Ep. 46 - When Medication Enters the Picture

Dr. Andrew Rosen and Dr. David Gross pull back the curtain on one of the most loaded questions in mental health care: when does someone actually need medication, and who decides that?

The two talk through how the field got here, including decades of therapists and psychiatrists operating in separate silos, rarely talking to each other, and why that siloed approach hasn't served patients well. They're honest about the turf issues that still exist today and why good collaboration between prescribers and therapists remains the exception rather than the rule.

A lot of the conversation centers on what people get wrong about medication. The fear of addiction, the belief that needing a pill means something is seriously wrong, the opposite trap of wanting a quick fix without doing the harder therapeutic work. They also dig into the difference between dependency and addiction, and why that distinction matters more than most people realize.

They get into specific scenarios too, like when someone's anxiety or obsessive thinking is so intense that therapy alone can't get traction, and how medication can quiet the nervous system enough for the real work to begin. There's also a frank discussion about lithium being underused despite being a gold standard, why sleep problems are more treatable than people think, and what a medication plan should actually look like versus a ten-minute appointment ending in a prescription.

The throughline is something they clearly both believe: medication and therapy work best together, referring a patient for a psychiatric consult isn't failure, and most people can get better.

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Email: twoshrinksandamic@gmail.com

Transcript

SPEAKER_01 0:05

Hi, I'm Dr. Andrew Rosen. I'm a psychologist. And I am Dr. David Gross, and I'm a psychiatrist, and we are at Two Shrinks in the Mike. Today we're going to speak about the use of medications in mental health care. We've alluded to medication and prescribing before, but we really haven't had a chance to get a discussion in depth about it. Both uh how you decide medications are necessary as well as um how is it w how how does your therapist who is a non-MD at some point make a recommendation for the possible need for medication? So these are all the areas that we'll talk about uh as we proceed.

SPEAKER_00 0:41

Yeah, it's it's a really important topic because for the average person who's going for any kind of help for a psychological, emotional issue, uh number one, the question is always, well, who should I go to? Do I go with to a psychiatrist and get medication for this? Or do I go to a non-psychiatrist and get uh talking therapy for this? And the patient doesn't really necessarily know. Some of that will be influenced by a person's subjective feelings about taking medications. So uh it's it's a little bit complicated. I think for our purpose today, we're going to talk about it from the perspective of the clinician uh a little bit because it's important for people to know that um there's a little bit of a background history to how does a mental health professional know when to uh refer for medication or not. Historically, uh the psychiatrist and the non-psychiatrists were really worlds apart, even in terms of communication and ever really talking to each other. So if you as a patient went to see a psychologist or a social worker, uh very often that psychologist or social worker was was not interested in at all with the possibility that a patient might need medication until down the road, if there was no progress happening or things were getting worse, then the clinician might pull the fire alarm and look for a psychiatrist to refer the patient to. That's not a very good method. And then on the other side of the coin, if the patient went to a psychiatrist first, whether it be for uh historically for therapy or medication, very often the patient would just stay in that realm and actually never get therapy, just would get medication. So fast forward to today, I think uh pretty savvy mental health professionals work closely uh as a team. So we've and we've talked about this, the psychologist, social worker works closely with the psychiatrist and vice versa. So that there's less of a bridge to cross over in terms of uh seeing uh even a new patient and deciding, does this person need medication from the get-go, or should I wait a while?

SPEAKER_01 3:04

You know, I wish I wish what you're describing uh in this day and age was the case, but unfortunately uh in our centers it is the case in our relationship over decades, you know, like I called you the other day about seeing a mutual patient and to tell you what my thoughts were and what the plan was. But y unfortunately, uh turf issues are still prevalent, meaning um uh whether you are a master's level therapist or a doctoral level therapist or a physician-level therap uh clinician, um there's a desire to hold on to the patient almost as if uh you can't share the patient. And that's a absurd, but it's it's what what it's been like in mental health care over the years. And um you really wonder how often uh uh psychiatrists call the therapist who refer to the patient to discuss cases and uh vice versa. The therapists who I in the community who I really respect are the ones who will um uh send me an email or give me a phone call and say, let's discuss our cases that we haven't talked about for a while and compare notes and treatment planning, et cetera. Um but the turf issue is a real issue. The other aspect of medication is it's a it's a bit of a uh of a a dichotomy in that um a lot of individuals will view themselves as really being sick if they need medication. You know, boy, do I have a major mental disorder or I must be insane or out of my mind if I need medication. The implication of medication uh can connote uh very negative things for some people. Then the opposite is true, and that's why I say it's dichotomy, whereas uh some people kind of view medication as a quick fix and don't recognize that uh they need more than just a medication, that the medication can serve a purpose, but it may not take care of the whole picture. And uh frequently I will see somebody new who has had uh significant anxiety or life-related issues and secondary depression. Uh, and uh I'll ask them, have have they been to therapy to learn techniques to deal with their anxiety and their overthinking and their worry, or have have they been working with a therapist on dealing with their life situation? The answer is no, instead they just want a pill. And I I tell people that, you know, I'll be happy to prescribe for you to help you with A, B, and C symptoms, but it's not the whole picture. And you're depriving yourself of of really moving forward in this whole process. And so medication, it's important to get an understanding of how a person feels about medication. Um and a lot of individuals I've seen over the years will say, you know, I I'm not a big fan of any medication, not just psychiatric medication, but the notion that I want I want my body to heal itself and I don't want to take anything foreign into my body, which on this on the one hand has some truth to it. On the other hand, it's a bit of an extreme approach. So um it's helpful for me in the beginning to hear from somebody if if they have anxieties about medication, because I know for sure they're gonna consult Dr. Google if I recommend a medication, and before I know it, I'll be getting phone calls about I'm worried about this side effect, that side effect, et cetera, et cetera.

SPEAKER_00 6:04

Yeah, and from my perspective, when I first see a patient, um, you know, generally speaking, I will get a sense as to whether or not this person is at all open to the concept of medication. But also, uh what I look for is to see how much suffering the person is actually doing symptom-wise in the beginning. Uh most of the people that I see are not suffering severely, so that their symptoms are somewhat manageable or very manageable. Uh so that for that kind of patient, I said, well, let's let's get started with looking at what the issues are and and seeing if you can learn how to manage your anxiety and depression. But for the patient who comes in and they're really not sleeping, they're waking up with massive anxiety, their appetite is is is uh impaired, uh, their ability to even go out of the house or to go to work is significantly impaired. That's the person that really from the get-go, I have to let them know that regardless of how you feel about medication, we really need to consider it because it's it's your your symptoms is so significant that it's really going to get in the way of your recovery. And if we can give you something even just temporarily, to calm those symptoms down, it will open the door for you to be better able to recover through the use of the therapies that we will do. So it's very important to for the non-uhpsychiatrist clinician, and we teach this all the time, to evaluate the current symptoms and don't uh just dismiss them as uh uh always amenable to therapy because sometimes they're not. Sometimes the the nervous system has to be quieted down enough for you to be able to provide a good therapy uh protocol for a patient.

SPEAKER_01 7:56

You know, you're you're right about uh the symptom component. Uh study after study has demonstrated that in individuals with uh boot disorders, depression, anxiety, and insomnia, difficulty falling asleep, staying asleep, or even waking up in the middle of the night and and and and being anxious and worried that if you do nothing more than treat the sleep problem, uh their other symptoms will improve. It may not recover, but they will improve. And so uh the worst thing in the world is not being able to sleep. Um but looking at medications in general, um, they have tended to follow the advances in our diagnostic capabilities. Uh in mental health, our diagnostic Bible is called the Diagnostic and Statistical Manual in Mental Health, DSM. And there are now five different versions, five editions of it, um, constantly changing. Uh and the that that that diagnostic Bible has uh depression diagnoses, anxiety diagnoses, and the medications um, and I say this as a negative thing, not a positive, have unfortunately followed the diagnoses. So if you look at classes of medications in in mental health, there are antidepressants, there are anti-anxiety agents, and there are anti-psychotics. Um, almost as if these medications depend upon a diagnosis. And we're beginning to recognize that a better approach to this is more of a symptom approach rather than letting a diagnosis rule the day. And an example of that is if if you talk to ten individuals who come in with a a diagnosis of depressive disorder, um, sure they have sadness and negative thinking, but many of them, if not the majority, will have obsessive anxiety. I can't turn my brain off. I'm worrying about things that I shouldn't be worried about. Um, it's like torture. It interferes with my ability to sleep, it interferes with my ability to uh have a helpful conversation with my friends and family. Um and so in in those individuals, um, when we give them an antidepressant, especially a serotonin active agent, serotonin being one of the major brain chemicals involved in depression and anxiety, these medications like Prozac and Zoloft and Lexapro and Fluovoxamine and Silexa, et cetera, have anti-anxiety, anti-obsessive benefits. And that's what gets the depression better, because you're treating first the obsessive anxiety. When that gets better, an individual begins to feel relieved and they uh over time get less and less depressed. Uh uh antipsychotics have uh uh now been used as mood stabilizers, which uh I don't buy in completely at all because I I don't think they truly are mood stabilizers, but they can be helpful in the early stages of, for example, bipolar mania um uh in stabilizing somebody. But in terms of relying on an antipsychotic for long-term stability of somebody who has a mood swing disorder, I'm not impressed that that that the data is there. To this day, the the gold standard is lithium. Unfortunately, lithium, because it's an element, if you remember your high school or college uh chemistry and the table of elements, it's right next to sodium as an element. It's mined from the earth. As a consequence, it's dirt cheap to produce, and therefore the pharmaceutical companies are not motivated to uh to to advertise it and get it out in the marketplace because they're not going to make much money out of it. And so many of the the newer antipsychotics that are out there, and you've seen all the commercials on television, have been pushed as mood stabilizers. Um and uh uh as I said, I'm not convinced that that's the case. Um and lithium is needs to be used more than it has been. Um but but unfortunately uh it's not taught as as intensively in in residency training uh and psychiatry as it should, because of the fact that all these newer, fancier, as quote unquote sexier agents uh that are antipsychotics are being pushed for this purpose. And so the the take-home message from what I just said is that um uh mental disorders um uh uh best to follow symptoms as as you're suggesting, Andy. And and uh once you pay attention to the symptoms, it helps you better understand from a pharmacologic perspective what direction to go in.

SPEAKER_00 12:07

And here's another example of some very often a person, let's say with anxiety or depression, will come in and they have very, very negative thinking, catastrophic thinking, and they're and it's obsessive as well. So they really, really can't stop thinking negatively. They have constant over uh valued negative catastrophic thinking, you know, all the what-ifs, right? And the person can either know that this thinking is uh mal uh maladjustment and inappropriate, and they know that this negative overthinking is is not accurate and they need to give it up. And they can even start to learn in the beginning in the cognitive behavior therapy some techniques, but their obsessiveness is so strong that they just can't stop. So they can know I have to change that thought, but they'll come back to the negative thought as it's like in the old days with a broken record and they can't stop. It's not like they can hit the arm on the on the record player and and and it'll reduce or stop. And when it's that severe, when the negative over-obsessive type thinking is so severe and the the the thoughts are intrusive, and day and night they don't stop, and the person is getting so tired from these thoughts, that's where medication can be very helpful and slow down that obsessive process. And then over it, I mean it doesn't happen overnight, but over a period of weeks or a couple of months, that it slows down enough for the person to be able to get uh their hands around this type of thinking and start to control it on their own. But it's a process. In the interim, if the anxiety is very bad, you know, and we're waiting for the antidepressants to kick in, there's other medications that David can talk about, the anxiolytics, that calm a person down for those first few weeks, and again, give a chance for the therapy to take hold and also, which we've talked about, offer some hope to the person so that they could see, okay, I'm not better yet, but uh I'm starting to feel like I can get on top of this thing. So that's where the junction is between the medication and the therapy. Medication, I think mostly that we could see in our work together, is there to help the therapeutic process along. Of course, there are certain disorders where, like with uh bipolar disorder, um, you know, the medication is is central and in many cases can make a person fine even without the psychotherapy. But there has to be a good communication between the prescribing doctor and uh mental health clinician who's doing the therapy. That's what we do all the time. I mean, I don't think there's a day that goes by where at the end of the day where we don't catch up on somebody. But in the real world out there, it doesn't necessarily exist very often.

SPEAKER_01 15:05

You know, there are the cases where, you know, I'll refer an individual to you who's had uh uh horrendous panic disorder or obsessive anxiety disorder, which we call generalized anxiety disorder, and you'll get to see them and say, you know, I I can teach them the techniques in cognitive behavioral therapy, but the level of their uh obsessiveness or their panic is so great that they they're not going to benefit right now. So for the person with panic disorder, oftentimes they need to have an agent they can use as a rescue agent to abort the panic attack when they have it, or the person with a horrendous obsessive anxiety will benefit from a serotonin active agent. Uh and and I'll tell them, look, this is the way you'll get your the most money, most progress for your money by being able to really benefit from the treatment because uh psychotherapy requires a lot of work on the part of the patient's part. Um medication is prescribed to a patient and they're passive, they just have to take the medication. Um but but the the other therapies are a totally different story. Um but the other piece of this puzzle around medication is uh something that I I recall from my early days of training, which was uh I remember b s seeing individuals and trying to treat them and they weren't making any progress, and I was either feeling like I was failing, or I was getting feedback from my supervisors that, well, that you're just seeing resistance of the patient. You know, blame it on the patient, which unfortunately was uh old thinking and and uh unfair thinking. Um but in terms of a a a non-psychiatrist, therapist in the community making a decision about referring to a psychiatrist, it it's often difficult because of feeling like, gee, I must be not doing my job and uh I I uh I I'm failing at what I'm doing. And so it's almost as if a black mark on yourself if you have to refer to a psychiatrist for medication. And as we mentioned a few a few podcasts ago, there also is the issue in the community of uh if you get a patient referred to you uh uh holding on to that patient and not giving them back. It had been uh an issue for psychiatrists who would get a referral from a therapist, uh, and uh they would end up doing the therapy and medication and basically stealing the patient, which is not right either. And fortunately we've in our centers we've had that team approach, which is a wonderful approach, where we're all part of the same therapeutic community, and the goal is to get people better the best that we can. But it's uh oftentimes difficult for uh clinicians who do the therapy to acknowledge the need to refer. Um uh and the ones that I value their their input are the ones who will call me ahead of time and say, you know, I've got uh John Doe or Jane Doe that I've been treating, and they're not making progress. And what they'll say to me, which I think is really uh a sign of wisdom, is they'll say, you know, I really want you to to get your two cents in terms of what's going on. Maybe I have um misconception as to what the core issues are. Um one of the things that happens in in psychotherapy is that you can get kind of stuck in the in in in the in the uh in the trees and not see the forest. You may miss some of the bigger issues. And so um we we enjoy uh the the the the c collegial interaction by sharing cases and uh picking each other's brains and learning from each other. So um it just because you refer a patient for medication does not mean in any way that you have failed. It just means that you're a good clinician. It's like the you know, the internist who's treating uh diabetes, which they're able to treat, but finds that um the person is not making progress and they need to, and and therefore refers their patient to an endocrinologist. That's not a sign of failure, it's just a sign of good therapeutic thinking.

SPEAKER_00 18:50

And to add to that, think about how the patient feels. Let's say the patient has been seeing this uh therapist for the last two months or three months or six months or whatever it is, and they're not really getting much better, or they may even be getting worse, and uh then finally the the therapist says, Well, I think I need to refer you to uh psychiatrist because you need medication. Well, now that patient might have a bunch of feelings there, like, well, why didn't we talk about this earlier? But also, does that mean I'm too sick for you? You know, uh you can't treat me or you're not helping me because I'm really, really, really sick? So it conveys something that isn't true. It's not that the person has to be sick or sicker to be on medication, it's more that some people's nervous systems and biology can do better with a medication. And it's not a a uh a death sentence in terms of severity, it's just we can do this better with. And uh so it's it's just very important to have this concept of really it's a team. You don't always need both parts of the team, but it's important to consider the need for that uh in the beginning in particular, but even as you go forward, sometimes a person's doing better and better, and then you may find or factors that are even beyond our awareness, just you know, some sort of time of the year or or aging process or something where a person may be much better, but at this particular point may even need medicine to do and to continue to do better. So it it's it's a whole different mindset that we have that some people are starting to have more of in the field, but it's definitely different than the mindset that has existed over the last, I don't know, 10, 20, 30, or 40, 50 years. I'm gonna stop at 50 because I don't want us to look too old.

SPEAKER_01 20:49

Well, that is that is the case of having gray hair for sure. And some hair. The medication piece is an important piece. And you know, I see a lot of individuals who had seen other psychiatrists uh for anxiety or depression, and you know, before they know it, they've been in the in the meeting with that psychiatrist for 10, 15 minutes and they get a prescription for a medication. But it's terribly important that you get a prescription for a medication plan that is to understand why you're on this medication, what's the purpose, um, and most importantly, is this a medication that you're going to be on forever, or a medication that will have a limited use? Um I tell a lot of individuals who I see with obsessive anxiety disorders, um uh panic disorder, et cetera, that uh I see the medication as uh as building a foundation upon which you can do the psychotherapeutic work, which oftentimes is cognitive behavioral therapy, uh, make the progress. And eventually uh you'll be retraining and reprogramming your brain. Um, and so the medications that I'm giving you will not be needed. But people need to know that. Um it's amazing how many people I see who have been on a sleeping medication like. Ambien um for decades. They're now in their 50s or 60s, but in their twenties or 30s, they went through a rough patch in life and had sleep difficulty and got ambient and were kept on it almost as if the belief was that the sleep disorder was permanent. But it's not. Sleep disorder was transient based upon going through a stressful time, but nobody reevaluated whether or not that medication is necessary. And so before you know it, they've developed a physiological dependence on this medication. And after being on it for years, it's not easy to stop. What happens when you stop it after being on it regularly is you'll have rebound insomnia, which is not a return of your original insomnia, but instead is uh the brain reacting to the absence of the medication and getting into an activated hyperactive state that causes insomnia. So um getting a good plan as to why you're on the medication, how long you'll need to be on it, uh does it indicate that this is a more severe disorder? Most of the time the answer is no. Um and it also indicates uh greater belief in recovery and hope. We've talked a lot about the concept of hope, and uh adding on medication to uh an individu an individual's treatment plan is an expression of hopefulness and not a sign of, boy, you're in a lot of trouble.

SPEAKER_00 23:17

One of the things that scares off a lot of patients uh in terms of medication is the fear of being an addict. And very often I'll have somebody uh say, well, if I take this, will I become addicted to it? And I make a very strong point to differentiate addiction from dependency. When you take a medication over a period of time, your body will get familiar with it, whether it's a psychiatric medication or cholesterol medicine or thyroid medicine or or any kind of blood pressure medicine, your your brain and your nervous system and the rest of your body become uh familiar with it and expect it. And so if you were to abruptly stop, yes, you'll buy you you'll get a message back from your body saying what's going on here. That's not the same thing as addiction. Addiction involves craving, it involves wanting more, it involves when can I get some more of this stuff. It's a big difference. And you know what I'll say to PIPatients is no, it's not an addiction issue. You've never been an addict. These medicines, some of them uh uh some of the benzodiazepines in particular, we have to be aware of and monitor so that um you don't have a dependency issue, but you we we're careful about it so that at some point, usually it's a it's a soon thing, is to get off that particular drug. But it's not an addiction issue. And once that's clarified, most people feel more relaxed about the idea of taking a medicine. But they may ask it about all kinds of medicines. And that's why some people really, as you said, David, hate all medicines. I have people who won't take the medicines that their primary care doc has for blood pressure or for cholesterol or whatever. Many people are afraid of medicines. It's the concept of, you know, if I take this pill and I put it inside my body, I lose control of what's going to happen to me. So that's scary for people. So there's a lot of work that I do for the uh issue of if a patient looks like they'll need medicine or at least a consult with you, or if they're on medicine to help them deal with uh the fears and the negatives of being on medicine.

SPEAKER_01 25:29

You know, the the other aspect of uh prescribing in psychiatry that makes it difficult is that if if if you go to your internist and and and you get some blood work done because you've been gaining weight and you're tired and you have got no energy and um your pulse is low and you can't tolerate air conditioning, those are all signs of a sluggish thyroid, and the blood tests come back positive for hypothyroidism, which is a sluggish thyroid, you don't have any difficulty accepting that there's something wrong and that you need to correct it. Whereas when we're dealing with depression and anxiety, other people look at you and can't tell there's anything wrong with you, especially family and loved ones and friends. And and that's part of the issue, which is um it's harder to accept that there's an abnormality in how my brain is working that uh usually is transient, that needs to be addressed with medication. Uh that's a form of the MRI called a functional MRI that actually looks at um activity within brain areas uh in real time. Uh so you can see hot spots, you can see spots in the brain that are not working as well. And so in in anxiety disorders, especially, we've been able to demonstrate that um people with obsessive anxiety, like OCD, um, you can see areas on the functional MRI before treatment that are overactive in areas that are underactive. And with the appropriate medication, you see normalization of these areas. I've wished for a long time if I had to be able to have uh in my office a functional MRI machine. They don't exist, but if if it was possible to have that, it'd be so much easier. Uh it's similar to if you know if you go in uh with a terrible cough and a fever and you get an x-ray and it's clear that you have pneumonia based upon the x-ray of your lungs, it's uh more objective. And and mental health work is all subjective, uh, which is part of the challenge for all of us. And so, as I've said before, and as you said before, one of our major roles is as an educator to help individuals uh really understand what's wrong and that it's not the end of the world and that there is a chance for recovery.

SPEAKER_00 27:31

But again, I think the main takeaway we'd like you to have is that uh the work that's involved in overcoming psychological, psychiatric problems is uh first of all, much b different and and much more effective than it was X number of years ago, where medications and therapy were uh either scary medicines and or the technique of therapy was one that was uh going to take years and years. So we're in a different place now. Um therapy's more concise and brief and focused, and medications are definitely not uh of the nature that existed 30, 40, 50 years ago. It works. We help people, and the reason we love to do what we do, and the reason we're here on our podcast is because we love to help people. And we and just like I said to a patient the other day who had been convinced they were never going to get better, and they just came back from a vacation with family and they were very happy. And I said, Okay, this is the my favorite thing to do. It's like get ready, and they said what? I said, I told you so. My favorite activity is telling patients I told you so. You can get better.

SPEAKER_01 28:40

And it it is a living, um, but we've been doing it for so many years we wouldn't have stayed in it if it wasn't for the fact that people can get better. And uh otherwise it would have been difficult to maintain a career for decades like this. And uh I'm Dr. David Gross, psychiatrist.

SPEAKER_00 28:54

And Dr. Andrew Rosen, psychologist, and this is Two Shrinks in a Mike. And we'll see you next time. Bye-bye. The Two Shrinks in a Mike podcast is for informational and entertainment purposes only. The views expressed are those of the hosts and guests and do not constitute medical, legal, or professional advice.

SPEAKER_01 29:14

Please always consult a qualified healthcare provider before making any medical or wellness decisions. Our content is not a substitute for professional medical guidance, even though our mothers tell us we have the best advice possible.