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Practicing internist and psychiatrist Muhamad Aly Rifai discusses his article, “How America became overmedicated—and what we can do about it.” He raises concerns about the high rate of psychotropic medication use in the U.S., citing CDC data suggesting nearly 1 in 4 adults may be taking these drugs, often without clear long-term plans or exit strategies. Muhamad contrasts this with U.K. NICE guidelines that emphasize structured deprescribing protocols, highlighting a significant gap in U.S. clinical guidance. He points to systemic issues like short medication management visits, lack of industry incentives for deprescribing, and the need for better physician training in distinguishing withdrawal symptoms from relapse. Dr. Rifai advocates for a national shift towards wellness, emphasizing medication optimization, integrated behavioral health (including therapy and trauma-informed care), addressing social determinants of health, and fostering recovery-oriented conversations that explore non-pharmacologic approaches like peer support, nutrition, and exercise. Actionable takeaways include the need for robust deprescribing guidelines, investment in holistic and integrated care models, and a conscious effort by clinicians to discuss not just starting medications, but also safely stopping them when appropriate.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Muhamad Aly Rifai. He’s an internal medicine physician and psychiatrist. Today’s KevinMD article is “How America became overmedicated and what we can do about it.” Muhamad, welcome back to the show.
Muhamad Aly Rifai: Thank you very much for having me to talk about this very important and timely topic in psychiatry: How our patients have become overmedicated in psychiatry.
Kevin Pho: OK. Tell us what your article is about.
Muhamad Aly Rifai: So, I start the article with the recent survey from the Centers for Disease Control and Prevention. We now know that one in four Americans is on a psychotropic medication. And by a psychotropic medication, I mean a variety of medications: antidepressants, anti-anxiety medications, mood stabilizers, antipsychotic medications, medications for attention deficit hyperactivity disorder, medications to support a variety of symptoms that are associated with other medications.
Twenty-five percent of the population, one out of four walking in the street, they are taking a psychotropic medication, and these medications come with a variety of adverse effects.
Now, these medications are very important for a lot of these individuals; they are life-sustaining. They are lifesaving but are also associated with a lot of side effects, and for some medications, there’s really no trajectory in terms of a condition that they treat.
So for example, with antibiotics, we got a prescribed antibiotic regimen. An individual takes the antibiotic for five or 10 days and they’re done. In the majority of psychotropic medications, there’s no prescribed course. So, for example, an antidepressant for an episode of depression: when do you stop?
When do you try to taper off the medications? With antipsychotic medications, if they’re given for schizophrenia or bipolar disorder or for augmentation for depression, when do you change these medications? So we don’t have a lot of data to support that.
But these medications are essential. They save lives, but they also have a lot of side effects, and we need to have a call for action to the fact that we need to work on a plan so we can taper off a lot of people that are just kept on these medications indefinitely.
Kevin Pho: So what do you see as some of the root causes why an increasing number of patients are being prescribed psychotropic medications?
Muhamad Aly Rifai: So, a big part of it is the practice of medicine and the field of psychiatry. We have turned into the 15-, 16-minute psychiatrist med check where there’s very little conversation between the treating physician and the patient. You’re there just to check on them to make sure that their symptoms are OK, that they are not in any crisis, but there’s not enough time for a nuanced conversation between the psychiatrist and the patient. OK. What are we achieving with these medications? Are we at target? Have we achieved it? Do we need to start talking about tapering down these medications?
Additionally, there’s very little research, so the pharmaceutical companies have very little incentive to actually conduct research on what to do to taper off these medications. You will see advertisements on TV for all these medications that could be add-on or for primary for a condition. There’s no research; there’s no studies of what happens. What do you do to taper off these medications if they’re on long-term, and if the condition is in remission?
And is this gonna be a chronic condition, or is this just a condition that was treated, especially like, for example, with depression, anxiety? How about ADHD? So we don’t have the research to support us in being able to have that conversation with our patients.
Plus, we have very short visits. And the health insurance system is just not helping that situation. But that also leads to significant increased expenditure on the cost of pharmaceuticals, sometimes that is unneeded.
Kevin Pho: So you mentioned that side effects sometimes are underreported when it comes to these types of medications. I know there are so many different classes of psychotropic medications, but what are the most common scenarios where side effects become an issue?
Muhamad Aly Rifai: Sure. So the most serious medications where side effects become significant are the antipsychotic medications. And, you know, antipsychotic medications now are approved for a variety of conditions. They’re not just for the treatment of schizophrenia. They’re approved for the treatment of depression, augmentation for depression. They’re approved for the treatment of bipolar disorder. They’re approved for the treatment of anxiety, but antipsychotic medications have a variety of adverse effects.
The metabolic adverse effects: weight gain, the induction of development of diabetes, metabolic syndrome. They have also adverse effects: movement disorders and the development of tardive dyskinesia.
So, these side effects sometimes are very significant and may lead to the patient discontinuing the medication on their own but also puts a lot of responsibility on the treating psychiatrist in terms of being able to have a conversation with their patient about that.
But sometimes what happens is these side effects become so significant that the patient discontinues the medication on their own and will face decompensation.
And so that self-discontinuation is very, very important because sometimes they don’t tell their doctor; the patient doesn’t tell their physician that they have discontinued these medications, and then they decompensate and they’re rehospitalized and they start the cycle again.
Kevin Pho: In your article, you contrast the guidelines in the United Kingdom versus the lack of structured guidance in the U.S. when it comes to antidepressant discontinuation. So we’ll talk more about that.
Muhamad Aly Rifai: Sure. So this is a very important topic, and the guidelines from the NHS had a significant development. It’s called the NICE guidelines, the National Institute for Health and Care Excellence. And that’s the equivalent of the U.S. NIH, but basically, they developed guidelines about what to do if somebody is on an antidepressant for more than six months, and then an evaluation tool of figuring out: does this person need to continue on this antidepressant or does it need to be tapered off and discontinued? And there’s a lot of variables: Is this the first episode of depression? Is this the second episode of depression? Is this a chronic depression? Is this a depression with psychotic features?
So there are multiple variables, but it also entails a conversation between the psychiatrist or the primary care doctor who’s prescribing the antidepressant and the patient: Is it time to discontinue this antidepressant? Are symptoms of depression well controlled? Is there a need for continuation of this antidepressant? Does the patient feel that the medication is helping them? And a structured way to taper off this medication safely, being able to monitor symptoms and identifying parameters where you need to reinstitute the medication?
There’s also a very important phenomenon that we see as practicing psychiatrists: sometimes somebody is responding to a medication and then they decide to taper off their medication, and then they develop a recurrence of their depression and you try the same medication again and they don’t respond and they need a different antidepressant medication.
So all of these things need to be in a conversation between the patient and the physician to make a decision whether to continue on this medication or whether to taper off the medication.
Kevin Pho: You also talk about this pharmaceutical industry; there is a lack of incentive on their part for deprescribing, of course. And does that play a role in terms of the lack of clinical practice guidelines when it comes to discontinuing psychotropic medications?
Muhamad Aly Rifai: Sure. And part of it, I think, has to do with the fact that we don’t have the data. I mean, so there’s no incentive for the pharmaceutical industry to fund research to develop such information about when to taper off their medication. I mean, that’s the medication that they’re promoting; they get paid for, so they don’t have that incentive.
Unfortunately, our National Institute of Health, our National Institute of Mental Health, has not conducted the research to answer these critical questions that can help these patients because these patients are just experiencing side effects from these medications: from the antipsychotic medications, mood stabilizers, antidepressants. All of these medications have significant side effects, but they’re also life saving and life sustaining.
But how do you draw that balance between OK, being on the medications or tapering off the medication? And what’s unfortunate is, and I mentioned that in the article, some patient groups now are stepping in and they’re acting as coaches or chaperones to the patients or patient guides where they tell people, well, without the help of a psychiatrist or a physician. OK. We can hold your hand while you’re tapering off your medications.
And I think that’s very dangerous, but it also fills a void that we, the pharmaceutical companies, and the NIH created. The fact that there’s nobody that’s helping these patients who are experiencing significant side effects to the psychotropic medications that we prescribe, and they don’t have anybody to help them.
So this kind of patient movement group that basically chaperones these patients on medication discontinuation, and sometimes the results are good; sometimes the results are catastrophic.
Kevin Pho: How about in a primary care setting? Give us a common scenario where a physician like myself in a primary care setting would consider tapering off a psychotropic medication. And let’s give a common scenario, let’s say an antidepressant, for instance. We have so many patients on antidepressants. What would be some signs that it would be OK to taper off some of these antidepressants?
Muhamad Aly Rifai: Sure. So a lot of our primary care colleagues, when they experience a patient with depression, sometimes the identification of that patient is related to measurement-based assessment, so like a PHQ-9 or other screening tools for depression. And the patient scores high on that score and they get started on an antidepressant.
The majority of the literature that we have for a first episode of depression is that patients need to be on an antidepressant medication for six to 12 months at least. So a reassessment of the patient’s symptoms and response to the antidepressant is very important, and you can use the same measurement tool that you’ve used, for example, the PHQ-9 at the beginning, and then you can do that at six months or 12 months and see if their depression is in remission. And you really need to make sure that the patient verbalizes that they feel that their depression is in remission.
The other variable that you also need to understand and factor in is a family history of depression, or whether this is the first, second, or third episode of depression. Is this chronic depression, treating a chronic condition that will require this medication long term? Or is this their first episode of depression?
And then maybe six to 12 months of antidepressant treatment is OK. And then you can talk to them about attempting to taper off the medication, and tapering off medications is different for different classes of antidepressants.
But there are some medications where you could just flat out discontinue the medications. So, for example, I’ll give an example: fluoxetine, the old name of Prozac, could be discontinued because it auto-tapers. It has a very long half-life, so you don’t need to go through a taper-off regimen. You can just stop the medication and it’ll auto-taper through several weeks, and then you can monitor the patient whether their depression continues to be in remission and whether you need any further interventions.
In a first episode of depression, 70 percent of patients will do OK. Only 30 percent will have a recurrence of their depression within a year after discontinuation of an antidepressant. But it is those patients who are more complicated with several episodes of depression, chronic depression, family history of depression; maybe those could be referred to a psychiatrist for a more expert opinion.
But there is definitely room for the primary care doctors to be able to intervene and assist in that process with the guidance of a psychiatrist.
Kevin Pho: So let’s talk about some paths forward. Are we looking more towards discontinuing some of these psychotropic medications, or not starting patients on as many of these medicines in the first place, or a little bit of both? What do you see as the most feasible path forward?
Muhamad Aly Rifai: I think a little bit of both. I mean, you know, not to be political, but this new administration and they’re talking about the fact, the real fact that we are overmedicated; I mean, 25 percent are on psychotropic medication is significant. And compared with other parts of the world where only one or 2 percent of inhabitants of different countries are on psychotropic medications. So we’re definitely significantly overmedicated.
And so, a part of both: not starting medications when they’re not needed, with other treatment modalities we can advise patients to: therapy, biofeedback, transcranial magnetic stimulation, supplements, different other modalities that could be implemented instead of medications; but also those who are on medications long term, talking to them about tapering medications.
And I can tell you, you know, a lot of my patients, they’re relieved, they’re excited when I start talking to them about tapering. They’re like, ‘Well, let’s talk about tapering me. You mean I can get off the medication? Potentially?’
So they’re actually relieved that there’s a physician who’s not telling them, ‘Oh, you need to be on this medication for life,’ because that’s basically the message that we have given as physicians to a lot of our patients: ‘You’re gonna be on this medication for life. Don’t even talk about going off of it, because catastrophic consequences will happen.’
You know, the literature and the trajectory doesn’t show us that there are catastrophic consequences that happen when people are tapered off, even antipsychotics, even mood stabilizers or antidepressants.
So having that conversation with patients and monitoring them very closely. I mean, so being available for the patient, if they decompensate, if they decide that we’re gonna get off this medication, they decompensate, we’re available there to help them in that, seeing whether any additional or other medications are indicated.
Kevin Pho: We’re talking to Muhamad Aly Rifai. His article is “How America became overmedicated and what we can do about it.” Muhamad, let’s end with some take-home messages you want to leave with the KevinMD audience.
Muhamad Aly Rifai: Thank you. Psychotropic medications are essential to treat life-threatening conditions: depression, anxiety, schizophrenia, bipolar disorder, attention deficit hyperactivity disorder. A lot of our patients need those medications legitimately; they need to stay on it, but a lot of our patients can have and should be offered a chance to be able to taper off these medications and avoid the adverse effects that are associated with the psychotropic medications. I hope that we’re gonna be able to plot a path where we’re able to offer that opportunity for our patients.
Kevin Pho: Muhamad, thank you so much for sharing your perspective and insight and thanks for coming back on the show.
Muhamad Aly Rifai: Thank you very much for having me.
