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Prescribing Cascade

Psychiatric drug therapy often starts with a single drug. It is prescribed to decrease certain symptoms and often causes a set of side effects. A second drug may be prescribed to partially address these side effects, but this new drug often introduces a set of problems of its own. This cycle too often continues.


Soon, the patient and the practitioner are uncertain where the cycle began, and what impact - both positive and negative - each drug is having.


Researchers call this the prescribing cascade. Each drug in the accompanying diagram can address specific symptoms. However, the larger picture highlights how one drug can easily lead to another, and how individuals can be prescribed an ever increasing cocktail of drugs with ever compounding side effects.


This process can lead to unpredictable consequences, and has the very real potential of reducing wellness. It can also create difficult drug withdrawal scenarios and impede the body's normal functioning through increasing drug toxicity. It is not uncommon for people with a mental health diagnosis, especially bipolar, to be on 4 or more drugs.


Prescribing cascade results in polypharmacy - the simultaneous use of multiple drugs to treat a single condition. Polypharmacy is associated with longer hospital stays [1] and is among the major causes of drug-related deaths.[2]  


Even though some forms of polypharmacy are less dangerous than others, we lack solid evidence that polypharmacy is effective and safe, and have insufficient evidence-based strategies to guide the practice.[3]


Antipsychotic polypharamacy (using multiple antipsychotics) is associated with grim results: increased mortality,[1] higher rates of metabolic disorders and diabetes,[4] as well as Parkinson’s-like movement disorders.[5] The American Psychiatric Association has joined forces with the American Board of Internal Medicine to curb this practice.[6]


Integrative practitioners often work to halt and reverse prescribing cascade. They typically start by adding appropriate non-drug approaches to decrease overall symptom levels. Then, working with the prescribing physician, they reduce to minimum effective dosages all necessary drugs over time. These dosage reductions should occur in small increments, since abrupt changes can wreak havoc on the body.


Through this process, people can often reduce the number of drugs they take, and in some cases be able to reduce symptoms to such a degree that no drugs are needed.


Nearly all psychiatric drugs have withdrawal difficulties, so always work with appropriate practitioners if you seek to reduce or get off of psychiatric drugs.

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[1]  Kingsbury S, Psychiatric Polypharmacy: The Good, the Bad, and the Ugly, Psychiatric Times, 1007,

[2]  Akici A, Rational pharmacotherapy and pharmacovigilance, Curr Drug Saf. 2007, PMID: 18690951.

[3]  Medical Directors Council and State Medicaid Directors. Alexandria, Virginia: 2001. National Association of State Mental Health Program Directors: Technical Report on Psychiatric Polypharmacy, full-text link.

[4]  Correll CU et al, Does antipsychotic polypharmacy increase the risk for metabolic syndrome?, Schizophr Res. 2007, PMCID: PMC2718048.

[5]  Paton C et al, Patterns of antipsychotic and anticholinergic prescribing for hospital inpatients, J Psychopharmacol. 2003, PMID: 12870571.

[6]  American Psychiatric Association, Five Things Physicians and Patients Should Question, Choosing Wisely, 2015,

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