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Do Mental Illnesses Need To Be Medicated?

Valarie Ward

Table of contents

If you or a loved one are struggling to manage your mental health, there are many resources available to get you feeling better. Depending on the diagnosis, you and your care team might consider lifestyle changes, therapy, and/or medication. 

However, medication for your mental illness can be complicated. Some medications come with unfortunate side effects that leave one wondering whether they’re worth taking. Many medications won’t work for your particular genome, which makes the process of finding the correct medication lengthy and frustrating. Some also worry about being tied down to a medication for the rest of their lives. 

If you’re currently on medication that is helping you manage your mental illness, that is wonderful, and you should never feel ashamed for that! In fact, you should never alter your medication without your doctor’s knowledge. Many mental illness medications need to be tapered off for the body to adjust properly, and it can be very dangerous to alter your medications without support from your doctor. 

If you haven’t started a medication and are wondering whether you should, the answer is: it depends. Keep reading to learn about your diagnosis, types of medication available, and some alternatives to keep in mind.

Your mental illness Diagnosis

The biggest factor in whether you need mental illness medication is your diagnosis. The 5th edition of the Diagnostic and Statistical Manual (DSM-5, the current industry standard for diagnosing and defining mental illnesses) breaks diagnoses down into a few categories. We’ll go through each of the main disorders and discuss the DSM recommendations and scientific evidence.

Psychotic disorders, including schizophrenia

This chapter of the DSM-5 (p 87-122) includes schizophrenia and schizoaffective disorder, both of which occur in less than one percent of adults worldwide. Psychotic disorders are characterized by “delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms” (incl. diminished emotional expression and avolition). About 20% of those with schizophrenia attempt suicide.

Treatment for psychotic disorders is usually lifelong. According to research in P&T: a peer-reviewed journal for formulary management, rehabilitation programs typically need a combination of medication and therapy. Antipsychotic medications help relieve the delusions and hallucinations, which are necessary for therapy to stick; and therapy is necessary because the nature of psychotic disorders leads many to stop taking their medication. 

You can learn more about antipsychotic medications here.

The DSM-5 considers bipolar and its related disorders (including bipolar II and cyclothymia) a “bridge” between schizophrenia and depression, and places it accordingly (p 123-154). These disorders occur in less than 3% of U.S. adults, and most cases are severe. In the International Classification of Diseases (ICD-11), both bipolar and depressive disorders are classified as “mood disorders.” 

Bipolar disorders are classified by periods of mania or hypomania and periods of depression. Mania alone includes psychotic episodes, while both moods include irritability, elation, grandiosity, less sleep, increased talkativity, racing thoughts, distractibility, increased attention to goals, and/or risky behavior. A diagnosable manic episode lasts for at least one week, while a diagnosable hypomanic episode lasts for at least four days. 

Major depressive episodes present in both types of bipolar disorder include a low mood, anhedonia, inconsistency in sleep or weight, loss of energy, and/or suicidal ideation, among other factors. Diagnosable depressive episodes last at least two weeks.

Because of the risks associated with bipolar disorder (including risky behavior while manic and suicidal ideation while depressed), most experts recommend both therapy and medication for the treatment of bipolar disorder. Therapy can help change the negative thoughts associated with depression, develop self-care, and recognize patterns of manic or depressive episodes. A mood stabilizer (such as lithium) is the first-line pharmacological treatment for bipolar disorder, but sometimes an antidepressant and/or antipsychotic will also be diagnosed. 

You can learn more about mood stabilizers here. 

Depression

Depression, dysthymia, and other depressive disorders (DSM-5 p 155-188) include the diagnosable depressive episodes described above: low mood, anhedonia, inconsistency in sleep or weight, loss of energy, and/or suicidal ideation, among other factors. As the DSM states, “Careful consideration is given to the delineation of normal sadness and grief from a major depressive disorder”–in other words, sadness and depression are not the same thing. Depression affects 7% of adults in the U.S. each year.

Dysthymia, otherwise known as persistent depressive disorder, is a chronic form of depression lasting for at least two years, affecting between 3-6% of the US population. 

Most people recommend a combination of therapy and medication to treat depression–but this is a contentious subject. Studies suggest that when compared with a placebo, only about 20% of individuals taking a medication affecting their serotonin levels (SSRIs and SSNRIs) saw improvement.

This may prompt some to suggest forgoing antidepressant medication altogether in favor of therapy and lifestyle changes, such as healthy diet and exercise. However, for many with extreme depression, low energy means that they may not even be able to get out of bed most days, let alone cook a healthy meal or go for a run. Medication may be necessary to improve one’s mood enough to even be able to attend a therapy appointment!

Everyone’s depression is different. No one should be judged or shamed if they’re on medication for their depression; nor should anyone be pressured into taking a medication when therapy and lifestyle changes might provide an effective solution. Your preference matters, so make sure you are open and honest with your mental health team about what you want.

You can learn more about types, efficacy, and side effects of depression medication here.

Anxiety

This chapter of the DSM-5 (p 189-234) describes anxiety disorders, classified by persistent feelings of fear, escape behaviors, and physical symptoms. It includes social anxiety disorder (social phobia), panic disorder, agoraphobia (and other phobias), generalized anxiety disorder, and others. In prior editions of the DSM, obsessive-compulsive and post-traumatic stress disorders were listed under anxiety disorders, but these have now been given their own sections. Affecting over 19% of US adults and 7% of US children, anxiety disorders are the most common mental health diagnosis. 

Cognitive behavioral therapy (CBT) is one of the most commonly prescribed types of therapy for anxiety and depression. One meta-analysis shows that CBT and medication are about equally as effective for treating anxiety, meaning that you might not need to take medication to feel better. 

As with depression medication, your personal preference matters; you may be able to treat your anxiety with therapy and lifestyle changes, but if you feel your anxiety symptoms are severe to the point where you cannot function, consider talking to your mental health team about your options.

Common medications for anxiety include antidepressants, described above, and benzodiazepines. You can learn more about benzodiazepines here.

Obsessive-compulsive disorder and its relatives–body dysmorphia, hoarding, disorders of pulling hair or picking skin, and others–are described in pages 235-264 of the DSM-5. As the DSM explains, 

“Obsessions are recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, whereas compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.”

Some common examples of obsessions and compulsions include cleaning, symmetry, repetition, taboo thoughts, and thoughts of harm. Less than 2% of U.S. adults have an OCD diagnosis.

A form of cognitive behavioral therapy known as exposure and response prevention (ERP) therapy is commonly recommended for individuals with OCD, and is effective in about 55% of cases. However, access to proper OCD treatment is poor, with less than 10% of patients receiving adequate therapy. 

Antidepressants are a common treatment for OCD; according to NAMI, “Treating OCD with antidepressants often takes longer to take effect than treating depression. Also, these medicines must sometimes be given in larger doses and for a longer period of time than for depression.”

The most common trauma-related disorder described in the DSM-5 (p 265-290) is post-traumatic stress disorder, affecting under 4% of U.S. adults. The disorder is characterized by anxiety, fear, anhedonia, dysphoria, aggression, and/or dissociation, as onset by a traumatic event.

There is also a newer form of PTSD not listed in the DSM, known as CPTSD (complex post-traumatic stress disorder). While PTSD is onset by one traumatic event, CTPSD is onset by long-term trauma, such as an abusive or neglectful home life, or the effects of war over a long period of time. We do not yet know how many Americans are affected by this disorder, as it is still relatively new.

When you’ve undergone trauma, medication alone cannot heal your wounds; you need trauma-informed therapy to help you process and cope with what happened to you. However, some antidepressants can help relieve symptoms of PTSD such as hypervigilance, irritability, and problems sleeping.

Dissociative disorders

This chapter of the DSM-5 (p 291-308) describes several dissociative disorders in which there is a disconnect between one’s thoughts, memories, identity, and consciousness. This includes depersonalization disorder (detachment from yourself, as though you are watching yourself in a movie), dissociative amnesia (difficulty remembering details of a traumatic event or information about one’s identity), and dissociative identity disorder (alternating between multiple identities; formerly known as multiple personality disorder). There is a close relationship between dissociative disorders and trauma.

According to NAMI, “Up to 75% of people experience at least one depersonalization/derealization episode in their lives, with only 2% meeting the full criteria for chronic episodes.”

While some medications might help manage the symptoms present with dissociative disorders, the standard treatment for dissociative disorders is psychotherapy.

Eating disorders

The most common eating disorders are anorexia, bulimia, and binge-eating disorder, but this chapter of the DSM-5 (p 329-354) also includes pica (eating items that are not food, such as hair), rumination disorder (regurgitation), and avoidant / restrictive food intake disorder (in which avoidance of foods causes nutritional deficiency). Just under 10% of Americans have an eating disorder. 

Medication is not part of the standard treatment for an eating disorder (although it may be used when your eating disorder co-occurs with another mental health condition). Instead, therapy and a nutrition plan can help correct some of your distorted views about food, exercise, and weight.

Substance use disorders

The DSM lists 10 substances as having the potential for disordered use (p 481-590):

Criteria for intoxication, withdrawal, and diagnosis are included for each of these drugs. Excessive use of any of these drugs activates the brain’s reward system, which reinforces the behavior and makes the cycle of addiction increasingly hard to beat. (The DSM mentions behavioral addictions as well, but as there is insufficient evidence, it only includes gambling as a behavioral addiction t this time.) Approximately 6% of Americans (starting at age 12) battled a substance use disorder in 2017.

Substance use disorders can be very difficult to treat, as the temptation to return to one’s drug of choice may be lifelong. Typically, treatment of substance use involves detoxification–ridding your body of the drug. Medication can assist in helping manage the withdrawal symptoms. Medication can also help decrease one’s craving for their drug, including (but not limited to) methadone for opioid addiction, bupropion for tobacco addiction, and naltrexone for alcohol addiction. However, substance use disorders are complicated; medication alone cannot fix the problems in one’s life that led them to their drug of choice. An effective treatment plan for substance use disorders must include therapy for the disorder itself and any co-occurring mental health conditions.

Personality disorders

There are 10 personality disorders listed in the DSM-5 (p 645-684), grouped into three clusters:

It’s estimated that about 10% of Americans have a personality disorder, with obsessive-compulsive PD (averaging 5.5% across studies), schizotypal PD (4.76%), and borderline PD (2.26%) as the most common. 

Because personality disorders are so diverse, there is no single treatment plan which applies to all of them. Antipsychotic, anti-anxiety, and antidepressant medications may all be used to manage symptoms as needed, but the standard treatment for personality disorders largely depends upon psychotherapy.

Other disorders

The DSM includes many other disorders and categories, such as neurodevelopmental disorders, sexual dysfunctions, and gender dysphoria. We can’t cover every disorder here, so please consult the DSM for more information on your particular diagnosis.

Summary

There’s much we still don’t know about the causes of mental illness, including whether they are caused by brain chemistry, environment, or both.

In cases where one’s brain chemistry is more likely to be a factor (especially bipolar disorder and schizophrenia), treatment that includes medication is more common. In addition, medication may be an appropriate intervention when the person is a danger to themselves or others, or otherwise cannot take care of themselves enough to attend appointments. There’s no shame in taking medication for these or any other reasons!

However, if you’re newly diagnosed with an anxiety disorder or depression, consider trying therapy and lifestyle changes over medication. It can often be just as effective as medication – and without all the side effects.

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