The Fine Art (and Science) of Nonprescribing

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COMMENTARY

“Though the doctors treated him, let his blood, and gave him medications to drink, he nevertheless recovered.” –Leo Tolstoy, War and Peace

In my career as a psychopharmacology consultant for over 25 years, much of the advice I gave to consultees involved discontinuing unnecessary medications, or at least greatly reducing the dose—a practice now termed “deprescribing” and originally applied to geriatric medicine.¹ Deprescribing is usually defined as “reduction or cessation of medications for which benefits no longer outweigh risks,” and is comprehensively reviewed in an excellent paper by Gupta and Cahill.²

In this article, however, I reflect on the art and science of medication nonprescribing, and the use of psychotherapy as initial or first-line treatment. Definitions of “first-line” differ, but as I use the term, it refers to a therapeutic intervention recommended for initial treatment, based on proven efficacy and tolerability in controlled, clinical studies. Accordingly, there may be more than 1 first-line agent or treatment for a given condition.

But caveat lector: what I have to say comes with all the baked-in biases associated with the phrase, “In my experience,” and should be taken with a decent-sized grain of salt. Whenever feasible, I try to supplement my personal experience with published research. I need hardly emphasize that when properly prescribed and carefully monitored, psychiatric medication can be both life-saving and life-enhancing.³

Nevertheless, our medications can have a significant downside for some patients, including the development of adverse effects and, in some cases, serious difficulty discontinuing the drug. Adverse effects are especially likely when inappropriate polypharmacy is involved—a topic beyond the scope of the present article but well-covered in the book, Polypharmacy in Psychiatry, edited by my colleague, S. Nassir Ghaemi, MD.⁴

In short, there are compelling reasons to avoid or defer use of psychiatric medication when psychotherapy is a reasonable, first-line alternative. Of course, medication and talk therapy are not mutually exclusive, and there are circumstances in which combined treatment is most effective.⁵

Is Psychiatric Medication Overprescribed? The Twin Peaks Phenomenon

Before focusing on nonprescribing, I want to cast a critical eye on the popular notion that psychiatric medication is egregiously over-prescribed in the US.⁶ In reality, the picture is much more complicated. Indeed, there is evidence for both over- and underprescribing of psychiatric medication in the US—something I call the “twin peaks” effect. Much depends on the clinical setting; the patient’s diagnosis; their social, ethnic, and demographic features; and, in my experience, the degree of pharmacological sophistication of the clinician. (I am limiting my discussion here to the practices of US clinicians).

Please note that my brief, selective discussion does not cover the complex issues and controversies involved in benzodiazepine and stimulant prescription, about which, please see references 7 and 8.

Antidepressants, Lithium, and Antipsychotics

Consider the prescription of antidepressants. Despite the popular impression that these drugs are “handed out like candy,” Mark Olfson, MD, has pointed out that “Antidepressants are overprescribed and underprescribed in the United States… Many adults with major depressive disorder go for long periods of time without receiving treatment."⁹ At the same time, Olfson adds, many individuals with mild depression are prescribed antidepressants even though they are not likely to benefit from these agents.

On the other hand, research by Simon et al using PHQ-9 severity scores suggests that “…over-prescribing of antidepressants for mild depression is not a significant public health concern,” and that “community antidepressant prescribing is usually consistent with guideline recommendations, with only a small proportion of patients starting treatment having minimal or mild symptoms.”¹⁰

Ethnic and socio-economic disparities may also lead to underprescription of antidepressants¹¹:

“Despite the overall growth in anti-depressant treatment, studies have reported persistent racial and ethnic disparities in use of antidepressants: among persons with a similar diagnosis of depression, the odds of antidepressant use were lower among blacks and Hispanics than whites by 20%-70% in the 1990s and early 2000s. Lack of access to health insurance and relatively low income in minority groups are among the main explanations for these disparities.”

Another prime example of underutilization is the prescription of lithium for bipolar disorder. As Post et al have shown, “Lithium is underutilized in the treatment of bipolar disorder, especially in the United States compared with the Netherlands and Germany and likely many other European countries…[Furthermore] in an epidemiological survey, 80% of adolescents meeting criteria for a bipolar spectrum disorder were not in treatment of any kind.”¹² 

In contrast, in my experience, antipsychotic medication is more often overprescribed than underprescribed. This may be especially true in adolescent populations and nursing home settings, where antipsychotics are often inappropriately used off label for control of unwanted behaviors.¹³

One notable exception is clozapine, which is arguably underprescribed, owing in part to stringent monitoring requirements and overblown fears of agranulocytosis. Clozapine’s beneficial effects (including its probable antisuicide properties) make it an important and under-used option in treatment-refractory schizophrenia.¹⁴

The Fine Art of Nonprescribing

The physician Oliver Wendell Holmes Sr (1809-1894) tartly observed that⁴:

“…if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes.”

Of course, Dr Holmes was reflecting the state of medical treatment in his own day, and I do not believe that our current pharmacopeia warrants a dunk in the ocean. That said, a good deal of psychiatric care can be provided successfully without need of medication. Indeed, for many types of psychiatric impairment—particularly for the anxiety disorders—psychotherapy ought to be considered a first-line treatment (Table 1).^15-23

Table 1. Psychiatric Conditions for Which Psychotherapy Is a First-Line Treatment^15-23

Note: This list is representative, not exhaustive.

Of course, the art of nonprescribing begins with accurate diagnosis, which is really the bedrock on which everything else rests. I will come back to this shortly. The next step, however, is a general assessment of the patient’s overall level of functioning, including the degree to which the patient is suffering and incapacitated. (The DSM-5 uses the rather attenuated terms “significant distress or impairment” in social, occupational, or other important areas of functioning). Clearly, this is a trans-diagnostic determination, though we would expect that the most serious psychiatric illnesses would exact the greatest toll on function and produce the greatest degree of suffering and incapacity.

To be clear: the general assessment of function is not a substitute for formal diagnosis. In clinical practice, psychiatric diagnosis and assessment of overall function are rarely separate or sequential determinations; rather, they are interwoven strands that compose the tapestry of the psychiatrist’s initial interview and evaluation of the patient, including a complete biopsychosocial formulation of the patient’s problem.

Assessing Internal and External Resources

In addition to assessing the patient’s ability to carry out routine activities of daily living (ADLs), it is important to assess the patients internal and external resources and supports.

• Internal resources include the patient’s habitual ego defenses (repression, denial, projection, etc); degree of emotional resilience; and usual coping strategies. In general, mature defense mechanisms are associated with relatively adaptive functioning; more “immature” or psychotic-level defenses, with dysfunction.^24-31
• External resources include emotional support from close friends and family; ready access to health care; and vocational/economic resources. Religious affiliation is also recognized as a source of support for many patients.

Now, as a broad generalization—and all other things being equal—patients who present with (a) a low or mild degree of suffering and incapacity; and (b) have abundant internal and external resources, are often good candidates for medication nonprescribing. In my experience, these patients often do well with psychosocial treatment alone as first-line treatment.

To be sure, this is a diagnostically heterogeneous group. Many such patients are experiencing ordinary life stressors or losses, and may not need extended professional treatment. For example, some may be experiencing uncomplicated grief related to bereavement. Others with mild adjustment reactions will respond to supportive psychotherapy alone as initial treatment. Some may fit the older (and somewhat nebulous) term “neurotic” and may benefit from some form of psychotherapy. What this group has in common is their suitability for medication nonprescription.

The situation is more complicated when the patient presents with (a) a high degree of suffering and incapacity; and (b) minimal internal and external resources. This picture may warrant medication as first-line treatment, but this is not necessarily the case. Here, diagnosis is critical.

Let’s say a patient who fits this description is diagnosed with schizophrenia or a bipolar spectrum disorder. They are very likely to require and benefit from long-term medication, though there are occasional exceptions.

On the other hand, consider the patient diagnosed with borderline personality disorder (BPD). They are likely experiencing a high degree of suffering and incapacity, but are not likely to benefit greatly from medication as the primary treatment.³² Indeed, in my experience, psychiatric medications are often vastly overprescribed for patients with BPD. Most of the research suggests that these patients are best treated with psychotherapy as the first-line and primary treatment; eg, dialectical behavior therapy³³ or transference-focused psychotherapy.³⁴ That said, adjunctive medication can be symptomatically helpful in some cases.³⁵

So, too, with complicated grief, now classified in DSM-5-TR as prolonged grief disorder. Patients with PGD may present with “intense emotional pain” and marked impairment in function; ie, “The persistent grief is disabling and affects every day functioning in a way that typical grieving does not.”³⁶ However, notwithstanding this level of suffering and incapacity, the preferred, evidence-based, first-line treatment of PGD is complicated grief therapy—not medication.²³

In other words, pronounced suffering and incapacity is not, by itself, a dispositive indication for psychiatric medication.

On the other hand, the mere absence of severe suffering and incapacity does not warrant withholding medication. Thus, in the case of a biologically-driven condition that is recurrent, a preventive approach with medication may be justified, even if the patient is now functioning well. For example, a patient with cyclothymia may have little or no functional impairment; however, they have a high likelihood of eventually developing full-blown manic and depressive episodes (S.N. Ghaemi MD, personal communication, 3/24/24). Even if the patient’s current mood swings are not particularly distressing or incapacitating, some experts favor starting the patient on a low dose of a mood stabilizer. As Dr Ghaemi has observed, cyclothymia...

"…is not very disruptive. I have had many patients seek treatment for it though, mainly because it is like having a slow leak in your basement rather than a flood; eventually it fills up with water. Cyclothymia has benefits and harms; you get more of the former with less of the latter with low dose [mood stabilizer] treatment to take off the edges…the second reason to treat cyclothymia is to prevent future manic or depressive episodes, since such patients are at higher risk for them." (S.N. Ghaemi MD, personal communication, 3/24/24)

Ghaemi favors low dose lithium (300-600 mg/d) or low dose Depakote (250-500 mg/d) for cyclothymic patients. Of course, a thorough risk/benefit discussion of this strategy is important, as with all medical treatments, but the adverse effect burden at these low doses is usually light.

Table 2. Patient Prototypes and First-Line Treatments^15-31

*Dr Mark L. Ruffalo notes that “identification with the aggressor captures so much of the behavior we see in borderline pathologies.” (personal communication, 3/25/24)

The foregoing principles are summarized in Table 2.^15-31 This organizes the aforementioned patient types into 3 main prototypes, commonly encountered in outpatient and hospital-based psychiatry, and often the focus of psychopharmacology consultation. These prototypes are admittedly quite heterogeneous, and do not map easily onto DSM-5 diagnoses, though there is some overlap. This table is not a formal classification scheme but may serve the psychiatrist as a rough guide to first-line treatment.

Two further caveats:

1. The use of medication for, say, schizophrenia or bipolar disorder in no way implies that psychosocial approaches are not useful as a part of holistic, comprehensive care. On the contrary, various forms of talk therapy, family educational approaches, vocational counseling, and other psychosocial treatments are often necessary and integral components of care in these conditions. Recently, cognitive remediation was shown to be useful in patients with schizophrenia.³⁷
2. Psychotherapy as the preferred or first-line treatment does not preclude the addition of medication at some phase of treatment, if clinically warranted. Furthermore, as noted earlier, there are situations in which one would likely begin treatment with a combination of medication and some form of talk therapy; eg, when treating a severely depressed patient with melancholic features. The issue of sequencing psychotherapy and pharmacotherapy is complex and beyond the scope of this article.⁵

Concluding Thoughts

The great French physician Philippe Pinel (1745-1826) wisely remarked that³⁸:

“In diseases of the mind…it is an art of no little importance to administer medicines properly; but it is an art of much greater importance and more difficult acquisition to know when to suspend or altogether omit them.”

The art and science of nonprescribing is indeed difficult to acquire, especially in an age when physicians are hurried, harried, and sometimes pushed to write out a script for the patient with anxiety or depression. On the other hand, inappropriately withholding medication when it is clearly needed is also a clinical failing. As in most of life, there is a reasonable and cautious middle-ground, in which the first-line treatment has been proved effective for the condition at hand, and is best-suited to the medical and psychological needs of the particular patient. In many cases, this means that talk therapy is our first and best intervention.

Acknowledgments: I thank Dr Mark L. Ruffalo and Dr S. Nassir Ghaemi for their very helpful comments and suggestions regarding this article.

Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry Emeritus, Tufts University School of Medicine; and Editor in Chief Emeritus of Psychiatric Times (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on Amazon.

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