What does it mean for a patient to be undermedicated?

A 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 come 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 used when describing medication management of pain, a thyroid conditionmania, 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 is 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 here as well, 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.

Steven Reidbord is a psychiatrist who blogs at Reidbord’s Reflections.

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  • guest

    As a psychiatrist, I must say that one of the factors that keeps me engaged in a practice situation in which I almost exclusively treat the severely mentally ill is this: their diseases respond well, in most cases, to just one or possibly two, medications. The “worried well,” or the type of patient described above, generally do better with psychotherapy alone.

    But here’s the terrible thing about psychiatry today: most people cannot actually afford to receive regular, high-quality psychotherapy, as their insurance will not pay for it, and most psychiatrists want to charge $200-300/hour for psychotherapy, which is unaffordable for all but the very wealthy.

    And so patients like that end up receiving “symptom-based medication treatment.” A medication is added to treat some anxiety, and an antidepressant is added to treat some depression, and an atypical antipsychotic is added for irritability (because the patient might be “bipolar”) and then maybe Topamax is added because all the other meds are causing weight gain, and before you know it you have a patient on five different medications, not getting much of a benefit, but experiencing lots of side effects.

    It’s a crime. In a previous job at a voluntary hospital where most of my patients fit this description, I spent more time taking patients off meds than putting them on new ones. This pleased a few patients, but made most of them upset, ironically enough.

    • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

      You sound insulted, but of course I meant no such offense. Those who almost exclusively treat the severely mentally ill may use terms like overmedicated and undermedicated quite sensibly. Nor did I criticize symptom-based medication treatment, which I readily offer to my own patients, usually as an adjunct to psychotherapy. As you note, the “worried well” generally do better with psychotherapy alone — but not always.

      I agree with your description of thoughtless polypharmacy, and also spend plenty of time taking patients off meds instead of adding more.

      However, you draw a false dichotomy: either spend $200-300/hr for therapy, or “end up unnecessarily medicated.” Fortunately, there are skilled psychotherapists who charge far less than that, not to mention sliding scales, training clinics, group therapy, etc. Moreover, if medication is unnecessary, unaffordable psychotherapy is hardly an argument in its favor. In contrast to much of the rest of medicine, a non-emergent, elective intervention such as psychotherapy reacts to market forces. Apparently there’s a market for $200/hr psychiatrists, $150/hr psychologists, $100/hr masters-level therapists, and so on. I certainly hope the inability to afford the most expensive option doesn’t relegate 99% of the population to treatments that are unnecessary.

      My post was about the use of the term “undermedicated” to describe a patient who doesn’t have enduring target symptoms. How we got to insurance parity and “colleagues with more egalitarian practices” I’m not sure. I also see Medicare patients, by the way.

      • guest

        I am not really sure that “biological etiology is being increasingly assumed in psychiatry” at all.

        The research that has been done, and my personal experience working with the insured but non-affluent population (that is, people for whom even a $100/week MSW-level psychotherapist is completely out of reach), suggests that limited access to psychotherapy, or even to adequate amounts of time with a medicating psychiatrist, drives much of the polypharmacy that affects our patients. I cannot tell you how many patients over the years I have struggled to provide with a discharge plan that could include needed psychosocial treatment of one sort or another. Limited access to that sort of care is a huge problem in our community.

        It is popular to assume that medication-only treatment and polypharmacy are the result of ideology; I know that the psychoanalytic community in particular loves to rail about this, having sat through numerous grand rounds during my residency in which one or another analyst from the outpatient side of my training program took pot shots at the faculty on the inpatient side, which included Jeff Lieberman.

        I do think that’s an outdated construct however. These days, the barriers to a patient getting a careful assessment of whether their target symptoms are enduring or not, and to then getting adequate therapy rather than another medication are much more likely to be financial, rather than ideological.

        I am not personally insulted by what you have to say at all; how could I be? We essentially agree with each other on most of what you had to say. But I do get weary of my colleagues who have gone into cash-only practices calling me on their day off (Friday) to complain about yet another patient they heard about who was misdiagnosed with bipolar disorder by an insurance-accepting psychiatrist who probably only had about 35 minutes to assess the patient, since that’s what the patient’s insurance pays for.

        • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

          Biological etiology is very much increasingly assumed: the wording of DSM5, RDoC, federal research grants, etc. And it’s reflected in insurance reimbursement, underlining your point about economics driving treatment.

          I’ll need to confirm with my patient, but I believe there were no time or resource limitations influencing his prior psychiatrist, which is why I felt free to chalk it up to ideology. I’m not so cruel as to “blame the victim” when circumstances are the real culprit. I work in an affluent city with lots of resources; I realize others are not as fortunate.

          But having said that, we all have choices to make. While all of us docs are human and make occasional mistakes, participation in a system that demands inadequate, error-prone 35 minute assessments ought to tug at our professional ethics. Maybe on balance it’s better that the patients are seen, but there should be no illusions about risking misdiagnoses, with patients paying the price. I think we agree that a system that requires us to practice unprofessionally is a system that needs to change. Perhaps where we differ is whether we should participate in the meantime.

          • guest

            I am all for us declining to participate in a corrupt system of payment which does not serve our patients well and functions mostly to enrich insurance executives and corporate shareholders. In fact I am a big proponent of direct pay practices, particularly in primary care.

            In psychiatry, however, the rise of direct pay practices has led to access problems for our patients, and some PR problems for our profession, some of which have created a lot of extra work for people like me who are actively involved in advocacy for our profession and our patients. I would just hope that those psychiatrists who have made the choice to pursue a direct pay practice would use some of the extra time and energy freed up by that to getting involved with our profession’s efforts to work on the underlying problems in the system we have now for delivering mental health services to our patients.

          • Deceased MD

            i think another problem that is out of control is the closing of many psych hospitals and lack of beds. I would think that many private practices have to be cautious on who they accept if there is no hospital backup. it is wrong and i bet leaves many patients in the lurch.

  • querywoman

    Hospitals routinely undermedicate diabetics. I have been given two percent of my normal insulin in the hospital.
    To undermedicate diabetics and not patients with other illnesses is discriminatory.

  • John C. Key MD

    In most fields of medicine, patients seem to do best on fewer medications, whether it be antibiotics, antihypertensives, or psychiatric meds. As a GP it is frustrating to me to encounter patients who may be on six or seven different psychiatric meds, from the same doctor, most of which they can’t afford and most of which seem unnecessary.

    I realize that for years psychiatry was limited to an armamentarium consisting of phenothiazines, tricyclics, and a benzo or two, but now that more choices are available many psychiatrists seem to be going “overboard” and following a one-pill-for-each-complaint model that is not helpful to the patient. Sloppy diagnosis seems to add to this: are you sometimes nervous? Here’s an anxiolytic; sad? an SSRI. Trouble sleeping? add a hypnotic. feel like people don’t like you? Here’s a Seroquel. Hard to concentrate? Adderall of course. Get mad sometimes–surely bipolar, take some depakote. Voila! You end up with polypharmacy and a messed up patient.

    I think Psychiatry has a whole lot to offer, but unless the profession as a whole tightens up its diagnostic criteria and becomes more responsible in “medication management”, good results are going to be elusive.

    • guest

      Actually I would say that the problem (one of them) is that the diagnostic criteria, especially with the latest iteration of DSM, have become too tight. In the time that the typical insurance-accepting psychiatrist has to assess a new patient, it is frequently not possible to get the large volume of very specific historical information that is required to make a firm diagnosis for some psychiatric illnesses. PTSD and intellectual disability in particular now have such a vast array of complex criteria that must be probed for and met that making those diagnoses are far outside the scope of the typical 45 minute meeting. So a lot of psychiatrists resort to approximate diagnoses, and symptom-based management.

      Thank you for mentioning the addition of Adderall, a particular pet peeve of mine when I see patients who are prescribed Klonopin for anxiety, and then Adderall because they have a hard time staying awake during the day.

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