What Medication Can and Can’t Do

People come into my office wanting a pill that fixes their life. They don’t say it like that. They say things like “I just want to feel like myself again” or “I need something to take the edge off” or “my friend got on Lexapro and it changed everything for her.” Underneath all those sentences is the same hope, which is that a chemical compound, taken once a day with breakfast, will quietly rearrange the parts of their existence 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 of my life. The version of help it delivers is just not the version most people are imagining when they fill the first script.

The honest sentence is this. Medication turns the volume down. It doesn’t change the song, it doesn’t change the room you’re listening in, and it doesn’t pick up the phone and call your mother for you. It makes the worst part quieter, so the rest of the work becomes possible. The work is still yours.

The marriage Zoloft was supposed to fix

I had a patient last spring, a woman in her late thirties, came in for what she called “anxiety and low mood.” Two sessions in, what she actually wanted to talk about was her marriage. Her husband had checked out about four years prior. They were roommates with a shared mortgage. She’d tried therapy alone, she’d tried couples therapy that he half-attended and then quit, she’d tried gritting through it. Now she was here for the medication option, which she’d been resisting because her mother was on three psychiatric drugs and she didn’t want to “end up like that.”

We started Zoloft. 50mg, then 100mg by week four. It worked the way Zoloft usually works. Her sleep got better. The 4 AM ruminating stopped. She wasn’t crying in the car on the way to work anymore. By week eight she felt, in her words, “like a person again.” Around week ten she came in and told me she was disappointed.

I asked her what she’d been hoping for. She thought about it for a long minute. She said, “I think I was hoping it would either make me okay with the marriage or make me brave enough to leave it. It didn’t do either one.”

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. It was never going to tell her whether to stay or go. That’s a decision her medication cannot make for her, no matter the dose.

Where the inflated expectations come from

Direct-to-consumer drug ads are partly responsible. The U.S. and New Zealand are the only two countries on earth that let pharmaceutical companies advertise prescription medication on television, 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. The 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 probably want the pill too. Medication is the option that doesn’t require you to have a hard conversation with your spouse or quit your job or admit your drinking is a problem. It’s structurally the path of least resistance, and humans take paths of least resistance.

There’s also the way psychiatry gets talked about in popular media, which makes psych meds sound either miraculous or evil with very little ground in between. The truth is profoundly less interesting. They help some symptoms some of the time, partially, and the rest is on you.

The pill makes the room quiet enough that you can hear yourself think. It does not think for you.

What I have to explain in nearly every first appointment

I keep a mental list of what I end up saying out loud to almost every new patient. Worth writing down.

The Adderall point is one I end up making constantly. Guy came in two years ago, tech job, mid-30s, convinced he had ADHD because he couldn’t focus at work. We did the workup. He probably did have some inattentive traits. We tried Vyvanse, 30mg, then 50mg. The focus improved. He came in three months later 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. It removed one obstacle, and what was left underneath was the actual problem he’d been medicating around for a decade.

Medication doesn’t replace therapy either. This one I have to repeat constantly. SSRIs work better in combination with CBT than alone for most anxiety and most depression. The drug brings the volume down, the therapy teaches you what to do in the quieter room. Skip the therapy and what you get is six months of feeling somewhat better followed by a slow drift back toward where you started, because nothing about the way you respond to your life has changed.

The “I felt great so I stopped” mistake

This is the thing patients do that breaks my heart a little every time. Person starts Lexapro. They feel awful for two weeks. They push 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 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 in my office and the depression is back, and now they’re also dealing with the disappointment of having “failed” at being off medication. They didn’t fail. They just stopped the thing that was helping while it was helping, and got the predictable result.

The lesson here is the whole point of the article. You felt great because the medication was working. The medication working does not 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, usually after at least 9 to 12 months of stability, and usually slowly. Not a decision to make alone at month six because you’re feeling good on a Tuesday.

What I tell patients, often more than once, is that 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 to do. 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. Some patients hear this and get frustrated. Most, eventually, find it more useful than the version where the pill was supposed to do everything.