Using Medication

Posted on September 24, 2007

Medication presents me with an interesting and, at times, difficult dilemma. As a psychiatrist, it one of the more useful, powerful weapons in my arsenal for helping my patients feel better. However, its introduction can bring with it unintended ramifications. As an example, I recently saw a patient who had been struggling with a clinical depression for several months, and finally came in. As it turned out, there were several environmental stressors which had placed her in a psychologically difficult bind, which with the help of family we seemed to be able to address effectively. She and her family were very reluctant to accept medication, and while I did think medication would have been appropriate, and would enhance her likelihood and perhaps speed of recovery, I decided not to insist. We agreed on therapy and watchful waiting instead, and to revisit the question if need be.

So what are some the issues with medication?

Pros:

1) Known effectiveness. Antidepressants are known to be the most effective treatment for depression, slightly edging therapy. Of course, the combination of both seems to be the most effective. For other conditions, medication may be even more strongly indicated.
2) Ease and convenience. Taking a pill once or even twice a day is very convenient, and doesn’t take as much time or require the often emotionally difficult work of therapy.
3) Cost. Medication is often expensive, but for some conditions there are generics. In any case, particularly if one doesn’t have insurance, once a week or more therapy can be much more costly.

Sounds good so far, but what are the downsides?

Cons:

1) Negative self-esteem. For many people, there is a belief that “needing” medication means there is something intrinsically wrong with them. Thus, by accepting medication they are accepting that they are “bad” or “faulty” as human beings. This can have the unintended result of creating a loss of motivation or self-esteem, which can interfere with the healing process, and set the stage for treatment resistance or treatment failure. Or, it can exacerbate pre-existing feelings of poor self-esteem which likely contributed to their current problems, and make things worse.
2) Dependency. I will go into this more in another post, but one issue which both psychiatrists and therapists have to address is the issue of dependency. Some patients will come to depend on the medication as a kind of “security blanket”, or transitional object, which represents the doctor, and “health”. When this dynamic is present, it can make the likelihood of sustained remission off medication much lower.
3) Stigma. Besides the personal issues, there are the real issues of what it means to “society” when a person is on, or has been, on psychotropic medication. I recognize that when another physician or therapist takes a person’s history, and that person’s history includes medication, there is a difference in perception, and likely unconscious judgments compared to the person who has never been on medication. Never mind the perceptions and judgments of lay people who may happen upon that history.
4) Known and unknown side effects. Unfortunately, medicines have side effects. For some people they are not noticeable, for others they may be so severe as to preclude using that particular medication. In addition, risks of birth defects or long term potential side effects must sometimes be considered.

So where does all this leave us? In my case, I weigh the pros and cons with my patient and talk it out. In particular cases, I may advocate strongly for medication, in others I may be more neutral, as in the case above, in other cases I may discourage it. It sometimes helps that often I see a patient in referral from another therapist, because then I have an idea that the therapy alone approach has failed. Also, the opinion of another experienced health professional that a patient needs medication, especially when the patient has been seen by that person for awhile, can be a helpful (though not certain) indicator.

As I read over the above, I see there is much left to say, but this is a blog entry and not a book, so I hope I have given the reader something reasonable to consider. There are other pros and cons. In the final analysis, it will up to the patient to choose, and then it will be incumbent on me to try to support that decision as best I can.

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