Problems with Piecemeal Prescribing
As a practicing psychiatrist, I see many patients. Many have psychiatric symptoms such as anxiety, insomnia, depressed mood, low energy, and irritability. My first task is to address the symptoms that trouble my patient the most in the safest, most practical way possible.
Unfortunately, many are increasingly presenting with a list of medications that appear to contradict the basics of the way physicians are trained to prescribe. It’s as if the prescribing manual was thrown out the window. People are taking one medication for this, that for another, and one more for an additional symptom. That is not the intention in training, yet it has become all too common in practice.
Physicians are trained to look at the big picture of symptoms in order to arrive at a diagnosis, so that the best, most tolerable medication can be prescribed for the underlying disorder that is causing the symptoms.
People naturally look for relief of unbearable symptoms like anxiety or insomnia. In such cases, certain medications with sedative properties would be ideal. Alternatively, prescribing a sleeping medication and a non-sedating antidepressant would also be appropriate. However, there can be unintended consequences to the second approach like creating dependence on a habit-forming medication in a patient with a substance use disorder history. It doesn’t make it wrong. However, as the list of medications grows longer, so does the risk of more interactions between them.
Such a prescribing approach may unintentionally convey a quick fix or piecemeal mentality, whereby the link between different symptoms is not properly made like anxiety leading to insomnia. In reality, most anxiety and depressive disorders that cause insomnia are actually chronic, fluctuate in time, and require a comprehensive treatment strategy including therapy as well as education about sleep habits and medications combined, all of which take time to fully appreciate. The aim should be to tie these seemingly disparate symptoms together so that patients themselves can embrace the notion of treating their disorder as a whole.
In medicine, the prescribing of several medications simultaneously is called polypharmacy. It is usually discouraged as medicines can interact with one another, causing more side effects or reducing the effectiveness of each added medicine.
On the other hand, the reality is that psychiatrists may need to add to the effectiveness of one medication with another when the first has only been partially helpful. An example of this is adding a mood-stabilizing agent to an antidepressant for treatment-resistant depression. However, the original medication dosage needs to be maximized before the augmenting agent is added. This is called rational polypharmacy. The good news is that the addition of a lower dose of another medication in such a case can actually achieve a faster result.
The practice of irrational or piecemeal prescribing is common in healthcare. By this, I mean the chronic prescription of, for example, a sleeping medication, when in fact, the underlying problem is a depressive disorder.
Another example would be two hypnotic medications – one supposedly for sleep, the other for nightmares. This is where the science contradicts such a practice because the combination of different sleeping medications can prove risky and even fatal. This was famously highlighted by Michael Jackson’s death when it came to light that he was receiving several sedative medications simultaneously.
It also makes little sense to duplicate sedative medications. When I see this in practice, I question why one medication was never maximized. Unfortunately, I see this all too commonly in intakes with patients who complain how unsatisfied they are with their current medication combination. They are usually exasperated that they have not had adequate explanation along the way for this either.
Another common example I have seen is the chronic prescription of “as-needed” addictive medications for years on end. The doctors have not focused on treating the underlying anxiety disorder or explained why this approach is not ideal in the long term.
Thus, a patient is prescribed (as needed or PRN, the technical term) benzodiazepines for panic attacks. The person struggles from one episode to the next, without a proper strategy for treating the underlying anxiety disorder that has given rise to these and other symptoms of anxiety in the first place.
Physicians need to be cognizant of what medications are indicated for short term and long-term treatment of, say, an anxiety or depressive disorder, and what the research literature is recommending as to when to use them.
Let me cite another example: Prazosin has acquired an increasing reputation for treating nightmares for those with Post-Traumatic Stress Disorder. However, I would typically not prescribe it before I had first tried a mainstay SSRI antidepressant like Prozac® or Zoloft® to reduce the other associated symptoms that might be driving the nightmares. In addition, therapy is also a valuable intervention that would be included in my comprehensive plan to address the content of these nightmares.
Of course, if somebody comes to me on a medication I would not recommend, I wouldn’t just abruptly stop it. I would assess if it is actually helping and know that any abrupt cessation in medication is always considered unsafe. A delicate balancing act is required in tidying up even a haphazard prescription medley of medications. The decision must be driven by what’s in the patient’s best interest, including an awareness of the patient’s persisting symptoms—all with the aim of providing symptom relief, while using the simplest, most effective medication combination possible.
All of these examples hopefully illustrate the importance of sound prescribing principles, in order to treat any patient’s psychiatric condition safely and effectively. In my own training of medical students, I use the adage “start low, go slow” for initiation of a new medication. Another would be “primum non nocere” which means: first…do no harm.” If I wanted to dismantle what appears to be an overly complicated medication combination, I would go about it in a safe and prudent way.
To my dismay, I am noticing less and less use of these well-established prescribing principles over the years. I appreciate that there may be good reason for a particular medication combination and that prescribing is as much an art as it is a science. Nonetheless, I am increasingly noticing over my years of practice is that there is a dearth of adequate explanation and documentation, typically leaving myself and the patient in the dark as to what has been going on in their medication history.
My own conclusion is that there are currently overriding forces in our current healthcare system that have successfully undercut such principles and approaches. I do not blame fellow individual physicians for this trend. Those forces include the current healthcare system’s emphasis on digitization, speed, and turnover. Treatment has become checking of boxes rather than quality of care, connection with the patient, or even basic explanations of why a medication is being prescribed to them.
It’s as if the world has been caught in an endless race, just trying to jump through hoops to get to the end of the day. This opens up a larger discussion as to how doctors and hospitals are paid. I am seeing corners being cut in order just to financially survive. However, this drive-through approach for medication management is ineffective and dangerous.
I end this discussion with the above concepts only to illustrate that forces larger than just the individual have unduly shaped our collective cultural approach and mentality in healthcare. I just hope as physicians we are able to hang on to what I have always known to be true: focus on your craft and your patient above all else!