A patient I see for psychotherapy, without medications except for an occasional lorazepam (tranquilizer of the benzodiazepine class), told me his prior psychiatrist declared him grossly undermedicated in one of their early sessions, and had quickly prescribed two or three daily drugs for depression and anxiety. He shared this story with a smile, as we've never discussed adding medication to his productive weekly sessions that focus on anxiety and interpersonal conflicts. Indeed, the lorazepam is left over from his prior doctor. I doubt I would have ordered it myself, although I don't particularly object that he still uses it now and then.
Of course, there's a completely innocuous way to explain this difference between his prior psychiatrist and me. My patient could have looked much worse back then, in dire need of pharmaceutical relief. However, he didn't relate it to me that way, and I have no reason to doubt him. There's also the possibility that I'm missing serious pathology in my patient — that I too would urge him to take medication if only I recognized what I'm now overlooking. But... I don't think so. I'm left to conclude that his prior psychiatrist and I evaluated essentially the same presentation rather differently.
In particular, I'm struck by the term "undermedicated" (more often spelled without the hyphen, according to my Google search). This judgment most often comes up in speaking about populations, as in the debate over whether antidepressants are over-prescribed or under-prescribed in society at large, or whether children are diagnosed with ADHD and prescribed stimulants too often, or not often enough. Under- and overmedication are also commonly mentioned when describing medication management of pain, a thyroid condition, mania, or chronic psychosis in an individual. Here the terms express disagreement with a particular dosage, where the benefits of treatment and adverse side-effects or risks are deemed out of balance one way or the other.
"Undermedicated" also implies that adding medication is the preferred or only sensible treatment approach. While this may always be true in hypothyroidism, it clearly isn't with regard to physical or emotional pain. The term rhetorically denies non-medication alternatives. I would also add that, to my ear, "overmedicated" and especially "undermedicated" sound dehumanizing, as though referring to a machine that is out of adjustment, or a chemical solution being titrated on a lab bench. Since the natural state of human beings is not to be medicated at all, it sounds a bit odd to hear someone — as opposed to one's disease — assessed this way. Perhaps I am especially sensitized to this after reading a controversial article by Moncrieff and Cohen that highlights the "altered state" induced by psychotropics and their lack of known, specific mechanisms of action. There is often a supposition that medication dosage correlates with symptom relief. This is not always true of subjective states, underscoring that the complexity of human experience often belies simple "over/under" judgments.
My patient's mood and anxiety vary with his interpersonal situation. It wouldn't occur to me to turn his "thermostat" up or down in general, even if drugs reliably could do this. Yet I know colleagues who'd argue that one, two, or even three daily medications could help him overcome his everyday challenges of dealing with people. These approaches point to different fundamental viewpoints in psychiatry. Does the patient have a disease, an as-yet-undiscovered chemical (or electrical, viral, inflammatory, etc) imbalance in the brain that is best remedied by a medical intervention, accurately dosed neither "over" nor "under"? In acute mania or florid psychosis, as in hypothyroidism, it seems to me the answer may be yes, although this is unproven and time will tell. Perhaps, too, in severe melancholic depression. But in social anxiety? Self-consciousness? Feeling discouraged about one's career? The field's perspective on these has shifted in recent decades, such that now a hidden biological cause is assumed by default, or at least held out as a rationale for treatment. It is only by making this dubious assumption that one can speak of undermedicating such complaints, or the people who have them.
My second post in this series on sloppy thinking in psychiatry is devoted to polypharmacy, the medical term for prescribing multiple medications at once, especially for the same problem. Polypharmacy is at best a risk thoughtfully taken because nothing simpler and safer will do. At worst it's a dangerous error, exposing patients to unnecessary hazards purely as a result of laziness and sloppy thinking by their doctors. Unfortunately, the latter is all too 
There is an active debate underway in the popular literature about whether antidepressant medications actually do anything chemically helpful for depressed patients. No one doubts that many patients report feeling better, and that most evidence less depression on standardized rating scales, following treatment. But much of that improvement appears to be due to psychological factors, i.e., the placebo effect. The debate is over how much improvement is not due to the placebo effect. What beneficial effects can be attributed to the active ingredients in the tablet or capsule?
It's disconcerting to enter this debate decades after the popularization of antidepressants. These are among the most common prescriptions in America: In 2010, antidepressants were the second most commonly prescribed class of drugs in the U.S., according to IMS Health. They are so widely used that Consumer Reports publishes "best buy" 
I'd like to take this opportunity to comment on the article that appeared in today's New York Times: "
Yesterday I evaluated a new patient, a young woman who wondered whether medication might ease her depression. She was in therapy elsewhere, and although seeing me was her idea, she was apprehensive about adding an antidepressant. I did end up recommending one, at which point she asked: "Aren't antidepressants just a crutch?"
I relish this question. It is asked in anxiety, hesitation, and doubt, yet carries within it its own hopeful answer.