When I’m teaching medical students about a mental health diagnosis, I love to ask an important question: is this a problem that responds better to medication or psychotherapy?
In most cases, the answer is simple. Therapy and medications produce similar results, and both together outperform either alone. That’s why I tend to recommend that people start with therapy. It has fewer risks and the benefits will likely persist better after treatment than meds alone. If the treatment stalls or the problem is more severe, adding medication may be helpful.
There are, of course, some situations where the science supporting medication is so overwhelming that starting with therapy is unlikely to be helpful, and may even be life-threatening. Likewise, some problems don’t really respond to medication, and people often find themselves stuck because they haven’t engaged in good psychotherapy.
There are a million more nuances in this line of thought. (Which therapy? Which medication? What does the patient want? What is available? etc.) But even though clinical mental health tends to focus on therapy and medication interventions, almost all actual mental health has very little to do with these interventions. Do you have stable housing? Do you have a job that treats you with human decency and sufficient income? Are you able to experience the natural world? Do you have support from a loving family? Are you safe at home and in your community? Is your voice heard? Are you seen with dignity? What epigenetic changes occurred because you experienced preventable early life trauma?
Now don’t get me wrong: good therapy helps people change the things they can change, appropriate medication can improve overall function, and community mental health programs have brilliant case managers who work hard to connect people with limited resources. But so many problems are beyond the scope of simple “treatment.” Mental health–and physical health for that matter–cannot be fully addressed on an individual level. You can work hard and still be met with systemic barriers. That doesn’t make trying any less worthwhile. It’s an acknowledgment that we need to work together to make change happen.
I’m not prescribing any specific set of changes except this: let’s stop thinking about mental health as solely a personal problem. We are all in this together, and even though we may have different beliefs about how change should happen, the overarching goal must be a better world for all of us.
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