Ep. 50 - When Do You Actually Need Medication and When Do You Just Need to Talk It Out

Dr. David Gross and Dr. Andrew Rosen dig into one of the harder questions in mental health care: how do you know when talking isn't enough, and medication makes sense? And on the flip side, if you're already on something, how do you know if you still need it?

They walk through what actually goes into that decision, from how someone is sleeping and eating to whether they can get out of bed, and why "I'm suffering" doesn't automatically mean a prescription is the answer. The conversation gets honest about the pressure clinicians feel, the resistance patients bring to the table, and why anxiety in particular makes people want to stay in control of what they put in their bodies.

There's also a real conversation about what's become a growing problem: people staying on antidepressants far longer than necessary, often because a family doctor handed them a prescription without much evaluation behind it. They're not saying the medications don't work. They're saying they work best when someone actually takes the time to figure out what's going on first.

The red nose metaphor toward the end is worth hanging around for.

Contact the Docs:

Email: twoshrinksandamic@gmail.com

Transcript

SPEAKER_01 0:08

Hi, I'm uh Dr. David Gross, psychiatrist. And I'm Dr. Andrew Rosen, psychologist, and welcome to Two Shrinks in a Mike.

SPEAKER_00 0:16

Today we're going to continue to talk about some of the uh challenges that both the mental health professionals face as well as uh patients who come in for treatment. Um we've talked many times before about how our field is so different than uh other fields in uh healthcare, especially medicine. You know, if you uh if you have uh high blood pressure and you go to your internist or you go to an endocrinologist, uh generally speaking, the evaluation and treatments are going to be the same, whether you're in uh the state of California or the state of Florida. Um their protocols are very, very similar. But in our field, there's a huge spectrum of treatments and a huge uh spectrum of evaluative techniques so that it's uh much more difficult to really clarify it. So today we thought we'd spend some time talking about how do you decide uh if you're seeing a psychotherapist when it's time to be on medication, and when do you decide if you're on medication, seeing a psychiatrist that psychotherapy is involved, and how do the professionals make those decisions?

SPEAKER_01 1:17

It's a tough one, and it it's it's also different than general medicine, because in general, if you go to a doctor for whatever your illness is, and the doctor says, Well, you need to take this medicine, uh, there's very little resistance to it for the most part, or anxiety about it, even if there's fear of the side effects of the medicine, there's generally a very high level of compliance. With our field, people have a resistance to taking medicine because they're afraid of it, they're not sure what it's going to make them feel like. And even if you reassure them that it's geared towards re reducing or eliminating their symptoms, uh, they still are afraid that maybe it'll change the way they are, they'll change their personality or things like that. So you're really up against a few forces. One, trying to decide if the person really needs medicine, and then two, dealing with the natural apprehension resistance about taking psychiatric medicine in general. It's it's a it's a much bigger step for most people to take the medicines that we utilize compared to if you go to your primary care doctor or your ear doctor or something.

SPEAKER_00 2:31

You know, we both of us will see individuals who have seen a number of other mental health professionals before and come to us because of uh either lack of adequate response or other reasons. And then we also see individuals who have never seen a mental health professional before for the first time. So the challenge for both of us, I think, in the beginning is to clarify the nature of the problem. You know, the it's somebody who's come in fresh. My initial job is to be a good listener, ask the cor right questions, and get as much valuable data and objective data as possible to figure out whether this is a major psychiatric disorder that requires intensive treatment or whether this is a life situation that requires some transient uh psychotherapeutic treatment to where talking about the situation and learning how to cope with it is really the good the goal. Um and so the first stage really is to do a good evaluation and figure out what's going on and and come up with an idea as to what direction to go in. Individuals who have seen a number of other mental health professionals before, first question I have in my own mind is um, what what's the reason they're coming to see me? Sometimes there can be uh conflict of personalities, and you know, I didn't really get along well with that mental health professional, or uh I'm not responding well, I'm not I'm not getting uh the kind of improvement I hoped I would get. So my my initial goal there is to figure out, you know, what's missing, um, to start from scratch. Uh if if I was a um uh an endocrinologist and somebody had a thyroid problem and they'd seen other physicians before, um, but they weren't responding well, they'd still come to me with laboratory results so I could have objective data. But in our field, we don't have that. It's all subjective. And so we have to really clarify by the questions we ask and uh the interaction we have with the individual uh what the symptoms are, what the nature of the problem is, how much of this seems to come from inside biologically, how much of this is due to a life situation, or how much of this is due to a combination of f of both. And that and at that point, we then have to make a decision about what direction to go in.

SPEAKER_01 4:40

I mean, pretty much anybody who's going to see us uh is suffering in some way at some level. And uh the word suffering can be seen as too strong a way of describing some of the reasons why people do come in to see me or to see you. But uh whether it's feeling sad with grief or m even marital problems or just straight anxiety symptoms or uh existential worries, all kinds of things. To to make the uh step of coming in, making an appointment to see somebody like me and spending the money to do it, you have to assume that that person has some degree of suffering. Now, does the realization that the person's suffering automatically mean that they should take medicine or need medicine? No. So my job is to determine uh what the suffering is like and how severe it is. And clearly some people when they come in, uh they're really suffering so badly that uh they do need medicine. And the things that I'll look for are uh has the person been sleeping at least reasonably well? Do they have an appetite? Uh they have any degree of uh pleasure in their life? Are they staying getting out of bed? Are they taking care of basic daily skill, you know, behaviors like taking a shower, things like that? If they're not, then I put that under the really suffering category, and they most likely, I mean, will really, really need to see uh and be evaluated for medicine. If they're not experiencing that type of suffering, then it's a function of spending a little bit more time, maybe a few sessions, to determine levels of motivation, uh what their resources are in their life, do they have uh any help or assistance from people in their life to help them along while they're going through maybe a longer psychotherapeutic process? But um, as long as they're able to kind of carry on with their day-to-day lives reasonably well, I will not necessarily jump towards uh medication. But if they're not really functioning, then certainly uh they'll get a knock on your door.

SPEAKER_00 6:59

The I'm glad you raised the concept of suffering because uh that that's a major issue. A lot of people come in and say, you know, my my wife or my husband really can't appreciate the amount of emotional pain I'm in. Uh and that's the problem with our field, because you know, if you have uh pneumonia, you're gonna look terrible, you're gonna be coughing, you're gonna be weak, and people can really tell that you're suffering. But in in our field, oftentimes you look at a person who's got anxiety difficulties or depression, and they don't necessarily look terrible. They don't look sick necessarily, and so it's very hard for friends or family members to appreciate the amount of emotional pain and suffering that they go through. Um, a number of years ago, there was an antidepressant that was uh advertised as uh uh as treating the pain of depression, that uh indicating that the amount of emotional pain with uh with depression can be as severe as uh pain from a bad back or pain from a kidney stone. Um it's a different kind of pain, uh, but nevertheless, it's uh it's it's it's persistent. It wears somebody down and it interferes with functioning. And so um for me, the the first step is besides coming up with a clear-cut diagnosis is to understand whether or not there are situational factors there. In addition to the fact that they may have a biological depression that's come out of the blue, is there problems with the job? Is there problems with the marriage? Is there are there issues with school? Uh, because all those things have to be addressed. And then my my challenge is to come up with a uh prioritized system. You know, what what's the highest priority issue that has to be addressed first, and then what else has to be worked on? And um, it's often often a mistake just to to view the the pill as a quick fix. And that's one of the the the pressures that I that I that I find myself experiencing with individuals come in to see me because they want the quick fix. And so when I say to them, you know, this you've had marital discord for 10 years and it needs to be addressed, and it may not be causing a depression, but it'll certainly make it much worse. Um, you really need to address that. And people are are reluctant to take that extra step. They want that quick fix and think it's gonna make everything better, but there's there's no way that a a little pink pill is going to uh help improve a marriage. It may improve a person's emotional state, but it's not gonna improve a marriage. So um I have to keep my eyes and my ears open to the potential need for more than just uh medication treatment.

SPEAKER_01 9:26

But the reality is some people do need not a quick fix, but they may need a jump start. And uh very often I'll see somebody who really has no, I use the metaphor, no wind in their sails. They just have no psychic energy or mental energy or even physical energy. And as a result, they've just kind of come to a halt. And um one of the things that I try and see in the beginning is can my encouragement, can my uh offering some ideas, some insight, and some hope, can I get a a little spark of enthusiasm to get some wind in those cells? And if it doesn't look like talking alone is gonna put any wind in those cells, then that's the person that may need, pretty well sure does need, some medication to get some of that spark going so that they can start to make use of the therapy, or they can get some traction uh under their feet to make some changes, to make some progress. So it's not obviously it's not a quick fix, but it may give some boost to their ability to get going and make some changes in their life. But truly there's no quick fix, except for I'm there definitely are some uh diagnoses where uh it's heavily loaded, uh the answer is heavily loaded on medication as opposed to working through problems. But uh in general, life is complicated enough so that it's it's hard to imagine really if a person is really suffering, that all they need is a pill.

SPEAKER_00 11:03

Now, I saw somebody recently who um I thought had significant uh mood instability issues uh and and problems. And um uh after our first session and and and just talking and trying to clarify some of the issues that this individual had and the fact that that the person was motivated to work on the issues and be introspective. Interestingly, uh there was tremendous improvement just after the initial session, independent really of medication. And and uh that made me realize that one of the things that were missing in our field is we don't have a biological meter. We we don't have any way of assessing how much of this is due to a person's biology, how much of this is actually due to something going on in their brain directly. Whereas we've talked before, other uh health professionals can get blood tests and x-rays, uh, EKGs, electroencephalograms, etc., which gives you a picture of the biology at some level. Uh we now have in in the mental health care the functional MRIs. Uh, functional MRI is an MRI that uh is able to take a look at the active uh metabolic activity in the brain. So you can see areas that are underactive and areas that are overactive, and so you can actually see the biology, but those machines are huge in terms of uh the size and huge in terms of cost. And so there's certainly not something that we can have in our office. Um so eventually that will be the case. I think eventually we'll have that. But right now, um, I'm always surprised when people turn out to have uh less of a biological component uh and more of a psychological component. And you don't know initially. You can't you can't judge a book by its cover. Uh so you have to decide over time um and uh and meeting with them and and getting a in more information and understanding how they're feeling and and get a better sense of the life situation and the psychological issues that they're wrestling with, uh, whether or not that's uh it's more of a situational psychological issue versus a true underlying biological issue. Certainly it can be a mixture of both. Um and then the goal is really to determine which one is uh which is more significant, and we'll talk about that a little bit later in terms of how long to be on medications.

SPEAKER_01 13:14

But you know, it may not be that we're our field is so different because I was just thinking of uh the person who has high cholesterol. Yeah, we we know that a person manufactures cholesterol, and for some people, no matter how they do with their diets and getting uh to get control of what they eat, they can't get their cholesterol down. And yet we know that some people can get their cholesterol down quite a bit if they change their eating behaviors. So it it it is some degree of some interaction there. And even another example would be high blood pressures, where you know, we know that high blood pressure can be genetic and a function of their person's biology, no matter what they do. But for some people, it's some interaction between what they are eating and the the amount of salt intake, et cetera. So I think we're different in in the kinds of problems that we face, but maybe we've been dealing with this nature-nurture issue from way, way, way, way back when. And I don't know if we'll ever completely be able to separate nature from nurture, but I guess we can get better at determining, you know, which is the more uh important, if you will, treatment modality to help the person. But uh what we have found out is that many patients that we've worked with, uh it's a mixture. And um very often we see dramatic change in people really fairly quickly who uh we can identify. This is a person who really really do well with an anti-obsessive medication while we're trying to get them to change the way they think and trying to change their what we would call catastrophic thinking or overthinking. And it's hard to get control of your thinking, but with medicines that can make it a little easier, then a person can get ahead of the curve and really start to make changes. And I think we, you know, you and I could probably identify right away at least a half a dozen patients who we've seen in the last few months who have made dramatic progress with that combination. And that's why it's so important to have in mental health more than any other, I think, uh, a team that can evaluate appropriately and treat appropriately.

SPEAKER_00 15:31

You know, when people come in uh and have not seen a mental health professional before, or have not seen a psychologist before, even though they've worked with psychotherapists, and and the the biggest fear is uh the this that I'm gonna tell them they're they're sicker or crazy than they think they are, um, or that this is a permanent condition. And what after I do an evaluation and begin to talk about what I think the nature of the problem is, um, and then talk about the role of medication, people are fearful of that, as we've talked about before, because of the implications. They also fear the fact that here, I'm gonna have to be on this medication forever. And I tell people from the get-go that, you know, this is not the the tenth depressive episode you've had the past five years. Uh so this is uh this is a a unique situation. It's uh a lot of a lot of life events that have triggered it, and some of this may be your own biology, but I need you to agree to medication to get some relief for a limited period of time. You know, now the recommendations are for depression. Um, if this is a single episode or a second episode in a number of years, to be on the medication for at least three to six months uh after they begin to feel better. And we've learned from the hard way that people who stop sooner can can't can have recurrence of the depression. But letting people know that it's not going to be a lifelong commitment um is very helpful. Um I cannot say that to individuals who have had uh recurrent depressions over the course of their lives. Um and sometimes I I uh I'll have to say to them that they need to be on a specific boot stabilizer that addresses recurrent depressions as opposed to being on an antidepressants. Um but um uh the biggest mistake that I see, and and and we'll be hitting on this as well in the course of this discussion is the individuals who get placed on an antidepressant by their family doctor, and ten years later they're still on it. Uh, and that's an issue.

SPEAKER_01 17:23

Aaron Powell And it may not be even helping.

SPEAKER_00 17:26

And definitely it's not helping. That's also true for anti-anxiety medications, too. I mean, one one of the uh eye-openers from that I saw years ago in a study uh th that came out in the lit literature was uh after people have been on an anti-dep anti-anxiety agent like Xanax or Atavan or Valium or Clonopin for anxiety, after two weeks, the true anti-anxiety effects are beginning to diminish and pass. Um and so it's not necessarily a long-term agent. And so you um you'll see people who have been on uh Xanax for 20 years straight, uh thinking that they needed to still be on it. But the reality was that it probably stopped working years ago, and at this point in time, it's just a placebo.

SPEAKER_01 18:09

And you know, I think people are when they get on medication that's helpful, and they're starting to feel better, and now they can see, oh, I've bit it's been months now, and I really feel like I I feel better and my life is good again. It's very hard for them to uh think, well, maybe we can start to look at getting off that medicine. This has become my lifesaver. And but on the other hand, we often see people say, you know, I'm feeling better now. I don't think I need it. And then on their own they go off of it. And uh as if, you know, I I'm all cured and I don't need it anymore. I think in general, most of the people that I see don't want to be on medicine. And and that's somewhat a function of most of the people that I see have anxiety problems. People with anxiety tend to want to feel in control and to take a medicine, you know, it's the old thing of I take the pill and put it on the inside, and when it's once it's on the inside, I don't have control over what is gonna happen to me. So generally, anxious people don't want to take medicine. Uh, but when they start to feel good from it or calm from it, they quickly change their mind about it. Um but people in general, I think, don't want to be on medicine, but at the same time in our world today, everything is so quick and push the send button and you know, in two seconds I have a a generated report through AI. So we want quick fixes in general, but it's a mixed bag in terms of whether people want the quick fix with medicine or they don't.

SPEAKER_00 19:44

You know, it's an interesting uh occurrence when people unilaterally decide to stop their medication. Um one of the issues with that, and I tell people this all the time, is that um if you if you stopped your antidepressant during the critical period of needing to be on it prematurely, there's a risk if you have a recurrence after stopping it that the same medication that helped you to begin with may not work again. And that's a significant risk. And then the opposite occurs. I've had individuals who have been on the antidepressant for a prolonged period of time long enough to be comfortable with stopping it, who's who th who thought they needed to be on it indefinitely and just decided to stop it and they did fine. And at that point, I'll say, well, you you did you tested the system and let let's let's let's stay off of it. Um But the other issue that I think we need to talk about is something that's been in the press recently. Um, our Department of Health and Human Services run by uh Robert F. Kennedy Jr., somebody who I don't necessarily agree with his uh his health-related uh suggestions. There's one thing I do agree with, and that is a number of individuals uh tend to be on antidepressants longer than they should be. And there may be more people on antidepressants that need to be in the first place. Um it's easier to write a prescription for uh antidepressants sometimes than to do a comprehensive evaluation. I've heard stories from from patients who've uh been to see a mental health professional um uh and filled out a form that's often used to do a checklist for depressive symptoms. So because it's positive, within five minutes of seeing that doctor, they get an antidepressant prescription. Um and and as you can imagine, that's not the whole story, but it it it it has led to probably the over-prescribing of antidepressants. Um and so uh, you know, there's certainly an indication for them, but it's uh too easy to get out the prescription pad and write the antidepressants. Uh, you know, the primary care doctors, internists are under the gun all the time because of the volume of patients they have to treat and how sick people are, and um how needy a lot of the uh health uh mental health related problems cause people to become. Um, and oftentimes we'll view writing a prescription for an antidepressant as the path of least resistance as a Then there's the other issue of staying on antidepressants uh indefinitely. Like I indicated earlier, if if uh if you've done somebody who's some suffered from recurrent depressions over years, uh there's really no indication to stay on it indefinitely. There is an indication for being on the lookout for any recurrence of the depression so that you could start an antidepressant as soon as possible to cut it off at the past, so to speak. Um but um more and more um it makes sense to begin to really, really evaluate, you know, if I started this antidepressant two years ago during the time of uh losing a job or losing a marriage or being very, very sick and being under a lot of stress in life, um, do I still need to be on that antidepressant now that my life situation is stabilized and there really aren't the external stresses I had before? So the key issue there is, you know, what what's what's the biology all about? And um there are individuals who are predisposed to having depressions. And if uh the the road is flat and there are no potholes, you're not gonna have one. But if the the road is not flat and there are plenty of potholes and you're uh bouncing along in the car, uh they're at risk for having a depressive uh relapse because of your own biology. So all of this is important to take into account. But for those of you out there who have been on antidepressants for years, it pays to really question whether or not it's still necessary. What was the context in which the depression began to begin with? How frequently have you had recurrences, if any, uh, and then to begin to talk with your your physical psychiatrist about should I still be on it?

SPEAKER_01 23:41

You know, I was pretty happy when that came out a few weeks ago about uh we really need to re-evaluate whether people need to be on antidepressants as much as they are, and and also anti-anxiety agents as well. Um and the and the reason is is that uh I I don't have the data to know, maybe you do, David, as to what percentage of the uh time people who are put on antidepressants are actually put on by their uh uh family physician or or primary care physician or general practitioner or et cetera. Um because look, the truth is you have spent many years knowing everything there is to know about how to figure out what a person should do in terms of medicine and whether a person needs that medicine. I spent many years from a different perspective trying to figure out who needs to be on medicine. And that's what we do. We kind of know that whole thing inside and out. But the primary care doc doesn't do that. You know, most of it is just uh a kind of like a collateral thing. And and and the certainly in many offices now it's the nurse practitioner who's making decisions about the whether or not a person needs to be on an antidepressant. And typically the format is if a patient says, you know, I've been feeling depressed, out comes the prescription pad. And maybe I'm being a little harsh with this, but I really think it it's rather true. So you have so many people what do they do? They go to their, as they should, they go to their family doctor to say, I'm feeling bad, and then okay, that person should be referred to see what that particular person really needs, not just, okay, go off to CVS and get on some Prozac. So I I think it really is a serious problem. I think there's a lot of people who are on medicines that don't need to be on it. On the other hand, I know, you know, in my training, way back when, especially in my training in psychoanalysis, it was rare for anybody to say uh a patient needed to be looked at for medicine. In fact, in fact, it was like I still I still get emails on certain uh listserv, and the question from people who aren't trained uh not medically does anybody know a good psychiatrist in town? You know, like you should know who's a good psychiatrist in town, and you should be working with a good psychiatrist in town, not does anybody know one that I can send off this patient to who I've had on the couch for six years. So, you know, I don't mean to be too gloomy about this, and I know you don't either, but it kind of is a mess sometimes. So for patients out there, for people out there who are listening, you know, just listen to this, and that is if you think you need either psychotherapy or medication or both, if you have questions, the place to go to are the people who know the answers to that. You don't go to Dr. Google and you don't go to somebody who only knows a little bit about it. That's what I have to say.

SPEAKER_00 26:47

Well, but you're right, it is it is a bit of a mess. And and uh we won't get into it now, but how how do you define a good therapist or define a good psychiatrist? I mean, that's really the issue. And um but the way the way that I take a look at uh to the whole medication issue and and where to go from there is is make believe that uh biological depression leads to a bright red nose that is so red that you can't ignore it. So if somebody comes into your office and they say I'm sad and I'm blue and their nose is bright red, that's the biological sign they have a depression. Uh no different than if somebody says, you know, I've got a terrible sore throat and a fever, and you look in their throat and there's a lot of white gunk in there, and and uh you get a strep uh test and comes positive, then you know they've got strep throat, they need to be an antibiotics. So for our work, the toughest differential is to determine what is unhappiness and what is biological psychiatric depression. And that's critical. And I tell people this all the time. You know, what you're describing for those last two days is unhappiness. Generally speaking, biological depression is day after day after day. It's like a black cloud came over you and won't go away, or the fog rolled in and the sun didn't burn it off. It's as it's you fell into a dark hole and you can't get out of it. But uh most of us when we get uh feel go through unhappiness, sometimes jump to conclusions that it's the kind of depression that has to be addressed. And that's and that's a mistake. Um and it requires some education. Um but so that I tell people this all the time. And especially people who have had horrible depression where they've been non-functional for weeks or months, and they finally come out of it and they're feeling well, and they have a bad day or two. That's when I tell them that that's nothing but a bad day. Like sometimes a cigar is nothing but a good smoke. Um so that that that kind of education is critical. Um, so I hope this discussion today has been helpful. Uh, I'm Dr. David Gross, psychiatrist. Dr. Andrew Rosen, psychologist. And we are two shrinks in a mic. Bye-bye. Bye bye.

SPEAKER_01 28:49

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.