Category: Psychotropic Medication

More Americans than ever before are taking psychotropic medication. The number of people on antidepressants doubled between 1996 – 2006, yet the number of people seeing mental health professionals declined during that time period. Over 80% of prescriptions for psychotropic drugs are written by primary care physicians. I find these trends a little hard to swallow.

The overuse of psychotropic medication and the corresponding underutilization of behavioral and psychosocial treatments are disturbing on several levels. First, these trends are clearly driven by greed and profit. It serves the financial interests of the pharmaceutical industry and the insurance companies to minimize patient contact with healthcare professionals, even at the expense of quality of care. Pharmaceutical companies, with their numerous advertisements on television, on the internet, and in magazines, have the potential to reach a very large number of consumers.

Second, clients are not fully informed about all of their treatment options. More information is usually better than less information. The problem, however, is that most Americans don’t have the education and training to understand this information, nor should they. It is up to the professionals to use their knowledge and expertise, as well as their clinical judgment, to decide whether, when, and what medication to prescribe for a particular patient. That’s the way it should be. Remember the good old days when your doctor told YOU which medications you should take? Now, the commercials use cartoon neurotransmitters and wind-up dolls and present overly-simplified portraits of recovery from depression, while urging you to “Ask your doctor” how the drug du jour can help you. Another ad reads: “Taking an antidepressant? Still having symptoms of depression? Adding Abilify to your antidepressant may help.” The benefits are exaggerated and the serious side effects are downplayed. The ad does not tell you that psychotherapy, lifestyle changes, increased social support, improved nutrition, regular exercise, and adequate sleep are also likely to help. But hey, who has time for all of that? And when is the last time you saw a TV commercial touting the benefits of Dialectical Behavior Therapy? The result of this advertising is that patients go to a psychiatrist who quickly prescribes a medication after a brief evaluation and, in most cases, does no psychotherapy whatsoever. Even worse, the majority of patients will go to their primary care physician who, after a five or ten minute conversation, prescribes the psychotropic medication that the uninformed client saw on TV last night or the one of which she has samples left over from yesterday’s drug representative’s visit. There is usually minimal, if any, follow-up care, and many of these patients are maintained on a dosage of medication that is so low that it results in no therapeutic benefit whatsoever. Except maybe a placebo effect.

Third – and this point is closely related to my first and second points – clients are not getting adequate, quality mental health care. For many mental illnesses, such as panic disorder, bulimia nervosa, mild depression, generalized anxiety disorder, and PTSD, certain forms of psychotherapy are more effective than medication. For other mental illnesses, such as recurrent major depression, the combination of psychotherapy and medication generally produces the best outcome. In many cases, adding psychotherapy to medication treatment allows clients to take fewer medications and lower doses of medication. Clients who receive a combination of psychotherapy and medication are less likely to relapse when the medication is discontinued, compared to clients who are treated with medication alone. The benefits of good psychotherapy are long-lasting and, in some cases, curative. In contrast, medication is merely palliative, and its benefits usually fade once it is discontinued. For certain conditions, such as bipolar disorder, schizophrenia, and recurrent major depression, medication is clearly indicated as a necessary component of treatment and should be started immediately after diagnosis. Even in these cases, medication alone is often insufficient. Clients’ symptoms can be reduced even further, and their quality of life improved even more, when psychotherapy is combined with medication.

Finally, the fact that psychotropic medication is grossly over-prescribed and over-marketed seems to trivialize the experience of people who genuinely need psychiatric medication. Many times, I have raised the issue of psychiatric medication with clients whom I think can benefit from it. Many times, they have responded: “Oh, no. I don’t want to take a happy pill.” Or “No, I don’t want to use medication as a crutch.” Or “I don’t want to become dependent on something.” Or “That’s the easy way out.” I believe that our society’s nonchalance regarding psychotropic medication is directly responsible for some clients’ aversion to it. However, the fact that psychotropic medication is prescribed at the drop of a hat does not negate the reality that some people genuinely need it and some people truly benefit from it.

My own experience as a therapist has reinforced what I have learned by studying the research. My views on psychotropic medication can be summarized as follows: medication can be a very helpful adjunct to psychotherapy for clients who clearly need it. In other words, while I am by no means anti-medication, I am somewhat conservative in my approach to it. Case in point: although virtually all of my clients have a diagnosed mental illness, only half of them are taking psychotropic medication. For most clients, the first form of treatment should be psychotherapy focused on improving self-care, making lifestyle changes, acquiring coping skills, improving symptoms, and dealing with interpersonal issues. Medication may be introduced as an adjunct to therapy if the client does not make substantial improvement with therapy alone. I have seen many clients make marked improvements or recover completely without ever taking psychotropic medication. With clients for whom medication is clearly indicated (e.g., those with bipolar disorder), I will refer them to a psychiatrist immediately while also emphasizing that therapy, behavioral interventions, and self-care are important aspects of treatment as well. I don’t like my clients to take psychotropic medication prescribed by their family doctor for all of the reasons mentioned above. If a client comes to me on a psychotropic medication prescribed by their family doctor, I explain the importance of seeing a psychiatrist (e.g., they have specialized training in psychiatric illnesses and are more knowledgeable about psychotropic medication, they provide more thorough evaluations and better follow-up care than general practitioners) and I provide them with psychiatric referrals.

In order to rectify this situation, I believe that the following things must happen:

1.) Primary care physicians should not prescribe psychotropic medications. Instead, they should identify those patients who may have a mental illness and refer them to a psychologist or a psychiatrist for treatment.
2.) Psychiatrists should fully inform patients about the risks and benefits of taking medication, the risks and benefits of not taking medication, and scientifically-sound information on the effectiveness of medication. In addition, psychiatrists should inform patients about the effectiveness of various forms of psychotherapy, either in lieu of medication or in addition to medication. Psychiatrists should only prescribe medication to patients who are also in therapy.
3.) Psychologists and other therapists should be conservative in referring patients for psychiatric treatment and in recommending psychiatric medication.
4.) The pharmaceutical companies should stop advertising to consumers. They can still market themselves to physicians and mental health practitioners, since these professionals have the training and knowledge to use this information appropriately.
5.) Insurance companies should provide coverage for psychotherapy that is equal to the coverage they provide for psychotropic medication. Likewise, insurance companies should reimburse psychologists and other therapists at the same rate as psychiatrists.
6.) Every American should have access to local, affordable, quality, evidence-based psychotherapy.

Optimistic? Yes. Idealistic? Yes. Impossible? Absolutely not. It may not happen anytime soon, but for now, I can practice what I preach and apply my philosophy to my own clinical work.