Mental Health and Meds: A Therapist’s Advice on When to Consider Medication

Over the past 15 years that I’ve been providing therapy to teens and families in the Washington, DC area, the topic of psychiatric medication has come up frequently. As a Licensed Clinical Social Worker, I don’t prescribe medication and I always recommend discussing questions and concerns with your primary care doctor or psychiatrist; but often I find that I have a role in exploring feelings about medication and helping a client decide if they are ready to talk to a psychiatrist. It can be a very sensitive topic, especially when we discuss medication for children, and can bring up a range of emotional reactions- curiosity, shame, fear, even anger. There are some very common questions, concerns, and misconceptions about psych meds that I’ve found I often need to address with my clients. If you’re considering meds for your mental health or for your child, here are some things I like to think about with my clients in order to make decisions about medication:

• Have you ruled out physical causes for symptoms? Especially when a client tells me their symptoms are physical- like fatigue with depression, or chest tightness with anxiety- I recommend getting a checkup and blood work done with a primary care doctor to rule out possible causes like thyroid issues, vitamin deficiencies, sleep apnea, mono, etc, that should be treated first.

• Have you tried other approaches and it hasn’t worked? In most cases, I like to give therapy and/or some other changes a good shot before trying meds. That means if someone comes to me with an anxiety disorder, we might try a couple months of Cognitive Behavioral Therapy, increasing exercise, reducing stressors, and maybe some natural supplements like magnesium to see whether the anxiety improves. Local child and adolescent psychiatrist Dr. Michelle Seelman adds that, “For most kids and adolescents, therapy alone is sufficient and effective, depending on the problem. But at times symptoms are so overwhelming they can’t make good use of the treatment–for instance when kids are too reactive to use the skills they’ve practiced in the therapist’s office, so in real time in everyday life they’re unable to use the coping strategies. In those situations where the client has tried therapy and isn’t getting traction or symptom improvement, it can make sense to consider medication.”

• Is the problem interfering with functioning? If your symptoms are so bad or chronic that your ability to work, socialize, sleep, or take care of hygiene is impaired, then it might be important to consider meds sooner rather than later to prevent other problems like loss of employment or relationships, or developing or worsening other health issues.

• When was the last time you/your child seemed like your/their “self”? I like to ask this because it gives me a sense of how embedded the symptoms have become. Over time, symptoms start feeling like our norm, and it is harder to even remember the last time we felt like ourselves. That means treatment might take longer too, and that might make it reasonable to try medication.

• What are your worst fears about medication? This is something to think about if you or your child have been experiencing symptoms that are intense or chronic, yet there is opposition to taking medication. Psychiatric medications are so stigmatized in our society, that the automatic response from my clients is often, “Oh no, I don’t believe in meds,” or “No way I’d give that to my kids.” It’s important to consider what is a knee-jerk negative reaction based on feelings, versus actual concerns based on medication risks- either are important to explore further.

Some of my clients have brought up concerns about an increase in suicidal ideation for adolescents going on antidepressants; this is obviously a sensitive topic and a terrifying thought for parents. I never dismiss concerns like this, yet I also acknowledge there can be risks of not treating depression too–so I advise parents to talk through their concerns with a psychiatrist, in order to consider all information when making treatment decisions, just like you would ask questions regarding treatment for a physical condition in order to weigh risks and benefits. 

Dr. Seelman shares that often patients have concerns about side effects of medications, “and the tipping point for them is ‘I don’t know how it could get worse.’ It’s sometimes true that medication side effects could be trading out one problem for another (like ADHD medication suppressing appetite but improving behavior at school). But it’s a process from a psychiatrist’s perspective to talk about what to look for, and what are the signs of what’s working and what’s not working.”

Some clients also bring up fears about dependency or being stuck on meds permanently. I let them know that the goal for most people is coming off of the medication once symptoms are better. As Dr. Seelman explains, “I try to be really intentional about evaluating symptoms and deciding when to taper off. We talk about what we’d watch for that would mean we’d be ready to go off the medication. And then I help monitor going off of it. Whether you work with a psychiatrist or pediatrician, there should be regular discussion and monitoring.” She adds, “The course of the medication depends on what we’re treating- but it’s never the case that we’d put a kid on medication and then never consider coming off. The vast majority are able to come off and there’s consistent evaluation about whether to come off of meds.”

• What story have you told yourself about medication? Again, there is unfortunately a lot of stigma around mental illness and medication. You might have told yourself you would never need it, or that going on medication is some type of failure, or that you’d never want people to find out. I often ask my clients, would you have the same self-judgments about medication for a physical health issue? In either case you are feeling unwell and medication could help you feel better- so we work on rewriting some of those inner narratives, and separate the negative beliefs from the actual facts about what meds can offer.

• Do you feel like you don’t know enough to have an opinion or make a decision? Sometimes clients don’t have negative ideas about medication but just don’t know much about it, since once again, it’s a slightly taboo topic. When symptoms warrant medication and clients are hesitant, I recommend that clients have a consultation with their doctor, their child’s pediatrician, or a psychiatrist, to discuss their symptoms, find out options for medication, and weigh the pros and cons based on factual information and expert medical advice (the same as you would for a physical condition!).

I hope this clarifies what a therapist is considering when we suggest medication to help with treatment, and also empowers you as a client or parent to understand some important considerations as well. If you’d like to know more, we have therapists who can talk with you about different treatment plans and provide referrals for psychiatrists.

Thank you to Dr. Michelle Seelman for contributing to this blog, Dr. Seelman (drseelman.com)