When you need a psychiatrist first: signs that therapy is not the first step

Most of this blog is about what conversation can do. This piece is about the opposite: situations in which conversation is not the first step, and in which sending someone to therapy would be wrong.

I am writing it because it happens in practice. People come to a therapist in a state that needs medical assessment, and sometimes months pass before anyone says so out loud. Sometimes because the therapist does not recognise it, sometimes because the person does not want a doctor, and sometimes because an impression has formed that a psychiatrist is the last stop.

Below are the signs for which the first address is a doctor. Not as the opposite of therapy — in most of these cases therapy follows or runs alongside — but as an order that is not a matter of taste.

The first sign: thoughts of suicide

The most important and the most direct.

Thoughts about death occur in distress more often than people assume, and in themselves do not necessarily mean immediate danger. The difference that matters is between passive thoughts — “it would be better if I weren’t here” — and a plan: thinking about method, timing, preparations.

With a plan, with access to means, or after a previous attempt, medical assessment is needed, and immediately. Therapeutic work is not excluded by this, but it is not first.

Worth knowing: talking about it does not increase risk. This is a common fear among those close to someone, and research does not support it. The question “are you thinking about harming yourself” is safe and often a relief.

The second sign: the body has given out

When distress moves into the body to the point that basic functioning is at risk.

Practically: if you have barely slept for weeks, if you have lost a significant amount of weight, if you cannot eat or drink, if you do not get out of bed — this is no longer a question of motivation. A body in that state cannot sustain a process that demands concentration and energy.

A doctor does two things here: rules out physical causes and, where needed, lowers the intensity enough to make everything else possible. On why combination works better than either approach alone in more severe states, I have written in antidepressants and therapy are not rivals.

The third sign: loss of contact with reality

This includes voices others cannot hear, beliefs that those around you do not share and that evidence cannot shift, a sense of being watched or followed, and unusually confused speech.

These are signs that require psychiatric assessment and do not wait. Psychotherapy has its place in psychotic states — demonstrated and useful — but alongside appropriate treatment, not instead of it.

A common difficulty for those close by: how to raise it without pushing the person away. A useful route is to speak about the distress rather than the diagnosis: “You look very burdened and you’re sleeping badly. Shall we go to the doctor together?” works better than naming a condition.

The fourth sign: swings in both directions

With depression the question about the opposite pole often goes unasked, though it matters.

If you have ever had a period of sleeping three hours and being full of energy, when thoughts raced faster than you could speak them, when you spent more than you could or started several things at once — that is information that changes the treatment. In bipolar disorder an antidepressant without appropriate cover can make things worse.

This is why a doctor treating depression also asks about such periods. If they did not ask, say so yourself. And if you are in such a period now, a psychiatrist is the first address.

The fifth sign: addiction that governs the day

When alcohol or other substance use is such that it shapes the course of the day, therapeutic work is limited — not out of moral judgement, but because the substance alters exactly what therapy works with.

Important and not widely known: withdrawal from alcohol and benzodiazepines can be dangerous and in severe cases requires medical supervision. Stopping abruptly on your own is not risk-free.

The order is therefore medical support first, with therapeutic work alongside or immediately after — and it is often therapy that ensures the state does not return.

The sixth sign: suspicion of a physical cause

The part people most often overlook, because it seems unrelated.

Some physical conditions cause symptoms almost impossible to distinguish from depression or anxiety without testing. Thyroid disease, anaemia, vitamin B12 and vitamin D deficiency, diabetes, sleep-disordered breathing and certain medications can all produce fatigue, low drive, poorer concentration and irritability.

So a basic blood test with newly arisen low mood or marked fatigue is sensible, even when the cause seems obvious. Nobody wants to spend a year working on “patterns” caused by a thyroid.

The same applies with a sudden change of behaviour or personality in an older person, where neurological assessment is essential.

What a good therapist does

Since this is a question of boundaries, it is fair to say what my job is.

I ask. At an introductory session I ask about sleep, weight, appetite, physical symptoms and also about thoughts of death. That last question surprises many people — it is asked deliberately and calmly.

I say when I judge that medical assessment is needed. Not as a refusal but as part of the work. If someone resists, we talk about it; if the state is serious, I insist.

I do not discourage medication and do not comment on doses. That is not my remit. On how the remits are divided, I have written in who may diagnose and who may prescribe.

I stay in contact. Referring onwards does not mean the end; work often continues alongside.

A therapist who did not point you onwards with these signs, or who discouraged you from seeing a doctor, is not acting in your interest. This is one of the few criteria I hold without hesitation.

Why people avoid psychiatrists

Worth addressing, because the avoidance is common and understandable.

“Then it will be on record.” Health data is protected and access to it is restricted. For most people the consequences are considerably smaller than those of an untreated condition.

“They’ll put me on tablets.” A psychiatrist is not a prescription machine. Many appointments end with an assessment, a recommendation and an agreement to review.

“It means I’m seriously ill.” It does not. Psychiatric clinics treat a wide range of conditions, and most people attending them go to work and have families.

“I’m afraid they’ll detain me.” Detention against someone’s will is rare, tightly regulated by law and tied to immediate danger. Attending an appointment does not trigger it.

What someone close can do

If you are reading this because of someone else, a few concrete things.

Ask directly. “Do you ever think about harming yourself?” The question does not increase risk and often breaks the isolation.

Do not promise silence. If someone asks you not to tell anyone and there is danger, you cannot keep that promise. Better to say so in advance.

Offer to go with them. Many people will not go alone but will go with someone. A concrete offer — “tomorrow at ten I’ll come with you” — works better than advice.

Do not take everything on. Someone close is not a therapist and cannot be a guard. Your task is to help them reach help, not to replace it.

What to remember

Therapy is a good choice for most forms of distress. With a plan for taking your own life, with loss of contact with reality, when the body has given out, with swings in both directions, with addiction that governs the day, and with suspicion of a physical cause, it is not first.

The order here is not a hierarchy but a sequence. A doctor makes things safe and workable; therapy takes care of what medication cannot. Almost always these add up, and almost never do they exclude each other.