When the Prescription Becomes the Plan

Medication can lower the volume. It cannot teach you what to do when life turns it back up.

People ask me fairly often what I think about psychotropic medication. My answer sometimes makes people uncomfortable: I don’t have a problem with medication. I have a problem with medication becoming the treatment plan. There is a very big difference.

By psychotropic medication, I mean medications that act on the brain and can affect mood, thinking, emotion, attention, or behavior—antidepressants such as SSRIs and SNRIs; benzodiazepines such as Xanax/alprazolam, Ativan/lorazepam, and Klonopin/clonazepam; other anti-anxiety medications; mood stabilizers; antipsychotics; and stimulants.

For this conversation, however, I am primarily talking about the very common outpatient world of antidepressants and anti-anxiety medications prescribed for depression, anxiety, stress, panic, and emotional distress. I am not suggesting that medication should routinely be removed from the treatment of bipolar I disorder, schizophrenia and other psychotic disorders, acute mania, severe recurrent depression, or psychiatric crises. Those are different clinical conversations. And I am certainly not suggesting that anyone stop medication because they read a blog post.

What I am suggesting is that we ask better questions about what the medication is actually doing—and what we are doing alongside it.

The prescription can help. It just can’t do the whole job.

Medication can be enormously useful. It can lower anxiety enough for someone to sleep, lift depression enough for someone to get out of bed, or quiet panic sufficiently for a person to return to work, participate in relationships, or meaningfully engage in therapy.

Fantastic.

Now what?

Because medication cannot teach you boundaries. It cannot teach you how to tolerate discomfort without blowing up, shutting down, drinking, spending, avoiding, or texting somebody you absolutely know you should not be texting. It cannot repair your marriage, teach you how to ask for what you need, or help you recognize that you have spent twenty years saying yes while meaning no.

It cannot reorganize a dysfunctional workplace, teach your teenager accountability, resolve grief, increase emotional intelligence, or tell your mother that Thanksgiving will, in fact, be at your sister’s house this year.

Different tool. Different job.

Medication can change your state. Skill-building changes your capabilities.

And ultimately, capabilities are what I want my clients to own.

What does the research actually say?

This conversation is much more interesting than “medication good” or “medication bad.”

For adult depression, both psychotherapy and antidepressant medication are evidence-based treatments. Research comparing the two has generally found that both can reduce symptoms, while combining psychotherapy and medication can be especially effective during acute treatment. In one large analysis of more than 100 studies and nearly 12,000 adults with depression, psychotherapy and medication alone produced similar response rates, while the combination performed better than either treatment by itself during the acute phase.

But longer-term outcomes are where things get particularly interesting. Research examining people months after treatment has found that psychotherapy can have durable effects, and combined treatment has shown stronger long-term outcomes than medication alone in some analyses. Psychotherapy alone has also performed comparably to combined treatment at longer follow-up in some studies.

That matters to me.

Medication may reduce symptoms while it is being taken. Therapy has the opportunity to do something different: change the way a person thinks, behaves, communicates, regulates emotion, responds to stress, makes decisions, and relates to other people.

There are also studies showing that people who respond to cognitive therapy may retain some protection against relapse even after treatment ends. That does not mean everybody should eventually discontinue antidepressants. Maintenance medication can substantially reduce relapse risk for some people, particularly those with recurrent depression or higher risk of recurrence.

The science does not support the bumper-sticker version of either argument.

It does support asking whether we are merely reducing symptoms—or also building the person’s capacity to live differently.

What are we building while the medication is helping?

For much of the anxiety-and-depression work I see, I tend to think of medication as scaffolding rather than the building.

If you need scaffolding, use it. There is no medal for suffering unnecessarily.

But while it is there, build something.

Build emotional regulation. Build better thinking. Build boundaries. Build communication. Build distress tolerance. Build healthier relationships. Build routines that support your nervous system. Build the ability to recognize your own patterns earlier. Build the confidence to experience discomfort without automatically interpreting it as catastrophe.

Then periodically reassess the scaffolding with the person prescribing it.

That is very different from deciding that needing medication represents failure. It doesn’t.

The question is simply whether the medication is still providing more benefit than cost, whether side effects are acceptable, whether the original reason for prescribing it is still present, and what has changed since treatment began.

That seems like common sense.

A young woman who slowly came back into focus

I’ll change identifying details, but this vignette reflects a pattern I have seen in my work.

A woman in her mid-twenties came to me taking multiple psychiatric medications. By the time we met, she was a mess.

Not because she was weak. Not because every medication she had been prescribed was “bad.” She simply no longer knew what belonged to what.

She was foggy and tired. Flat in some moments and emotionally flooded in others. She struggled with motivation and decision-making. Most importantly, she did not trust herself. She could no longer tell what was depression, what was anxiety, what might be a medication effect, what followed medication changes, and what was simply the complicated business of being twenty-something and trying to build an adult life.

So we did not declare war on medication.

And I certainly did not pull her off anything.

We started building.

We worked on her thinking patterns, emotional regulation, boundaries, relationships, routines, decision-making, ability to tolerate discomfort, understanding of her triggers, direct communication, and the critical distinction between feeling something and having to act on it.

As she became more stable and skilled, she wanted to reassess her medications. That portion of the process belonged with the clinicians responsible for prescribing them. When reductions were appropriate, they were medically managed while our work focused on making sure there was something underneath her besides a prescription bottle.

There was.

More and more of her started showing up.

Over time, she needed less pharmacological support. Today she is successful, clear, productive, connected, and thriving without psychiatric medication.

That is her outcome. It is not a prescription for somebody reading this article.

But I have watched enough versions of this transformation to think we should pay attention to the question underneath it: what if someone who appears to need more medication sometimes actually needs more skills?

Maybe they need more sleep. Better boundaries. Movement. Connection. Purpose. A healthier relationship. A different workplace. An honest conversation. More structure. Less avoidance. Or the willingness to stop repeating the same behavior and wondering why life keeps producing the same result.

And yes—sometimes that person needs medication too.

Those ideas can coexist.

When the prescription started years ago

I frequently hear some version of, “My GP put me on it years ago.”

That is not unusual. A substantial amount of psychiatric medication in the United States is prescribed outside psychiatry, particularly in primary care. That is understandable. Primary-care clinicians are often filling enormous gaps in an overstretched mental-health system, and many manage psychiatric medication thoughtfully and responsibly.

But we should acknowledge the structural limitation.

A brief medical appointment designed to identify symptoms, review health conditions, select medication, and monitor response cannot accomplish the same thing as sustained psychological work.

Your doctor can appropriately recognize depression and prescribe an SSRI.

The SSRI cannot teach you why every criticism feels like rejection.

Those are two different interventions.

What concerns me is when the first happens and the second never does. Then five years pass. The prescription remains. Nobody remembers exactly why it started, the person has adapted their life around it, and continued use quietly becomes synonymous with continued need.

Maybe the medication is still necessary.

Maybe it isn’t.

That deserves a thoughtful conversation rather than an assumption.

Benzodiazepines deserve their own paragraph

Benzodiazepines—medications such as Xanax, Ativan, and Klonopin—are a particularly important example because they can work very quickly.

Anxiety is screaming. A benzodiazepine turns down the screaming.

You can understand the appeal.

They also carry recognized risks of physical dependence, tolerance, withdrawal, sedation, and misuse. For that reason, clinical guidance generally treats them cautiously, particularly for ongoing management of generalized anxiety, and they are often better suited to selected short-term situations rather than becoming the permanent foundation of treatment.

That does not make them evil.

It makes them tools whose strengths and limitations should be understood.

A fire extinguisher is incredibly useful.

I just don’t want to heat my house with one.

“But I feel better on medication.”

Good.

I mean that sincerely.

If medication gives someone their life back, improves functioning, reduces suffering, or makes therapeutic work possible, I am glad we have it.

There is no moral superiority in being medication-free. There is no trophy.

My position is not ideological. It is strategic.

If medication creates enough stability for you to do the work, use the window.

Learn what happens inside you when somebody disappoints you. Learn what anxiety actually feels like before your brain converts it into catastrophe. Learn how to repair after conflict. Learn to challenge distorted thinking. Learn how to say no. Learn how to sleep. Learn what regulation feels like. Learn your early warning signs. Learn the difference between discomfort and danger.

Those abilities belong to you.

And sometimes the medication needs to stay

There are absolutely people for whom long-term medication is appropriate.

Some people experience recurrent depression and receive meaningful protection from maintenance antidepressants. Others live with conditions for which ongoing pharmacologic treatment is an important part of preventing serious recurrence or maintaining stability.

That is why I do not tell clients to simply “get off their meds.”

If someone wants to explore reducing medication, the prescriber manages the medication; I support the person doing the psychological work around it.

That distinction matters.

Psychiatric medications should not be stopped casually or abruptly. Antidepressants and benzodiazepines in particular can produce withdrawal symptoms, and those symptoms can sometimes be mistaken for the return of the original condition. Appropriate tapering is individualized and may occur over weeks or months depending on the medication, dose, duration of treatment, and the person taking it.

There is nothing therapeutic about turning withdrawal into an endurance sport.

The goal is health, not proving a point.

What I think we have been oversold

Here is the part where I am willing to get closer to the edge.

I think we have sometimes been sold a very convenient idea:

If the symptom decreases, the problem has been treated.

I don’t buy that.

Sometimes the symptom is the primary problem, and treating it pharmacologically is entirely appropriate.

But sometimes anxiety is information.

Sometimes depression exists inside isolation, burnout, grief, resentment, avoidance, chronic sleep deprivation, a terrible marriage, a life constructed entirely around other people’s expectations, or a nervous system that never learned how to regulate itself.

Sometimes we need to ask why the system is screaming instead of exclusively asking how to make it quieter.

And no, that does not mean we need twelve years of therapy, three archaeological expeditions into your childhood, and a dramatic breakthrough involving your third-grade teacher.

A surprising amount of this work is practical.

See the pattern. Understand what maintains it. Learn a skill. Make an adjustment. Practice something different. Repeat.

Not always easy.

But not necessarily mysterious either.

I want you to leave treatment with something you own

This is ultimately why I have such a strong bias toward insight, strategy, action, and skill-building.

Medication comes from the pharmacy.

Skills leave with you.

Once you learn how to regulate yourself differently, you know how. Once you understand your conflict pattern, you begin seeing it in your marriage, parenting, friendships, workplace, and family. Once you can catch the thought that normally sends you into a spiral, you have options. Once you learn to tolerate discomfort without immediately trying to eliminate it, your world gets bigger.

Once you know how to communicate clearly, repair, set boundaries, make decisions, ask directly, recognize your triggers, and notice when your own thinking has gone off the rails, those things become part of you.

That is transformation.

The prescription isn’t the problem. The absence of a larger plan is.

So when people ask me what I think about psychotropic medication, this is my answer:

I think medication is a tool. Sometimes it is an excellent one. Sometimes it is poorly matched. Sometimes the dose is wrong. Sometimes side effects outweigh benefits. Sometimes it is genuinely necessary for years. Sometimes it saves lives. Sometimes it gives someone exactly the boost they need to finally do the work.

And sometimes we are asking medication to accomplish something no pill was ever capable of accomplishing.

I don’t simply want people feeling less terrible. I want them understanding themselves better. Thinking more clearly. Making better decisions. Relating differently. Recovering faster when life knocks them sideways. Recognizing an old pattern before it creates another old outcome. Knowing what to do when anxiety returns. Knowing what to do when the relationship gets hard. Knowing what to do when life changes—because it will.

Medication may help turn down the volume long enough for us to hear ourselves think.

But when clinically appropriate, I want the plan to be bigger than the prescription.

Insight. Strategy. Action. Transformation.

Clinical note: This article reflects my professional perspective on treatment planning and is educational, not individual medical advice. Psychiatric medications should be started, changed, tapered, or discontinued only in consultation with an appropriately qualified prescribing clinician.

References & Further Reading

American Psychological Association. Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts. Updated 2025. The guideline recognizes both psychotherapy and second-generation antidepressants as evidence-based treatments for adult depression.

Cuijpers, P., Noma, H., Karyotaki, E., et al. (2020). “A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression.” World Psychiatry, 19(1), 92–107. Combined treatment produced stronger acute outcomes than either psychotherapy or medication alone.

Karyotaki, E., Smit, Y., Holdt Henningsen, K., et al. (2016). “Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects.” Journal of Affective Disorders. Longer-term outcomes favored combined treatment over antidepressant medication alone, while psychotherapy alone showed comparable long-term outcomes to combined treatment in the studies analyzed.

Hollon, S. D., DeRubeis, R. J., Shelton, R. C., et al. (2005). “Prevention of relapse following cognitive therapy vs medications in moderate to severe depression.” Archives of General Psychiatry, 62(4), 417–422. The study found evidence that cognitive therapy continued to reduce relapse risk after treatment ended.

National Institute for Health and Care Excellence. Depression in adults: treatment and management. NICE Guideline NG222. Includes recommendations regarding ongoing antidepressant review, relapse prevention, and gradual tapering rather than abrupt discontinuation.

National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults: management. NICE recommends benzodiazepines for generalized anxiety only as a short-term measure during crises rather than routine ongoing treatment.