Congratulations! You have finally decided to reach out and seek help for your emotional difficulties. I know that this was not an easy decision. Despite all of our 21^stcentury know-how many of us still believe that psychiatric disorders reflect personal weakness and a failure of free will. As discussed in past discussions, the first step in treatment is obtaining the proper diagnosis. You are then faced with a most important decision; should you pursue psychiatric medication or embark on a course of talking therapy, or a combination of both? It would not be fair to leave the decision in your hands alone. This decision should involve an educational process that is free of confusing medical or psychological jargon. I am hoping to make this path more user friendly.

The first question to ask concerns the context in which your symptoms have developed. Is your life situation essentially stable and not responsible for the difficulties you are experiencing? Or, have the events of the recent past been so stressful that they have resulted in your current degree of emotional upset? Each of us has a stress threshold that once reached can result in symptoms that resemble clinical depression or anxiety. Take for example the loss of a loved one. The grieving period may consist of impaired sleep, sadness and crying, hopelessness, poor appetite, social avoidance and negative thinking, all symptoms that at first glance would appear to resemble clinical depression (aka major depressive disorder). However, for most people this period of mourning is time-limited and eventually resolves.

But what if the context in which your symptoms have developed does not really explain the degree of your upset? Generally speaking, this more strongly supports a disorder that is in need of treatment and suggests that there has been a spontaneous biological shift in brain activity that is the root of the problem. Why this brain shift occurs is poorly understood. But even when there is an identifiable life stressor responsible for one’s upset there still can be an underlying biological process that puts you at greater risk of developing a psychiatric syndrome. I call this type of response astress-diathesis reaction. It suggests the presence of a biological predisposition that in the presence of the right type of life stress leads to a sequence of events that produces your symptoms. Individuals with such a biologically predisposed nervous system are at greater risk of stress-induced difficulties.

The other key feature that indicates the presence of symptoms that require pharmacologic (medication) intervention involves the ongoing nature of your difficulties. By this I mean, if it feels like your current mental state has developed “a life of its own” and you have been unable to recover and return to your normal mental state, medication administration may be necessary for your recovery. If we take the most common psychiatric depressive syndrome called major depressive disorder, we do know that if nothing is done, most major depressive episodes will eventually end. However, the impact of this disorder on life functioning (family, friends, work, etc.) not to mention the degree of emotional suffering incurred clearly points to the need to intervene. Moreover, to make matters worse, we believe that untreated episodes of depressive may contribute to progressive worsening of the disorder. Therefore treatment is directed at not just symptom remission but in many instances illness prevention.

Our discussion is prompted by the reality that Psychiatry is a unique medical specialty. Unlike other medical disciplines, Psychiatry is at a disadvantage because we do not have a system of diagnostic tests to provide us with objective data to guide treatment planning. Laboratory testing can help rule-out non-psychiatric medical disorders like hypothyroidism that can often function as medical mimics of psychiatric syndromes. In the absence of objective laboratory testing the clinical history becomes critical. Here, the context, course and nature of your symptoms represent the critical data that allows for diagnosis and treatment planning.

In no way am I suggesting that there is no indication for psychotherapy. Our scientific literature abounds with studies supporting the benefits of combining medications with talking therapy. We now know that psychotherapy can lead to positive changes in brain biology that synergizes with prescribed medications. In addition, the benefits of psychotherapy often continue long after medications are discontinued. In addition, when it appears that one’s anxiety and/or depressive complaints are purely situational, psychotherapy alone may be all that is required.

One of the most difficult decisions to make with regard to medication therapy is how long to stay on medication. We believe that for the treatment of major depressive disorder a six to twelve month course of medication is indicated, that early discontinuation despite feeling well can lead to illness recurrence. But what if your depressive episode is not your first? In that case we often will recommend ongoing antidepressant therapy to try to prevent recurrences down the road.

As you can see, Psychiatry is not a perfect science. Despite this reality, illness recovery and future wellbeing can be accomplished by careful attention to the nature of the disorder. I do hope that this brief discussion has helped you better understand the decision process involved in choosing a course of medication, psychotherapy or a combination of both.