The federal government is right to ask hard questions about psychiatric prescribing. Every patient deserves treatment that is evidence-based, individualized, and free from unnecessary medications.
But if the national conversation becomes primarily about deprescribing, we risk solving the wrong problem. America’s behavioral health system isn’t defined by widespread access to unnecessary care — it is defined by too little access to evidence-based care, too few behavioral health professionals, and too many people going untreated.
The goal should not be to prescribe less; it should be to prescribe better.
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I read the MAHA’s Action Plan on psychiatric prescribing and the Dear Colleague letter from SAMHSA, CMS, HRSA, and ACF with real interest, and I agree with many of their principles. But the policy conversation needs to shift from just deprescribing alone to building the clinical infrastructure that delivers consistent, high-quality behavioral health care.
We have a strong, evidence-based solution: standardized clinical care pathways that promote prescribing, real measurement, accountability, and individualized treatment. Instead of focusing the conversation on reducing medication use, policymakers should ensure every treatment is evidence-guided and tailored to the person.
Where I agree
I share the federal government’s commitment to person-centered, evidence-based behavioral health care, and I support several of the principles in the MAHA Action Plan and Dear Colleague letter.
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Psychiatric medications are often essential. For many people living with serious mental illness, they reduce symptoms, improve functioning, prevent relapse, and make recovery possible.
But medication shouldn’t be the only option; a full continuum of care should include evidence-based psychotherapy, peer support, family involvement, nutrition, and sleep interventions, which is the same standard we expect for diabetes, heart disease, or any chronic condition. Behavioral health should be no different.
The use of shared decision-making and informed consent is fundamental to behavioral health care. Patients deserve understandable and transparent information about the benefits, risks, and alternatives. Concerns about polypharmacy or the use of two or more drugs together to treat a single condition, among at-risk populations, which include children in foster care and older adults in nursing facilities, deserve continued attention, as does the Dear Colleague letter’s own caution that deprescribing isn’t universally appropriate and should never be done abruptly.
Where I have concerns
But those principles only hold if the federal response is better prescribing, not simply less of it. My concern is that a federal focus on “overprescribing” and “deprescribing” could unintentionally trigger a policy overcorrection within a behavioral health system already stretched thin.
The bigger challenge isn’t simply inappropriate prescribing; it’s widespread undertreatment, limited access to evidence-based care, persistent workforce shortages, and inconsistent provider training.
In 2022, less than half of adults in the U.S. with a mental illness received treatment, and only 25 percent of people with Opioid Use Disorder (OUD) receive lifesaving Medications for Opioid Use Disorder (MOUD). At the same time, much of psychiatric prescribing now occurs in primary care, where clinicians are asked to manage increasingly complex behavioral health conditions despite limited specialty training and ongoing shortages of psychiatrists and other behavioral health professionals.
For conditions such as schizophrenia, bipolar disorder, and treatment-resistant depression, medication can be the difference between stability and crisis. Using broad messaging for the need to reduce psychiatric medications could unintentionally discourage appropriate medication treatment for patient populations where evidence most strongly supports their use.
Additionally, the recommended alternatives are not consistently available. Access to alternatives such as psychotherapy, intensive outpatient programs, peer supports, and other non-pharmacologic interventions remains limited due to workforce shortages, inadequate reimbursement, geographic disparities, and lengthy wait times. If policymakers want to encourage greater use of these services, they must also ensure that these services are available. Research regularly demonstrates that, for many conditions, combining medication with psychotherapy produces better outcomes than either treatment alone.
Deprescribing itself also requires careful clinical oversight. Abrupt or poorly managed tapering of medications can result in severe withdrawal symptoms, relapse, hospitalization, homelessness, incarceration, or even suicide. These risks must remain central to any discussion of medication reduction.
The better path forward
The behavioral health field does not need new policies that focus narrowly on deprescribing. It needs stronger systems that support appropriate prescribing from the outset.
Existing medication management billing codes already allow clinicians to deprescribe when clinically appropriate. Creating separate fee-for-service incentives solely for deprescribing risks adding unnecessary administrative complexity and cost while placing additional burdens on an already overstretched workforce.
Instead, federal policy should prioritize expanding access to integrated behavioral health care, strengthening clinician education in evidence-based prescribing, supporting collaborative care models, and implementing standardized clinical care pathways that help clinicians consistently deliver high-quality care.
Author bio:
Caroline Carney, MD, MSc, FAPA, FAPM, CPHQ, a board-certified psychiatrist and internist, serves as a senior advisor to a Healthsperien/s Center for Behavioral Health and is the CEO of Magellan Health. She has nearly thirty years of experience in clinical care, integrated care program development, health care policy, managed care, quality improvement, research, and medical education. Dr. Carney is the author of over one hundred peer and non-peer reviewed articles, and speaks at conferences and appears on podcasts regarding integrated care models, the effects of social media on youth, climate change and the effect on mental health, managed care, and other topics of the day.
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