5 Controversial Things I Do as a Psychiatric Prescriber: Not Everyone Agrees With This

5 Controversial Things I Do as a Psychiatric Prescriber: Not Everyone Agrees With This

There are parts of the way I practice psychiatry that are not especially conventional. That does not mean I ignore evidence. It means I take the evidence seriously enough to know that real patients rarely arrive looking exactly like a textbook chapter.

Psychiatric symptoms overlap. Medication responses can be messy. Diagnoses accumulate in charts. People compensate for problems for years. Hormones change. Sleep changes. Life changes. And sometimes the explanation that looks obvious at first is not the explanation that holds up once you look at the entire pattern.

That is where I think some of the most important psychiatric work happens. I am much less interested in quickly finding a diagnosis that matches a symptom than I am in understanding why that symptom is happening in this particular person. Sometimes that leads me to make a different clinical decision than another prescriber might make.

1. I won’t diagnose ADHD from one appointment

Adult ADHD is one of the clearest examples of why psychiatric diagnosis requires more than symptom matching. Someone may come in saying they cannot focus. They procrastinate. They lose things. They cannot finish projects. Their house is disorganized. Their thoughts feel scattered. They forget appointments. They struggle to start boring tasks.

Those symptoms absolutely can occur with ADHD. They can also occur with anxiety, depression, chronic sleep deprivation, sleep apnea, trauma, hormonal changes, substance use, medication effects, learning disorders, chronic stress, and several medical conditions.

The symptom tells me what someone is experiencing. It does not automatically tell me why they are experiencing it.

That distinction matters because ADHD is a neurodevelopmental disorder. The current symptoms are only one piece of the diagnosis. I also want to know what the person's brain and behavior looked like years before the current problem became obvious.

What happened in elementary school? Were assignments constantly forgotten? Was the person always losing belongings? Did they need enormous amounts of structure to stay organized? Did teachers describe them as daydreamy, impulsive, talkative, restless, or capable but inconsistent? Did they procrastinate because they could not initiate tasks, or because anxiety made the task feel overwhelming? Did the current concentration problems exist before the person became depressed, stopped sleeping well, entered perimenopause, developed a demanding career, or began experiencing significant anxiety?

And importantly, what does the impairment actually look like?

A positive ADHD questionnaire tells me that someone is endorsing ADHD symptoms. That is useful information. It is not the same thing as establishing that ADHD is the best explanation for those symptoms.

This is why I prefer a comprehensive adult ADHD evaluation that looks at current symptoms, childhood history, functioning across settings, sleep, mood, anxiety, medical factors, medications, substance use, learning history, and other plausible explanations.

Sometimes that process confirms ADHD very clearly. Sometimes it uncovers something else. And sometimes both are present. The goal should never be to prove that someone does or does not have ADHD before the evaluation begins. The goal is to get the diagnosis right.

2. I treat sleep before attention

Sleep is one of the most underappreciated variables in psychiatric diagnosis. A person may come in because their brain feels completely dysfunctional. They cannot concentrate. They forget everything. They are irritable. They procrastinate. Their motivation is terrible. They reread the same paragraph three times. They rely on caffeine just to get through the day. They feel mentally restless but physically exhausted.

And then I learn they are sleeping five or six hours a night. Or waking repeatedly. Or lying awake for two hours before falling asleep. Or sleeping for eight hours but never feeling restored. Or snoring heavily and waking with headaches.

Before deciding that this brain needs another medication aimed at attention, I want to know what happens when the brain is actually sleeping.

Sleep affects attention, working memory, processing speed, emotional regulation, impulse control, motivation, and executive function. In other words, it affects many of the same cognitive systems people are describing when they tell me they think they have ADHD.

There is another important distinction here. Poor sleep can mimic ADHD. Poor sleep can also make actual ADHD much worse. Those are not the same clinical situation.

If someone has lifelong ADHD and then develops insomnia, treating the insomnia may not eliminate the ADHD, but their cognitive functioning may improve substantially. If someone's concentration problems began after years of chronic sleep restriction, treating the sleep problem may change the diagnostic picture altogether.

This is why I ask more than, “How many hours do you sleep?” I want to know whether the sleep is restorative. How long does it take to fall asleep? How often does the person wake? What time does their brain naturally want to sleep? Are they forcing themselves into a schedule that conflicts with their circadian rhythm? Are there symptoms of sleep apnea or restless legs? Is a medication affecting sleep? Did the cognitive problem begin before or after the sleep problem?

Sometimes the most sophisticated psychiatric intervention is not adding another psychiatric medication. Sometimes it is fixing the thing that is preventing the brain from functioning normally in the first place.

3. I know the same medication can act like a different drug at a different dose

This is one of the most important concepts in psychopharmacology, and it is easy to miss when medication treatment is reduced to a simple question: Did this medication work or not?

That question is often too crude.

A medication can feel dramatically different at one dose than it does at another. That does not mean the chemical molecule literally changes into another medication. It means that the functional effects of the medication can change as the dose changes.

Different receptor systems and neurotransmitter transporters do not necessarily respond in a perfectly linear way. Increasing a dose may increase one pharmacologic effect more than another. At lower doses, one mechanism may dominate. At higher doses, additional mechanisms may become clinically meaningful. The balance between benefit and side effects can shift.

That is why I care about the details when someone tells me, “That medication didn't work.”

What dose were you taking? How long were you there? What changed when the dose increased? Was there a lower dose where you actually felt better? Did it help anxiety at one dose but make you emotionally flat at another? Did it improve mood but disrupt sleep? Did the activation begin only after the increase? Did the medication feel completely different after crossing a particular dose?

Those distinctions matter.

Sometimes a medication truly is a poor fit. Sometimes the dose was simply too low. Sometimes the dose was too high. Sometimes the medication produced a useful effect at one dose and an entirely different clinical experience at another.

And sometimes the answer is not, “This medication doesn't work for me.” It is, “This medication did not work for me at the dose and in the way it was being used.”

Psychiatric medication management becomes much more precise when we stop treating medication history as a binary list of “worked” and “failed.” The dose, timing, duration, response, side effects, and sequence all contain information. I want that information.

4. When antidepressants repeatedly don’t make sense, I reconsider the diagnosis

One of the easiest things to do in psychiatry is continue treating the diagnosis that is already written in the chart. Depression. Try an antidepressant. It helps somewhat. Then stops helping. Increase it. Try another. Add something. Try another class. Repeat.

Sometimes that is completely appropriate. Unipolar depression can be persistent and difficult to treat.

But there are situations where repeated antidepressant experiences make me want to stop and ask a different question: Are we sure we are treating the right mood disorder?

That does not mean antidepressant failure automatically means bipolar disorder. It does not. What matters is the pattern surrounding the medication response.

I become more interested when there are other pieces of the history that do not fit neatly into uncomplicated unipolar depression. Maybe the person has had periods where they needed substantially less sleep and still felt energized. Maybe there have been episodes of unusual productivity, confidence, impulsivity, creativity, irritability, or goal-directed activity. Maybe the mood episodes have a striking seasonal pattern. Maybe depression began unusually early. Maybe there is a strong family history of bipolar disorder. Maybe antidepressants repeatedly create agitation, insomnia, emotional volatility, or a period of feeling exceptionally good before the person crashes. Maybe the person has been labeled as having “treatment-resistant depression” for years, but nobody has gone back through the longitudinal history.

That history matters because bipolar II disorder and other bipolar-spectrum presentations can be much harder to recognize than classic mania.

Many people do not come into a psychiatric office saying, “I think I have hypomania.” They come in when they are depressed. The higher-energy periods may even be remembered as the times when they felt most like themselves. They were getting things done. They were social. They had ideas. They needed less sleep. They felt motivated again.

Without asking carefully about the pattern over time, those periods can easily disappear from the diagnostic picture.

This is why repeated treatment failure sometimes makes me more interested in the diagnosis than in the next medication. The medication may not be the main problem. The formulation may be.

5. I will question an established diagnosis and sometimes start over

Once a psychiatric diagnosis enters a chart, it has a remarkable ability to stay there. One clinician makes the diagnosis. The next clinician sees it. Then another. Eventually it begins to feel less like a clinical hypothesis and more like a fact.

But diagnoses are not sacred. They are our best explanation for a pattern of symptoms based on the information available at the time.

Sometimes the diagnosis is absolutely correct. Sometimes new information changes the picture. Sometimes the original diagnosis was reasonable but incomplete. And sometimes, when I hear the person's entire story, it simply does not fit.

When that happens, I am willing to go back to the beginning.

When did the symptoms first appear? What happened before them? Were there periods when the symptoms disappeared? Were there clear episodes, or has the pattern always been present? What happened during childhood? What changed during pregnancy or postpartum? What changed during perimenopause? What happens when sleep improves? What happens seasonally? What medications helped? Which ones made things worse? Was the person diagnosed during an unusually chaotic period of their life? Were symptoms attributed to a psychiatric disorder before a medical or sleep-related cause was recognized? Has anyone ever actually revisited the diagnosis?

This does not mean previous clinicians were careless or wrong. They were working with the information they had. But psychiatric diagnosis should remain responsive to new information.

If someone has carried a diagnosis for ten years and the pattern does not fit, I do not think the respectful thing is to keep treating it simply because it is already there. I think the respectful thing is to look again.

That may confirm the original diagnosis. It may refine it. It may uncover an additional condition. Or it may lead us somewhere completely different.

What these five things have in common

The common thread is not that conventional psychiatric treatment is wrong. It is that psychiatric symptoms are rarely specific enough to interpret without context.

Difficulty concentrating is not synonymous with ADHD. Depression does not automatically tell us which mood disorder is present. A medication trial cannot always be summarized as “worked” or “failed.” Poor cognitive functioning does not exist independently of sleep. And a diagnosis written years ago should not prevent us from noticing when the current pattern points somewhere else.

This is also why I think good psychiatric prescribing requires more than memorizing which medication belongs to which diagnosis.

The prescription is often the easy part. The harder part is figuring out what you are actually treating.

That requires looking at timelines, patterns, medication responses, childhood history, sleep, hormones, medical factors, periods of relative wellness, environmental changes, and the things that do not quite fit.

Those inconsistencies are often where the most useful information lives.

The bottom line

Good psychiatric care is not about being contrarian. It is also not about finding the quickest label that matches the most obvious symptom. It is about being willing to ask another question when the first answer does not explain the whole picture.

Symptoms are clues. Diagnoses are explanations. And the quality of the treatment depends heavily on the quality of that explanation.

Sometimes the first diagnosis is exactly right. Sometimes the first medication works beautifully. And sometimes the most important thing a psychiatric prescriber can do is notice that something does not add up and keep looking.

At Resonance Psychiatry in Everett, Washington, I provide comprehensive psychiatric evaluation and medication management with an emphasis on diagnostic clarity, thoughtful prescribing, and understanding the larger pattern behind psychiatric symptoms. Telehealth psychiatric care is available throughout Washington.

Learn more About Me at Resonance Psychiatry.