Prescribing Cascade

Psychiatric drug therapy often starts with a single drug that relieves some symptoms and causes a variety of side effects. A second drug may be prescribed to partially reduce these side effects, but this new drug often introduces a set of problems of its own. A third drug can then prescribed and the cycle continues. Soon, the patient and the practitioner are uncertain where the cycle began.

Researchers call this the prescribing cascadeEach drug in the diagram below can address specific symptoms. However, the larger picture highlights how individuals can spin around this wheel, being prescribed an ever increasing cocktail of drugs with ever compounding side effects. It has the very real potential of reducing wellness and creating situations for difficult drug withdrawal. 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 particularly grim results: increased mortality,[1] higher rates of metabolic disorders and diabetes,[4] as well as Parkinson’s-like movement disorders.[5] Realizing the significant problems with antipsychotic polypharmacy, the American Psychiatric Association has joined forces with the American Board of Internal Medicine to curb this practice.[6]

Integrative practitioners work to halt and reverse prescribing cascade. They typically start by adding appropriate non-drug approaches to decrease overall symptoms. Then, working with the prescribing physician, they reduce to minimum effective dosages all necessary drugs over time. They can often reduce the number of drugs taken, 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.