Search

Polypharmacy is common clinical practice in the United States for many psychiatric conditions and for many reasons. In this article we encourage clinicians to use the familiar practice of differential diagnosis to systematically identify etiological factors contributing to polypharmacy. We offer a clinical approach based on (1) reviewing the four main factors responsible for polypharmacy (the disease, the patient, the physician, and society) and (2) answering two questions about optimizing medication regimens (What can I do without explicit permission from the patient or others? What can I do with permission from them?). We contend that all physicians share a professional responsibility for prescribing medications judiciously because unnecessary prescribing exposes patients to unwarranted risks and squanders valuable and scarce resources. Psychiatrists can ask themselves a Kantian question: would my way of prescribing lead to good, socially acceptable outcomes if followed by all physicians treating similar patients?

Ms. A is a 36-year-old, married woman, referred by her gynecologist to psychiatry because the patient was having a difficult time accepting her diagnosis of uterine agenesis. When Ms. A was initially seen by the consulting psychiatrist in the Women’s Health Center, she was working full time at a local retail chain and was married, though she and her husband had always lived separately with their families of origin. She had graduated from high school and had held her current job for 15 years. She reported that she and her husband had been married for 4 years, with no children. The patient described a childhood full of medical tests attempting to explain her constellation of symptoms, which included low body weight, alopecia, and precocious breast development. Ms. A was unable to explain her medical diagnosis and stated that she had undergone an extensive workup at Children’s Hospital, though “they could never figure out what was wrong.” Ms. A has two brothers born with congenital problems—one with severe cognitive impairment and one with abnormal brain vasculature.