“I have a lot of anxiety and stress. Can I get Prozac, Lexapro, or something like that?”
“My moods are all over the place. One moment I’m happy, the next I’m sad, the next I’m enraged. Can I get a mood stabilizer?”
I hear requests like these constantly. They’re completely understandable. They also reflect a common misunderstanding: that psychiatry works the way the rest of medicine does, where a symptom leads straight to a pill that fixes it.
In most of medicine, a symptom kicks off a search for its cause. Chest pain might mean a heart attack, a blood clot, reflux, or panic, and figuring out which one determines everything about the treatment. Psychiatry often skips that step. Most psychiatric diagnoses aren’t diseases confirmed by a scan or a blood test. They’re descriptive syndromes, clusters of symptoms that tend to occur together, and they can hide a lot of different underlying problems under one name.
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Depression is a good example. One patient might be depressed because of alcohol use, chronic insomnia, untreated sleep apnea, grief, loneliness, or a life with no structure. Another might have a severe depression that looks like it’s arising almost entirely from within: profound loss of pleasure, slowed movement, appetite loss, waking at 4 a.m. every day, despair that doesn’t track with anything happening in her life. Both patients qualify for the same diagnosis. They are not having the same experience, and they will not respond the same way to the same pill.
Medication absolutely has a critical role in psychiatric care. Antipsychotics can be lifesaving in schizophrenia-spectrum psychosis. Lithium and antipsychotics can be highly effective in bipolar mania. Stimulants can be genuinely transformative for properly diagnosed ADHD. SSRIs can meaningfully help obsessive and ruminative anxiety.
But when someone’s suffering is being driven mainly by substance use, trauma, chaotic relationships, bad sleep, or a life with no structure or meaning, a prescription often does very little, because it isn’t aimed at the actual problem. At best it takes the edge off symptoms while the real driver keeps running underneath. In those cases, the more effective intervention usually isn’t pharmacologic at all: fixing sleep, treating substance use, trauma-focused therapy, behavioral activation, rebuilding relationships, and rebuilding a sense of structure and purpose.
None of this is an argument against medication. It’s an argument for using it accurately, for treating a diagnosis as a description of a symptom pattern rather than a confirmed biological target, and for being honest with patients when what they actually need isn’t in the prescription pad.
Too often in psychiatry, we reach for a pharmacologic answer when the more urgent task is figuring out what the real question even is.
Nebyou Belay is a practicing psychiatrist with twenty years of experience treating children, adolescents, and adults. He is affiliated with the Brown University Department of Psychiatry and practices at Rhode Island Hospital and Newport Hospital.
He writes about the practice of psychiatry itself: how diagnoses are made, how they’re communicated to patients and families, and how psychiatric language is understood (and often misunderstood) in the wider culture. His work touches on the science and the limits of psychiatric assessment, the boundaries of what medication and diagnosis can realistically offer, and the growing overlap between clinical language and everyday identity.
Across all of it, his aim is the same: to help patients, families, and the public engage with mental health more honestly, with less oversimplification and less noise. He is currently writing a book, The Myths and Misunderstandings of Psychiatry, and is a contributor to KevinMD. He shares updates on LinkedIn.
