Ryan Sultan, MD, grew up watching his father, Sady Sultan, MD, a child psychiatrist, approach medications for his patients with caution.
“First- and second-generation psychiatric medicines had terrible side effects,” the younger Sultan says.
So, when he entered medical school, following in his father’s footsteps, he wasn’t keen on the idea of psychiatric medicines either.
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’t engage with any non-pharmacological treatment, he couldn’t imagine how he’d have been able to help them without these medicines.
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.
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.
The concept of de-prescribing — safely tapering someone off a medication that is ineffective or has negative side effects — was coined in 2003 in reference to polypharmacy in older adults, a term for taking multiple medications that can increase the risks of adverse events. In recent months, de-prescribing has gained attention regarding psychiatric medicines.
In February 2026, the American Society of Clinical Psychopharmacology (ASCP) released a consensus statement on guidelines for de-prescribing psychotropic medications. Among them are recommendations to regularly review a patient’s 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.
The consensus statement came shortly before the U.S. Department of Health and Human Services (HHS) announced an action plan in May 2026 to “curb psychiatric overprescribing,” 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 to discuss forthcoming federal guidelines on de-prescribing and non-medication treatments.
“In psychopharmacology, the emphasis has been on initiation of medications, how to choose the right medication, the logistics of starting medication, and monitoring,” says Jonathan Alpert, MD, PhD, chair of the Department of Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine in New York City. “But 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’s a very appropriate focus.”
Risks of undertreatment
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 “overprescribed,” instead pointing to the well-documented mental health crisis 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.
This is, in part, due to barriers 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.
In 2023, more than 11% of U.S. adults took prescription antidepressants and about 16% of adolescents took some kind of behavioral health medication. And studies suggest 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.
“We live in a health care system that pressures physicians to have these short visits with people,” Sultan says. “People are coming in and they want help. The fastest way to help is to write a prescription.”
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.
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’s 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.
“Without question, there are people who have very mild anxiety or depression who could be well treated with psychotherapy alone or lifestyle interventions,” Alpert says. But “there’s a good deal of undertreatment in certain communities, either because of resource allocation or stigma. I, personally, worry more about undertreatment.”
In the United States, 137 million people — 40% of the population — 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.
One study, 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.
“Inappropriate, inadequate treatment costs dollars and lives,” says Robert L. Trestman, MD, PhD, chair of Psychiatry and Behavioral Medicine at Virginia Tech Carilion School of Medicine. “Death by suicide is very real.”
One model that could support better mental health care access is integrated behavioral health care (IBH). The AAMC has made recommendations for advancing IBH frameworks that embed these services into primary care. There is a robust body of research on the role of IBH in broadening access, enabling earlier intervention, reducing care fragmentation, and addressing the full range of patient needs.
“Integrated behavioral health care is really about whole-person care,” says Rosha McCoy, MD, medical director of health care affairs at the AAMC, who cowrote the recommendations. “It 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.”
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’t support integrated workflows.
Sultan adds that the structure of today’s 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’s 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.
“The situation is just going to get worse,” Sultan says, recalling a time he treated a child in the emergency department who had jumped off a roof after discontinuing his ADHD medicine. “In that example, the right answer is a combined treatment. Not medication alone and not behavioral treatment alone — both, working together. What is the minimum amount of medication that might be appropriate?”
Evaluating appropriateness
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’ symptoms are controlled and negative side effects are minimized.
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.
“Based on a patient’s symptoms, if their [medication is] ineffective, why would we continue any drug that’s ineffective?” Clayton says. “If they’re not getting a benefit, we need to think about what we’re doing.”
That’s why it’s 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.
When it comes to children with ADHD, there may be a question of what sequence to use when trying different medications, Sultan explains.
His research 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 — a class of medications carrying greater metabolic and neurological risk than stimulants — 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 and methylphenidate.
“What we were seeing is children receiving a more dangerous medication before a less dangerous one,” Sultan says. “That 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.”
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.
Discontinuing medication should be done under medical guidance, since sudden cessation can cause withdrawal symptoms, including nausea, fatigue, anxiety, and brain zaps — shock-like sensations in the head that some people coming off antidepressants experience.
However, there’s still a dearth of research into and guidelines for the optimal methods of de-prescribing, Alpert says.
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 in May saying it supports a national focus on mental health prescribing, so long as it takes an evidence-based approach.
“While the APA supports efforts to improve the quality, safety, and evidence base of mental health treatment, we strongly object to framing the nation’s mental health crisis as primarily a problem of ‘overmedicalization’ or ‘overprescribing,’” the statement said. “That 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.”
Innovative treatments
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.
Ketamine, which works through the brain’s 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 for applications in other mental health conditions, including post-traumatic stress disorder (PTSD) and bipolar disorder. And the FDA has accelerated clinical trials into psychedelic medications for depression and PTSD, though none have been approved yet. Transcranial magnetic stimulation (TMS), which is a noninvasive treatment that helps change brain waves, has received FDA approval for treatment of major depression and obsessive-compulsive disorder.
Researchers are also exploring other non-medication interventions, including the emerging subfield of “metabolic psychiatry,” a term coined by Shebani Sethi, MD, a clinical associate professor at Stanford Medicine and the founding director of the university’s Metabolic Psychiatry Clinical Program. The program focuses on the relationship between metabolic disorders and mental health conditions.
Research in the field finds that dysfunction in how the body processes sugar, insulin resistance, inflammation, and cholesterol can disrupt the energy that the brain requires to regulate mood and cognition, contributing to mental health disorders. Therefore, metabolic panels and improved nutrition should be addressed alongside medication, psychotherapy, and other lifestyle factors in mental health treatment, according to Sethi.
“The field is exploding, along with neuroscience,” Trestman says.
The introduction of artificial intelligence also holds promise for improving diagnosis and prescribing, he adds. “The opportunity for transformation in the field of psychiatry is extraordinary.”
