HHS Secretary Robert F. Kennedy, Jr. detailed an action plan May 4 to curb “overprescribing” of psychiatric medications when clinically indicated, with a focus on evaluating prescription patterns, assessing benefits and harms, and increasing use of nonmedication treatments.
Six behavioral health executives shared their reactions to the effort with Becker’s.
Editor’s note: Responses have been lightly edited for clarity and length.
Ken Dunham, MD. Executive Director Medical Operations of Behavioral Health at Sentara (Norfolk, Va.): I’m skeptical of plans that take away options, especially options that work, and this plan clearly states it plans to take things away. It would be better to invest in better healthcare insurance for kids so they could get more therapies, including nondrug options — and this plan doesn’t do that. This plan will succeed in reducing options and fail at increasing options.
Russ Micoli. Vice President of Behavioral Health, Strategy and Business for Virtua Health (Marlton, N.J.): The “overprescribing” of any medication warrants careful review and, if substantiated, further analysis. I tend to take a “follow the science” approach: verify, trust, and continue to monitor and reassess over time.
The use of antidepressants should remain a collaborative discussion between a patient and their trusted, licensed prescriber. Ideally, this occurs within an ongoing therapeutic relationship where medication management is part of a broader treatment plan that may include other medications as well as non-pharmacologic therapies.
As healthcare providers, we owe patients the opportunity to be educated about their conditions and informed of available treatment options. I do not see value in external pressures or attempts to influence care decisions that are not grounded in rigorous scientific evidence and framed as opportunities for thoughtful discussion between patient and prescriber.
My greatest concern is that the messaging around this issue could unintentionally promote the idea that antidepressant medications are inherently “bad” or unsafe, despite decades of clinical research and patient experience demonstrating their benefit for many individuals.
My hope is that this conversation ultimately leads to greater awareness, more informed discussion, and continued dialogue among patients, families, and healthcare practitioners.
Elias Shaya, MD. North Regional Medical Director and Senior Associate Executive Director for Behavioral Health Services at MedStar Health (Columbia, Md.): Let me start by echoing the position of the American Psychiatric Association, in ensuring that all our healthcare decisions should be evidence-based. Let’s study the evidence that suggests overprescribing and consider ways to prevent it. Just as importantly, there is substantial evidence for lack of access to care and undertreatment for patients in need; let’s enhance access and treatment, including prescriptions, for those who need it.
We have a long history of stigma that has plagued patients in need of psychiatric care. We must be cautious not to inadvertently add to that stigma by singling out psychiatric prescribing. Overprescribing and overtreatment occur in all healthcare; from the history of excessive C-sections, to overprescribing of antibiotics to excessive intake of vitamins and supplements to the recent surge of prescribing GLP-1 agonists. Messaging is critical. Let our message be clear: some patients benefit from psychiatric medications, and some do not; let the scientific evidence drive our healthcare decisions!
Garima Singh, MD. Chief Medical Officer of Centerstone (St. Louis): One major context that is missing is training and education. As a psychiatrist with ten years of training, I discuss at every visit the possibility of medication titration and psychotherapy with patients. However, there are times when patients are not in a position to decrease medications or they lack the means to continue therapy. This underscores the need for integrated medical care and sustained investment in the workforce.
A new JAMA Network Open study analyzed 240 million Medicare Part D claims from 2013 to 2023 and found one of the most significant workforce shifts in psychiatric prescribing:
– APRNs and PAs: 13.8% to 39.6% of claims.
– Psychiatrists: 48.4% to 32.4%.
– PCPs: 33.0% to 23.8%.
Nonphysician clinicians are now the largest prescribing group for one of the highest-risk medication classes in geriatric medicine.
Trend changes:
APRN and PA prescribers tripled from 19,554 to 63,154. Average claims per clinician barely changed. Those of prescribing psychiatrists and PCPs both declined. This is workforce expansion filling a workforce contraction.
The safety context:
Antipsychotics carry FDA black box warnings for increased mortality in older adults with dementia. Associated adverse effects include falls, sedation, cognitive decline, acute kidney injury, and cardiovascular events. Safe use requires specific expertise in initiation, monitoring, and deprescribing regardless of clinician type. Psychiatrists opt out of Medicare at 8.1%, the highest rate of any specialty. HRSA projects the shortage will worsen, particularly in rural and underserved areas where APRNs and PAs already write 45% of antipsychotic claims.
Robert Trestman, MD, PhD. Professor and Chair of Psychiatry and Behavioral Medicine at Virginia Tech/Carilion School of Medicine and SVP and Institutional Research Officer of Carilion Clinic (Roanoke, Va.): Depression is the leading cause of disability worldwide. In the U.S., it is under-recognized and undertreated in all age groups, including those under the age of 18. The death-by-suicide rates are a tragic reflection of under- rather than over-treatment. In the U.S., most antidepressant prescribing is done by primary care physicians and by nurse practitioners, not by psychiatrists. Further, in many non-psychiatrist settings, the use of measurement-informed care is minimal, and the frequency and appropriateness of follow-up sessions is woefully inadequate. The May 4 HHS announcement encouraging greater access and use of nonpharmacological treatments for depression, including evidence-based psychotherapies, incorporates elements of valuable guidance. Focusing on deprescribing, while important, needs to be balanced by evidence-informed decision-making. Many factors lead to suboptimal treatment of depression, and the notion of “overmedicalization” is oversimplified, risks stigmatizing treatment, and potentially discourages people from obtaining appropriate care for a potentially life-threatening condition.
Tobias Wasser, MD. Chair of Psychiatry and Behavioral Health, Hartford HealthCare — Fairfield Region and Chair of Psychiatry at Frank H. Netter MD School of Medicine at Quinnipiac University (Bridgeport, Conn.): As a field, psychiatry is at risk of drifting from its roots, which were based in striving to understand our patients and in the importance of building relationships, toward an overly medicalized check-box model of care. Our current system risks overemphasizing symptoms and diagnoses in an effort to meet coding and billing expectations. The reimbursement structures also do not support engaging in deeper, individualized, longitudinal care for our patients. For all these reasons, there are merits to some of the themes that underlie the recent HHS initiatives. Further, there are examples of very thoughtful approaches to considering this issue within psychiatry, such as the leadership of Javeed Sukhera at the Institute of Living in CT focusing on the concept of “radical recovery” as well as that of scholars Rebecca Miller, PhD, Swapnil Gupta, MD, and John Cahill in their text “Deprescribing in Psychiatry.”
However, while there may be benefits to thoughtful consideration of person-centered and evidence-based prescribing practices, there are also significant risks to overemphasizing this as the primary issue facing behavioral health. As stated eloquently in the APA’s written statement yesterday, we face significant challenges to accessing high-quality, evidence-based psychiatric care in many parts of our country and obstacles to appropriately and equitable reimbursement for psychiatric care. Placing too great an emphasis on overprescribing risks missing opportunities to allocate resources on addressing these important areas and sending a message that patients should stop using life-saving, evidence-based medications. I would urge a more comprehensive, balanced approach that incorporates this as one of several areas in need of federal attention and resources.
The American Psychiatric Association said in a statement that it “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.’ 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. It also fails to account for persistent workforce shortages, limited psychiatric beds, inadequate visit time, barriers to psychotherapy and social supports, insufficient integration of psychiatric expertise in primary care through the Collaborative Care model and the lack of a true continuum of care.”
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