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  • Writer's pictureRyan Sheridan, NP

Rethinking Polypharmacy in Mental Health: A Holistic Approach in Washington, DC.


Polypharmacy in Washington, DC

As an integrative psychiatric nurse practitioner in Washington, D.C., my practice is anchored in the belief that holistic treatments, alongside conservative and prudent medication use, offer a more sustainable path to mental wellness. This approach is not just a philosophy but a response to a growing body of evidence suggesting that we need to reconsider our reliance on medication as the primary treatment modality.


And before we go any deeper, I have to make clear that I do not oppose medication.


In the land of mental health care, we need to have a serious conversation about the direction we have chosen. The increasing trend of polypharmacy – prescribing multiple psychiatric medications to a single patient – coupled with the challenges of deprescribing, poses a critical question:


Are we truly improving health or merely chasing symptoms in an attempt to rid suffering?


The Cycle of Polypharmacy and its Consequences


The prescription of multiple psychiatric medications to a single individual, often starts with the best of intentions—to alleviate distress and improve quality of life. However, the consequences can be complex and far-reaching, affecting not just the individual but society at large.


Medication Overload


Consider this case of a teenager, who found herself on a staggering regimen of ten psychiatric drugs​​. Her journey from anxiety and depression to a cocktail of medications reflects a systemic issue within our model of care—a propensity to "add-on" medications in hopes of addressing emerging or persistent symptoms without fully understanding the interplay between these drugs. This "medication cascade" can lead to a condition where the treatment becomes as debilitating as the disease itself, trapping patients in a cycle where each new side effect potentially warrants another prescription.


More importantly, we are often seeking to prescribe away something that no pill or treatment can fix: suffering.


Unseen Risks and Silent Victims


The practice of polypharmacy extends beyond the immediate risk of adverse effects, which can range from mild to life-threatening. There lies subtler, insidious, and potentially more hazardous risk—the long-term impact on brain development and overall health and the reduced capacity for resiliency, particularly in adolescents.


The brain undergoes significant development during the teenage years, and the effects of multiple psychiatric medications on this process are not fully understood. The concerning truth is that we are navigating uncharted waters, with a generation of young people inadvertently becoming part of an ongoing experiment in psychiatric care​​.


Moreover, the reliance on polypharmacy perpetuates a cycle of short-term solutions to complex, multifaceted problems. Often times we use medication in place of executing emotional regulation, again relinquishing our agency. It overshadows the critical need for comprehensive care strategies that address the root causes of mental health issues, including environmental factors, trauma, and social determinants of health. By focusing primarily on pharmacological interventions, we risk minimizing the importance of therapy, lifestyle changes, and social support—integral components of a holistic approach to mental health.


Our reliance on medications may in fact be robing us of our capacity for resiliency by externalizing our agency. When we give up that agency, the impact is damning in that we relinquish control. Part of human development is learning to navigate the challenges of life. If we are medicating away the discomfort, aren't we preventing our growth too?


Wait a minute, you might be wondering about biology. Some folks have a "biological" or "chemical" condition that predisposes them to mental health issues, right? Well yes, that is true but it it is also true that medication is not the only form of intervention.


Our lifestyle, activity, nutrition, and other environmental factors can be augmented to elicit chemical and biological changes too. So why is a pile of pills our first line of defense?


A Call for a Paradigm Shift


The consequences of polypharmacy underscore the urgent need for a paradigm shift in how we approach mental health treatment. It calls for a move away from a one-size-fits-all, medication-first mindset to a more nuanced, patient-centered approach. This approach considers the unique circumstances, needs, and preferences of each individual, integrating pharmacological treatments with non-pharmacological interventions to support the whole person.


As health care providers and advocates for mental health, our goal should be to empower patients with the knowledge and resources they need to make informed decisions about their care. This includes being transparent about the benefits and risks associated with medication, offering alternatives when appropriate, and supporting patients through the process of deprescribing when medications are no longer necessary or beneficial.


This means being realistic with facts and truly treating every prescription with the utmost respect that it demands. There is a potential for serious harm, even with commonly prescribed medication like an SSRI.


A question to consider: can this problem be solved without medication at all?


Moving Forward: Towards a More Compassionate and Effective Approach


Addressing the challenges of polypharmacy and its consequences requires a collective effort from providers, patients, families, and policymakers. It involves advocating for more research into the long-term effects of psychiatric medications, particularly in young people, and pushing for greater access to a range of mental health services, including psychotherapy, community support, and integrative health practices.


By reevaluating our reliance on polypharmacy and committing to a more holistic, person-centered approach to mental health care, we can begin to untangle the complex web of medication overload. In doing so, we pave the way for a future where mental health treatment not only alleviates symptoms in the short term but fosters true well-being.


Deprescribing: A Path Less Travelled but Necessary


Deprescribing in psychiatry represents challenging the status quo so that we can reclaim the essence of personalized mental health care. The plan to taper and discontinue medication should be a part of the conversation on day one.


For those on many medications, this nuanced process involves a strategic, often gradual reduction of psychiatric medications, guided by the principle that less can be more. The aim is to minimize polypharmacy's adverse impacts, enhance the quality of life, and acknowledge the body's capacity to maintain equilibrium with minimal pharmacological intervention.


Understanding the Scope and Impact


The journey of deprescribing begins with recognizing its profound necessity in contemporary psychiatric practice. For individuals who have navigated through the acute phases of mental health conditions with the aid of medication, the question of "what next?" looms large.


The narrative that once necessitated the start of medication does not always mandate its indefinite continuation. For instance, a patient who has achieved stable remission from a depressive episode, particularly if it is their first, might not need to carry the burden or risk of long-term medication. The risks of side effects, medication interactions, and the psychological implications of lifelong pharmacotherapy warrant a critical evaluation of each individual's medication regimen over time.


The Challenges of Deprescribing


The path to effective deprescribing on the individual level and on the society level is not and will not be easy. One of the most significant barriers is the deeply ingrained belief, both within the medical community and the broader public, that most if not all psychiatric conditions necessitate long-term medication.


Even complex diagnoses like bipolar and schizophrenia can often be effectively managed with fewer medications than are regularly prescribed.


This perception is compounded by the complexities of mental health conditions, where symptoms can be profoundly debilitating, and the line between treatment necessity and emotional dependency is blurred. Additionally, the lack of robust guidelines for the safe reduction and discontinuation of psychiatric medications leaves many practitioners feeling ill-equipped to navigate this process confidently.


A Collaborative and Individualized Approach


The reality is, medication can actually be holding us back, so it warrants exploring a change. Effective deprescribing requires a shift towards more collaborative care models, where patients are active participants in their treatment and decisions. This involves open, honest conversations about the goals of medication, the potential benefits and harms of continuing versus discontinuing, and the patient's values and preferences.


It's about moving beyond the binary choice of medication versus no medication to explore a spectrum of options that might include dose reduction, switching medications, or integrating non-pharmacological interventions such as psychotherapy, lifestyle modifications, and social support.


This process is highly individualized, taking into account the patient's history, the nature and course of their condition, their current life circumstances, and their personal preferences. For some, the decision to start or stop medication might follow a period of stability and symptom remission. For others, it might arise from concerns about side effects or a desire to reduce their reliance on medications. Whatever the reason, the process should be gradual, monitored, and reversible, allowing for adjustments based on the patient's response.


Building a Supportive Framework for Deprescribing


To navigate the complexities of deprescribing successfully, several key elements must be in place. On the individual level, these include comprehensive patient education about the process, potential outcomes, and strategies to manage any withdrawal symptoms or symptom resurgence.


As a society, there's also a need for enhanced training for providers in the principles and practices of deprescribing, including how to identify candidates for deprescribing, how to taper medications safely, and how to monitor patients throughout the process.


Moreover, fostering an environment that supports deprescribing necessitates a cultural shift towards valuing mental health treatments that emphasize the whole person, not just their symptoms. This means advocating for policies and practices that support integrated care models, increased access to non-pharmacological treatments, and ongoing research into the long-term outcomes of deprescribing.


Embracing the Full Spectrum of Mental Health Care


Deprescribing is not about the wholesale rejection of medication as a valuable tool in managing psychiatric conditions. Instead, it's about recognizing that the path to mental wellness is multifaceted and that our approach to treatment must be equally diverse and adaptable.


By embracing deprescribing as a critical component of psychiatric care, we can move closer to a system that truly supports the long-term well-being of individuals living with mental health conditions. This path, though less traveled, holds the promise of a more balanced, patient-centered approach to mental health care—one that honors the complex interplay between mind, body, and spirit.


Holistic Approaches: The Road to Sustainable Mental Health (aka my Proactive Approach)


The holistic approach to mental health care seeks to address the individual as a whole, acknowledging the intricate connections between the mind, body, and spirit. This perspective expands the scope of treatment beyond the confines of traditional psychiatry, incorporating a broad array of therapeutic modalities to nurture all aspects of an individual's being.


As we venture deeper into this approach, we uncover a richness to our interventions that caters to diverse needs and preferences, ultimately fostering a more resilient and sustainable path to mental wellness.


Embracing a Broad Spectrum of Therapies


Holistic mental health care champions the integration of various non-pharmacological interventions, each offering unique benefits. Psychotherapy, including Acceptance and Commitment Therapy, dialectical behavior therapy, and psychodynamic therapy, forms the cornerstone of this approach, facilitating deep personal insights and behavioral transformation.


However, the holistic model extends far beyond these foundational therapies to include modalities such as:


  • Mindfulness and Meditation: Practices that enhance present-moment awareness and foster a sense of calm and clarity.

  • Art and Music Therapy: Creative outlets that offer expressive pathways for communication and healing.

  • Physical Wellness: Emphasizing the role of exercise, nutrition, and sleep in supporting mental health.

  • Nature Therapy: Leveraging the healing power of the natural world to reduce stress and improve mood.

  • Body-Centered Therapies: Techniques like yoga and massage therapy that focus on the physical body's role in emotional and psychological well-being.

Tailoring Care to the Individual


What sets holistic mental health care apart is its commitment to personalized treatment. Recognizing the unique journey of each individual and striving to craft care plans that resonate with the personal experiences, cultural backgrounds, and values of their patients. This patient-centered approach empowers individuals, inviting them to play an active role in their healing process.


We restore our agency and foster resilience.


Building a Community of Support


A key element of holistic care is the creation of supportive communities that reinforce the individual's journey to wellness. Support groups, peer counseling, and family therapy are integrated into treatment plans, offering a network of support that extends beyond the therapy room. These communities provide a space for shared experiences, mutual encouragement, and collective growth, reinforcing the notion that healing is not a solitary endeavor but a communal journey.


The Challenge of Accessibility


Despite the proven benefits of holistic approaches to mental health, a significant barrier remains: accessibility. Many of these therapies are not covered by insurance or are only available at a premium, putting them out of reach for those who might benefit the most. Advocacy for broader access to these non-pharmacological interventions is crucial. This includes pushing for policy changes, increasing public awareness, and working towards an integrated health care system that values and incorporates holistic treatments as standard care options.


On the individual level, this is why I provide integrative mental health treatment options for those in Washington, DC who cannot afford my high fees, including a needs-based sliding scale and out-of-network claim support.


Looking Ahead: The Future of Holistic Mental Health Care


The future of mental health care lies in a more integrative, holistic approach that honors the complexity of the human experience. As we continue to push the boundaries of traditional psychiatry, my hope is for a more compassionate, comprehensive, and accessible mental health care system. One that acknowledges the vast potential for healing that lies in treating the whole person—mind, body, and spirit—and recognizes the diverse pathways to wellness that are as unique as the individuals seeking care.


Charting a New Course


As we move forward, let's advocate for a mental health care system that prioritizes long-term wellness over temporary symptom relief. By embracing deprescribing when appropriate and expanding access to holistic treatments, we can offer a more compassionate and effective care model. This model respects the complexities of the human experience and honors the resilience of those on their journey to mental wellness.


So, as I said before, I do not oppose medication. What I do oppose is how we attempt to use medication to solve problems that cannot be solved by medication alone.


Feel free to reach me at ryan@proactivepsychiatry.com. Cheers!



 

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