Chapter 12: The Medication Landscape
Psychiatric medication is the other pillar of American mental health treatment. The numbers:
- Approximately 1 in 6 American adults (55 million people) take a psychiatric medication.
- Antidepressants are the third most commonly prescribed drug class in the United States.
- In 2022, approximately 16.5% of adults had filled an antidepressant prescription in the past 30 days.
- Benzodiazepine prescriptions number approximately 92 million per year.
- Antipsychotic use in children increased 800% between 1993 and 2009.
- Stimulant prescriptions (primarily for ADHD) exceed 45 million annually.
America is the most psychopharmacologically treated nation in human history. The question is whether this treatment is working.
Chapter 13: What Medication Can and Cannot Do
Where medication works (relatively well):
- Schizophrenia and schizoaffective disorder. Antipsychotics are essential and often life-saving. Without medication, most patients with schizophrenia cannot function. The medications have serious side effects (metabolic syndrome, tardive dyskinesia, sedation), but the alternative — untreated psychosis — is worse.
- Bipolar I disorder. Mood stabilizers (lithium, valproate) and atypical antipsychotics are the standard of care. For preventing manic episodes and reducing suicide risk, the evidence for lithium in particular is strong. Again, side effects are significant, and adherence is a constant struggle.
- Severe, acute depression. For patients in a major depressive episode with functional impairment, antidepressants provide meaningful benefit over placebo. Effect sizes are moderate, and the number needed to treat (NNT) is approximately 7-8 — meaning for every 7-8 patients treated, one will improve who would not have improved on placebo.
- Panic disorder. SSRIs and SNRIs show clear efficacy for reducing panic attack frequency and severity.
- OCD. SSRIs at higher doses show specific efficacy for obsessive-compulsive symptoms.
Where medication is more contested:
- Mild to moderate depression. The landmark STAR*D trial — the largest antidepressant effectiveness study ever conducted — found that only 37% of patients remitted on the first medication tried. After four sequential medication trials (each lasting 12+ weeks), the cumulative remission rate was approximately 67%, but relapse rates among remitters were 40-50% within a year. For every 100 patients who enter treatment for depression, approximately 30-35 achieve sustained remission with medication. The other 65-70 either never respond or relapse.
- The placebo question. Kirsch et al.'s (2008) meta-analysis of FDA-submitted antidepressant trials — including unpublished negative trials — found that the drug-placebo difference was clinically significant only for the most severely depressed patients. For mild and moderate depression, the advantage over placebo was small enough to be "clinically meaningless." This analysis remains contested, but it has never been definitively refuted.
- Long-term use. Antidepressants were developed and tested for acute episodes lasting months. Millions of Americans now take them for years or decades. The evidence base for long-term use is thin. Withdrawal effects (now acknowledged by major medical bodies) can be severe and prolonged, making discontinuation difficult and creating de facto pharmaceutical dependency.
Chapter 14: The Skeptic's View of Medication
We don't understand the mechanism. The "chemical imbalance" theory of depression — that depression is caused by insufficient serotonin — was never established by scientific evidence. It was a marketing narrative that pharmaceutical companies promoted and that the psychiatric profession allowed to propagate. A comprehensive umbrella review by Moncrieff et al. (2022) in Molecular Psychiatry concluded that there is "no convincing evidence that depression is associated with, or caused by, lower serotonin concentrations or activity." This does not mean that SSRIs don't help some patients — but it means that we don't know why they help, which makes the confident prescription of these medications an exercise in empirical guesswork, not targeted treatment.
Side effects are pervasive and under-discussed. Sexual dysfunction affects 40-65% of SSRI users. Weight gain is common with many psychiatric medications. Metabolic syndrome, cognitive dulling, emotional blunting ("I don't feel depressed anymore, but I don't feel anything"), sleep disruption, and GI disturbance are reported at high rates. For many patients, the side effects of medication are themselves a significant source of suffering.
Prescribing has outrun the evidence. Polypharmacy — the simultaneous prescription of multiple psychiatric medications — is common and largely unvalidated. A patient on an SSRI, a benzodiazepine, a mood stabilizer, and a sleep medication is not receiving evidence-based treatment. They are receiving a pharmacological collage assembled through trial and error, with no RCT evidence for the specific combination they are taking. Yet this is routine in American psychiatry.
The 15-minute med check. Psychiatrists in most practice settings see medication patients for 15-20 minutes per visit, often monthly or quarterly. The "evaluation" consists largely of asking the patient whether they feel better and whether they are experiencing side effects. There is no biomarker for depression, no blood test for anxiety, no imaging study for PTSD. The physician is making medication decisions based entirely on patient self-report — the same self-report that, as we established in Chapter 7, is systematically unreliable due to shame, fear, and social desirability.
Chapter 15: The Opioid Lesson
No discussion of psychiatric medication in America is complete without the opioid crisis — not because psychiatric medications are opioids, but because the opioid epidemic demonstrates what happens when a medical system:
- Trusts pharmaceutical company claims about safety and efficacy
- Prescribes aggressively based on incomplete evidence
- Fails to monitor long-term outcomes
- Creates dependency at scale
- Lacks the infrastructure to manage the consequences
Every one of these dynamics is present, to varying degrees, in psychiatric prescribing. The opioid crisis killed over 500,000 Americans. It began not with street drugs but with confident physicians prescribing FDA-approved medications based on pharmaceutical company representations that turned out to be catastrophically wrong.
The psychiatric medication system has not produced a single catastrophe as concentrated as the opioid crisis. But the cumulative effect of tens of millions of people on medications of uncertain long-term efficacy, with significant side effects, prescribed through 15-minute evaluations based on unreliable self-report, managed by a system with no outcome tracking — this is not a system operating responsibly. It is a system hoping for the best.