If you are in crisis, please call the Suicide and Crisis Lifeline at 988.<\/p>\n
Ryan Sultan, MD, grew up watching his father, Sady Sultan, MD, a child psychiatrist, approach medications for his patients with caution.<\/p>\n
\u201cFirst- and second-generation psychiatric medicines had terrible side effects,\u201d the younger Sultan says.<\/p>\n
So, when he entered medical school, following in his father\u2019s footsteps, he wasn\u2019t keen on the idea of psychiatric medicines either.<\/p>\n
Then, during his psychiatry rotation, he encountered people experiencing serious mental illness and saw how medications helped them. His residency training further reinforced his appreciation for the value of psychiatric medicine. When seeing people in crisis or with such severe symptoms that the patients couldn\u2019t engage with any non-pharmacological treatment, he couldn\u2019t imagine how he\u2019d have been able to help them without these medicines.<\/p>\n
Now Sultan is an assistant professor of clinical psychiatry at Columbia University Irving Medical Center\/New York State Psychiatric Institute who researches psychopharmacology trends in youth, including how often children with attention deficit hyperactivity disorder (ADHD) are prescribed antipsychotic medications before an adequate trial of safer, first-line treatments.<\/p>\n
Sultan says there are cases when patients are started on or continue taking medication that may not be appropriate for them, but that determining medication appropriateness is a complicated endeavor in a country where many people experiencing mental illness go untreated and face significant barriers to care.<\/p>\n
The concept of de-prescribing \u2014 safely tapering someone off a medication that is ineffective or has negative side effects \u2014 was coined in 2003 in reference to polypharmacy in older adults<\/a>, a\u00a0term for taking multiple medications that can increase the risks of adverse events. In recent months, de-prescribing has gained attention regarding psychiatric medicines.\u00a0<\/p>\n In February 2026, the American Society of Clinical Psychopharmacology (ASCP) released a consensus statement<\/a> on guidelines for de-prescribing psychotropic medications. Among them are recommendations to regularly review a patient\u2019s list of medications and consider adherence, effectiveness of symptom control, tolerability of side effects, interactions or redundancies with other medications, and, when symptoms are controlled, the risk of relapse if medication is discontinued.<\/p>\n The consensus statement came shortly before the U.S. Department of Health and Human Services (HHS) announced an action plan<\/a> in May 2026 to \u201ccurb psychiatric overprescribing,\u201d including educational webinars about medication side effects and de-prescribing methods, and convening a panel of mental health professionals and federal officials. The panel met in July<\/a> to discuss forthcoming federal guidelines on de-prescribing and non-medication treatments.<\/p>\n \u201cIn psychopharmacology, the emphasis has been on initiation of medications, how to choose the right medication, the logistics of starting medication, and monitoring,\u201d says Jonathan Alpert, MD, PhD, chair of the Department of Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine in New York City. \u201cBut there has been much less [emphasis] on the tapering off of medications and even the critical reappraisal of whether medications are still needed. I think it\u2019s a very appropriate focus.\u201d<\/p>\n Risks of undertreatment<\/p>\n Many experts agree on the need for more research into and guidelines for de-prescribing. At the same time, some reject the claim that psychiatric medications are \u201coverprescribed,\u201d instead pointing to the well-documented mental health crisis<\/a> in the United States, where 1 in 5 people experience mental illness and 1 in 20 experience serious mental illness each year. About half of those with symptoms receive no mental health care, according to the National Alliance on Mental Illness<\/a>.<\/p>\n This is, in part, due to barriers<\/a> to access, ranging from cost to a shortage of mental health providers. And even many of those who do receive treatment may not have the level of attention paid to their needs as psychiatrists would recommend.<\/p>\n In 2023, more than 11% of U.S. adults<\/a> took prescription antidepressants and about 16% of adolescents<\/a> took some kind of behavioral health medication. And studies suggest<\/a> that more than 60% of psychotropic medications in the United States are prescribed by nonspecialists, such as primary care physicians, physician assistants, and nurse practitioners.<\/p>\n \u201cWe live in a health care system that pressures physicians to have these short visits with people,\u201d Sultan says. \u201cPeople are coming in and they want help. The fastest way to help is to write a prescription.\u201d<\/p>\n In many cases, that may be the best option, Alpert says. Most psychiatric medicines are safe and can be lifesaving for people with severe mental illness.<\/p>\n Sultan adds that the way care is paid for reinforces pressure to prescribe. Most first-line psychiatric medications are available in a generic form. For example, a month\u2019s supply of a generic stimulant to treat ADHD can cost less than a single psychotherapy session, which averages roughly $100 to $250 out of pocket, and a course of therapy typically runs 12 to 20 sessions.<\/p>\n \u201cWithout question, there are people who have very mild anxiety or depression who could be well treated with psychotherapy alone or lifestyle interventions,\u201d Alpert says. But \u201cthere\u2019s a good deal of undertreatment in certain communities, either because of resource allocation or stigma. I, personally, worry more about undertreatment.\u201d<\/p>\n In the United States, 137 million people<\/a> \u2014 40% of the population \u2014 live in a federally designated mental health care Health Professional Shortage Area. This can make it challenging for people, especially those with more limited time and resources, to access psychiatric care or consistent psychotherapy.<\/p>\n One study<\/a>, published in Nature Medicine in July, projected a global economic cost of $12 trillion from 2025 to 2050 due to productivity lost to untreated depression and anxiety, and an additional $2 trillion due to suicide.<\/p>\n \u201cInappropriate, inadequate treatment costs dollars and lives,\u201d says Robert L. Trestman, MD, PhD, chair of Psychiatry and Behavioral Medicine at Virginia Tech Carilion School of Medicine. \u201cDeath by suicide is very real.\u201d<\/p>\n One model that could support better mental health care access is integrated behavioral health care (IBH). The AAMC has made recommendations<\/a> for advancing IBH frameworks that embed these services into primary care. There is a robust body of research<\/a> on the role of IBH in broadening access, enabling earlier intervention, reducing care fragmentation, and addressing the full range of patient needs.<\/p>\n \u201cIntegrated behavioral health care is really about whole-person care,\u201d says Rosha McCoy, MD, medical director of health care affairs at the AAMC, who cowrote the recommendations. \u201cIt is built around interprofessional collaboration between medical and mental health clinicians to optimize patient outcomes, and provides support for primary care physicians to tailor care for each patient.\u201d<\/p>\n Still, the AAMC recognizes there are barriers to the implementation of IBH, including a siloed health care system, workforce shortages, training gaps, and payment models that don\u2019t support integrated workflows.<\/p>\n Sultan adds that the structure of today\u2019s society has made non-medication interventions more logistically challenging. For example, he says he could work intensively with the parents of a child with ADHD on a 15-week training program that is moderately effective for the child\u2019s symptoms, but when the family is already stretched thin with work and being overwhelmed by modern life, going down that path without medication often sets them up for failure.<\/p>\n \u201cThe situation is just going to get worse,\u201d Sultan says, recalling a time he treated a child in the emergency department who had jumped off a roof after discontinuing his ADHD medicine. \u201cIn that example, the right answer is a combined treatment. Not medication alone and not behavioral treatment alone \u2014 both, working together.\u00a0 What is the minimum amount of medication that might be appropriate?\u201d<\/p>\n Evaluating appropriateness<\/p>\n According to Anita Clayton, MD, a professor in the Department of Psychiatry and Neurobehavioral Sciences at the University of Virginia School of Medicine, the concepts of overprescribing and de-prescribing have less to do with too many people taking psychiatric medications and more to do with ensuring patients\u2019 symptoms are controlled and negative side effects are minimized.<\/p>\n This requires reassessment over time and can mean changing, reducing, or discontinuing one or more medications. De-prescribing becomes particularly important and complex when a patient is taking multiple medications, including some that may interact badly or be redundant, she explains.<\/p>\n \u201cBased on a patient\u2019s symptoms, if their [medication is] ineffective, why would we continue any drug that\u2019s ineffective?\u201d Clayton says. \u201cIf they\u2019re not getting a benefit, we need to think about what we\u2019re doing.\u201d<\/p>\n That\u2019s why it\u2019s important for prescribers to have a longitudinal relationship with the patient that starts with an in-depth conversation about the benefits, risks, potential side effects, and long-term goals of starting a new psychiatric medicine and continues with reevaluation of the effectiveness and side effects over time, to see if a change is necessary.<\/p>\n When it comes to children with ADHD, there may be a question of what sequence to use when trying different medications, Sultan explains.<\/p>\n His research<\/a> has studied the problem of not whether a child gets medication, but which medication the child gets, and in what order different medications are tried. In a study of more than 187,000 commercially insured young people newly diagnosed with ADHD, Sultan and his colleagues found that among those who went on to receive an antipsychotic \u2014 a class of medications carrying greater metabolic and neurological risk than stimulants \u2014 roughly half had never been prescribed a stimulant at all, and only about 8% had first completed adequate trials of the two standard stimulant classes, amphetamines\u00a0and\u00a0methylphenidate.<\/p>\n \u201cWhat we were seeing is children receiving a more dangerous medication before a less dangerous one,\u201d Sultan says. \u201cThat is a sequencing problem, and I think it is the more useful way to frame this. The question is rarely medication or no medication. It is whether we worked through the safer, better-studied options first, and often we did not.\u201d<\/p>\n In some cases, it may be appropriate to take someone off medication altogether, particularly if the illness was episodic and has been in remission for more than six months. For example, Clayton points out, about 50% of people who have one depressive episode will not experience another. Patients in long-term remission may also prefer to stop medication due to its cost or because of negative side effects, Alpert adds.<\/p>\n Discontinuing medication should be done under medical guidance, since sudden cessation can cause withdrawal symptoms, including nausea, fatigue, anxiety, and brain zaps \u2014 shock-like sensations in the head that some people coming off antidepressants experience.\u00a0<\/p>\n However, there\u2019s still a dearth of research into and guidelines for the optimal methods of de-prescribing, Alpert says.<\/p>\n The February ASCP consensus statement was a step toward creating such guidelines, and the field is watching to see what federal guidelines may emerge from the HHS action plan. The American Psychiatric Association (APA) released a statement<\/a> in May saying it supports a national focus on mental health prescribing, so long as it takes an evidence-based approach.<\/p>\n \u201cWhile the APA supports efforts to improve the quality, safety, and evidence base of mental health treatment, we strongly object to framing the nation\u2019s mental health crisis as primarily a problem of \u2018overmedicalization\u2019 or \u2018overprescribing,\u2019\u201d the statement said. \u201cThat characterization oversimplifies a complex crisis and ignores the larger reality: too many patients cannot access timely, comprehensive care, while care remains unevenly distributed across our health system.\u201d<\/p>\n Innovative treatments<\/p>\n Even as the field of psychiatry continues to explore guidelines for prescribing and de-prescribing existing medications, research into innovative treatments for mental illness are also offering promising new alternatives.<\/p>\n Ketamine, which works through the brain\u2019s glutamate system to help repair neural pathways, was approved by the U.S. Food and Drug Administration (FDA) in 2019 for treatment-resistant major depressive disorder and is being studied<\/a> for applications in other mental health conditions, including post-traumatic stress disorder (PTSD) and bipolar disorder. And the FDA has accelerated clinical trials<\/a> into psychedelic medications<\/a> for depression and PTSD, though none have been approved yet. Transcranial magnetic stimulation (TMS)<\/a>, which is a noninvasive treatment that helps change brain waves, has received FDA approval for treatment of major depression and obsessive-compulsive disorder.<\/p>\n