The Medication Escalation Trap: When Distress Doesn't Mean Treatment Failure

This article reflects my clinical approach to medication management, not legal advice.
Adapt these frameworks to your scope, setting, and clinical judgment.

A subtle clinical trap I still have to watch out for: confusing symptom distress with medication failure.

One pattern I see a lot in clinical practice:

Patient is distressed → we assume the medication failed → dose goes up.

But distress ≠ medication failure.

By distress, I mean a spike in suffering that can come from context, sleep, substances, conflict, or overload—not necessarily progression of the underlying disorder.

When Dose Increases ARE Appropriate

This isn't about never increasing doses. It's about doing it for the right reasons.

Appropriate reasons to increase:

• Clear evidence of partial response with room to optimize

• Symptom severity consistently above baseline despite stable context

• Dose is below therapeutic range for the condition

• Patient has been undertreated from the start

• Reduced efficacy over time (class-dependent: can happen with stimulants, benzodiazepines, some sedatives—not the default explanation for most antidepressants)

Inappropriate reasons to increase:

• Patient is distressed and you want to do something

• Life stress spiked and symptoms worsened contextually

• Different problem emerged that this medication doesn't treat

• Baseline expectations were unrealistic

• You're uncomfortable sitting with their discomfort

If there's acute safety risk, severe functional collapse, or clear evidence of relapse, escalation may be appropriate—but still grounded in a timeline and differential, not discomfort.

Common Escalation Narratives

Anxiety worsens → antipsychotic dose increases

Insomnia worsens → sedating med gets pushed higher

Emotional overwhelm → "mood instability" → med escalation

Life stress spikes → "breakthrough symptoms" → polypharmacy

What gets missed is that the medication may still be doing exactly what it was doing before. The problem is that something outside the medication's lane got louder.

A Few Questions I Now Force Myself to Answer Before Increasing Anything

What symptom is actually worse?

Is that symptom one this medication reliably treats?

Has the patient's context changed?

Am I treating distress, or am I treating pathology?

What High Doses Don't Fix

Dose escalation can feel active and helpful, but sometimes it's just a way to relieve our discomfort in the room.

High doses don't fix:

• Sleep debt

• Burnout

• Anxiety mistaken for mood instability (and vice versa)

• Psychosocial overload

• Avoidance of harder conversations

When Distress Looks Like Medication Failure (But Isn't)

Example 1: The Panic Spike

Presentation:
Patient stable on sertraline 100mg for 6 months. Comes in reporting "panic attacks are back."

Reflex move:
Increase sertraline to 150mg or add buspirone.

Better question:
What changed?

What changed:
New manager at work, sleep dropped from 7 hours to 5, stopped exercising when schedule got tight.

Better plan:
Sleep hygiene reinforcement, brief CBT for panic triggers, short-term stress management. Hold sertraline dose, reassess in 2 weeks.

Result:
Panic frequency decreased with sleep restoration and targeted coping strategies. Medication didn't need adjustment.

Example 2: The ADHD "Breakthrough"

Presentation:
Patient on Adderall 20mg BID, doing well for a year. Reports "medication stopped working, I can't focus anymore."

Reflex move:
Increase to 30mg BID.

Better question:
What does "can't focus" mean right now?

What changed:
Started graduate school, workload tripled, expectations changed, baseline distractibility now feels intolerable in new context.

Better plan:
Discuss realistic expectations, executive function coaching, accommodation strategies. Consider small increase if truly undertreated, but mainly address the mismatch between demand and capacity.

Result:
Patient developed better organizational systems and adjusted expectations. Small dose increase to 25mg BID helped, but the real shift came from external structure.

Example 3: The Mood Destabilization

Presentation:
Patient with depression on bupropion 300mg, reports "mood swings, feeling more irritable and reactive."

Reflex move:
Assume emerging bipolarity or bupropion activation, add mood stabilizer.

Better question:
When did this start, and what else was happening?

What changed:
Relationship conflict escalated, financial stress from unexpected medical bills, drinking more to cope.

Better plan:
Substance use discussion, couples therapy referral, assess for adjustment disorder vs. mood disorder, hold medication changes until picture is clearer.

Result:
Irritability improved with reduced alcohol use and couples therapy engagement. Bupropion remained appropriate at current dose.

Questions That Slow Down Escalation Pressure

When a patient reports worsening symptoms and you feel pressure to increase:

"Tell me what's different in your life right now compared to when things were better."

"Is the problem that the medication stopped working, or that something new showed up?"

"What would need to change for you to feel better, other than a higher dose?"

"If we increased your medication and nothing else changed, would that actually solve the problem?"

These questions redirect focus from the prescription pad to the clinical picture.

What to Do Instead of Reflexive Dose Escalation

Reassess the diagnosis. Is this actually what you thought it was?

Review the timeline. When did symptoms worsen? What else changed?

Ask about adherence. Are they actually taking it as prescribed?

Check for substance use. Alcohol, cannabis, stimulants all muddy the picture.

Explore psychosocial stressors. Job, relationship, housing, finances, trauma triggers.

Clarify functional goals. What does "better" actually mean to them?

Consider non-medication interventions. Therapy, sleep, exercise, structure, boundaries.

Documenting the Decision NOT to Increase

When you hold a dose despite patient request, document your reasoning. This is the part that protects you.

Example:

"Patient reports increased anxiety over past 2 weeks. Discussed recent job change, sleep reduction from 7 to 5 hours nightly, and increased caffeine intake. Anxiety symptoms appear contextually driven rather than treatment-resistant. Escitalopram 20mg continues to be appropriate dose. Reviewed sleep hygiene, discussed reducing caffeine, and encouraged return to exercise routine. Reassess in 2 weeks. Patient voiced understanding of plan."

This shows:

• You heard the concern

• You assessed for contributing factors

• You made a clinical decision with rationale

• You have a follow-up plan

The Takeaway

The clinical skill isn't knowing when to increase a med. It's knowing when not to, even when the patient is asking.

Sometimes the right move isn't a higher dose. It's a clearer map.