The patient was a 38-year-old software engineer. By the time he reached me, he was taking sertraline for depression, buspirone for anxiety, trazodone for sleep, and low-dose Seroquel because the trazodone had stopped working. He had gained thirty-five pounds in two years. He was sleeping ten hours a night and waking up exhausted. His libido was gone. He described his cognition as "moving through fog." He had been told, at various points, that these were symptoms of his depression. No one had considered the possibility that they were symptoms of his medications.
Over four months, I tapered him off three of the four medications. His energy returned. His thinking cleared. He lost fifteen pounds without changing his diet. He told me, with a kind of bewildered anger that I have heard many times, that he felt like himself for the first time in years.
Composite patient. Details altered to protect confidentiality.
This patient's story is not exceptional. It is, in my practice, routine. He is one of many patients who arrive with a medication list that has grown over time, prescribed by multiple clinicians, with no single person ever stepping back to ask a basic question: does this patient still need all of these medications? Has anyone checked whether the side effects of the existing medications are being mistaken for new symptoms, generating new prescriptions, producing new side effects, in a cycle that only moves in one direction?
The word for this is polypharmacy. It means, simply, the use of multiple medications. In psychiatry, some polypharmacy is rational. A patient with treatment-resistant depression may genuinely need an antidepressant augmented by a second agent. A patient with bipolar disorder and comorbid anxiety may require a mood stabilizer and a separate medication for anxiety. These are deliberate clinical decisions made by a physician who understands the pharmacology of each drug, the interactions between them, and the overall treatment strategy.
That is not the polypharmacy I am writing about.
I am writing about the other kind. The kind that accumulates. The kind that has no strategy behind it. The kind where medications were added one at a time by different clinicians, each addressing the symptom in front of them without considering the whole picture, until the patient is taking four or five or six psychiatric medications and no one can explain, with any confidence, what each one is doing or whether the patient would be better off without it.
How It Happens
The pattern is remarkably consistent. It almost always begins with a single reasonable prescription: an SSRI for depression or anxiety. The medication partially works, or it works but produces a side effect. Rather than switching to an alternative, a second medication is added. The patient develops insomnia, which may be a side effect of the first medication, and receives trazodone or hydroxyzine. The sedation from the sleep medication creates daytime fatigue, which is interpreted as worsening depression. The antidepressant dose is increased, or a second one is added.
At some point, the patient changes clinicians. The new prescriber, often seeing the patient for fifteen minutes every three months, inherits a medication list that they did not build. They do not know why each medication was started. They do not know what was tried before it. They face a choice: spend the time to reconstruct the entire prescribing history and potentially destabilize the patient by changing multiple medications at once, or add to what already exists. The path of least resistance, the path that fits inside a fifteen-minute appointment, is to add.
So they add.
A Typical Accumulation
Primary care physician prescribes sertraline 50mg for anxiety. Reasonable first-line choice.
Partial response. Dose increased to 100mg. Patient develops insomnia, a known SSRI side effect. Trazodone 50mg added for sleep rather than reconsidering the SSRI.
Patient changes jobs, gains new insurance, sees a new prescriber at a large telehealth platform. Fifteen-minute intake. Prescriber continues all existing medications, adds buspirone 10mg for persistent anxiety. No one asks whether the persistent anxiety might indicate that sertraline is not the right medication.
Patient reports fatigue, weight gain, and difficulty concentrating. These are attributed to depression. No one considers that sedation, metabolic effects, and cognitive blunting are well-documented effects of the current medication combination. Wellbutrin is added.
Patient now on four medications. Feels worse than before treatment began. Presents to a psychiatrist for the first time.
I see variations of this timeline several times a month. The specific medications change. The pattern does not.
The Training Gap Behind the Prescription Pad
The growing shortage of psychiatrists has been addressed, in many systems, not by training more psychiatrists but by expanding prescribing authority to clinicians whose training in psychopharmacology is substantially shorter. A psychiatrist completes four years of medical school, which includes extensive coursework in pharmacology, physiology, and pathophysiology, followed by four years of residency devoted to psychiatric diagnosis and treatment. That is eight years of postgraduate training, thousands of hours of supervised clinical work, and a depth of pharmacological knowledge that cannot be compressed into a shorter curriculum without losing something essential.
What gets lost is precisely the thing that prevents polypharmacy: the ability to think in systems. To understand not just what a medication does in isolation, but how it interacts with other medications, how its metabolic pathway affects clearance of other drugs, how a side effect in one system might present as a symptom in another, and when the correct clinical decision is not to add but to subtract. This kind of reasoning requires a foundation in pharmacology and medicine that takes years to build. It cannot be acquired in a program that measures its pharmacology training in semester hours rather than years of clinical immersion.
The decision to prescribe a psychiatric medication is relatively straightforward. The decision to remove one is not. Deprescribing requires understanding withdrawal syndromes, discontinuation effects, rebound phenomena, pharmacokinetic interactions that change when one drug is removed, and the clinical judgment to distinguish between a returning illness and a transient discontinuation symptom. These are skills that develop over years of supervised training in psychopharmacology. They are the reason that psychiatric residency exists.
I am not saying that non-physician prescribers are unintelligent or uncaring. Many of them are working within a broken system that does not give them enough time, enough supervision, or enough training to manage the complexity they encounter. The problem is structural, not personal. But the structural problem has a predictable clinical consequence: when the prescriber's training does not include the depth of pharmacological reasoning needed to manage complex regimens, the path of least resistance is always to add. Adding is simple. Subtracting requires a level of confidence in pharmacology that only comes from extensive training.
The patients who arrive in my office on five medications prescribed by three different clinicians are not the victims of malice. They are the victims of a system that has prioritized access over expertise, volume over depth, and prescribing speed over prescribing judgment. The fact that they can get a psychiatric medication within 48 hours from a telehealth platform is presented as progress. The fact that no one on that platform has the training or the time to evaluate whether they actually need it is the part that does not make the marketing materials.
What Deprescribing Looks Like
Deprescribing is not the same as stopping medications. It is not something a patient should do on their own, and it is not something that happens quickly. It is a deliberate, supervised clinical process that requires more skill, more time, and more pharmacological knowledge than the original prescribing did.
The first step is a comprehensive medication review. I need to understand not just what the patient is taking, but why each medication was started, what it replaced, what the response was, and what side effects it has produced. This often requires requesting records from previous prescribers, which can be difficult when the prescribing history spans multiple clinics and telehealth platforms. Many patients cannot tell me why they are taking a particular medication. They were told to take it, and they have been taking it ever since. That alone is a signal.
The second step is identifying which medications are candidates for removal. This is a clinical judgment call that weighs several factors: Is the medication treating a condition the patient still has? Is the medication producing side effects that are being mistaken for symptoms? Is the medication interacting with another medication in ways that reduce the effectiveness of both? Was the original indication for the medication ever well-established in the first place?
The third step is the taper itself. Most psychiatric medications cannot be stopped abruptly. SSRIs produce discontinuation syndrome. Benzodiazepines produce withdrawal that can be medically dangerous. Even medications like trazodone and quetiapine, prescribed casually as sleep aids, can produce rebound insomnia if stopped suddenly. The taper must be gradual, monitored, and adjusted based on how the patient responds. This requires frequent follow-up, often more frequent than the appointments that created the polypharmacy in the first place.
The most revealing question I ask a new patient is not what medications they are taking. It is whether anyone has ever taken one away.
The answer, more often than I would like, is no. Medications were added, doses were increased, combinations were tried. But the possibility that the patient might do better on less was never raised, because the system that produced the polypharmacy is not designed to reverse it. It is designed to move forward: next symptom, next prescription, next appointment, next patient.
What Happens When You Get It Right
She had been on a benzodiazepine for eight years. It had been prescribed during a difficult period in her life by a clinician she saw for three months before moving to a new city. Every subsequent prescriber renewed it. When I asked her whether the anxiety that originally prompted the prescription was still present, she paused. She said she was not sure. She had been on the medication so long that she could not distinguish between her baseline anxiety and the interdose withdrawal that the benzodiazepine itself was producing.
We tapered the benzodiazepine over five months, slowly, with close monitoring and an SSRI bridge. The first two months were difficult. Months three and four were better. By month five, she told me her anxiety was lower than it had been at any point during the eight years she was taking the medication that was supposed to be treating it.
Composite patient. Details altered to protect confidentiality.
This is the experience that defines deprescribing when it is done well. Not a dramatic intervention. A careful, patient process of removing what is not helping and discovering what the person is actually like underneath the accumulated pharmacology. Many patients describe the experience as recovering a version of themselves they had forgotten existed. They did not know the cognitive dulling was from the Seroquel. They did not know the emotional flatness was from the SSRI dose being twice what they needed. They did not know the fatigue was from the trazodone, not from their depression. They had been told these were symptoms of their illness. They were symptoms of their treatment.
Not every medication can be removed. Not every patient will end up on fewer medications. Some patients arrive on three medications and stay on three medications because, after a thorough review, all three are doing important work and the patient is doing well. The goal of deprescribing is not to reach zero. It is to reach the right number, which is the fewest medications needed to effectively manage the patient's actual conditions, prescribed at the right doses, by someone who understands the pharmacology well enough to be confident in every line of the prescription.
What I Want You to Take From This
If you are taking multiple psychiatric medications, I am not telling you to stop any of them. I am asking you to consider several questions.
Do you know why you are taking each medication? Not just the name, but the specific reason it was started and what it is supposed to be doing for you. If you cannot answer that question, it is worth asking your prescriber. If your prescriber cannot answer it either, that is information.
Has anyone, at any point, reviewed your entire medication regimen as a unified treatment plan rather than a collection of individual prescriptions? Has anyone considered whether the medications might be interacting with each other, whether the side effects of one might be generating the symptoms that prompted another, whether the overall pharmacological burden is appropriate for your clinical situation?
And has anyone ever suggested that you might do better on less?
If the answer to that last question is no, it does not necessarily mean your medications are wrong. But it does mean that a question worth asking has not been asked. And in my experience, it is a question best answered by a physician whose training prepared them to answer it.
Deprescribing is among the most important things a psychiatrist does. It is also one of the least visible, because the result is not a new prescription but the absence of an old one. There is no billing code that captures the clinical reasoning involved in deciding that a patient does not need a medication. There is no telehealth platform built around the value proposition of prescribing less. But for the patients who have been carrying the cumulative weight of years of uncritical prescribing, the experience of having someone finally look at the whole picture and begin, carefully, to simplify it is one of the most therapeutic things that happens in my office.
It should not be this rare. But until the system that produces polypharmacy changes, it will remain the work of physicians who were trained to see it.
Frequently Asked Questions
What is psychiatric polypharmacy?
Psychiatric polypharmacy is the concurrent use of multiple psychiatric medications. It becomes clinically problematic when medications accumulate without a coherent treatment rationale, when side effects of one medication are treated with additional medications rather than addressed at the source, or when no single clinician has reviewed the full regimen. Some patients genuinely require multiple medications. The concern is not with the number but with whether each medication has a clear purpose and whether the overall combination has been evaluated as a whole.
What is deprescribing?
Deprescribing is the systematic, supervised process of tapering or discontinuing medications that are no longer necessary, are causing more harm than benefit, or were prescribed for a condition the patient may not have had. It is not the same as abruptly stopping medications, which can be dangerous. Deprescribing requires careful clinical judgment, knowledge of withdrawal and discontinuation syndromes, gradual dose reductions, and close monitoring throughout the process.
How do I know if I am on too many psychiatric medications?
Consider requesting a comprehensive medication review if you are taking three or more psychiatric medications, if you experience side effects being treated with additional medications, if you are unsure why you are taking one or more of your medications, if multiple different clinicians have prescribed your current medications without coordinating, if you have been on the same regimen for years without reassessment, or if you feel sedated, emotionally flat, or cognitively dulled in ways that could be medication-related.
Is it safe to stop psychiatric medications on my own?
No. Many psychiatric medications require gradual tapering under medical supervision. Abrupt discontinuation of SSRIs can cause discontinuation syndrome with flu-like symptoms, dizziness, and brain zaps. Stopping benzodiazepines suddenly can cause seizures. Even medications commonly perceived as mild, such as trazodone, can produce rebound insomnia and anxiety if discontinued abruptly. Deprescribing should always be supervised by a physician, ideally a psychiatrist, who can design an appropriate taper schedule and monitor for withdrawal effects.
Why does the prescriber's training matter for managing multiple psychiatric medications?
Managing complex psychiatric medication regimens requires understanding drug-drug interactions, metabolic pathways, receptor pharmacology, withdrawal syndromes, and the ability to distinguish medication side effects from symptoms of illness. Psychiatrists complete four years of medical school followed by four years of residency training devoted to these topics. This depth of pharmacological training is what enables a psychiatrist to evaluate a multi-medication regimen as a system rather than as a collection of individual prescriptions, and to make the complex clinical judgments that safe deprescribing requires.
What should I expect during a medication review with a psychiatrist?
A thorough medication review involves reconstructing the prescribing history for each current medication, including why it was started, what it replaced, and what the response was. The psychiatrist will assess whether each medication still has a clear clinical indication, screen for side effects that may be mistaken for symptoms, evaluate drug-drug interactions, and consider whether any medications are candidates for tapering or discontinuation. At Bay Area Neuropsychiatry, medication reviews are conducted by physicians and given the time they require rather than compressed into a brief appointment.