What Medication Can and Can’t Do

People come in wanting a pill that fixes their life. They don’t say it that way. They say “I just want to feel like myself again,” or “I need something to take the edge off,” or “my buddy got on Lexapro and it changed everything for him.” Underneath all of those sentences is the same hope, which is that a chemical compound, taken once a day with breakfast, is going to quietly rearrange the parts of life that hurt.

It won’t. I have to say that carefully because medication does help, it helps a lot of people a lot of the time, and I prescribe it every working day. The version of help it delivers is just not the version most people are picturing when they fill the first script.

The honest version goes like this. Medication turns the volume down on the stuff that’s screaming so loud you can’t hear yourself think. It doesn’t change the situation that was screaming at you. The job is still your job, the marriage is still your marriage, your mother is still going to call on Sunday with the same opinions she had last Sunday. The medication makes the worst of the noise quieter so the rest of the work becomes possible to do. The work is still on you.

The marriage Zoloft was supposed to fix

Say you’ve got a guy who comes in for what he calls anxiety and low mood. Two sessions in, what he actually wanted to talk about was his marriage, which had been over in every meaningful way for a long stretch of years. He and his wife were roommates with a shared mortgage. He’d tried therapy alone, half-attended couples therapy and quit, he’d tried gritting through it. Now he was here for the medication option, which he’d been resisting because his dad was on three psychiatric drugs and he didn’t want to “end up like that.”

We started Zoloft (sertraline, one of the more boring SSRIs, the workhorse first-line antidepressant most people land on first). 50mg, then 100mg by week four. It worked the way Zoloft usually works. His sleep got better, the 4 AM ruminating stopped, he wasn’t crying in the car on the way to work anymore. By week eight he felt, in his words, “like a person again.” Around week ten he came in and told me he was disappointed.

I asked him what he’d been hoping for. He thought about it for a long minute and said, “I think I was hoping it would either make me ok with the marriage or make me brave enough to leave it. It didn’t do either one.” Yeah. That’s almost always the conversation, eventually. Zoloft did exactly what Zoloft is supposed to do. It turned the volume down on a nervous system that was screaming, which let him sleep, which let him think. It was never going to tell him whether to stay or go. That’s a decision the medication cannot make for him no matter the dose, and honestly anybody selling you a pill that makes the hard conversation with your wife happen for you is a damn liar.

Where the inflated expectations come from

Direct-to-consumer drug ads are a real piece of this. The US and New Zealand are the only two countries that let pharmaceutical companies advertise prescription drugs on TV, which honestly explains a lot about our industry, and you can hear the effect in the language patients bring into the room. The woman on the commercial walks out into the sunshine and pets a golden retriever, voiceover says her depression got better. What it doesn’t show is that her job is still her job, her ex is still her ex, and her mother is still going to call on Sunday with the same opinions she had last Sunday.

The other piece is just hope. People come in suffering, they want the suffering to stop, and “take this pill” sounds cleaner and faster than “go reorganize your life.” I get it, if I were on the other side of the desk I’d want the pill too. Medication is the option that doesn’t require you to have a hard conversation with your wife or to admit your drinking has been a problem for years or to acknowledge that the job is killing you. Structurally it’s the path of least resistance, and humans take paths of least resistance, which is half of psychiatry as a field if we’re being honest.

Then there’s how psychiatry shows up in movies and on TV, which makes psych meds sound either miraculous or evil with no ground in between. The actual truth is so much more boring. They help some symptoms some of the time, partially, and the rest is on you, and saying that out loud in a marketing meeting would get you fired.

I was hoping it would either make me ok with the marriage or make me brave enough to leave it. It didn’t do either one.

What I end up saying in nearly every first appointment

I keep a mental list of what comes out of my mouth in almost every first visit with somebody starting a psych med. Worth writing down.

The stimulant point is one I end up making constantly, especially with the guys who are convinced they have ADHD because they can’t focus at work. Say you’ve got a guy who sounds like he probably does have some inattentive traits, you do the workup and try Vyvanse 30mg, then 50mg. The focus came in fine. Three months later he sat down and said, “I can pay attention to my work now, and I’ve realized I hate my work.” The stimulant did exactly what stimulants do, which is remove one obstacle, and what was left underneath was the actual problem he’d been medicating around for a decade. Also worth noting on stimulants, which I’ll cover elsewhere too, that they aren’t no-risk in anybody with a heart history, and the prescriber who tells you they’re completely safe in cardiac patients is a damn liar.

Medication doesn’t replace therapy either, and this one I have to repeat all the time. SSRIs work better in combination with CBT (cognitive behavioral therapy, the structured worksheet-and-homework kind, not the talk-about-your-mother kind) than alone for most anxiety and most depression. The drug turns the volume down, the therapy teaches you what to do in the quieter room. Skip the therapy and what you usually get is about six months of feeling somewhat better followed by a slow drift back toward where you started, because nothing about how you actually respond to your life has changed.

“I felt great so I stopped” is the move that breaks my heart

This is the thing patients do that breaks me a little every time it happens. Person starts Lexapro, feels awful for two weeks, pushes through. Around week six they start to feel like themselves. Around month four they feel pretty good. Around month six they decide they don’t really need the medication anymore because they feel fine, and they stop, sometimes cold, sometimes tapering on their own without telling me. Six weeks later they’re back, the depression is back, and now they’re also dealing with the disappointment of having “failed” at being off medication. They didn’t fail at anything. They just stopped the thing that was helping while it was helping, and got the predictable result.

The lesson is the whole point of the post. You felt great because the medication was working. The medication working doesn’t mean you no longer need the medication, any more than your blood pressure being controlled means you can stop the lisinopril. For some people, eventually, yes, you can taper off, that’s a conversation to have with your prescriber and it’s usually after nine to twelve months of stability and it’s slow. It isn’t a decision to make alone at month six because you’re feeling good on a Tuesday.

Where this lands, and what the appointment is actually for

Two things, mostly. The first is that the medication’s job isn’t to be the thing that makes life good. The job is to bring you back to a baseline where the rest of the work becomes possible. Therapy, relationships, sleep, exercise, the hard conversations you’ve been avoiding for a decade. The pill clears the fog. Walking out of the fog is still on you.

The pill clears the fog. Walking out of the fog is still on you.

The second is the part everybody who walks in here needs to hear out loud at least once. If you want the medication, you get the medication. I’m a provider, not a parent. My job is the honest take on what’s likely to work and what the trade-offs are, your job is the choice. Sometimes that means I’m writing a script I’d personally have voted against if it were my appointment, and that’s fine, the appointment isn’t mine. The most I’ll do is make it a disapproving yes, where you walk out with the prescription and a clear picture of what I’d watch for and why I wasn’t thrilled about it. I hardly ever say no. The field gets this wrong in both directions, by the way. Psychiatry overmedicates patients who could be doing the work without it and undermedicates the ones whose chemistry has made the work impossible, and most prescribers pick a side of that error and stay there.

What I tell patients, often more than once, is that the appointment isn’t really about whether the medication is the right thing. It’s about whether you and I have an honest read on what the medication can and can’t do, so the version of you a year from now isn’t the version sitting back in this chair wondering why the Zoloft didn’t fix your marriage.

Sources

1. Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet. 2018;391(10128):1357-1366. PMID 29477251.
2. Cuijpers P, Sijbrandij M, Koole SL, et al. Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis. World Psychiatry. 2014;13(1):56-67. PMID 24497254. (Combined treatment beats medication alone in depression and anxiety)
3. Bandelow B, Reitt M, Rover C, et al. Efficacy of treatments for anxiety disorders: a meta-analysis. Int Clin Psychopharmacol. 2015;30(4):183-192. PMID 25932596.
4. Cortese S, Adamo N, Del Giovane C, et al. Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder. Lancet Psychiatry. 2018;5(9):727-738. PMID 30097390.