When More is Not Better: Understanding Polypharmacy in Psychiatry
One of the most important and often overlooked challenges in psychiatry is something called polypharmacy, which refers to the use of multiple psychiatric medications at the same time. While there are situations where combining medications is appropriate and even necessary, polypharmacy becomes problematic when prescriptions accumulate without a clear or unified clinical direction.
This issue is especially relevant in psychiatry because, unlike many other medical specialties, we lack precise objective tools to confirm a diagnosis. There is no blood test for anxiety or imaging scan that shows depression. Instead, diagnoses are based on a thorough history, observed behavior, and most critically, what the patient reports about their inner experience. This subjectivity is a natural part of psychiatric practice, but it also means that misdiagnosis is not uncommon.
As one of my favorite psychiatrists, Dr. Nassir Ghaemi, puts it, “Your treatment regimen is only as good as your diagnosis.” That simple statement gets to the heart of the problem.
How Polypharmacy Develops
In my clinical practice, I often meet patients who have been treated by several providers over the years and are now taking a long list of medications. Their journey typically begins with distressing symptoms such as low mood, poor sleep, anxiety, or irritability. A provider evaluates the symptoms, assigns a diagnosis, and prescribes a medication. But if the diagnosis does not fully capture the nature of the problem, the treatment may not help.
The patient, still suffering, seeks another opinion. The new provider may offer a different diagnosis and add another medication but hesitate to stop the original one out of concern for destabilizing the patient. This cycle can repeat, with each provider layering a new perspective and another prescription. Eventually, the patient is on multiple medications but still feels unclear about which ones are helping and which are not.
Why Polypharmacy Matters
Polypharmacy is not just about the number of pills. It can significantly affect a person's quality of life and the overall effectiveness of treatment. Some common consequences include:
Increased side effects from drug interactions or overlapping mechanisms
Cognitive fog, fatigue, or emotional dulling from medication overload
Difficulty adhering to treatment due to complex dosing schedules
Mistaking side effects for new symptoms, leading to further prescriptions
Greater confusion in clinical decision-making when it is unclear which medications are responsible for improvement or worsening
Tapering medications becomes more complicated as well. Patients often fear that stopping a medication will lead to relapse, especially if that medication was started during a time of crisis. Even when symptoms have improved or changed, there can be a strong emotional attachment to the medications themselves.
The Case for Simplification
It is important to acknowledge that polypharmacy is not always inappropriate. There are legitimate clinical situations where multiple medications are needed, especially when treating complex or co-occurring conditions. However, every medication should have a clear purpose, and its effectiveness should be reassessed regularly.
One of the most helpful things we can do as clinicians is to pause and ask whether the treatment plan still aligns with the diagnosis. Are we treating the root condition, or are we trying to patch symptoms that have not been fully understood? A treatment plan built on uncertain or evolving diagnoses can lead to unnecessary complexity that ultimately clouds the clinical picture.
Patients can play an important role by being informed and curious. It is helpful to ask: Why was each medication started? Is it still needed? What specific benefits have I noticed from it? These are not always easy questions to answer, but they help open the door to more meaningful and personalized care.
Moving Forward
Psychiatry is an inherently complex field. Human emotions, thoughts, and behaviors do not always follow a neat formula. But the best treatment plans come from a clear understanding of the problem being addressed. When that clarity is missing, medications can accumulate in ways that do more harm than good.
At Calivor Psychiatric Solutions, I approach each patient’s history with care and curiosity. I believe in the value of precision—not just in medication, but in diagnosis. When medications need to be simplified, I aim to do so collaboratively and thoughtfully, recognizing that the goal is not just to reduce the number of pills, but to improve clarity, function, and overall well-being.
A good treatment plan starts with a good diagnosis. And sometimes, the path to healing involves doing less, not more.
