under-medicatedA patient I see for psychotherapy, without medications except for an occasional lorazepam (tranquilizer of the benzodiazepine class), told me his prior psychiatrist declared him grossly undermedicated in one of their early sessions, and had quickly prescribed two or three daily drugs for depression and anxiety.  He shared this story with a smile, as we’ve never discussed adding medication to his productive weekly sessions that focus on anxiety and interpersonal conflicts.  Indeed, the lorazepam is left over from his prior doctor.  I doubt I would have ordered it myself, although I don’t particularly object that he still uses it now and then.

Of course, there’s a completely innocuous way to explain this difference between his prior psychiatrist and me.  My patient could have looked much worse back then, in dire need of pharmaceutical relief.  However, he didn’t relate it to me that way, and I have no reason to doubt him.  There’s also the possibility that I’m missing serious pathology in my patient — that I too would urge him to take medication if only I recognized what I’m now overlooking.  But… I don’t think so.  I’m left to conclude that his prior psychiatrist and I evaluated essentially the same presentation rather differently.

In particular, I’m struck by the term “undermedicated” (more often spelled without the hyphen, according to my Google search).  This judgment most often comes up in speaking about populations, as in the debate over whether antidepressants are over-prescribed or under-prescribed in society at large, or whether children are diagnosed with ADHD and prescribed stimulants too often, or not often enough.  Under- and overmedication are also commonly mentioned when describing medication management of pain, a thyroid condition, mania, or chronic psychosis in an individual.  Here the terms express disagreement with a particular dosage, where the benefits of treatment and adverse side-effects or risks are deemed out of balance one way or the other.

“Undermedicated” also implies that adding medication is the preferred or only sensible treatment approach.  While this may always be true in hypothyroidism, it clearly isn’t with regard to physical or emotional pain.  The term rhetorically denies non-medication alternatives.  I would also add that, to my ear, “overmedicated” and especially “undermedicated” sound dehumanizing, as though referring to a machine that is out of adjustment, or a chemical solution being titrated on a lab bench.  Since the natural state of human beings is not to be medicated at all, it sounds a bit odd to hear someone — as opposed to one’s disease — assessed this way.  Perhaps I am especially sensitized to this after reading a controversial article by Moncrieff and Cohen that highlights the “altered state” induced by psychotropics and their lack of known, specific mechanisms of action.  There is often a supposition that medication dosage correlates with symptom relief.  This is not always true of subjective states, underscoring that the complexity of human experience often belies simple “over/under” judgments.

My patient’s mood and anxiety vary with his interpersonal situation.  It wouldn’t occur to me to turn his “thermostat” up or down in general, even if drugs reliably could do this.  Yet I know colleagues who’d argue that one, two, or even three daily medications could help him overcome his everyday challenges of dealing with people.  These approaches point to different fundamental viewpoints in psychiatry.  Does the patient have a disease, an as-yet-undiscovered chemical (or electrical, viral, inflammatory, etc) imbalance in the brain that is best remedied by a medical intervention, accurately dosed neither “over” nor “under”?  In acute mania or florid psychosis, as in hypothyroidism, it seems to me the answer may be yes, although this is unproven and time will tell.  Perhaps, too, in severe melancholic depression.  But in social anxiety?  Self-consciousness?  Feeling discouraged about one’s career?  The field’s perspective on these has shifted in recent decades, such that now a hidden biological cause is assumed by default, or at least held out as a rationale for treatment.  It is only by making this dubious assumption that one can speak of undermedicating such complaints, or the people who have them.

2 comments to Undermedicated

  • M Joiner

    While I agree with most of your statements because many doctors overmedicate patients, I disagree with your assessment of chronic pain management. I’ve been a pain management patient for over a decade and I can tell you for a fact that the vast majority of pain patients are UNDERmedicated. Study after study backs this up as well as myself and all the other pain patients I know never have their pain treated adequately.
    Because the feds are bulldogs when it comes to pain management narcotics many legitimate pain specialists have their ability to adequately control the pain of their patients for fear of having their DEA numbers taken and then their patients would have NO pain management. It is medical professionals like yourself who treat those suffering with chronic pain as drug addicts when only 10% of those taking narcotics are actually drug addicts. We are NOT drug seekers, we are quality of life seekers who are isolated by not only our pain but the perception of the public and many medical professionals.
    As a matter of fact, people who have chronic pain have the highest rates of depression than any other group because chronic pain makes you depressed and the depression makes the chronic pain worse and the monkey chases it’s tail around and around. Not to mention that many of us have to travel long distances to receive care from a pain specialist, and I myself had to travel 3 hours one way for many years to see my doctor and only in the past 2 years I found one taking new patients that is 1-1/2 hours away one way.
    Please STOP blasting pain patients. By continuing the stereotype you are making it harder not only for pain patients to get the care they desperately need but also preventing them from seeking the mental health care they need for fear of you and your colleagues treating them as if they are drug addicts.

    • I agree that most chronic pain patients are undermedicated by their doctors. However, my post above doesn’t say one word about chronic pain, doesn’t “blast” pain patients, and doesn’t stereotype anyone except some of my fellow psychiatrists. Indeed, the link in my post to the word “pain” brings up an article about pain patients being undermedicated, your very point. Your comment is completely misdirected.

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