There's an art to deciding if a patient needs medication...
NR: The most important factor is whether her day-to-day functioning is impaired. I've been seeing a woman who's had a lifelong history of depression, who always just assumed that was who she was—that she was low-energy and negative, that everything took a lot of effort. I felt medication could help her.

...and to deciding which medication to prescribe.
NR: I consider how the illness is presenting. Is it an agitated, anxious, or melancholy depression? Each may require a different approach. If she has bipolar disorder, is she manic, depressed, or both? Does she want to have children? I choose meds that carry the least risk. If she's worried about weight gain or sexual side effects, I'd choose a medication that minimizes them, or a second medication to counteract them.

When the medication works, you'll know it.
NR: Think of the illness as a cloud (a cliché, yes—but accurate) that medication dissipates, making life brighter. Or as a roadblock that medication lifts, enabling you to make more progress in psychotherapy. Or as a broken bone, where medication and psychotherapy are the cast. That's a useful metaphor for people who want to go off their medication too soon—if you take a cast off prematurely, the limb is vulnerable to reinjury.

We always have options.
NR: Most patients will try more than one medication if they feel they're being heard, that you're in it with them. Sometimes the diagnosis is wrong. If, say, I think someone has depression but antidepressants don't seem to help, she may actually have bipolar disorder. I'll reexamine, get a second opinion, and make a new plan.

Bottom line: Help is here.
NR: Studies show that about 60 to 70 percent of patients will respond to antidepressants, but in my practice it's closer to 90 percent, likely because it's combined with psychotherapy. For example, the woman I mentioned didn't want medication initially, so we stuck to psychotherapy. She improved but was still struggling with thoughts of suicide. She's a strong person; she'd been able to push through depression for years. I started to question my judgment: Maybe this isn't depression. But her suffering had become unbearable. When she finally tried medication, she became more hopeful and energetic, and saw how different her view had been. It doesn't mean her life is perfect. Medication isn't a panacea. But in the hands of a skilled clinician, it can be life changing—even lifesaving.


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