Shrinks In Sneakers

Tag: medications

  • Psychiatry Is on Trial. We Should Not Plead Guilty to the Wrong Charges

    Psychiatry Is on Trial. We Should Not Plead Guilty to the Wrong Charges

    Psychiatry is on trial. It was probably inevitable. A field that treats suffering, suicide, psychosis, trauma, addiction, violence risk, loneliness, despair, and meaninglessness was always going to be dragged into the political arena. Psychiatry sits at the intersection of medicine, culture, family trauma, public fear, pharmaceutical influence, personal liberty, and moral injury. That makes it uniquely vulnerable to distortion.

    But the current moment feels different.

    With Health and Human Services Secretary Robert F. Kennedy Jr. placing psychiatric medications and “overmedicalization” at the center of federal attention, psychiatry is no longer only being debated in journals, clinics, and academic conferences. It is being litigated in public. Increasingly, it is also being litigated in court. On May 4, 2026, HHS announced a MAHA action plan aimed at curbing psychiatric overprescribing, promoting informed consent, shared decision-making, nonmedication interventions, and deprescribing when clinically indicated.1

    Some of that language is reasonable. In fact, many psychiatrists already agree with it.

    Psychiatric medications should not be the default response to every form of human distress. Patients deserve informed consent. Deprescribing should be part of competent care. Psychotherapy, exercise, sleep, nutrition, family support, social connection, and meaning making should not be treated as decorative add-ons. They are often central to recovery.

    But that is not the same as saying psychiatric illness is not real. It is not the same as implying psychiatric medications are broadly dangerous, unnecessary, or responsible for America’s mental health crisis. And it is certainly not the same as turning painful anecdotes into national policy.

    That is where psychiatry must draw the line.

    The American Psychiatric Association has appropriately pushed back on the idea that the mental health crisis can be reduced to overprescribing, noting that this framing ignores workforce shortages, limited access to care, lack of psychiatric beds, and uneven distribution of evidence-based treatment.2 That is exactly right. Deprescribing may be good medicine in selected cases. But deprescribing is not a national mental health strategy.

    It is a clinical tool.

    There is a dangerous pattern in the current conversation. A public figure describes a deeply personal experience: a family member struggles to discontinue an antidepressant, someone feels emotionally blunted on medication, a young adult regrets being started on an SSRI as a teenager, or a patient develops withdrawal symptoms after stopping too quickly. The story is real. The suffering is real. The problem deserves attention.

    But then the anecdote becomes a theory of psychiatry.

    The assumption becomes: because this happened to someone I love, this must be what psychiatry is doing to the country.

    That is not science. That is narrative capture.

    Psychiatry should not dismiss these stories. We should listen to them. We should admit that antidepressant discontinuation can be difficult for some patients. We should acknowledge that medications are sometimes started without a clear enough plan, continued without adequate review, and stopped too abruptly. We should be honest that some patients are placed on medication when what they needed first was psychotherapy, time, structure, sleep, exercise, substance use treatment, grief work, family intervention, or a change in environment.

    But honesty cuts both ways.

    Some patients are not “overmedicalized.” They are undertreated. Some are not being harmed by psychiatry. They are being harmed by the absence of psychiatry. Some patients do not need fewer medications. They need the right diagnosis, the right medication, the right dose, the right monitoring, the right therapy, and a system that does not abandon them after discharge.

    I work in real-world psychiatry. I have seen patients whose lives were devastated by undertreated depression, bipolar disorder, psychosis, catatonia, OCD, addiction, and trauma. I have also seen patients placed on medications they did not need, for longer than necessary, without enough discussion about risks, benefits, alternatives, or exit strategies. Both realities are true.

    That is the entire point.

    Psychiatry’s critics often want one story. The real world gives us several.

    Psychiatric medications can be overused. They can also be lifesaving.

    Antidepressants can cause side effects. They can also help patients return to work, reconnect with family, survive suicidal depression, and function again.

    Stopping medication can produce withdrawal symptoms. Stopping medication can also reveal relapse of the underlying illness. Clinically, those are not always easy to separate, and the distinction matters.

    Psychiatry has a difficult history. It also remains one of the few medical specialties willing to sit with the most frightening, stigmatized, and disabling forms of human suffering.

    The field does not need denial. It needs precision.

    One of the most important reforms psychiatry should embrace is building the off-ramp into treatment from the beginning. When starting an antidepressant, clinicians should discuss expected duration, criteria for continuation, warning signs of relapse, tapering principles, and what remission means. Patients should know that medication is not a moral failure, not a life sentence, and not something to stop abruptly to prove toughness.

    Abrupt discontinuation is not courage. It is usually bad medicine.

    And it is not only psychiatrists saying so. The American Foundation for Suicide Prevention, responding directly to the HHS action plan, warned that “abrupt discontinuation or inappropriate ‘deprescribing,’ particularly outside a collaborative patient-provider process, can increase risk, including the potential for symptom relapse and elevated suicide risk for some individuals.”3 AFSP also reaffirmed what decades of clinical trials, population-level studies, and health system data have shown: judicious use of antidepressants reduces suicide risk overall.3

    That is the suicide prevention community speaking. Not the pharmaceutical industry. Not organized psychiatry. The organization whose entire mission is keeping people alive.

    If HHS wants to support better tapering education, better informed consent, better access to psychotherapy, and better reimbursement for clinicians who take the time to deprescribe carefully, psychiatry should welcome that. In fact, we should lead it. The HHS action plan specifically emphasizes informed consent, shared decision-making, review of risks and benefits, nonmedication approaches, and tapering when patients are not experiencing clinical benefit.1 Those are not anti-psychiatry principles. Done correctly, they are good psychiatry.

    But the same public conversation has also entertained the claim that psychiatric medications cause mass shootings, a claim that has been repeatedly examined and found to lack credible scientific support. When prominent voices repeat it anyway, the harm is not abstract. Patients hear it. Families hear it. Lawmakers hear it. People already afraid of treatment become more afraid. Stigma grows. Care is delayed.

    And delayed care kills. AFSP said as much in its response to this action plan.3

    Psychiatry should not respond to this moment by becoming reflexively defensive. We should not pretend the field has always gotten it right. We have not. We should not deny withdrawal, side effects, diagnostic uncertainty, pharmaceutical influence, rushed prescribing, or the medicalization of ordinary distress. Those criticisms contain enough truth that ignoring them would be a mistake.

    But we should also refuse to accept a false indictment.

    The problem is not that psychiatry exists. The problem is that too many Americans receive fragmented, rushed, algorithmic, poorly monitored, under-resourced mental health care and then call that psychiatry.

    The problem is not that antidepressants are prescribed. The problem is that they are sometimes prescribed without enough diagnostic clarity, psychotherapy access, follow-up, deprescribing planning, or attention to the difference between illness and distress.

    The problem is not that psychiatrists believe in medication. The problem is that our health care system often reimburses medication management more reliably than psychotherapy, family work, lifestyle intervention, prevention, community support, and time.

    That is not an argument against psychiatry. It is an argument for better psychiatry.

    Psychiatry must be willing to say something politically inconvenient: not all suffering is mental illness, but mental illness is real. Not everyone who is sad needs a diagnosis, but some people with depression will die without treatment. Not every anxious child needs medication, but some children are severely impaired and deserve evidence-based care. Not every patient should remain on an antidepressant indefinitely, but some patients relapse repeatedly when treatment is stopped. Not every psychiatric outcome is preventable, but some bad outcomes occur because systems fail.

    It is possible to do everything right in psychiatry and still have a tragic outcome.

    It is also possible to have a tragic outcome because we did not do enough.

    That distinction is where serious medicine lives.

    This is why psychiatry must reclaim the public narrative. We cannot allow the field to be defined only by its critics, by pharmaceutical marketing, by political theater, or by the most extreme anecdotes on social media. We need to speak plainly to the public.

    Yes, antidepressant withdrawal can happen.

    Yes, some patients are overmedicated.

    Yes, informed consent needs to improve.

    Yes, therapy and lifestyle interventions matter.

    Yes, deprescribing should be part of psychiatric competence.

    And yes, psychiatric medications remain essential treatments for many people with serious and disabling illness.

    The future of psychiatry should not be pill-first. It should not be pill-never. It should be patient-first, diagnosis-first, evidence-first, and humility-first.

    Psychiatry will not survive this moment by going quiet, and it will not survive it by going defensive. It will survive by becoming better, and by saying so out loud.

    We are not the cause of America’s mental health crisis. We are also not its cure. We are physicians treating the most disabling illnesses medicine has ever named, in a system that has never funded us to do it well, in a country that wants the suffering to stop but does not want to pay for the treatment that stops it.

    If HHS wants better psychiatry, psychiatry should be the first to demand it. If patients want safer prescribing, we should be the ones leading it. If the public wants honesty, we should give them more of it than they expected.

    Psychiatry does not need to plead guilty to the wrong charges. But we do need to stop letting other people write the indictment.

    The defense rests when the work begins.

    References

    1. HHS launches MAHA action plan to curb psychiatric overprescribing. US Department of Health and Human Services. News release. May 4, 2026. Accessed May 13, 2026. https://www.hhs.gov/press-room/hhs-launches-maha-action-plan-curb-psychiatric-overprescribing.html

    2. APA welcomes national focus on mental health, urges evidence-based approach and continued focus on access to care. American Psychiatric Association. News release. May 4, 2026. Accessed May 13, 2026.

    3. Moutier CY. AFSP statement on the importance of antidepressants and evidence-based treatment for suicide prevention. American Foundation for Suicide Prevention. News release. May 5, 2026. Accessed May 13, 2026. https://www.prnewswire.com/news-releases/afsp-statement-on-the-importance-of-antidepressants-and-evidence-based-treatment-for-suicide-prevention-302762738.html

    4. Espí Forcén F, Hatters Friedman S. Psychiatry on trial: are psychiatrists responsible for their patients’ criminal behavior? Psychiatric Times. August 27, 2026. Accessed August 29, 2026. https://www.psychiatrictimes.com/view/psychiatry-on-trial-are-psychiatrists-responsible-for-their-patients-criminal-behavior

    Disclaimer: Views are my own not associated with any employer. This is not medical advice, and the information is provided for educational purposes only. Please consult your doctor for any specific medical questions. All content is created for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider. If you think you have a medical emergency, call your doctor, go to the emergency department, or call 911. We do not endorse any specific treatment, tests, or procedures. Reliance on this information is solely at your own risk.

  • The Pill Won’t Solve It All 💊🚫

    The Pill Won’t Solve It All 💊🚫

    When every problem you face has been treated exclusively by a pill, you start to believe that the answer to all your struggles lies in finding the right one. 🤔💡

    With this mindset, you will never be well. 🧠❌

    It’s no different than someone searching for the perfect car 🚗 or the dream home 🏡 to fix their life. Sure, it might bring temporary relief, but in the end, it steals your power, leaving your happiness dependent on external factors you can’t control. 🎭🔗

    True healing starts when you reclaim your own agency. 💪🔥

  • Clozapine: Unlocking Relief for Negative Symptoms in Schizophrenia

    Clozapine: Unlocking Relief for Negative Symptoms in Schizophrenia

    Clozapine has been studied extensively in schizophrenia, particularly for treatment-resistant cases. Its role in managing negative symptoms (e.g., apathy, alogia, anhedonia, social withdrawal) has been investigated in various randomized controlled trials (RCTs).

    RCT Evidence for Clozapine in Negative Symptoms

    1. Clozapine vs. Typical Antipsychotics
      • Several studies have shown clozapine’s superiority over first-generation antipsychotics (FGAs) like haloperidol in reducing negative symptoms.
      • Example: A landmark RCT (Kane et al., 1988) demonstrated that clozapine not only reduced positive symptoms but also had beneficial effects on negative symptoms, potentially due to its unique pharmacology (e.g., serotonin-dopamine antagonism, NMDA receptor modulation).
    2. Clozapine vs. Other Atypical Antipsychotics
      • Mixed Results: Some RCTs suggest that clozapine is more effective than other atypical antipsychotics (e.g., risperidone or olanzapine) in improving negative symptoms, while others show no significant difference.
      • A meta-analysis of head-to-head RCTs found that while clozapine had modest effects on negative symptoms, differences between it and other atypicals were small.
    3. Clozapine in Primary Negative Symptoms
      • Challenges: True primary negative symptoms (not secondary to positive symptoms, sedation, or depression) are challenging to isolate in trials.
      • Some RCTs highlight that clozapine’s effects on negative symptoms might be indirect, mediated by improvements in positive symptoms, cognitive function, or overall social functioning.
    4. Adjunctive Therapies
      • RCTs combining clozapine with adjuncts like antidepressants (e.g., fluvoxamine) or cognitive enhancers (e.g., aripiprazole, NMDA modulators) have been conducted. While adjunctive strategies show promise, the evidence remains preliminary and inconsistent.

    Potential Mechanism

    Clozapine’s effects on negative symptoms may be attributed to:

    • Serotonin-Dopamine Antagonism: Improved dopamine transmission in the mesocortical pathway.
    • Glutamatergic Modulation: Effects on NMDA and AMPA receptors.
    • Anti-inflammatory Properties: Reduced neuroinflammation may play a role in symptom improvement.
    • Sedation Reduction: Lower propensity for extrapyramidal side effects compared to FGAs.

    Limitations of Evidence

    • Heterogeneity: Most RCTs mix patients with primary and secondary negative symptoms, confounding results.
    • Measurement Challenges: The assessment of negative symptoms in trials is often subjective and prone to bias.
    • Indirect Effects: Improvements may stem from reductions in positive symptoms or cognitive enhancements rather than direct action on negative symptoms.

    Key Takeaway

    Clozapine shows some benefit for negative symptoms, particularly when compared to FGAs and in cases with secondary negative symptoms. However, its effects on primary negative symptoms are modest, and it is generally not considered the first-line choice for this domain of schizophrenia. Adjunctive approaches or newer agents might offer additional promise.

  • Medication Side Effects: “I feel nauseous”

    Medication Side Effects: “I feel nauseous”

    Introduction:

    Did you know that the researchers that conduct drug trials do not ask patients about specific side effects? Rather, they ask a generic question such as “are you having adverse reactions to the medication” the patient then has to self-report any specific side effects they are having. Sometimes physicians during medication management sessions will use a similar question when asking about side effects. Some physicians also make statements when prescribing the medication such as “don’t worry most people do not have side effects with this medication.” This is egregious, considering we know these medications have side effects as all medications do. What I want to do over the next several posts, is discuss the common side effects of SSRIs and what you can do about them. The biggest issue we face with psychiatric medications is adherence, and many times side effects play a role. 

    I want to start with the most common side effects and work our way down. Nausea is one of the early side effects that is disturbing to patients and may result in discontinuation of the medication. Several things can be done to reduce the risk of nausea. 

    Medication Starting Dose and Titration

    One simple step could be to start the medication at the lowest possible dose and titrate slowly. Titrating the dose over one week has been shown to cut the risk of nausea in half. Another potential intervention is to split the dose and give the split dose with separate meals. If possible, use sustained/extended release preparations of the medication. For example, starting a patient on escitalopram 5 mg instead of 10 mg might help reduce the risk of nausea. Another simple change could be the timing of medication administration. Taking the medication after a meal may be helpful. Many patients find that food helps reduce the nausea and most of these medications can be taken with or without food. 

    Ginger Is Good

    If the above interventions fail to help you can consider ginger root. This dietary supplement can be purchased over the counter from your local health food store. Ginger root 550 mg one to two capsules up to three times per day if the slow titration and other intervention are ineffective. 

    If All Else Fails

    Finally, if the nausea does not respond to the above interventions then anti-nausea medications are appropriate. The two most commonly used at ondansetron and Mirtazapine which also blocks 5HT-3 receptors leading to reduced nausea. 

  • Medication Side Effects: Doctor I’m Gaining Weight!

    Medication Side Effects: Doctor I’m Gaining Weight!

    One of the biggest challenges we face in the field of psychiatry is medication adherence. A large portion of the people fail to get better either because they do not start the medication, or do not take it as prescribed. One of the most common reason cited by patients for stopping medication is weight gain. In this article I will detail the approach I take to weight management for patients on psychiatric medications. 

    Initial Visit: 

    Weight management is a discussion that should happen between the patient and clinician at the first meeting. It’s important to use primary prevention (preventing the onset of weight gain) if possible. We always obtain some objective measures such as height, weight, and calculate the BMI on the initial visit and subsequent visits. Additional tests that may be ordered include HBA1C, fasting blood glucose, and lipid profile. This is where I will take the opportunity to discuss the importance of diet and exercise. For people with little diet or exercise experience I will keep the information very basic. The discussion will center around eliminating processed foods, calorie containing beverages, increasing fruit and vegetable intake, and making good choices when shopping at the food store. I have several handouts with food choices on them that help guide the patient when making food choices at the grocery store. I also recommend patient’s keep a food diary or track their food intake on a mobile app such as my fitness pal. This will help us to understand more about the patient’s eating habits and identify potential areas for improvement. I will build on diet interventions and monitor progress with the food diary or app at each visit. I do not recommend a specific diet, as it’s far more important for the patient to pick something they can be consistent with, and there are multiple ways to achieve weight management goals. At this time the closest diet we have that I’m comfortable recommending is the Mediterranean diet. There is some good evidence that the Mediterranean diet can have an antidepressant effect which is an added bonus.

    Exercise

    Exercise is the next area to address. I like to ask some screening questions about what type of physical activity the patient engages in, and how much experience they have with fitness/athletics. I will then ask them to track their exercise over the subsequent weeks prior to returning for follow up visit. On the initial visit I will recommend they begin a basic walking program of at least 30 minutes per day preferably seven days per week. This is a simple thing to incorporate on a daily basis, and does not require any special equipment or gym membership. We can improve on this routine and incorporate resistance training on a case by case basis. 

    Medication Choice

    The next step in the process is to make a medication choice that limits the potential for weight gain. Most psychiatric medications cause weight gain. This is an unavoidable fact. Avoiding the use of medications with the highest propensity of weight gain including Clozapine, Olanzapine, and Mirtazapine is good planning on the physician’s part. It’s important to note that it’s not always possible to avoid these medications. Medications such as Aripiprazole which are considered to be weight neutral, from clinical experience are not weight neutral at all. It’s important for the clinician to make good choices if weight gain is a potential issue that will interfere with treatment.

    Medication For Weight Management

    My last line of defense against weight gain which often comes too late is medication management. I like to start with Metformin extended release 500 mg daily after the largest meal. This is to test the patient’s tolerance for the medication. The goal is to titrate to 2000 mg/day in divided doses. A B12 level should be checked once per year as Metformin has been known to reduce levels. There is evidence in the literature from a Meta-analysis of all RCTs supporting the use of Metformin for antipsychotic induced weight gain. The important thing to remember is to start the medication at the earliest signs of weight gain, or even before the onset of weight gain in high risk patients. The patients most likely to benefit are those who are younger, more recently started on antipsychotics, overweight but nor obese, and those that had rapid weight gain. 

    The second medication I will talk about is Topiramate There is evidence from RCTs to support the use of Topiramate for antipsychotic induced weight gain. There is greater weight loss with Topiramate over placebo, with a mean decrease of 2.8 kg. The effective dose for the medication is 100 to 200 mg/day depending on the patient’s tolerance. Getting to an effective dose can often take some time with this medication.

    Final Points

    Weight management discussions begin day one when medications are going to be used. Prevention is the first line option with lifestyle modification including diet and exercise. Medication choice also plays a big role. When initiating medication being mindful of the propensity for weight gain, and using medications that are weight neutral if possible, can help. If these measures fail, there are a few options backed by research evidence which can be used but I believe lifestyle modification is the best option.