do so. Still others don’t want to take medication because of side effects.

It’s very important to explore all the possible reasons why a patient doesn’t want to take anti-depressant medication, particularly in someone for whom it has worked before. There may be reasons that the patient is reluctant to talk about e.g. they have started a new romantic relationship and had sexual side effects in the past. I find that exploring the reasons — but not too insistently — is usually helpful. Once the refusal is properly understood, the discussion can become more specific. For example, double standards can be pointed out, or strategies for dealing with side effects suggested. Simply showing an empathic understanding of the difficulties of accepting the need for an antidepressant can often go a long way. I’ve had patients in psychotherapy who have taken a couple of years before they have been able to accept a trial of an antidepressant. After exploring the underlying reasons, I bring it up from time to time and gently suggest that it might be helpful. I appreciate that psychiatrists often have the luxury of time but usually the situation isn’t urgent and can wait. If it’s very urgent, the physician might have to certify the patient in order to administer the appropriate treatment.

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