Vitamodo School · Bundle 4: Antipsychiatry — The Critique Analyzed · Brochure 6 of 10 · Version 1.0
Andris Saulitis, MD
For those who: have noticed, in yourself or someone close to you, that a psychiatric prescription seems to have been initiated lightly, continued without re-evaluation, or scaled in a way that does not match the clinical picture.
Not for those who: want this brochure to argue that all psychiatric prescribing is wrong. The empirical picture is more differentiated than that, and so is the right response.
What this is — the clinical reality
In modern public conversation, the question of whether psychiatric medications are overprescribed is one of the most heated, and one of the most likely to be answered well by the available evidence. The general antidepressant debate covered in the previous brochure of this bundle is, at the level of careful synthesis, genuinely contested — both sides have substantial arguments and the answers vary by patient and condition. The question of overprescribing is different. Here the careful critique has accumulated a substantial empirical case that the mainstream profession has only partly absorbed. This is the brochure in which the critique lands most firmly.
This brochure is for the reader who has noticed, in themselves or someone they love, that a psychiatric prescription seems to have been initiated lightly, continued without re-evaluation, or scaled in a way that does not match the clinical picture. It is also for the reader who has heard general claims about overprescribing and wants to know which specific practices the evidence supports concern about, and which it does not.
A note before we go further. Overprescribing is not a single phenomenon. It includes prescribing for indications that do not warrant medication, prescribing at doses higher than needed, prescribing for durations longer than needed, prescribing combinations (polypharmacy) that have not been tested together, prescribing for populations in whom the evidence base is thin, and prescribing in clinical contexts where the time and follow-up that the prescription requires are not available. Each is a different problem with different solutions. The general claim too many people are on these medications is true in some specific senses and not in others; the careful reader needs to know which.
Three frames carry the question.
The first frame is the empirical picture. The documented facts on which the critique is built. Across most high-income countries, antidepressant prescribing has risen substantially over the past three decades. In the United Kingdom, about one in six adults is currently receiving an antidepressant prescription; the number has roughly doubled in fifteen years. In the United States, the figures are higher, with up to one in four middle-aged women on at least one psychotropic medication. Benzodiazepine prescribing, after declining from its 1970s peak, has substantially risen again, often in combination with opioids and antidepressants in ways that produce documented mortality risk. Stimulant prescribing for attention-deficit conditions has risen substantially in both children and adults; the increase has been particularly steep in the United States, the Nordic countries, and increasingly elsewhere. Antipsychotic prescribing in elderly residents of nursing homes, often for behavioural management rather than for psychotic illness, has been substantially documented and substantially regulated, with limited effect. Antipsychotic prescribing in children, including in those with developmental conditions, has risen substantially despite a thin evidence base in this population. Polypharmacy — multiple psychotropics in the same patient — has risen sharply, particularly in primary care, where the prescribing clinician often lacks the specialist knowledge to evaluate interactions and cumulative effect. The rates of psychiatric medication prescribing have risen much faster than the rates of psychiatric illness, which appear stable across most measured populations. This last fact is the careful critic's strongest empirical claim: the increase in prescribing is not principally being driven by an increase in illness.