By Chloe Nazra Lee, MD, MPH

New to outpatient psychiatry as a third-year resident, my medication intake appointments usually come in one of two flavors: no prior contact with psychiatry or transfers from other clinics with frightening medication regimens.

"You might as well consolidate this med list by giving her propofol [an anesthetic], it would have the same effect," snickered one of my attendings facetiously. The patient was on a combination of opioids, as-needed benzodiazepines, and anticholinergics. (Those classes are all sedating and increase fall risk and cognitive slowing. Some of them are addictive and run the risk of causing respiratory depression.)

That particular medication regimen was an extreme. Other medication lists marked by polypharmacy are not necessarily as dangerous but may include multiple medications in similar drug classes at ineffective doses. These patients end up taking many different medications that aren't targeting anything effectively but run the risk of precipitating adverse drug interactions.

Sometimes, providers add more drugs to subtherapeutic regimens, with significant consequences. One patient was taking both venlafaxine (Effexor) and sertraline (Zoloft) at subtherapeutic doses for anxiety -- these are both antidepressants with serotonergic effects. Her provider interpreted her ongoing anxiety and decision-paralysis as attention-deficit/hyperactivity disorder (ADHD) and added a stimulant. Her symptoms dramatically worsened, which is exactly what you'd expect when you give a stimulant to someone with poorly-controlled anxiety who likely does not have ADHD.

Polypharmacy definitions are variable, but the most commonly used definition is five or more medications daily. That definition feels reductive, so I'll add another dimension to it: taking more medications for a given pathology than are situationally inappropriate, where the risk outweighs the benefit.

Art Informed by Science

Sometimes we err on the side of polypharmacy to stabilize a critically ill patient. In inpatient psychiatry, where patients are extremely unwell and can be dangerous, we tend to throw medications at symptoms for rapid stabilization. A bipolar patient with florid mania may indeed need an antipsychotic and standing benzodiazepine to help them sleep. A hopelessly depressed patient may need a mood stabilizer to augment their antidepressant. These medications can be situationally appropriate for the severity of illness at the time.

Even some complex outpatient cases of severe persistent mental illness warrant long-term polypharmacy to keep the patients functional -- they'd never leave the hospital otherwise, and often need more community support than the average person. Again, polypharmacy may be situationally appropriate.

In many cases, trialing a medication taper is warranted. But tapering carries its own risks -- the patient may become symptomatic again, in which case you add the medication back.

Before I inherited her, one of my bipolar patients tried to taper lithium after doctors noted adverse effects on her kidneys. She promptly became manic, and that is how we learned she needs lithium to function independently. Here, the risk of mania outweighed the risk of chronic kidney disease, and our management involves keeping her on a mood stabilizer, monitoring her closely, and collaborating with nephrology.

In others, tapering works well. An agitated, psychotic patient stabilized on a standing benzodiazepine among other medications does not necessarily need to be on a benzodiazepine for life and may do very well with antipsychotic monotherapy. Unfortunately, in many instances, it remains on their list indefinitely.

Confused yet? The whole point is that managing any psychiatric medication regimen is an art requiring intimate knowledge of the individual patient, ongoing risk-benefit calculations, and the willingness to take measured risks.

Evidence and Community, Not Fear

As physicians, we make mistakes sometimes, which is to be expected in any venture with any amount of risk. As such, many physicians and advanced practice providers are hesitant to taper medications, worrying about destabilizing a patient.

Or, if a patient continues to be distressed or even angry and demanding, providers may feel desperate for a solution and throw even more medications at the problem. For instance, I had a patient inappropriately request alprazolam (Xanax), a stimulant mix of amphetamine and dextroamphetamine salts (Adderall), and an opioid within the same month. I'm a little older for my level of training and have dealt with enough angry people to become comfortable saying no; I also have extremely supportive supervisors who usually validate my "no." Not every provider is comfortable saying no, and they may feel pressure to capitulate.

For one reason or another, many patients end up on inappropriate medication regimens. I can appreciate why this might engender distrust in our field. There's a whole anti-psychiatry movement that reliably protests each American Psychiatric Association annual meeting.

Unfortunately, distrust has entered the mainstream, with current healthcare policy debating the necessity of our interventions. The debate is predicated not on evidence, but on deeply held beliefs that make dubious connections between societal ills like gun violence and selective serotonin reuptake inhibitors (SSRIs) or unfounded claims that therapy "can cause the crises it claims to cure," for example.

The question, "Do I really need to put this in my body?" has been broadly extended not only to the field of psychiatry, but also to critical public health measures, from vaccines to fluoridated water to prenatal support (like maternal acetaminophen [Tylenol] use), without basis in scientific evidence.

Upending trust in medical practice and our public health institutions has long-term ramifications for patients. Canada lost its measles elimination status, with the U.S. likely to follow. More American women, fearing lack of meaningful societal support, are avoiding pregnancy with consequences for our fertility rate. These adverse public health outcomes are direct consequences of fear-based health policy that doesn't meaningfully address the core issue of polypharmacy.

The questions around polypharmacy are valid. The distortions and broad application of them without nuance are not.

Our system is imperfect, but not irreparable. One meaningful way to address polypharmacy starts with medical education that emphasizes good diagnosis over treating symptoms superficially, and clarifies that "doing something for the patient" does not always involve medication. It may involve the courage to deprescribe cautiously or to optimize non-medication interventions, like psychotherapy.

Another meaningful way to address patient distress with fewer medications is to invest in sustainable community resources to meet patients' basic needs. Mental health is obviously going to suffer when people do not have access to food, reliable transportation, good education, and stable housing.

And finally, a willingness to model integrity, respect, and emotional vulnerability is critical to a healthy society. At the end of the day, we are social creatures who need each other; this may conflict with the unique individualism that spurs American innovation, but drives loneliness and shame when taken to excess. If we invest in a healthy community with substantive values from the ground up, perhaps fewer providers would offer -- and fewer patients would demand -- the "quick fix" they mistakenly imagine our medications can afford in an effort to feel human.

Chloe Nazra Lee, MD, MPH, is a resident physician in the Department of Psychiatry at the University of Rochester Medical Center in New York.