Why I Sometimes Don’t Recommend Medication

I prescribe psychiatric medication. I have also completed psychiatric evaluations where my recommendation was not to prescribe anything at all.

Those two decisions are not contradictory. The purpose of a psychiatric evaluation is not simply to determine which medication matches a diagnosis. It is to understand what is happening well enough to decide what kind of intervention is most likely to help.

Sometimes that intervention is medication. Sometimes it isn't.

A symptom does not automatically require a prescription

Someone may seek psychiatric care because they are anxious, exhausted, unable to concentrate, sleeping poorly, increasingly irritable, or simply not feeling like themselves. Those symptoms deserve to be taken seriously, but their presence does not automatically tell us what treatment should come next.

Difficulty concentrating, for example, might reflect ADHD. It might also be related to depression, anxiety, chronic sleep deprivation, substance use, medication effects, overwhelming workload, or a medical condition. Insomnia may be part of a psychiatric disorder, but it can also be driven by behavior, circadian disruption, another medication, substance use, sleep apnea, or a schedule that provides too little opportunity for sleep.

Prescribing something before understanding what is driving the symptom can sometimes mean treating the manifestation while overlooking the cause.

Sometimes distress is an understandable response to life

Psychiatry also occupies an unusual position because many painful human experiences resemble symptoms of psychiatric illness.

Grief can disrupt sleep and concentration. A deteriorating relationship can produce anxiety. A hostile workplace can leave someone dreading Monday morning. Caring for an ill family member can produce exhaustion, irritability, and emotional depletion. Major transitions can temporarily make someone feel unlike themselves.

That does not mean the distress is trivial or that someone should simply “deal with it.” Nor does it mean that significant life stress cannot precipitate a psychiatric disorder. Both can be true.

But not every painful emotional state is evidence that something in the brain needs to be medicated.

Sometimes the appropriate intervention may be psychotherapy, better sleep, addressing substance use, changing an unsustainable situation, strengthening support, allowing time for grief, or treating an underlying medical problem. Sometimes the most useful thing psychiatry can provide is a clearer understanding of what is happening and what does, and does not, require treatment.

High performers can present a particular challenge

This becomes especially interesting with high-performing professionals because the request for medication may sometimes be framed around restoring performance.

“I need to focus.”

“I need more energy.”

“I need something for sleep because I only have five hours.”

“I can't afford to feel this anxious before presentations.”

Those concerns are legitimate, and medication may sometimes be entirely appropriate. But there is an important question underneath them: Are we treating an illness, or are we asking medication to help someone tolerate circumstances that have become unsustainable?

If someone routinely allows five hours for sleep, the first question may not be which medication will make five hours feel sufficient. If a workplace is producing relentless anxiety because the environment itself is dysfunctional, eliminating every sensation of anxiety may not address the most important problem.

Medication can be powerful. But it cannot make every environment healthy, every workload sustainable, or every painful situation painless.

The opposite mistake matters, too

There is another side to this conversation that is equally important.

Not prescribing medication is not automatically more thoughtful, holistic, or sophisticated than prescribing it. There are psychiatric conditions for which medication has substantial evidence of benefit, and there are circumstances in which delaying effective pharmacologic treatment can prolong significant suffering or increase risk.

I am equally cautious about the idea that avoiding medication should always be the goal.

Some people arrive for treatment reluctant to consider medication because they believe needing it represents weakness, means their condition is particularly severe, or somehow makes their recovery less authentic. Others have been told that exercise, supplements, meditation, better nutrition, or sufficient willpower should be able to solve the problem.

Those interventions may have value, but they are not interchangeable with evidence-based treatment for every psychiatric condition. The goal should not be to prescribe as much medication as possible. It should not be to prescribe as little medication as possible either.

The goal is to use medication when the expected benefits justify it and when it meaningfully contributes to the treatment of the problem in front of us.

Medication should have a job

When I recommend a medication, I want to be able to answer a few basic questions: What are we trying to treat? Why does this particular medication make sense? What improvement are we looking for? What adverse effects matter for this person's health and lifestyle? How will we know whether it is working?

That last question is especially important.

“Feeling better” matters, but treatment goals can often be more specific. Is sleep becoming more restorative? Is concentration improving? Are panic attacks less frequent? Is someone able to engage with relationships again? Has motivation returned? Is the person functioning better without unacceptable adverse effects?

A prescription should have a clinical purpose, not simply occupy a place on a medication list.

Good psychiatric care is not pro-medication or anti-medication

Psychiatric medication is one tool among several, and for the right person in the right circumstances, it can be an extraordinarily valuable one. For someone else, the most appropriate recommendation after a psychiatric evaluation may be psychotherapy, behavioral change, further medical evaluation, improved sleep, addressing a substance, changing an environmental stressor, or simply monitoring symptoms before intervening.

The difficult part is determining which situation you are actually looking at.

That is why I don't think the most useful question is: “Do you believe in psychiatric medication?”

A better question is: “What problem are we trying to solve, and what treatment gives this particular person the best chance of solving it?”

Sometimes the answer includes a prescription. Sometimes it doesn't. Good psychiatric care isn't pro-medication or anti-medication. It is pro-appropriate treatment.