Medication presents me with an, at times, difficult dilemma. As a psychiatrist, it is one of the more powerful weapons in my arsenal for helping my patients feel better. As a psychotherapist however, its introduction can bring with it unintended ramifications. Here are some of the pros and cons as I see them:
1) Known effectiveness. Antidepressants are known to be the most effective treatment for depression, edging therapy alone, and they work pretty quickly. Though 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 which are quite inexpensive. In any case, once a week or more therapy can be much more costly.
Sounds good so far, but what are the downsides?
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.
5) Related to the dependency issue above, is the concern that medication can sometimes alleviate the symptoms of depression or anxiety to the extent that one loses the motivation to address the underlying environmental or psychological stressors that caused the anxiety or depression in the first place. If this happens, one no longer has the sense that anything is wrong until a trial wean of the medication is attempted, and the symptoms recur.
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, in other cases I may discourage it. Sometimes, 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 you something reasonable to consider. In my own practice, I try to get patients off medication when I think it is safe to do so. I do get resistance at times. What do you think? Do you feel medications are overused or not used enough?