The Prescription Is Not the Care
A recent New York Times article followed a man attempting to stop taking antidepressants after more than two decades. Like many people who have tried to discontinue these medications, he discovered that getting the prescription had been considerably easier than getting off it.
He began taking psychiatric medication before he turned ten. Over the years, the medications and doses changed, but the treatment continued. When he eventually decided that he wanted to stop, there was no established plan waiting for him. There was no clinician who had followed the entire course of his treatment, periodically reconsidered the original diagnosis, weighed the benefits against the accumulating side effects, and prepared him for the possibility of discontinuation.
Instead, he became the manager of his own complicated psychiatric experiment.
He researched withdrawal online, sought advice from internet communities, and learned about tapering schedules, liquid formulations, and the difficult distinction between withdrawal symptoms and the return of the condition the medication had been treating. He believes that antidepressants may have blunted his emotions and prevented him from experiencing parts of his life fully. He also experienced the return of obsessive-compulsive symptoms as he reduced his medication. It is impossible to know where withdrawal ended and his underlying illness began, which is precisely why this should not have been a project for a patient with an internet connection.
While the story was presented as one man’s attempt to discover who he was without medication, I read it and saw something else: a patient performing work that should have belonged to the healthcare system.
As a pharmacist, I regularly speak with people who have been taking antidepressants for years. Some have clearly benefited from them. Others cannot remember exactly why they started, whether they were ever supposed to stop, or when anyone last evaluated whether the medication was still helping. Refills arrive with such regularity that the treatment eventually begins to feel less like a clinical decision than a permanent feature of the patient’s identity.
When these patients decide they want to reduce their dose, the pharmacy counter often becomes the place where they first encounter the practical difficulties. They ask whether tablets can be split, whether capsules can be opened, whether a smaller strength exists, and whether the symptoms they are experiencing are normal. They may have received a brief tapering schedule from a prescriber, but little preparation for what happens if their body does not cooperate with it.
Pharmacists can answer questions about formulations, dosing, and withdrawal. We can identify a taper that appears too aggressive and call the prescriber. We can help locate a liquid medication or suggest that a patient may need a compounded dose. But what we cannot do from behind a counter is monitor someone’s psychiatric condition over several months (or years) and determine whether anxiety, insomnia, depression, or intrusive thoughts represent withdrawal, relapse, or some combination of both.
Someone has to know the patient well enough to make those judgments. Increasingly in America, nobody does.
This is not only a problem with antidepressants. It is the predictable result of a healthcare system that has gradually replaced care with access to medical products.
Every week, I see patients receiving GLP-1 medications from prescribers who appear to have little involvement in what happens after the prescription is written. Some patients are doing well and receiving appropriate monitoring. Others continue losing weight until they look frail, yet the prescriptions keep arriving. The prescriber may be a telehealth clinician, a concierge provider, or someone the patient has met only briefly. The pharmacy can see that something appears wrong, but the person authorizing the treatment may see little more than a weight entered into a portal and a request for the next dose.
The business has completed its part of the transaction. The patient received the product.
That is not the same as receiving care.
We have spent years celebrating the “democratization” of medicine. Patients have access to more information, more tests, more specialists, more medications, and more ways to obtain them than ever before. They can arrive at an appointment with data from a wearable device, laboratory results ordered online, a proposed diagnosis from Google, and a list of medications recommended by an algorithm. If they dislike the answer they receive from one clinician, another may be available through an app by the end of the afternoon.
Some of this is genuine progress. Patients should understand their treatment and participate in medical decisions. They should be able to question a diagnosis, seek another opinion, and reject a plan they do not want. The paternalistic model of medicine, in which the doctor spoke and the patient obediently followed instructions, was due for change.
But somewhere along the way, we confused giving patients control with leaving them alone.
Patients are increasingly expected to function as their own case managers. They must decide which professional to see, determine whether a medication is working, recognize adverse effects, and somehow know when the plan needs to change. When formal medicine fails to provide an answer, they turn to Reddit, Facebook groups, podcasts, Google, and Claude.
It’s easy for healthcare professionals to sneer at this behavior. It is also dishonest. Patients go looking for strangers on the internet because the people with medical training have left an information and management vacuum. The internet did not create that vacuum. It merely filled the empty space.
Calling this “patient empowerment” makes the arrangement sound more noble than it is. A patient can have autonomy without being qualified to manage a disease. Those are separate concepts. The patient should retain control over medical decisions, but trained professionals should remain responsible for explaining the options, monitoring the outcome, and adjusting the plan.
The person experiencing antidepressant withdrawal should not have to determine alone whether he is suffering from discontinuation symptoms or the return of obsessive-compulsive disorder. A patient taking a GLP-1 should not be responsible for deciding when weight loss has become muscle wasting. A person prescribed a medication indefinitely should not have to notice, years later, that nobody ever established what “indefinitely” meant.
These failures are not simply the work of careless doctors. There are certainly clinicians who treat prescribing as the easiest way to end an appointment, just as there are telehealth companies whose business models depend on converting patient concern into recurring revenue. But many excellent doctors practice inside systems that make genuine continuity extremely difficult.
Our healthcare economy is very good at rewarding activity that can be counted: visits, prescriptions, tests, and procedures. Following a patient closely is harder to measure. So is reconsidering an old treatment, coordinating among clinicians, or spending months helping someone discontinue a medication. Predictably, those parts of medicine are often poorly reimbursed.
The system gets what it pays for. It rewards the moment a treatment begins and shows remarkably little interest in everything that follows.
Our reimbursement system should reward clinicians for documenting meaningful follow-up after starting a patient on a chronic medication. Did the treatment work? Were the expected clinical benchmarks reached? What adverse effects developed? Does the original diagnosis still make sense? Is the patient supposed to remain on the medication, and if so, why? If discontinuation is appropriate, who will manage it?
These are not unrealistic expectations. They are the basic obligations implied by the word “care.”
A prescription is just one tool within care. Sometimes it is the most important tool. Antidepressants can be lifesaving, and the lesson of the Times article should not be that taking psychiatric medication represents a failure or that reaching zero milligrams is inherently virtuous. For some patients, stopping will improve their lives. For others, it will bring back an illness that the medication had successfully controlled.
The goal should not be freedom from medication at any cost. It should be the best possible life with the lowest appropriate treatment burden. Determining what that means requires more than access to a prescription and a search bar.
Patients need ongoing relationships with clinicians who know why treatment began and are willing to remain involved as circumstances change. That usually starts with a good primary-care provider, although primary care itself has been hollowed out by short appointments, administrative demands, and declining access. Rebuilding those relationships will require paying clinicians for judgment and continuity, not merely for the number of transactions they complete.
The most troubling part of the antidepressant story is not that a man took medication for decades. It is that when he decided to reconsider the treatment, the responsibility for understanding his brain, his symptoms, and his future had somehow become his burden to bear.
Healthcare can offer patients information, access, autonomy, and an expanding catalog of products. None of those things, individually or together, guarantees that anyone is actually caring for them.
Care begins when another human being accepts responsibility for following what happens next. Without that responsibility, healthcare is just another industry selling products to consumers.
Giddy up.
Alec Wade Ginsberg, PharmD, RPh
4th-Gen Pharmacist | Owner & COO, C.O. Bigelow
Founder, Drugstore Cowboy
