The psychiatric “prescribing cascade”: A patient story

By Judith Garber | July 2, 2019

As the Lown Institute revealed in their recent report on Medication Overload, millions of older adults are at risk of adverse drug events from taking too many medications. However, younger adults are not immune to harm from overprescribing, particularly when it comes to drugs for psychiatric conditions, for which diagnostic criteria are often uncertain.

We spoke with Steve, who experienced a “prescribing cascade” firsthand, in which one prescription of a psychiatric drug led to side effects, which prompted another prescription, and another, and another. Steve wanted to share his story to shed light on the harm that can happen from an overload of psychiatric medications.

Steve’s story of overprescribing began when he experienced symptoms of depression as an undergraduate and sought psychological help. He was prescribed an SSRI (Zoloft), which led to feelings of apathy and numbness. He also began to experience sexual dysfunction, which is often common in patients who are prescribed antidepressants. In order to treat erectile dysfunction, Steve was prescribed Wellbutrin, another antidepressant. Within a month or two he began to lose motor control of different parts of his body, often causing him to bang his head uncontrollably against the wall. When he confronted his psychiatric nurse practitioner over this traumatic and abnormal side effect, she attributed it to bipolar disorder. “She saw the problem as ‘existing in me’ and not an effect of the drugs,” said Steve.

Additional antipsychotics were prescribed to tame the behavior, but the combinations of, and cross titration between, medications left him feeling more depressed then when he first sought out help. When he would try to stop, he often was left feeling non-functional, in what he described as a vegetative state. The worst to discontinue, in Steve’s experience, were the antidepressants.

For ten years, Steve saw different mental health providers who added medications and changed dosages. At its peak, Steve was taking five different psychiatric medications. When he would tell clinicians about his concerns with the psychiatric medications he was taking, he heard over and over, “The medications are safe and the doctors mean well.” Not one recommended he stop. It wasn’t until Steve was admitted to the hospital for multi-organ failure that a gastroenterologist set him on the path to deprescribe his psychiatric medications.

Steve had been initially diagnosed with mild depression, and then after starting antidepressants a more complex mood disorder, but was skeptical of the later diagnosis and hired a forensic psychiatrist to give her opinion. It was eventually determined that he may have been misdiagnosed, as the psychiatrist observed that Steve was not showing symptoms of mania or bipolar disorder as she understood it, but that he had almost certainly been traumatized by side effects of medications that were supposed to help him.

Steve’s experiences have left him disillusioned with the reliance on medications to treat mental health issues, given that the risks and benefits of these drugs are not always certain.

Steve believes that psychiatrists, instead of just prescribing medications to relieve symptoms, should support patients by being kind and providing concrete advice and more structured and interactive activities. Medications can be an important tool to treat mental health conditions, but when the only tool you choose to pick up is a hammer, everything tends to like a nail. “Psychiatrists should feel like they can talk with patients, go on walks with them, and help coach them,” said Steve. He is hoping that by sharing his story he can help young people who have experienced the harsh side effects of antidepressants and other psychiatric medications feel less alone.

To eliminate medication overload, serious cultural, educational, and policy changes are needed. This action plan offers recommendations for policymakers, health care institutions, clinicians, and patients across five key categories to reduce harm from multiple medication use. Suggested Citation: Eliminating medication overload: A national action plan. Working Group on Medication Overload. Brookline, MA: The Lown Institute, 2020. DOI: https://doi.org/10.46241/LI.YLBW4885

Pharmaceutical marketing is a significant factor in the growing public health crisis of medication overload, which puts millions of older adults at risk of preventable harm and premature death. This issue brief provides recommendations to reduce pharmaceutical industry influence by limiting pharma sales rep visits to clinicians and direct-to-consumer advertising.

This issue brief provides recommendations for clinical practice guidelines and electronic health records that would give clinicians the information they need to appropriately prescribe and deprescribe.