Judith S. Beck, PhD, President

Anti-depressant medication can play an important role in the treatment of depression, but clients may struggle to take medication consistently, manage side effects, or respond to unhelpful thoughts and beliefs that interfere with adherence. Cognitive Behavior Therapy (CBT) can help clients address both psychological and practical barriers to medication adherence. They can provide support to clients who are anxious about starting or continuing to take an anti-depressant or who are having trouble remembering to take their pills. CBT therapists can also help when clients fear getting side effects or do experience side effects, and when they taper their medication.

Conceptualizing Non-Adherence

 Sometimes clients are reluctant to start an antidepressant. Or they may miss some doses or stop taking their medication prematurely. In these cases, therapists should conceptualize the difficulty. Did unhelpful thinking get in the way?

Increasing Medication Adherence

A male client meets with a therapist.

The use of standard CBT strategies often improves adherence. Many clients have negative thoughts and beliefs about medication, for example:

  • “Medication can be toxic.”
  • “Taking medication shows I’m weak.”
  • “People will think I’m crazy.”
  • “I’ll have intolerable side effects.”
  • “I should get better on my own.”

Common techniques to address concerns like this include:

  • Psychoeducation
  • Examining the advantages and disadvantages of taking medication versus the advantages and disadvantages of not taking medication
  • Examining how the antidepressant may allow clients to live in alignment with their aspirations and values
  • Employing Socratic questioning to evaluate the validity and utility of clients’ cognitions
  • Decatastrophizing clients’ fears (“If the worst happened, how would I cope with that?” “What’s the most realistic outcome?”)
  • Testing clients’ assumptions through behavioral experiments (“Medication won’t work.”)
  • Using guided discovery to elicit and respond to the meaning of taking medication to the client
  • Suggesting the client bring the first dose of a medication to treatment and take it at the beginning of the therapy session.

When clients are reluctant to take meds, but do so anyway, it’s important for them to give themselves credit and for therapists to provide positive reinforcement.

Solving Practical Problems

Practical problems can also interfere with adherence, especially remembering to take the medication. Clients can be encouraged to

  • set a daily alarm on their phone,
  • put the medication in plain sight on a bathroom or kitchen counter,
  • pair taking the medication with another action (such as eating breakfast), and/or
  • use a days-of-the-week pill organizer.

Some clients also need practical advice about remembering to take medication with them when they’re away from home.

Addressing Predicted Side Effects

Fears or concerns about side effects may arise before a client actually starts an antidepressant. Clients may fear physical harm (“What if this medication damages my brain?”) or loss of control (“What if it affects my thinking?”). They may be concerned about becoming dependent on the medication (“What if I get addicted and can’t stop taking it?”). They may be afraid of an increase in negative mood (“What if it makes me feel even worse?”). They may predict sexual side effects (“What if I can’t function sexually?’) or changes in their appearance (“What if I gain weight and can’t lose it?”)

Therapists should use both psychoeducation and strategies to decatastrophize the feared outcome. And it’s frequently useful to collaboratively develop a list of questions and concerns for the client to ask the prescriber.

Managing Actual Side Effects

Distressing cognitions may also arise once clients start taking an antidepressant and experiences symptoms. The symptoms may indeed be side effects of the medication. Or they may be due to something else, for example, the sensations may actually be a sign of intense anxiety related to their negative thoughts and images.

It’s important to validate the clients’ symptoms and discuss their options. “I’m sorry you’re experiencing headaches. Had [the prescriber] mentioned headaches as a potential side effect? Did they say whether most side effects were likely to be temporary or to persist? Could there be other explanations for your headache? Would you like to contact [the prescriber] if your headaches persist or get worse?  

Also ask clients about potential hypervigilance. “Do you think you could be scanning your body for side effects? One thing we know is that when we pay too much attention to a symptom, it increases its intensity. Maybe you’ve seen this yourself when you have a mosquito bite. Have you noticed that when you focus on it, the itching gets worse? But if you get distracted, it doesn’t bother you as much. Do you think you could be paying too much attention to [the symptoms]?”  

Likewise, question clients about reassurance seeking. “How much searching have you been doing online about side effects—or asking other people about them? What did you find out? How did that affect your anxiety? Seeking reassurance can actually increase anxiety. Is that what you’ve discovered?”

Helping Clients Taper Antidepressants

Some antidepressants are more likely than others to cause withdrawal symptoms when clients abruptly stop taking them. Clients should ask their prescriber for a schedule to reduce the dose. Symptoms can begin within a few days of stopping an antidepressant and can persist for days or weeks or even longer.

When a prescriber recommends that a client taper their antidepressant, the therapist can

  • provide psychoeducation about withdrawal symptoms,
  • differentiate between normal low mood and depression,
  • identify clients’ worst-case scenarios (e.g., “If I reduce my dose, I’ll get depressed again”) and collaboratively develop a concrete plan of what to do if that happens, and/or
  • collaboratively develop a relapse prevention plan, including the client’s early warning signs of depression (such as avoidance) and the steps the client should take if they become aware of these signs.

CBT therapists can help clients navigate challenges in taking antidepressants by addressing unhelpful thoughts and beliefs, helping them manage side effects, and developing strategies to overcome practical barriers to adherence.

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