When Treatment Success Requires Re-Examining the Treatment Itself
By Charles Miller, CRNA, CMO, Founder/Owner of Scenic City Neurotherapy
Recently, I had a conversation with a psychiatrist regarding a shared patient receiving ketamine infusion therapy. The patient had undergone stabilization and achieved an excellent clinical response. For months afterward, her self-reported depression scores on the PHQ-9 remained below even the threshold for mild depression. By many conventional measures, the depressive illness had substantially improved.
And yet one symptom cluster persisted: anxiety.
This is where modern mental health care often reaches a crossroads. When a patient improves in one domain but continues to suffer in another, clinicians should be willing to ask a difficult but necessary question:
Could part of the remaining problem be treatment-related rather than disease-related?
In this case, the patient was taking Cymbalta (duloxetine), a commonly prescribed SNRI antidepressant. Like many medications in its class, its prescribing information acknowledges the potential for adverse effects such as anxiety, nervousness, restlessness, agitation, and even panic symptoms in some individuals.
That does not mean the medication is “bad.” It means the medication is biologically active, and biologically active treatments can help, harm, or do both depending on the patient, timing, dose, and context.
My suggestion was straightforward: if depression remained in remission, perhaps a cautious, gradual, hyperbolic taper could be considered to evaluate whether the patient’s anxious state might lessen over time. The response was not curiosity. It was defensiveness.
Unfortunately, that response is not uncommon.
Medicine advances when clinicians remain willing to revise assumptions.
Yet in clinical psychiatry – as in many specialties – there can be a tendency to interpret persistent symptoms through only one lens:
- Anxiety means the disorder is still active
- Depression means medication dose is insufficient
- Relapse risk means continue the same strategy indefinitely
- Distress means add another medication
Sometimes those interpretations are correct.
But sometimes the medication itself contributes to the very symptoms being treated.
This is not controversial pharmacology. It is basic clinical reasoning.
Many patients are started on antidepressants during a genuine period of suffering. Some benefit meaningfully. Some partially benefit. Some experience side effects but remain on them for years because no one revisits the original rationale.
Once a medication becomes part of the baseline, clinicians may stop questioning whether it is still helping.
The result can be:
- Emotional blunting mistaken for stability
- Activation mistaken for anxiety disorder severity
- Withdrawal mistaken for relapse
- Polypharmacy mistaken for sophistication
- Chronic side effects mistaken for personality traits
That is not patient-centered care. That is therapeutic inertia.
Defensiveness in medicine is understandable, even if unhelpful.
Prescribers carry enormous responsibility. They make decisions under uncertainty. They want to protect patients. No one wants to feel that a treatment they recommended might be contributing to distress. But professionalism requires the ability to tolerate that possibility.
The goal is not to defend prior decisions. The goal is to help the person in front of us now. We need a culture that values re-evaluation as much as initiation.
That means being willing to ask:
- Is this medication still necessary?
- Is it helping all target symptoms … or worsening some?
- Have we mistaken discontinuation symptoms for relapse before?
- Could dose reduction improve function?
- Have we included non-pharmacologic options in the plan?
- Are we treating the chart, or treating the patient?
These questions should not be seen as threats to expertise. They are signs of expertise.
For many psychiatric medications, discontinuation should not be abrupt or casual. Careful tapering, often slower than traditionally taught, may be necessary, especially after long-term use.
Hyperbolic tapering models deserve more attention because receptor occupancy and neuroadaptation are rarely linear. Small reductions at lower doses can produce disproportionately large physiologic effects.
This area needs humility, education, and more clinician familiarity.
To psychiatrists, primary care clinicians, nurse practitioners, physician assistants, and all prescribers:
Please remain open to the possibility that a persistent symptom may not always signal under treatment. Sometimes it signals the need to reassess treatment itself.
Please welcome thoughtful interdisciplinary feedback rather than dismissing it.
Please make room for de-prescribing conversations with the same seriousness given to prescribing conversations.
Please remember that changing course in light of new evidence is not weakness, but rather the essence of good medicine.
Patients do not need clinicians who are loyal to medications. They need clinicians who are loyal to outcomes.
And sometimes the most important prescription is the courage to reconsider the last one.
About Scenic City Neurotherapy
At Scenic City Neurotherapy, we help people find real answers and lasting relief through advanced, evidence-based treatments designed to address the root of mental health and chronic pain challenges, not just the symptoms.
Founded in 2019 by Charles Miller, CRNA, our clinic leads the way in Minimally Stimulated Ketamine Infusion Therapy (MSKIT®) and Transcranial Magnetic Stimulation (TMS) – two cutting-edge therapies proven to safely and effectively restore healthy brain communication.
Our approach is evidence-backed, informed by research, and focused on helping you feel clear, resilient, and capable of moving forward.
If you’re ready for treatment that’s built on proof, not trial and error, contact us today.
