If you’d asked my grandmother about attention-deficit/hyperactivity disorder (ADHD), she would have replied, “That’s a white people thing.” What Western medicine pathologizes, my Asian family would’ve just called “life.”
Child with ADHD? Well, no one can possibly focus for 8 hours in a stuffy classroom with a paltry half-hour of unstructured play (if that — only eight states require daily recess in elementary schools). Depressed young woman? Family must not be supportive enough, and her husband is likely useless. Who wouldn’t be depressed?
Though I believe in psychopharmacology’s value, this worldview has heavily informed my own practice, and I also believe in deprescribing wherever appropriate, particularly when I see frightening medication regimens.
And I confess that I, in some contexts, question whether our medications can be sufficiently effective. “Doctor, please give me something, anything, for the anxiety,” wept one patient. She worried me. A month earlier, she’d disclosed her husband’s abuse and her anxiety was intolerable. I passed her my tissue box and sighed. She needs therapy and an order of protection, I thought.
But her insurance wouldn’t cover therapy, and the out-of-pocket cost was prohibitively high. I was using medication appointments as mini psychotherapy sessions, but it was hardly adequate. As gently as I could, I told her, “I can go up on your escitalopram (Lexapro), but there isn’t a medication that can eliminate your fear of how close your husband’s fist comes to your head.”
Psychiatric Chronification
In a “Dear Colleague” letter from May, Health and Human Services Secretary Robert F. Kennedy Jr. calls for individualized, person-centered mental healthcare and attention to psychiatric deprescribing. While the letter itself is not unreasonable, Kennedy has reportedly explored banning some selective serotonin reuptake inhibitors (SSRIs) and has made outrageous public claims about these medications.
SSRIs have had significant benefits for millions of patients, myself included. As I left an abusive relationship, they were a big part of the difference between Chloe lying virtually catatonic and suicidal in a dark room and Dr. Lee functioning optimally as a psychiatry resident.
But antidepressants do indeed carry risks (not school shootings or teratogenesis), which standard of care mandates we discuss thoroughly with patients prior to initiation. Furthermore, some patients may find tapering SSRIs challenging.
Firstly, long-term use may create a physiologic dependence, and antidepressant discontinuation syndrome — a constellation of uncomfortable symptoms including nausea, sensory disturbances, headache, and irritability — can emerge upon tapering the medication.
Secondly, independent of their biological mechanisms, medications may carry deeper meaning for patients and become integral to their identity. Patients often identify strongly with their mental health diagnoses, finding community and validation in the shared language of illness, which is overall protective against potential stigma. Medications and doctors become pillars of stability for them, and the idea of parting with either can create enormous distress that feels uncontrollable. Treatment resistance may emerge not because the medication is ineffective per se, but because the medication, treatment, or wellness holds a psychological meaning for the patient that must be explored clinically through intensive psychotherapy in conjunction with serotonergic agents.
But how do we usually control emotional distress in our too-short visits? We prolong the prescription or add a new medication, unwittingly de-emphasize the patient’s agency and ability to self-regulate, and contribute to psychiatric chronification, the process by which psychiatric disorders become debilitating chronic illness.
This isn’t wholly the fault of psychiatrists but a function of the system in which we operate. Though Kennedy included the relevant psychotherapy billing codes, his letter ignores the reality of under-resourced communities with long wait times and chronically understaffed and underfunded psychiatric services with decrepit facilities, as well as the fact that the intensive psychotherapy that can benefit so many patients is often inaccessible. The Austen Riggs Center, for example, is private-pay and charges $97,000 for 6 weeks of treatment. I do not have a spare $100,000, and I’m in a better financial position than most of my patients, the vast majority of whom are on Medicaid, which the Trump administration slashed viciously last year.
Our capitalistic society created a pivotal shift from the historically psychodynamic ethos of our field to a short-sighted predominantly biologic model. In our profit-driven healthcare system that values rapid patient turnover and doesn’t reimburse cognitive services especially well, we simply don’t have the infrastructure to incentivize psychotherapy and other non-medication interventions, despite their clear benefit. And even if we did, what protection do we have against political decisions that irreparably harm the fabric of our culture?
A Case for Consideration: Intimate Partner Violence
I frequently return to the intimate partner violence population because it is my area of specialization; this patient population is rife with complex trauma and mood disorders — but are they disorders or appropriate responses to inexcusable circumstances? The poet Nikita Gill captures this tension beautifully: “You are angry and anxious because you never agreed to live in a burning home while the people who should care pretend the fire doesn’t exist.”
Medical students learn that SSRIs are the first-line medication for patients with post-traumatic stress disorder. But what would benefit an abused woman most from a mental health perspective? I’d argue that stable housing, a legal system that doesn’t revictimize her and exacerbate her trauma symptoms, supportive communities, access to quality healthcare, and reproductive and financial autonomy go much further than 200 milligrams of sertraline (Zoloft).
But we don’t have that infrastructure. The Trump administration is proposing massive cuts to programs funded by the Violence Against Women Act. The Supreme Court, packed with conservative justices that President Trump chose, overturned reproductive autonomy, disproportionately harming domestic violence survivors. And the administration defends violent man after violent man, while remaining non-compliant with the Epstein Files Transparency Act, functionally protecting a massive network of male abusers of women and girls and nominating a complicit lawyer to lead the Department of Justice. The message that this population is receiving from people in power is that those who could help them simply don’t care.
When sociopolitical circumstances directly contributing to mental health pathology are intolerable and inflexible, SSRIs have limited benefit.
Some mental health pathologies warrant not medical but political solutions. While Kennedy is correct in advocating for person-centered care that transcends pharmacotherapy and avoids polypharmacy, he is oxymoronically a bastion of a political administration that has actively worsened many of the social conditions that contribute heavily to mental health pathology in the first place.
The views above belong only to the author and are not shared by any institution with which she is affiliated.
