The GoodTherapy.org Position on Psychotropic Medication
As the leading advocate for healthy psychotherapy, we are approached daily by people who want advice about psychotropic medication. The most common question people have is whether GoodTherapy.org recommends medication to deal with mental health concerns such as depression, anxiety, and others. "Should I take medication for _______" is one of the most frequent queries we receive. In all instances we recommend that site visitors discuss medication with their health care providers. GoodTherapy.org is not authorized to make recommendations about medication or serve as a substitute for professional advice. Nonetheless, we aim to provide useful resources about medication to our visitors and clearly outline our position on the use of medication for mental health purposes.
- Medication can be useful. For example, for those with paralyzing anxiety, medication can "turn the volume down." For those unable to get out of bed in the morning because depression has stolen all motivation, medication can provide a "kick-start." And for those with a severe mental health condition such as schizophrenia, medication can be a necessity for stability and/or safety. Therefore, certain people may benefit from taking psychotropic medication, determined by qualified health care providers on a case-by-case basis. For example, a study funded by the National Institute of Mental Health found that some individuals who were prescribed the selective serotonin reuptake inhibitor (SSRI) Paxil for moderate to severe depression experienced, along with an improvement in depressive symptoms, decreases in neuroticism and increases in extroversion, with these personality characteristics changing approximately twice as much in eight weeks as those of most adults do in the course of a lifetime.
- Medication can support the psychotherapy process. Similar to Maslow's hierarchy of needs, it is difficult for most people to focus on symptom relief and self-growth when they are in crisis or struggling with anxiety, depression, or other mental health conditions. In some cases, medication can help to stabilize a person, allowing him or her to progress in psychotherapy. For example, a study published in the Journal of the American Medical Association shows that cognitive behavioral therapy combined with targeted medication tends to lead to significant improvement of attention deficit hyperactivity symptoms in adults. Of course, a common outcome of successful psychotherapy is the reduction or elimination of the need for psychotropic and other medications.
- Medication can be harmful. We recognize that medication is an important part of the therapy process for some individuals. However, psychotropic medications, like all drugs, do not come without potential risks or side effects, including physical side effects such as dizziness, drowsiness, changes in appetite, sleep disturbance, and/or weight gain and emotional/psychological side effects such as mood swings, disinterest in activities, or emotional numbness. Antipsychotics may cause permanent damage by leading to conditions such as tardive dyskinesia or Parkinsonism, and may even cause death if taken for too long or at an incorrect dose. This is supported by a 2005 article in Harvard Mental Health Letter, which details the increasing awareness of risks associated with SSRI antidepressants, such as a potential increase in suicidal thinking and behaviors for adolescents under 24 years of age. While research has shown that there are people who benefit from taking these medications, it has also shown that there are people who may experience lasting harm as a result of antidepressant use. One should always discuss the risks of medication use with a qualified health professional and decide if the risks are worth the potential benefits or if an alternative treatment method may be a better option.
- Medication is not always necessary. While psychotropic medication may be effective for treating some conditions, researchers at the University of Pennsylvania and Vanderbilt University found that 16 months of cognitive therapy were both cheaper and slightly more effective at preventing a relapse into depression than antidepressants alone were, when taken for the same length of time. A study published in the Journal of the Amercan Medical Association found that while antidepressants were helpful for those experiencing severe depression, individuals who experienced mild to moderate depression obtained more benefit from other treatment options, such as therapy, than they did from medication. A 2010 article published in Newsweek supports these findings, citing research suggesting that, for some individuals, antidepressants may only be slightly more effective than a placebo.
- Medication can interfere with the emotions as well as the psychotherapy process. A common side effect of psychotropic medication is difficulty feeling certain emotions once the drug accumulates in a person’s system. For example, many people complain of losing the feelings they used to have, report a reduction in their ability to laugh or cry, or experience a decrease in libido. Side effects of SSRIs that might affect one’s sexuality and love relationships, such as diminished sexual interest, are discussed in a chapter from Evolutionary Cognitive Neuroscience. Medication can also impede emotional processing for some, covering up underlying issues and slowing or hindering the psychotherapy process. A possible consequence of taking too much medication and becoming numb to feelings is the increased likelihood that a person will not become conscious of the emotional or somatic burdens which often fuel symptoms.
The Role of Psychotherapy
Many emotional and mental health issues are not reducible to a biochemical imbalance. Often, psychological concerns originate and are influenced by life events—what happens to and around us. Because medications do not change how people relate psychologically to their experiences, medication alone cannot "fix" all psychological issues. Treatment with medication alone can be like stitching up a bullet wound without taking the bullet out first.
What’s more, according to research done at Northwestern University, oversimplification of what causes depression has led to the development of antidepressant drugs that are actually designed to treat stress. Because the same research shows that, in animal models, chronic stress does not cause depression, these medications are often ineffective. Psychotherapy, on the other hand, is often able to discover and treat some of the mental health issues that may contribute to depression, such as psychological trauma and anxiety. For example, a 1995 Consumer Reports study shows that some individuals experiencing mental health issues were significantly helped by psychotherapy. The study found that long-term therapy had, in general, the most beneficial effect, and that treatment with therapy alone was no less effective than treatment with medication and psychotherapy.
Dr. Daniel Carlat, a psychopharmacologist, wrote about his own experiences prescribing psychotropic medication in the article “Mind over Meds,” which appeared in a 2010 issue of The New York Times Magazine. He found that the individuals he treated responded better to treatment with psychotherapy and medication together than they did to treatment with medication alone, and that by providing more counseling, he was better able to understand the true nature of their concerns. Research supports his findings, showing that therapy can stimulate the growth of neurons and synaptic connections between neurons. Medication for depression, anxiety, and other emotional problems does not do this. This is why therapy is capable of healing core problems and facilitating long-term changes, and why medication alone cannot.
For an in-depth comparison of medication and psychotherapy, read Doctor, Do You Think I Need Medication?
Overview of Psychotropic Drugs and Mental Illness
Psychotropic drugs are prescribed to treat a variety of mental health issues when those issues cause significant impairment to healthy functioning. Psychotropic drugs typically work by changing or balancing the amount of important chemicals in the brain called neurotransmitters. Some mental health issues show improvement when neurotransmitters such as dopamine, serotonin, and norepinephrine are increased or decreased. Psychotropic drugs are usually prescribed by a psychiatrist, a psychiatric nurse practitioner (PMHNP), or a primary care physician; in some areas, clinical psychologists may have prescriptive privileges as well.
One in four individuals, or about 25% of the population, will experience a mental health issue at some point in their lives, according to the World Health Organization. Depression and anxiety are among the most common issues, and these issues can affect people regardless of age, gender, ethnicity, or background. Researchers cannot say with certainty what causes most instances of mental health impairment. Environmental factors and genetics often combine to predispose someone to a particular problem. In other cases, traumatic events or serious injuries result in psychological symptoms that persist for years.
Some individuals feel that psychotropic drugs are often not enough by themselves to help someone overcome a mental health issue, and many healthcare providers recommend that an individual use them as a supplement to therapy, not as a replacement for therapy. Social support from family and friends, structured therapy, lifestyle changes, and other treatment protocols can all be important factors in the recovery process. Severe mental health issues may require inpatient rehabilitation before the person experiencing them can return to everyday life.
Certain individuals who are prescribed psychiatric medications may prefer not to take them, or they find that these medications do not improve their symptoms enough to outweigh any side effects or risks. The Freedom Center's Harm Reduction Guide for Coming off Psychiatric Drugs, a 40-page guide written by Will Hall and published by The Icarus Project and Freedom Center, offers information about reducing or stopping psychiatric medications. The guide is not meant to instruct anyone to stop taking psychiatric medications, but rather, it aims to educate consumers about their options if they decide to explore going off of psychotropic medications.
Psychotropic Medications and Children
A cause of concern to many is the practice of prescribing medications that were originally developed for adults to children. The increase in diagnoses of psychiatric conditions in children---bipolar in particular---has led to an increase in the amount of children who take psychiatric medications, some of which have only been fully tested in adults.
Though these medications have been shown to help relieve at least some symptoms in minors, at least for the short-term, questions have been raised about the long-term effects that some of the medications might have on developing children and whether these children actually have conditions that were originally thought to only exist in adults. In the PBS FRONTLINE production, The Medicated Child, this topic is explored by Marcela Gaviria, who questions psychiatrists and researchers about the risks and benefits of prescribing psychiatric medications to children with mental health conditions.
Types of Psychotropic Medications
Several different types of medications are used to treat mental health conditions. The following is a list of the major categories of psychotropic medications:
- Antipsychotics: These medications are most often prescribed for the treatment of psychotic issues such as schizophrenia. These drugs fall into two categories, typical and atypical antipsychotics.
- Typical antipsychotics include:
- Atypical antipsychotics include:
- Antidepressants are a broad category of psychotropic drugs used for treating depression. There are several different classifications of antidepressants:
- Selective serotonin reuptake inhibitors (SSRIs): These medications gradually increase the amount of serotonin, a neurotransmitter, in the brain. Common SSRIs include:
- Monoamine oxidase inhibitors (MAOIs): A less common variety of antidepressant drugs, MAOIs are often a last option with complex, treatment-resistant depression. Common MAOIs include:
- Emsam (selegiline)
- Marplan (isocarboxazid)
- Nardil (phenelzine)
- Parnate (tranylcypromine)
- Tricyclics (TCAs): These older antidepressant medications have been pushed to the sidelines by newer, generally safer medications. Still, some people do not respond to the new antidepressants, so TCAs may be prescribed. Tricyclic medications include:
- Seretonin norepinephrine reuptake inhibitors (SNRIs): These medications work by slowly increasing the amount of norepinephrine in the brain. Common SNRIs include:
- Antianxiety/antipanic medications: These medications are used to treat a variety of chronic and acute anxiety issues, from generalized anxiety to panic attacks. Antianxiety and antipanic medications on the market include:
- Stimulants: Typically, stimulants are prescribed to people with attention-deficit hyperactivity (ADHD). They help regulate disorganized thought processes. Psychomotor stimulants include:
- Mood stabilizers: This category of psychotropic medication is typically used to treat intense, repeated shifts in a person's mood, which may be common for those experiencing bipolar, schizophrenia, or borderline personality. Many mood stabilizer drugs are also commonly categorized as anticonvulsant medications.
Most Frequently Prescribed Psychotropic Drugs
Based on 2013 data, here is a list of the 10 most prescribed psychotropic drugs in the United States (with the number of prescriptions written during the year):
- Xanax (alprazolam), 48.5 million
- Zoloft (sertraline), 41.4 million
- Celexa (citalopram), 39.4 million
- Prozac (fluoxetine), 28.3 million
- Ativan (lorazepam), 27.9 million
- Desyrel (trazodone HCL), 26.2 million
- Lexapro (escitalopram), 24.9 million
- Cymbalta (duloxetine), 18.6 million
- Wellbutrin XL (bupropion HCL XL), 16.1 million
- Effexor XR (venlafaxine HCL ER), 15.8 million
Medication that works well for one person may not work well for another. It is important to have an in-depth conversation about your medical history, symptoms, diagnosis, and goals with your medical provider before beginning a psychotropic medication. You cannot legally purchase psychotropic medication without a prescription.
References:
- Gabbard, G. (August, 2000). A neurobiologically informed perspective on psychotherapy. Retrieved from
http://bjp.rcpsych.org/content/177/2/117.abstract.
- Grohol, J. M. (2013). Top 25 psychiatric prescriptions for 2013. Retrieved from
http://psychcentral.com/lib/top-25-psychiatric-medication-prescriptions-for-2013.
- Mayo Clinic. (n.d.). Depression (major depression). Retrieved from
http://www.mayoclinic.com/health/antidepressants/MH00071.
- Mental disorders affect one in four people. (2001, October 4). Retrieved from http://www.who.int/whr/2001/media_centre/press_release/en.
- National Institute on Drug Abuse. (n.d.). InfoFacts: Stimulant ADHD medications - methylphenidate and amphetamines. Retrieved from
http://www.drugabuse.gov/publications/infofacts/stimulant-adhd-medications-methylphenidate-amphetamines.
- National Institute of Mental Health. (n.d.). Mental health medications. Retrieved from
http://www.nimh.nih.gov/health/publications/mental-health-medications/compelte-index.shtml#pub8.
- Seligman, M. (1995, December). The effectiveness of psychotherapy: The consumer reports study. Retrieved from
http://horan.asu.edu/cpy702readings/seligman/seligman.html.