Sometimes the most useful question in psychopharmacology is not “What medication should we add?” but “What are these medications actually doing?”
I frequently see children, adolescents and adults who have been in treatment for years and are taking two, three, or sometimes four psychiatric medications, yet continue to experience significant symptoms.
One of the first questions I ask is simple: What does each medication do for you?
Surprisingly often, the answer is unclear. A medication may have been started years ago, another added later, and another added after that. The original diagnosis may have changed, symptoms may have changed, and yet the medications have remained.
At that point, rather than simply adding another medication, I think it is important to reconsider the treatment from the beginning.
Taking a Fresh Look
A medication re-evaluation begins with a careful review of the patient's history, diagnosis and previous treatment.
I want to understand why each medication was originally prescribed, whether it clearly helped, what symptoms remain, what side effects may be present, and whether the current combination still makes sense.
Sometimes the conclusion is that the existing treatment is appropriate and simply needs adjustment. At other times, it becomes difficult to know which symptoms belong to the underlying condition and which may be related to medication, medication interactions, or an inaccurate or incomplete diagnosis.
Establishing a Baseline
When it is clinically appropriate and can be done safely, I may recommend gradually reducing some or all of a patient's psychiatric medications.
The purpose is not to be “anti-medication.” Quite the opposite. It is to understand what the medications are actually accomplishing and, when possible, to get a clearer picture of the patient's underlying symptoms.
I think of this as establishing an unmedicated baseline.
For some patients, this may mean reducing only one medication. For others, it may be useful to gradually reduce several medications in order to establish a clearer baseline. This is done carefully, with consideration of the medications involved, the diagnosis, the patient's history and the potential risks of discontinuation.
Starting With a Blank Canvas
Once we have a clearer understanding of the patient's baseline, we can look again at the diagnosis.
Does the original diagnosis still make sense? Is there another explanation for the symptoms? Which problems actually require treatment? What have we learned from previous medication trials?
Sometimes we confirm the original diagnosis. Sometimes we modify it. And occasionally we arrive at a substantially different understanding of what has been going on.
From there, we can start with a blank canvas and develop a treatment plan based on what the patient needs now, rather than simply continuing a medication regimen that has accumulated over the years.
The Goal Is a Clearer, More Effective Treatment Plan
The goal of a medication re-evaluation is to understand what is helping, what is not, and why.
In many cases, patients do ultimately end up taking fewer medications and doing better. This is not because fewer medications are necessarily better, but because medications that are not clearly helping—or are contributing to side effects or complicating the clinical picture—may no longer be necessary.
For some patients, several medications remain appropriate. For others, a simpler regimen may prove more effective. What matters is that each medication has a clear purpose and follows from our best understanding of the diagnosis.