Jagged Little Pills

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.

11 Replies to “Jagged Little Pills”

  1. The book Starving in the Silences makes an astute observation about the treatment of anorexia that I think extends to other mental illnesses: that the course of treatment is often determined along class lines. This is something you touch on lightly towards the end, but I think it deserves emphasis that medication is often the cheapest, easiest route. True, most counties offer free or state-subsidized mental health options, but they are woefully inadequate, especially for illnesses like eating disorders that require more specific treatment. Attending therapy also requires shuffling lives (arranging transportation, childcare, etc.) in a way not everyone is capable of. When faced with few options, some hope is better than no hope. Cue the pill.

  2. Micco,

    Thanks for your comment. You are right – the course of treatment for mental illness is often determined along class lines. Finances dictate the course of treatment not only on the end of the pharmaceutical companies and insurance carriers, but also on the end of the consumers who are unable to afford comprehensive health care. This is completely unacceptable. All Americans, regardless of race, age, ethnicity, or socioeconomic status, deserve local, high-quality, affordable, evidence-based mental health treatment including psychiatrists, psychologists, and other mental health professionals. Part of the problem is that the government, the insurance companies, and society in general do not share my conviction that psychological treatment is a necessity, not a luxury.

    I think it is dangerous, however, to presume that inadequate or insufficient mental health treatment (e.g. low dose of medication prescribed by primary care physician) is better than no treatment at all. All psychotropic medications have side effects, some of which are very serious, and people who are taking them deserve to be under the care of a psychiatrist who provides adequate follow-up. I believe that many of the suicides that have occurred in patients, supposedly as a consequence of taking antidepressants, could have been prevented with thorough evaluations by specialists and frequent, thorough follow-up care.

    None of these issues are the patients’ fault or the patients’ responsibility. Patients are simply trying to do the best they can do with the limited finances, resources, and information they have. If I were uninformed about mental health treatment and lacked the finances for specialized care and therapy, I’m sure I would use my internist for psychotropic medication as well if I thought I needed it. The point is that it shouldn’t have to be this way. The government, the pharmaceutical industry, the insurance companies, and healthcare professionals have the resposibility to work together to devise a better plan for comprehensive, high-quality, evidence-based mental healthcare for all American citizens, regardless of their ability to pay.

  3. I take an SSRI and I’m fairly upfront and honest about it. But maybe I’m lucky in that this ‘jagged little pill’ doesn’t completely do away with my anxiety and depression. It just enables me to do the work I need to do in therapy.

    I’m lucky in the sense that I have the resources (and yes, the sheer stubbornness) to access the care that I need. I have done both CBT and DBT work and found them to be tremendously helpful. Without my meds, I would be so depressed and anxious I wouldn’t get out of bed except that I would hope I might get hit by a bus while I was out. My therapy is a long way from over- though I’ve been seeing a therapist for the greater part of the last 8 years, much of that time was pretty useless. I don’t know if I’ll be able to discontinue the SSRI after I have developed a strong repertoire of coping skills. Given my history (both personal and family), I highly doubt it. I don’t like it, but I’m becoming much more okay with that fact.

    The irony is that advertising for psych meds has made some of the people who desperately need them (read: some of my relatives) unwilling to take them as all of the ads have left a bad taste in their mouths. Yet many people find themselves medicated unnecessarily due to lack of resources/knowledge/time.

  4. Hi Carrie,

    It sounds like your story is a perfect illustration of the points I’m making. Like you, most people taking SSRI’s find that these meds allow them to function and bring them to the point that their brains are working well enough to engage in therapy. But also, like you, most people on SSRI’s find that they don’t completely resolve their symptoms. In this way, meds for bipolar disorder, major depression, and OCD,are analagous to weight restoration in AN.

    Many people, due to the nature of their illnesses and family history, will probably need to stay on SSRI’s for the rest of their lives. Even so, evidence-based therapy can take them from “functional” to “fulfilled.” It sounds like this is what you’re working towards. For people in this category, medication is necessary but not sufficient. There’s absolutely nothing wrong with lifetime medication treatment if that’s what you need. SSRI’s are a great tool, and successful management of mental illness involves good self-care, therapy, mindful awareness of symptoms, and using all of the tools at your disposal to help yourself.

    It is such a shame that advertising has turned off people who could genuinely benefit from medication. I see this a lot, too.

    Thanks for your input, and best of luck.

    – Sarah

  5. Dr. Ravin,

    The phrase “necessary but not sufficient” is so perfect in this case. For me to live a “normal” life (yes, I know, normal is just a setting on the washing machine, but it works in this context), I need meds. But it’s not enough. Sort of like weight restoration- necessary but not sufficient for full recovery.

    A great book I just read that reminded me of this post a bit was “Lincoln’s Melancholy” by Joshua Wolf Shenk, which talked about how learning to deal with your mental health issues can be empowering.


  6. I agree with almost everything you have to say except that insurance companies should reimburse therapists at the same rate as psychiatrists. A psychiatrist has completed four years of professional school plus at least four additional years of residency training after that. It’s already difficult enough to recruit medical school graduates into fields like psychiatry that are not as well compensated as the procedure oriented fields. And it’s even more difficult in psychiatry to incorporate psychotherapy into practice when you could fill that same hour with four fifteen minute med checks. So, to put the psychiatrist on the same billing level as someone who has spent considerably less time in training and has a lower debt level is a step backwards for the mental health field.

  7. Hi Elizabeth,

    Thank you for your comment. I think you might not realize how much training psychologists actually have. I spent 7 years in a very demanding Ph.D. program in Clinical Psychology, followed by a residency which I am still in the process of completing. Clinical psychology Ph.D. programs are highly competitive, highly selective, and lengthy (average time to completion is 7 years). We also have to do a 1-2 year residency. So the length of time we spend in training is equivalent to the 4 years med school plus 4 years residency that psychiatrists complete. I won’t go into specifics, but doctoral students in psychology certainly rack up their share of student debt as well!

    I’m not saying that psychiatrists should be reimbursed less. Rather, I’m saying that psychologists should be reimbursed more. Clinical psychologists are doctoral-level professionals with highly specialized training, and they should be compensated as such. Master’s level mental health professionals, such as clinical social workers and licensed mental health counselors, have considerably less training (usually only 2 years). It would make sense to reimburse them at a lower rate than psychiatrists.

    It is such a shame that it’s hard to recruit med school graduates into psychiatry. We could certainly use more psychiatrists.

  8. I was aware that the training in clinical psychology can be lengthy depending on what route you choose, and I’m sure individuals with a PhD in clinical psychology do deserve better reimbursement. Yet, a psychiatrist is qualified to provide what the clinical psychologist does, psychotherapy, with the addition of continued evaluation of the need and benefit of psychotropic medications. So, theoretically, a psychiatrist engaging in psychotherapy could be fulfilling two roles- psychotherapy and medication management. I think that alone would merit a higher level of compensation. Also, psychiatrists tend to be referred the more complicated patients- patients who have been seen by therapists but now need medication in addition to behavioral therapy, patients with disorders like schizophrenia that cannot be managed by behavioral therapy alone, patients who have been seen by primary care physicians for ADHD, anxiety, depression, etc. and failed to respond, and patients with problems that intertwine with other medical conditions. Even within medicine, doctors tend to bill more based on increasing complexity. So, a practice composed of patients with bipolar disorder, schizophrenia, patients with depression or anxiety that have failed to respond to first line treatments, etc. seems to me to deserve a corresponding increase in compensation. Given the shortage, especially of child psychiatrists, I would hope most psychiatrists aren’t caring for patients who could have been managed just as well by a therapist alone or a therapist working in tandem with a psychiatrist for the medication piece. (In general, I actually think the latter situation is the ideal one for patients who require medications)
    I suppose I could be a little bit prejudiced, though, by the fact that I’m getting a medical degree and not a PhD:)… In any case, it may be a foolish point to argue, as I doubt financial compensation for any of the mental health fields will improve in the immediate future.

  9. Hi Elizabeth,

    I’m sure you and I are both biased as a result of our specific degrees and career paths 🙂 Nonetheless, I really appreciate the dialogue. This is an important issue that deserves intelligent debate.

    In my experience, psychiatrists really run the gamut in terms of their training and the services they provide. I know some psychiatrists who are excellent psychotherapists, who use psychotherapy and medication for the majority of their patients. I know other psychiatrists who do no psychotherapy whatsoever and view themselves purely as psychopharmacologists. I have met many psychiatrists (mostly younger ones) have little or no training in psychotherapy. I think compensation should be based on the types of services actually rendered, meaning psychiatrists who play the dual role of therapist and psychopharmacologist deserve higher compensation than those who play only one of these roles.

    In any event, I agree with you that all psychiatrists deserve better compensation. Maybe a pay increase would compel more talented young doctors to go into psychiatry.

  10. I read your article on psychiatric medications with interest. It’s an unfortunate trend that unproven pills are being pushed for uses they were never studied for.

    You mentioned Abilify. I wrote an article on the lack of science behind that pill for depression. See here. And as for antidepressants? We simply don’t know enough about them.

    I hope that you find those articles useful. Your readers may also be interested in them.



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