Sustainable prescribing in psychiatry: a responsibility and opportunity

In the Netherlands, pharmaceuticals contribute the largest environmental footprint of the healthcare sector (1). Much of the impact caused by prescribing in rich countries is hidden, primarily impacting the health of communities overseas, but increasingly pharmaceutical pollution is a concern in our local environments also (2).

In psychiatry we do not prescribe the most problematic chemicals (these include anaesthetic gases and metered dose inhalers). However we do have special opportunities for more sustainable prescribing practices.

1. Deprescribing

Think about how much time you give to starting vs. stopping medication.

Psychiatric medications should be prescribed at the lowest effective dose and for no longer than necessary. Yet many patients end up repeat prescriptions for many years after their acute episode is treated. Withdrawal effects are under recognised and often mis-attributed to a relapse of the problem the initial prescription was given for.

You probably spend a lot of clinical time persuading patients of the benefits of starting medications, educating about side effects, monitoring effectiveness of new prescriptions and so on.

How much time do you spend on deprescribing? That is, reviewing prescriptions and supporting patients to reduce and stop medicines safely.

Stopping psychoactive medication is often more difficult than initiation, and often needs careful clinical supervision.In some countries de-prescribing clinics have been set up to develop specialist knowledge about the deprescribing process, and this year the Maudsley Deprescribing Guidelines (3)has been published to guide clinical practice in this area.

Takeaway: Educating yourself about safe deprescribing is the responsibility of all prescribers.

2. Avoid over-diagnosis

In many cases, unnecessary prescriptions might be avoided in the first place. Overdiagnosis is the detection of harmless conditions that could be safely left undiagnosed and untreated. Once diagnosed, a cascade of interventions and treatment usually follows (4).

It is especially easy to over-diagnose psychiatric conditions, because diagnostic practice relies on normative criteria, and symptom self-reporting which is susceptible to social trends (5).  

Takeaway: In areas with rapidly shifting diagnostic norms, pharmacological treatment might not be evidence based. To prevent over-medication, approach diagnosis with caution.

3. Balanced communication

It’s a problem often hidden from prescribers, but evidence suggests that up to 60% of drugs prescribed for serious mental illness are never taken (6).

Reducing medication non-adherence is not about persuading patients to take medicines that do not suit them. It is sometimes about holding back on prescriptions which are not fully consensual.

This requires non-judgemental communication with the patient as an equal from the start. In psychiatry, with its historical (and current) coercive practices, patients may hold back expressing their true feelings about medication. Studies suggest that wastage of medicine can be reduced by up to 30% if patients starting treatment are given the option to discuss their medication-related concerns (7).

It is also helpful to ask the patient how long they expect to be on medication. It is a common misperception that psychiatric illnesses are life-long conditions. Setting up an expectation that treatment can be time-limited gives the patient confidence to let their doctor know when they feel ready to try cutting down their dose.

True informed consent requires discussing withdrawal effects at initiation of treatment. Some patients who are on the fence about starting a medication may choose an alternative treatment, knowing their chances of having difficulties stopping medication down the line.

Finally, it is responsibility of the prescriber to provide information about appropriate disposal of medication. In Denmark there is always the option to return unused medications to the pharmacy (8).

If a patient is expressing uncertainty about a prescription, check your instinct to ‘write a prescription just in case’. Instead, invite the patient to discuss alternative treatment options or return once they’ve had more time to think. With some patients, opening these conversations might reveal preferences for lower impact treatments more in line with their values (this is known as green informed consent (9)).

Takeaway: It is not a failure if open conversations and sharing of information leads to lower prescription rates.

For further reading see the resources below:

https://sustainablehealthcare.org.uk/

https://vaelgklogt.dk/

https://deprescribing.org/resources/deprescribing-guidelines-algorithms/

A Handbook for Nature on Prescription to Promote Mental Health

https://formulary.yewmaker.com/ (a website where you can compare the carbon footprints of equivalent medications)

https://sustainablehealthcare.org.uk/resources/lancet-commission-case-studies (call for case studies from the lancet commission)