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Practical Practice: ‘Courageous’ conversations with clients about a medication evaluation may be necessary

Psychotherapy for depression is the treatment of choice over medication for people willing to seek mental health help. The American Psychological Association’s Clinical Practice Guidelines for the general adult population suggest that a shared decision-making model be used to help people with depression make informed decisions about treatment with psychotherapy and/or second-generation antidepressants.

Ideally, psychologists would screen all new clients presenting for psychotherapy treatment with standardized assessments for depression, anxiety, and psychological wellbeing. If symptoms do not improve, the clinician could discuss the potential benefits of a consultation with a prescriber to determine whether augmentation with psychotropic medication might be appropriate.

In practice, there is a great deal of heterogeneity in how clinicians respond to those whose depression does not improve with therapy. The conversation about a medication consult should be approached carefully.

My clients, like many Americans, are often suspicious of medication to treat depression, citing stigma, side effects, or worry that medication might numb or blunt emotional response. An ongoing discussion about the client’s feelings about the stigma of taking medication often ensues.

I don’t feel conflicted when a client makes an informed decision not to take medication. Our job as clinicians is to educate patients. Sometimes it feels like an uphill battle to educate reticent, skeptical clients. Competent, knowledgeable prescribers are in short supply and the barriers to finding a prescriber, added to a client’s apprehension about medication, can be tremendously frustrating.

Among my colleagues, many accurately argue that antidepressants are over prescribed in the medical setting, often without an accurate psychiatric diagnosis or any plan for ongoing psychological monitoring. Direct marketing of pharmaceuticals to consumers in the United States has given rise to valid concerns that Americans are over prescribed and inappropriately prescribed medications for mood.

I often wonder how psychologists’ attitudes affect whether their patients receive a recommendation for a medication evaluation. There is substantial empirical study of the attitudes of the public toward psychotropic medication and a limited number of studies of physicians. But relatively little research is devoted to the attitudes of psychologists and non-prescriber mental health professionals. It is surprising, given that mental health practitioners are often involved in the shared decision-making process of whether to seek out a prescriber.

Though I try to stay aware of my own values, beliefs, and attitudes on this controversial topic and make effort to stay up to date on the changing science, I still find conversations about a medication consultation one of the more difficult topics to broach with clients.

In a memorable example of blunder, I can recall the withering look given to me by a client when she correctly stated that medication would not alter any of the serious health conditions with which she struggled. She was correct, as was I, in my belief that the severity of her depressive symptoms warranted a medication consultation. In hindsight, I suspect my error was one of timing. I had not yet built sufficient rapport, nor did I have full understanding of her values and preferences. Fortunately, psychotherapy often allows the clinician an opportunity to resolve misunderstanding and repair ruptures as was the case in this instance.

I intentionally focused this column on discussion about medication for clients with depression. I suspect that most therapists would reach consensus on the need for medication for patients with psychosis.

Conversations about anxiolytics can be even more fraught than antidepressants. In a compelling article published in “The New Yorker” in 2019, Rachel Aviv explores the potential difficulties of going off antidepressants, a topic that has received little study.

It can be tempting as a therapist, to stay out of the fray and make only brief, superficial attempts to engage patients in a discussion about a medication consultation. But ethically, psychologists are bound to follow the APA guidelines. I don’t particularly like broaching conversations with clients about medication. Research supports that exercise can be as effective as antidepressants. If the client is receptive, I support increasing physical activity with the goal of improving mood. But it is difficult to muster the energy and motivation to begin exercise for the non-depressed and thus a challenging undertaking for many struggling with debilitating symptoms.

I believe in the value of psychotherapy. Evidence based psychotherapy treatment does not have the types of side effects associated with psychotropic medications, is more effective than medication at preventing recurrence of depressive symptoms, and can be tremendously life enhancing. But when clients continue to suffer with symptoms that could be ameliorated, it is important not to avoid having a courageous conversation about medication evaluation.

Ellen Anderson, Ph.D is a psychologist in private practice in Connecticut who specializes in working with adults coping with medical illness. She is also an author who has written books for health care providers focused on the psychological aspects of heart disease and cancer and is the editor of the American Psychological Association’s clinical health psychology book series.

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