Is Psychiatric Illness a Medical Condition or Volitional Behavior?
A new blockbuster novel argues the later...
Laura Delano’s recent bestselling novel Unshrunk is a powerful, at times heartbreaking personal narrative of recovery and reclamation of agency. Her story chronicles her turbulent child, teenage, and early adult years as she struggled with severe mental illness and various treatment options. Delano’s book reflects valid concerns about overmedication, inadequate informed consent, and the psychological toll of over pathologization. As an adult, Delano now takes no medications, concluding that a “medication free life” is healthier and safer. Her psychiatric diagnosis remains unclear.
As a psychiatrist, I deeply respect the importance of the patient voice. And her story resonates with many. Psychiatric illness is complex and often multi-factorial. And for many, our modern psychotropic medications only offer partial symptom relief, with noticeable side effects.
However, telling folks with moderate to severe mental illness that they should stop taking all their medications is absolutist, misleading, and dangerous. It’s a reductionist approach. It implies psychiatric illness is merely volitional behavior that can be cured with simple lifestyle interventions “if you just try hard enough.”
This view poses serious risks, particularly for individuals with moderate to severe psychiatric illness. While medications are not a panacea, they remain a cornerstone of treatment for many, much like insulin for diabetes or beta blockers for heart disease. Just as cardiologists and endocrinologists advocate for a combined approach—medications plus lifestyle changes, plus psychosocial support—so too does psychiatry benefit from a multidimensional model of care.
Take diabetes, for example. Lifestyle and dietary modifications are critical, but for many patients, they are not sufficient on their own. The same goes for major depression, bipolar disorder, schizophrenia, and many anxiety disorders: therapy, social connection, and self-care are essential—but for a significant percentage of patients, these alone do not provide enough symptom relief. In such cases, medications are not a betrayal of autonomy; they are a tool for survival.
In Unshrunk, Delano painfully discusses the suicidal thoughts she endured during and after psychiatric treatment. Suicidal ideation is one of the most life-threatening symptoms in psychiatry. In many cases, psychiatric medications are life-saving interventions. The reduction in suicidal thoughts and self-harm risk is one of the most well-documented benefits of antidepressants and mood stabilizers. To discourage their use outright, particularly among individuals in active crisis, is deeply concerning. We would never tell someone coming out of a diabetic coma, “Just stop taking your insulin and eat different foods. You’ll be fine.” Why would this be acceptable with severe mental illness?
Another common theme in Unshrunk is frustration with medication side effects. This is understandable—no physician should ever minimize the discomfort and distress medication side effects can cause. The benefits of symptom relief should always outweigh the medication side effect profile. There is no medication that is side effect free. And this is not unique to psychiatry.
Every field of medicine grapples with the challenge of balancing therapeutic benefit with potential side effect harm. Statins can cause muscle pain; insulin can cause hypoglycemia; chemotherapy can cause nausea, fatigue, and immunosuppression. In every case—including psychiatry—the decision to start or continue a medication requires a careful, informed conversation weighing the individual risks and benefits.
Delano also conflates medication side effects with physical dependency/addiction. The two are not the same. Many psychiatric and non-psychiatric medications cause temporary physical discomfort upon discontinuation—not unlike beta blockers or steroids. This is NOT equivalent to addiction, which is a chronic brain disease with continued long-term use despite negative life consequences.
Medication side effects or temporary physical changes with medication discontinuation does not mean that psychotropic medications are inherently harmful or addictive. It means these medications work on crucial brain and body receptors that serve multiple bodily functions: serotonin, the key brain neurochemical implemented in depression, is also found in gut lining and platelets. Thus, when someone stops taking an antidepressant that affects serotonin, they often have temporary gastrointestinal discomfort. Most psychiatric medications work on select neurochemicals that often serve multiple functions. This complex interplay underscores the need for gradual tapering under professional guidance, not abrupt discontinuation or unmonitored self-management.
Mental illness is not a monolith, and psychiatric medications are not a one-size-fits-all solution. But the answer to an imperfect system is not an all-or-nothing ideology. To reject medication wholesale, as Delano’s narrative sometimes implies, is to deny the legitimacy of those who find real, lasting benefit from psychiatric treatment. More dangerously, it may encourage some individuals to discontinue life-sustaining medication without a safety net—a decision that can have catastrophic consequences. And it implies that psychiatric illness is a behavioral choice cured by lifestyle changes, rather than a medical condition benefitting from both medication and non-medication interventions.
In psychiatry, just like in all of medicine, nuance matters. Informed consent, shared decision-making, and individualized care should be the standard—not rigid adherence to dogma on either side. Delano rightfully advocates for patients to be at the center of their treatment decisions. But patients also deserve the full range of evidence-based options, including medication, without stigma or shame.
Read Delano’s book with empathy, but also with critical discernment. All fields of medicine including psychiatry should be transparent, collaborative, and rooted in the best interests of the individual patient. At the same time, severe psychiatric illness is not a behavioral choice that is cured only with lifestyle interventions. It is a medical condition that requires a multi-thronged, patient specific approach-one that often (though not always) includes the thoughtful use of medication. Advocating for anything less perpetuates misunderstanding and stigma. It does a disservice to the millions of Americans suffering from mental illness who deserve meaningful, comprehensive, evidence-based care-Americans who are sick trying to get well, not bad trying to be good.
-Lauren