The Medication Life and the Moral Career
On antidepressants, ambivalence, and uncertainty
Among the five letters received and published by the New York Times in response to my op-ed on antidepressants, my favorite is the one by the author and psychotherapist Daniel Smith. The version published by NYT is highly condensed and Smith was kind enough to share with me the full text of the letter he had originally submitted, which I am happy to publish here (along with some comments and reflections prompted by it).
To the Editor:
I was glad to read Awais Aftab’s thoughtful essay highlighting the lack of research into the negative effects of psychiatric medications and the importance of taking patients’ concerns about side effects and withdrawal symptoms seriously. The narrowness of the scientific literature, which, as Dr. Aftab writes, has for too long prioritized basic research and drug development at the expense of everyday clinical concerns, is a serious problem that must be addressed.
That said, for those of us who take SSRIs and other psychiatric drugs, there is a more nebulous issue that also deserves attention—namely, the forces of confusion, fear, and inertia that keep us gobbling these pills for decades.
Patients start taking medication because they are suffering. In that state, even a slim shot at relief seems like a smart bet. But that’s when the confusion starts. “Are the drugs helping?” isn’t necessarily an easy question to answer. Some patients know that their lives have improved. They feel lighter, sharper, more capable day to day. But for many others, perhaps the majority, improvement is devilishly hard to measure. Moods shift. Anxiety fluctuates. Sadness waxes and wanes. Circumstances change.
To understand what the medication is doing, for good and for bad, often requires a deep dive into the murk of subjective experience, where everything is in flux and the variables seem infinite. “Are you feeling better?” the psychiatrist asks. “I think so,” you answer. “I’m not entirely sure. It feels like maybe I am.” And if you do feel notably better, is the medication the cause? Or is it a placebo effect? Is it the work you’re doing in psychotherapy? Is it the fact that you’re eating better and exercising more? Who could say for sure?
The answer is that no one can. Not the academic researchers, not the psychiatrists, not the federal regulators, and certainly not the pharmaceutical companies. Yet once you get it into your mind that you may need your pills to feel all right, it can seem almost impossible to stop taking them. Why run the risk? Why open yourself up to the withdrawal symptoms, to the resurgence of your anxiety, to another depressive episode? What’s the big deal? It’s just a pill. Just take it and move on.
In this way, years can pass, years in which you wonder what your life would be like without the drugs—whether you would feel more brightly; whether you would have more creative thoughts and more intense sensations; whether your orgasms would be stronger; whether you would know better who and what you are; whether you would have a more intimate, unadulterated sense of your own capabilities, your own resilience, your unique consciousness. The damage here is harder to measure even than the long-term efficacy of SSRIs, for it isn’t an empirical question; it’s a moral one. And it gnaws at many of us, even as, for the umpteenth time, we trudge to the pharmacy to refill our prescriptions.
Daniel Smith
Brooklyn
Daniel Smith is a psychotherapist in private practice and the author of the books “Monkey Mind: A Memoir of Anxiety” and the forthcoming “Hard Feelings: Finding the Wisdom in Our Darkest Emotions.”
The third principle in Bill Fulford’s list of ten principles of values-based medicine is the “science-driven” principle:
“Scientific progress, in opening up choices, is increasingly bringing the full diversity of human values into play in all areas of health care.” (Fulford, 2004)
Medical advances present us with the possibility of control over more and more aspects of our lives, but this control is often imperfect and comes with trade-offs. More choices, more values, and, crucially for my purpose here, more uncertainty and ambivalence.
Daniel Smith has articulated quite well the indecision and confusion that many patients experience with long-term antidepressant treatment (as well as other psychiatric medications). It’s hard to put numbers on an experience like this, but a 2016 survey from New Zealand which obtained open-ended responses from 1,829 antidepressant users, gives us a rough estimate of how many have a mixed rather than straightforward positive or negative experience. While responses from 54% were positive, 28% reported mixed experiences. The mixed category included themes such as feeling calmer but less like themselves, struggling to find the right medication or the right dosage, and feeling stuck with continuing on antidepressants when they wished to stop.
Alice Malpass and colleagues (2009) have reported, based on their meta-ethnographic work, that experiences of antidepressant use can be described as consisting of decision-making processes and meaning-making processes, which they conceptualize respectively as the “medication career” and the “moral career.”
Patients can have a bona fide relationship with their psychiatric medications. In a 2001 paper, Alicia Powell described this aspect as “the medication life.”
“Much like a patient’s sex life, work life, drinking life, or dream life, the medication life may have rich and important meaning and yet may be split off from the treatment dialogue. When we allow ourselves to listen for unconscious meanings, the possibilities for discovery involving medication are boundless. I find it useful to consider the patient’s medication life as I do the dream life—using not only manifest content but also transference and countertransference associations to further the inquiry. The patient's reactions to the suggestion of medication may cover a range of possibilities: silent assent, energetic willingness, flat-out refusal, narcissistic injury, grateful relief, and more.” (Powell, 2001)
The ultimate guru of the psychodynamics of the medication life is David Mintz (a brilliant psychiatrist, scholar, and speaker based at Austin Riggs), whose book “Psychodynamic Psychopharmacology” I highly recommend. Mintz focuses on how the meanings people assign to medications contribute to their treatment outcomes. He opens an article on addressing ambivalence in pharmacotherapy as follows:
“From a psychodynamic perspective, ambivalence and conflict are fundamental traits of mental life. Patients and doctors alike are always managing competing priorities and conflicting desires and fears. Pharmacotherapy is no exception.” (Mintz, 2024)
Aside from ambivalence, Smith is also pointing out the genuine element of uncertainty. It can frequently be difficult to say whether the improvement is attributable to the medication and to what extent ongoing treatment is still necessary for continued symptom control, relapse prevention, or well-being. How to handle this uncertainty is a clinical challenge. Some people prefer to be risk-averse and would rather stay on medications to minimize their chances of relapse or to avoid dealing with withdrawal. Some people are confident that the medication(s) they are on offer ongoing benefits and help them manage their symptoms and deal with life stressors. Some are determined to attempt discontinuation, with or without help from the provider. And some are, well, ambivalent about the whole thing and feel unsure about what to do, and they stay on medications more from exhausted inaction than a conscious affirmation of medication use. As a clinician, I try to be mindful of how patients really feel about starting and staying on medications. Patients can feel relieved from the improvement in symptoms, but they can simultaneously be fearful of possible harms; they may credit the drug as having saved their life, yet they may detest feeling dependent on it. They may feel better but feel uncertain about the role played by the medication in their recovery. By anticipating ambivalence as a common response among patients and addressing it directly (acknowledging fears and hopes, correcting erroneous beliefs, establishing realistic expectations, challenging stigma, and mobilizing social support), clinicians can help patients navigate their medication and moral careers in a better way.
The issue in clinical practice is that so few clinicians are even attuned to the meaning around medications. The more clinicians recognize and address ambivalence, the more they acknowledge uncertainties and explore the preferences, worries, regrets, and needs that occupy patients, the better it is for everyone. The goal should not be to encourage patients to stay on medications by default but to support them in making informed decisions in line with their priorities.
These aspects of psychiatric medication treatment—the medication life, the moral career, the ambivalence, and the uncertainty—are difficult to convey to patients ahead of time (without coming off as if we are actively trying to scare them away from a treatment they want amidst suffering). For some, this prospect may indeed be so unwelcome that they’d rather not start a medication at all. For instance, Lauren Oyler, in her essay “My Anxiety,” finds the enterprise of formal psychiatric diagnosis and treatment to be so rife with complications that it just doesn’t seem worth the effort to her. Oyler writes:
“While I have no idea what it’s like to be on psychiatric medication long term, no one else can say what it’s like, either; the medications famously interact with each person differently, so there is no way to understand them as an experience except through trial and error.” (Oyler, 2024)
“I do not want to have these problems that are notoriously difficult to solve, about which there is no professional agreement.” (Oyler, 2024)
The problem lies in thinking that we can resolve this difficulty by pretending that antidepressants don’t exist or by actively discouraging people from using them. Ambivalence is a fundamental part of human life, and uncertainty haunts all our attempts at medical decision-making. Antidepressants exist; we can choose to take them or not take them; we can choose to continue taking them or to stop them if we are taking them. But we can’t choose not to have this choice. Sometimes the patients I see start psychiatric treatment for depression, anxiety, ADHD, etc., for the first time in their 30s, after years of hesitancy. When the treatment works1, a common emotion I hear in such situations is regret: “I wish I had started this medication 10 years ago.” While people on long-term antidepressants wonder, “Who would I be off these medications?” the unmedicated are not immune from what-ifs of their own. Who could I be if I were taking antidepressants? Could I be more functional, more productive, a better parent, or a better spouse? Would I have been less obsessive, less neurotic, or more assertive?
What I recommend to my patients is the courage to make an informed choice, to start, to discontinue, to try and find out, whatever the case may be.
In the process of writing this, I was thinking of other decisions we have to make in life where uncertainty and what-ifs can plague us no matter what we decide. Getting married and having children are probably good exemplars. Did I marry the right person? Did I do the right thing by having kids? Did I go to the right college? Soon a lot more of us may be confronted with the choice of having powerful psychedelic experiences or using polygenic embryonic screening for our future children in healthcare contexts. Long-term antidepressant use can end up being in the same territory of decisions capable of generating tremendous gratitude, regret, and ambivalence.
Smith implies that the uncertainty and ambivalence around antidepressants is a kind of avoidable “damage,” but I see this as the moral cost of living in a world in which medical progress presents us with more and more choices, and by doing so, brings the full diversity of human values into play and generates dizzying varieties of uncertainties and trade-offs. The only way out is through.
See also:
Peter Kramer notes that the efficacy of antidepressants in dysthymia “is the great open secret of the antidepressant debate.” (Kramer, 2016. Ordinarily Well. p. 118).
I'm a psychiatrist.
We must also acknowledge that psychiatric medications are just one of many tools people use to modulate their mood, identity, and sense of self. People turn to their smartphones, scrolling through curated feeds; they reorganize their homes; adopt rigid fitness routines; spend hours immersed in work or caretaking; meticulously track habits and sleep; or build identities around aesthetic lifestyles or spiritual practices. These are not chemical substances, but they serve a similar purpose: to regulate experience, to feel a certain way, to exert control over inner life. And people often have ambivalent relationships with these as well. They provide relief and also create dependence. They offer stability and provoke self-questioning.
To isolate psychotropic medication as something categorically different—rather than a formalized, studied version of something humans are always doing—risks reinforcing the false belief that emotional self-regulation through medication is unnatural or illegitimate.
Of course, medications have distinct considerations: withdrawal syndromes, side effects, pharmacological impact on brain function. But they do not exist outside the web of self-shaping choices and tools that people reach for in modern life.
It’s also worth remembering that the impulse to regulate one’s inner life—moods, thoughts, energies, identities—is not a modern invention, nor is it unique to psychiatry. Long before SSRIs or diagnostic manuals, human beings turned to ritual, prayer, movement, storytelling, community roles, aesthetic expression, and environmental attunement to navigate psychological pain and existential confusion. To set psychiatry apart as the sole or primary discipline capable of holding these complexities privileges the field in a way that distorts history and dismisses millennia of human effort to grapple with the same questions: What does it mean to suffer? How do we endure? What helps? When we act as if psychiatric frameworks uniquely accommodate ambivalence and meaning-making, we inflate the importance of psychiatry and obscure the broader, older, and often more culturally rooted repertoire of tools that people have long drawn upon. The question is not whether someone should or should not take medication; it is whether we are expanding the conversation beyond it—asking what else might be possible, what other sources of coherence, connection, or relief could be available, particularly in an era when psychiatry has grown over-important as a primary methodology for self-betterment. We need a wider lens, not a narrower one.
My concern may be an artifact of the fact that you have been on this theme of "to medicate or not to medicate” but I'm beginning to wonder if you don't demand ambivalence of your patients. If there was a standard questionnaire regarding satisfaction with medication that would depersonalize the question. However, patients may be tempted to please you by the wrestling with this issue when it is actually not that big a deal for them.