Thinking about Taking Medication?

A friend recently asked me how someone might know when they may be ready to consider taking medication for emotional or psychological concerns. This is an important question and one that strikes at the heart of a complex and still emerging field of research. I first want to emphatically note that I am not a psychiatrist or medical doctor and what follows is not medical advice. What I’ve written below is information that I, personally, would want my friend to know as they think about taking medication, as well as, some considerations that I think might aid them in the process of discerning whether they feel like medication is right for them. The reasons to consider taking medication and the choice to take medication are vast and varied. By considering only a very limited number of these reasons and offering my personal thoughts on the which information I would try to communicate to a friend I have only scratched the surface on this topic. Still, hopefully my thoughts may be of benefit to someone.

I am aware that there will be those who have had great experiences with medications and who will strongly advocate for its use. There may be those who have had negative experiences on medications and found hope and healing through other means. I think both perspectives are valuable. Medication can and often does help individuals who are in significant psychological and emotional pain.  And, individuals who need medication should not feel ashamed or embarrassed. The need for medication is not a weakness of willpower or a sinful characterological flaw. Medication is not, however, a panacea—a golden bullet that will always and without fail reduce mood swings, anxiety, and general psychological distress. The conceptualization of mental illness as a simple “chemical imbalance” (which may have contributed to the perception of medication as a golden bullet)  is an antiquated misnomer that gives the impression that simply tweaking neurotransmitter systems to the optimal level will bring about psychological relief. This is a drastic oversimplification.

What We Know and Don’t Know (far from an exhaustive list)

• We don’t know what the ideal “balance” of neurotransmitters is for any individual’s brain chemistry. We also do not know whether abnormalities in brain chemistry cause a particular disorder or whether the disorder results in the abnormalities in brain chemistry.
• We don’t know exactly why medication works. Rather than simply increasing chemical levels, some antidepressants seem to actually promote the growth of connections between neurons. Many medications also seem to have indirect effects. That is, they do not immediately affect one’s mood, but rather through affecting other neuronal systems (a process we do not fully  understand yet) eventually bring about a changes in mood.
• We do know that thought, emotion, mood, and behavior may be related to as many as a dozen brain chemicals or more (with some of particular importance i.e. serotonin, dopamine, norepinephrine, GABA, and glutamate).
• We do know that certain mental disorders may be generally associated with abnormalities in a particular brain chemical. When medications that operate on these chemicals are taken, patients often improve.
• We do know that, as a result of some of the best research available, disorders seem to be best conceptualized as interactions between genetics, biology, psychology, environment, and social factors. Therefore, treating the biological (neurotransmitter) dimension of the disorder in isolation may ignore other significant and beneficial areas of growth and gains for an individual .

Hopefully this clears up some of the common misconceptions about medication. Now, in considering whether medication might be an avenue that an individual is interested in pursuing, the follow pieces information are limited and personal thoughts (of a psychotherapist in training, so there is a therapy bias) that may (or may not) be helpful in that discernment:

You have tried psychotherapy and are still experiencing significant distress. Therapy works. For many disorders therapy (whether it is a particular cognitive-behavioral therapy (CBT), acceptance and commitment therapy (ACT), or interpersonal therapy (IPT)) should be the first-line of treatment:

• Psychotherapy is as efficacious as medications for most non-psychotic disorders even in moderate/severe cases. There is also some evidence that while antidepressants work well for severely depressed individuals they are not significantly more effective than a placebo for mild/moderate cases.
• Psychotherapy has more enduring effects than medication for most non-psychotic disorders. That is, there tend to be fewer relapses following the termination of psychotherapy than following the discontinuation of medication.
• Psychotherapy is safer than medication for most non-psychotic disorders. Medications often have a number of side effects associated with their intake; increased suicidal ideation is sometimes among these side effects.

Some individuals may have had negative experiences in therapy or experienced no gains due to the therapist. It is important that your therapist be able to articulate what modality of therapy they are using and what expectations (and why) you should have about improvement through therapy . If you have worked with a competent therapist in a focused and deliberate way on a particular problem and you are still experiencing significant distress or an inability to meet the needs of the day, then this may be an indication that medication might be an helpful option.

You are unable to engage fully in psychotherapy because of the extent of your distress. Sometimes individuals are experiencing such significant distress or impairment that they are unable to actually participate actively in the therapeutic process. For example if you are unable to get out of bed due to lethargy and low mood in order to go for a daily walk or write in your daily thought log then taking medication might give you a sufficient boost to help you begin participating in therapeutic activities.

If you have a psychotic disorder. If you have a psychotic disorder such as schizophrenia, bi-polar, or depression with psychotic features, then taking medication is recommended as the first line of defense:

• Medications are more efficacious than psychotherapy for most psychotic disorders.
• Psychotherapy enhances the efficacy of the medication for most psychotic disorders.

In the past 30 years there has been a recent trend toward prescribing medication in lieu of psychotherapy. In some ways this is understandable. It is easier and significantly more convenient to get medication from a primary care physician than to attend weekly psychotherapy. Also, the ease with which health insurance companies will often cover medication over psychotherapy makes medication less of a financial burden in the short term (since relapse rates are higher with medication, however, individuals may need to stay on them longer, which can ultimately make them more expensive in the long run.)

Advances in clinical psychology have shown the importance of expectations, perceptions, and social interactions in helping regulate mood, stress level, and general psychological health. Addressing these particular areas with cognitive therapy, behavioral activation, or other treatment modalities can often have significant and lasting positive effects on an individual. Still, some individuals may experience significant emotional and psychological pain that is impairing their daily life and causing them significant distress. Others may for various reasons simply not desire to go to therapy. You should not feel ashamed or embarrassed. Talk to a informed psychiatrist about your options. Make sure that they have a concrete treatment plan for you and that they have walked you through what you can expect from the medication which you are considering. Ask for how long you can expect to take the medication and whether there is a plan to taper you off of the medication. Also, ask your psychiatrist whether the combination of medication and psychotherapy has been found to be more effective for the problem that is being treated. In some cases psychotherapy may enhance medication and create longer lasting gains (reducing the likelihood of relapse).

Do you have any stories or experiences concerning medication or therapy that you would like to share? Any questions or points of clarification that we can address? We’d love to hear from you.

I’ll attach some more links to accessible articles on the idea of mental illness as a  chemical imbalances, the efficacy of CBT as compared to medication for treating youth anxiety disorders and social anxiety, as well as an introduction to mental health medications (and here for a more academic review of psychiatric drug efficacy).

Next week we will talk about a cognitive-behavioral model for depression and anxiety. In the subsequent weeks we will discuss some practical ways that you can cope with depression and anxiety.