Prescribing by Default: The Cost of Conformity in Mental Health Care
Modern pharmacology can transform lives, and its power commands respect. For a child or adult grappling with debilitating symptoms, a well-chosen prescription can be a lifeline; humane, targeted, and effective (Faraone & Buitelaar, 2010). Yet, this power is not a license for reflex. Mental health systems, driven by efficiency, risk reducing patients to data points, prioritizing checklists over understanding and medication over meaning.
1. The Assembly Line of Care
Psychiatric and psychological intakes are typically confined to 45–60 minutes, dictated by Evaluation and Management (E/M) and psychotherapy coding conventions (American Medical Association, 2024; American Psychological Association, 2020; APA Services, n.d.). Follow-up sessions with psychologists generally last 45–60 minutes, while those with medical doctors can be as brief as 15 minutes. This structure isn’t inherently wrong, but when symptom inventories and dosage tweaks consume time, it sidelines functional analysis, observation, and contingency planning. The system pulls clinicians toward prescribing as a default, treating patients like units on a conveyor belt rather than individuals with complex needs.
2. The Diagnostic Trap of Medicating First
Starting medication before a thorough assessment distorts diagnostic clarity. In attention-deficit/hyperactivity disorder (ADHD) evaluations, if a medicated child’s symptoms remain elevated, the diagnosis holds. But if scores normalize, the question lingers: is the medication masking a deficit/excess, or was there no impairment to begin with? Stimulants enhance attention and memory even in those without ADHD, so improved test results don’t confirm pathology (Ilieva et al., 2015).
Imagine a doctor giving acetaminophen before checking a child’s temperature. A normal reading could mean no fever or a masked one; diagnosis becomes a matter of guesswork. Medicating before evaluation creates the same confusion. Guidelines recommend comprehensive assessments across various settings, preferably without the use of medication, to establish impairment and diagnosis (American Academy of Pediatrics [AAP], 2019; National Institute for Health and Care Excellence [NICE], 2019).
3. The Seduction of Quick Fixes
Stimulant prescriptions for U.S. children increased significantly during the pandemic, largely driven by the ease of access to telehealth (Danielson et al., 2023; Huskamp et al., 2024). These medications work when indicated (Faraone & Buitelaar, 2010), but their widespread use reflects a system seduced by quick chemical fixes. Convenience and scale often trump context, leaving environmental and behavioral factors underexplored.
4. The Perils of Polypharmacy
When medication becomes the go-to, polypharmacy follows. Studies show rising psychotropic combinations in pediatric populations, with heightened risks of adverse events like drug interactions (Bilsky et al., 2022; Radel et al., 2023; Borgelt et al., 2024). These risks aren’t just clinical; they’re also legal, especially when evidence for combined treatments is limited, offering little functional benefit.
5. Behavior Before Pills
For young children, behavioral therapy and parent training are the gold standard for ADHD, with medication reserved for severe cases or when behavioral options are inaccessible (AAP, 2019; U.S. Centers for Disease Control and Prevention [CDC], 2024; NICE, 2019). These interventions clarify diagnosis, improve outcomes, and often reduce medication reliance, grounding care in data rather than doses.
6. Protecting Patients and Clinicians
Shared decision-making and decision aids empower patients, align treatments with values, and reduce conflict (Stacey et al., 2017). Initiatives like Choosing Wisely demand transparency to avoid low-value care, requiring clinicians to document risks, benefits, and alternatives (ABIM Foundation, 2022). This isn’t bureaucracy; it’s a shield against ethical and legal scrutiny.
7. A Blueprint for Accountable Care
- Secure a baseline, preferably unmedicated, with multi-setting rating scales, observation, and functional analysis, per APA standards (American Psychological Association, 2020).
- For ages 4–6, start with parent training and classroom strategies; medication is a last resort for severe impairment (AAP, 2019; CDC, 2024).
- If medication is used, start low, set clear outcomes, and reassess regularly, including supervised trials off medication when safe.
- Avoid polypharmacy without a strong, guideline-backed justification and monitoring (Bilsky et al., 2022; Borgelt et al., 2024).
- Document shared decision-making, detailing risks, benefits, and alternatives, using decision aids where possible (Stacey et al., 2017).
Closing Call
Prescriptions are a tool, not a mandate. When efficiency overrides insight, when pills preempt understanding, and when behavior is reduced to a prescription pad, mental health care risks becoming a hollow routine. Respecting pharmacology means demanding precision: measure first, prioritize behavior, and ensure chemical solutions serve, not define, the patient.
References
ABIM Foundation. (2022). Choosing Wisely: About the campaign. https://www.choosingwisely.org/our-mission/
American Academy of Pediatrics. (2019). Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 144(4), Article e20192528. https://doi.org/10.1542/peds.2019-2528
American Medical Association. (2024). CPT 2025 professional edition: Corrections and errata. https://www.ama-assn.org/practice-management/cpt/cpt-errata-and-technical-corrections
American Psychological Association. (2020). Guidelines for psychological assessment and evaluation. https://www.apa.org/about/policy/guidelines-psychological-assessment-evaluation.pdf
APA Services. (n.d.). Psychotherapy codes for psychologists. https://www.apaservices.org/practice/reimbursement/health-codes/psychotherapy
Bilsky, S., Ballard, E. D., & Findling, R. L. (2022). Pediatric psychotropic polypharmacy: An evaluation of the evidence base. Journal of Child and Adolescent Psychopharmacology, 32(7), 372–380. https://doi.org/10.1089/cap.2022.0010
Borgelt, L. M., McQueen, R. B., & Lam, T. (2024). Prevalence of contraindicated combinations amid behavioral health pharmacotherapy in pediatrics. BMC Primary Care, 25(1), Article 528. https://doi.org/10.1186/s12875-024-02528-9
Danielson, M. L., Bohm, M. K., & Newsome, K. (2023). Trends in stimulant prescription fills among commercially insured children and adults—United States, 2016–2021. Morbidity and Mortality Weekly Report, 72(13), 332–338. https://www.cdc.gov/mmwr/volumes/72/wr/mm7213a1.htm
Faraone, S. V., & Buitelaar, J. (2010). Comparing the efficacy of stimulants for ADHD in children and adolescents. European Child & Adolescent Psychiatry, 19(4), 353–364. https://doi.org/10.1007/s00787-009-0054-3
Huskamp, H. A., Busch, A. B., & Raja, P. (2024). Trends in use of telemedicine for stimulant initiations, 2019–2022. Health Affairs, 43(7), 1010–1019. https://doi.org/10.1377/hlthaff.2023.01247
Ilieva, I. P., Hook, C. J., & Farah, M. J. (2015). Prescription stimulants’ effects on healthy inhibitory control, working memory, and episodic memory: A meta-analysis. Journal of Cognitive Neuroscience, 27(6), 1069–1089. https://doi.org/10.1162/jocn_a_00776
National Institute for Health and Care Excellence. (2019). Attention deficit hyperactivity disorder: Diagnosis and management (NICE Guideline NG87). https://www.nice.org.uk/guidance/ng87
Radel, L. F., Bramlett, M. D., & Brown, D. (2023). Psychotropic medication and polypharmacy among youths in the child welfare system. JAMA Pediatrics, 177(11), 1136–1145. https://doi.org/10.1001/jamapediatrics.2023.3677
Stacey, D., Légaré, F., Lewis, K., Barry, M. J., Bennett, C. L., Eden, K. B., Holmes-Rovner, M., Llewellyn-Thomas, H., Lyddiatt, A., Thomson, R., Trevena, L., & Wu, J. H. (2017). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews, 2017(4), Article CD001431. https://doi.org/10.1002/14651858.CD001431.pub5
U.S. Centers for Disease Control and Prevention. (2024). Clinical care of ADHD: Treatment recommendations by age. https://www.cdc.gov/adhd/hcp/treatment-recommendations/
Disclaimer
This article is provided for educational and informational purposes only. It does not constitute medical advice, diagnosis, or treatment. Readers should not interpret this material as a substitute for individualized clinical judgment, professional medical evaluation, or consultation with a qualified health-care provider.
While all references cited are drawn from reputable, peer-reviewed, or guideline-based sources current at the time of writing, clinical recommendations evolve. Readers and practitioners remain responsible for verifying the most recent standards of care before applying any information in a professional or personal capacity.
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