Episode 13; Rethinking Psychotropic Medication and Mental Health Reform

Muhamad Aly Rifai, MD

Welcome to our 13th episode of the Virtual Psychiatrist this is your host Muhamad Aly Rifai, I am a professor in Medicine and Psychiatry we will be talking today about the state of medicated America

Teresa Baron

So, nearly a quarter of adults in the U.S. are on psychotropic medications. That's a staggering number, and it really reflects the state of our national mental health.

Muhamad Aly Rifai, MD

Yeah, and what really stands out is how much higher that number surged during the pandemic. Isolation, stress—it all created this perfect storm. But, do you think it's just that? Or is there more at play here?

Muhamad Aly Rifai, MD

Well, the pandemic certainly acted as a trigger, but I I think the trend goes beyond those two years. Our healthcare system is, honestly, set up to foster this kind of over-reliance on medication. You see, with these 15-minute med management visits, there’s hardly time to dive into the root causes of someone’s distress. Physicians are kind of—or let’s say, often—pressured to prioritize quick fixes.

Teresa Baron

Right, like, prescribing becomes the fastest way out. But it’s not sustainable, is it? I mean, what happens, over time, to patients stuck on these meds?

Muhamad Aly Rifai, MD

Exactly, it’s not sustainable. And one issue we rarely talk about is this: there's no formal guideline for physicians on how to help patients safely taper off these medications when they're no longer needed. Instead, what we see is long-term use by default, not by design.

Teresa Baron

That’s concerning. Do you think there’s just not enough research on tapering, or is this more about systemic inertia?

Muhamad Aly Rifai, MD

It’s a bit of both. Take the National Institute for Health and Care Excellence in the U.K.—they have structured guidance for tapering antidepressants over months or even years. Here in the U.S., we don’t have anything like that. And without that roadmap, physicians are left guessing. But what’s really heartbreaking are the patients, who often face withdrawal symptoms or confusion about whether they’re relapsing. The lines blur, Teresa.

Teresa Baron

Yeah, I can totally see that. It’s gotta be terrifying for someone to not know if they’re feeling worse because they’re coming off the meds wrong or because their condition is flaring up again.

Muhamad Aly Rifai, MD

It is. Let me tell you about a patient I’ve worked with—we’ll call him Alex. He was in his late forties and had been on a cocktail of medications for years. When he first came to me, he said, “Doc, I don’t feel like myself anymore.” He wasn’t sure if the medications were helping or just numbing him, you know? But when we started tapering—very carefully—he began rediscovering pieces of himself he thought were long gone. And the process, it wasn't linear. There were hard days, but he eventually got to a place where he no longer needed most of the meds.

Teresa Baron

Wow. That’s powerful. And it kind of emphasizes what we’re saying, right? That while medications can save lives, they can also end up masking issues rather than addressing them directly.

Muhamad Aly Rifai, MD

Yes, and it shows just how much we need a paradigm shift. It’s not just about prescribing—it’s also about deprescribing responsibly. And that work requires time, patience, and a broader perspective that includes therapy, support systems, and addressing the social factors that might be fueling mental distress.

Teresa Baron

That really resonates, Dr. Rifai. our office have been working with someone who’s going through a similar challenge. His name’s Daniel, a sharp lawyer who’s been tapering off lithium for months now. Some mornings, he wakes up trembling with anxiety, questioning everything—whether it’s withdrawal, a relapse, or even something as simple as a bad meal.

Muhamad Aly Rifai, MD

I’ve heard that so many times before, Teresa . Patients often walk that tightrope where the withdrawal symptoms mimic the very conditions they’re trying to manage. And it’s not just physical—it’s the psychological strain of constantly second-guessing yourself, wondering if you’ll spiral down or finally find clarity. That’s why structured support is so critical.

Teresa Baron

Exactly! But here’s where it gets complicated—he’s also been working with a coach, not a psychiatrist. You know Laura Delano? She’s this ex-patient who now mentors people on how to quit medications, but without clinical supervision. I mean, her story is inspiring—she’s gone through it herself, walked away from psych meds, and says her life is better for it. But c’mon, isn’t that risky?

Muhamad Aly Rifai, MD

Very much so. What she’s offering might resonate with people because it feels accessible, but tapering off psychiatric meds is not a one-size-fits-all journey. Without a professional to guide you, you’re left guessing—exposing yourself to withdrawal symptoms, potential relapse, or worse. And while, yes, there’s value in peer support, it cannot replace clinical expertise.

Teresa Baron

Right. And the grassroots energy behind movements like hers is huge; there’s this growing theme of people wanting to reclaim control over their health. But, as empowering as that is, there’s also danger in thinking you can go it alone. I mean, I’m all for patient autonomy, but where’s the net to catch you if you fall?

Muhamad Aly Rifai, MD

That safety net is supposed to be clinicians, but—here’s the crux of the issue—we’re simply not equipped with the tools. In the U.K., for example, they have the NICE guidelines offering a systematic tapering approach for antidepressants. But here, most physicians haven’t even had proper training on withdrawal management. So patients feel stuck between staying on meds forever or venturing into uncharted waters without a map.

Teresa Baron

And it’s frustrating, Doc, because it’s not just the patients suffering here—it’s doctors too. Like you’ve said before, the system gives us 15 minutes to ‘manage meds,’ but no time to do what’s needed, like walking someone through an actual taper strategy. It forces both sides into corners.

Muhamad Aly Rifai, MD

Exactly. And let’s not forget that every case is unique. I’ve had patients who couldn’t handle the slightest reduction in their dose without severe rebound effects. Others tapered successfully because we went at their pace, addressing every change in their symptoms along the way. For some, the withdrawal isn’t just physiological—it’s this fragile dance of rediscovering who they are without the shield of medication.

Teresa Baron

Doc , that’s deep. Rediscovering themselves—it’s powerful. But you’re right, the stakes are massive. If these grassroots movements really want to help, they need to collaborate with professionals, not sidestep them. Safety can’t be optional.

Muhamad Aly Rifai, MD

Agreed. It’s not about discouraging people from taking back control of their health; it’s about guiding and partnering with them. Structured tapering isn’t just science—it’s stewardship. Which we’re going to need to explore further if we’re serious about changing this paradigm.

Teresa Baron

I can tell you from experience with my family they need to stay on their medications but have always wanted to go off their medications, not good..... hmmm

Muhamad Aly Rifai, MD

Teresa, picking up where we left off—structured tapering is such a critical piece, and you’re spot on about the need for collaboration. Take what’s happening in the U.K., for instance. Their NICE guidelines lay out a staged tapering approach for antidepressants. Patients are closely monitored, and the priority is ensuring withdrawal symptoms remain manageable or resolved before every dose reduction. It’s a thoughtful, methodical way to guide people safely through a process that can otherwise feel so overwhelming.

Teresa Baron

That’s interesting. So, they’re really taking what sounds like a much more granular approach compared to what we do in the U.S. That kind of thoughtful framework is sorely missing here. Why haven’t we adopted something similar?

Muhamad Aly Rifai, MD

It comes down to systemic priorities—or rather, the lack thereof. Structured tapering takes time. Time that many overburdened physicians just don’t have in their schedules. And let’s face it, our healthcare system is incentivized for management, not resolution. Contrast that with models like the U.K.’s, where the focus is on outcomes and longer-term patient well-being, not just short-term symptom control.

Teresa Baron

Right, and that shorter outlook creeps into everything else, doesn’t it? I mean, social determinants of health might as well be in a different galaxy given the way our system operates. Poverty, trauma, chronic stress—those factors are foundational, but there’s no space to address them in 15-minute med checks.

Muhamad Aly Rifai, MD

Exactly. The need to integrate behavioral health with primary care is critical here. For instance, stress doesn’t just affect your mental well-being—it’s tied to physical illnesses like heart disease and obesity. Supporting patients with therapy, community resources, and even lifestyle changes can make a huge difference. But when behavioral health isn’t easily accessible or embedded in the system, it leaves patients struggling on their own.

Teresa Baron

That’s where we really fall short, right? Accessibility and equity. If someone doesn’t have insurance or lives in a health desert, all the holistic care in the world isn’t gonna mean much. And let’s not get started on the mental health stigma that still keeps people from seeking help in the first place.

Muhamad Aly Rifai, MD

Absolutely. Now, take something like the President’s "Make America Healthy Again Commission." It’s an ambitious initiative targeting chronic disease and mental health reform. If implemented, it could push for greater integration of resources, but also reframe the healthcare narrative toward preventing illness instead of purely treating it. If successful, it might even make some headway in addressing the glaring inequities.

Teresa Baron

It could be a game-changer, honestly. But let’s not kid ourselves—it’s gonna take a monumental shift to overcome years, decades even, of systemic inertia. That said, even addressing simple things like reviewing medications regularly or funding comprehensive community programs would go a long way.

Teresa Baron

The potential is there. But we have to be purposeful about it, Teresa. The U.K.’s model works because they prioritize patient outcomes over pharmaceutical-driven incentives. Could the same approach work here? Only if we first rebuild trust in the system, invest in education for both patients and providers, and create policies that focus on holistic care.

Muhamad Aly Rifai, MD

It’s no small task, but the stakes couldn’t be higher. We’re at a tipping point, where people are increasingly skeptical of the healthcare system altogether. Any reform has to show tangible outcomes—make people believe in the system again. Otherwise, it’s just more bandaids on bullet holes.

Teresa Baron

And that means seizing this moment to rethink every element of care—starting with not only how we prescribe but how we deprescribe. It’s not just policy changes; it’s a cultural shift in how we view medicine and recovery in this country.

Teresa Baron

Dr. Rifai what about these giant pharmaceutical companies what impact do they have on these issues, Picking up from what you said about deprescribing as part of a cultural shift, it’s fascinating to me how little attention we actually give to the endgame of treatment plans. Once a prescription gets written, it feels like the conversation on how to safely taper or stop it often falls by the wayside. Why do you think that is?

Muhamad Aly Rifai, MD

It all comes down to incentives, Teresa. Pharmaceutical companies, for example, have no real motivation to fund research on discontinuation. I mean, why would they? There’s no profit in teaching people how to stop using their product.

Teresa Baron

Right, right. And let’s be honest, most of the time, it becomes the doctor’s problem to figure it out later. But even then, the system doesn’t really make space for it, does it?

Muhamad Aly Rifai, MD

Not at all. If you think about it, Teresa , our health insurance model forces psychiatrists to cram patient care into these ridiculously short sessions. Fifteen minutes isn’t enough time to have a deep conversation about, say, the long-term implications of staying on medication. And it certainly isn’t enough to design a thoughtful tapering plan.

Teresa Baron

Fifteen minutes? Forget thoughtful. That’s barely enough time to ask how they’re doing and write a refill. It’s frustrating because we’re putting people on lifelong treatments without revisiting the original question: Is this still helping them?

Muhamad Aly Rifai, MD

Exactly. And patients often feel like they're left out of the process entirely. There’s this top-down approach in psychiatry where medications are adjusted without enough collaboration. Imagine how different things would be if we actually included patients in those decisions—not just about starting medications but also about when and how to stop.

Teresa Baron

Totally. Because without that conversation, you’re leaving people to wonder, “Is this forever? Do I even have a choice here?” And, honestly, the lack of clear guidelines doesn’t help them or us as clinicians.

Muhamad Aly Rifai, MD

You’re absolutely right. If we had well-researched, structured protocols, we could guide patients better through these transitions. Look at the U.K. with their NICE guidelines—they’ve set up a gradual tapering framework that’s safe and patient-centered. What’s stopping us from doing the same? Resources? Priorities?

Teresa Baron

It’s all of it, isn’t it? The lack of funding, the systemic inertia, the focus on short-term fixes. But, Dr. Rifai , I think part of it is also that people don’t see tapering as its own skill set. It’s treated like an afterthought when, really, it can be just as complex as prescribing.

Muhamad Aly Rifai, MD

So true. And here’s where it gets critical—tapering isn’t just a clinical exercise. It’s deeply emotional. The process can feel overwhelming for patients, like letting go of a safety net they’ve relied on for years. Without proper support, they’re navigating blind.

Teresa Baron

And meanwhile, they’re asking themselves, "Is this withdrawal? Is this my original diagnosis returning? Or am I just failing at this process altogether?" That’s a scary place to be.

Muhamad Aly Rifai, MD

It is. And every patient’s journey is unique. Some taper quickly, others need months—or even years—to reduce safely. But all of that takes time, expertise, and communication. None of which are prioritized in our current system.

Teresa Baron

Well, it sounds like we’re not just talking about changing clinical practice here. We’re talking about a cultural shift in how we approach mental health care—from start to finish.

Muhamad Aly Rifai, MD

Absolutely. We have to move toward a system where we value recovery over mere symptom management. That means bringing patients into the conversation, educating physicians about deprescribing, and shifting the focus from quick fixes to sustainable health. It’s a holistic reimagining of what care should look like.

Teresa Baron

That’s a tall order, but it’s not impossible. And, honestly, it’s needed now more than ever. If we don’t rethink this soon, we risk losing trust—not just in psychiatry, but in the entire healthcare system.

Muhamad Aly Rifai, MD

Couldn’t agree more, Teresa. At the end of the day, this is about creating a system where patients feel seen, heard, and supported. It starts with acknowledging the gaps and asking tough questions about how we got here and how we can do better.

Teresa Baron

And doing better means being bold enough to try new approaches—whether it’s more comprehensive guidelines, better clinician training, or simply making space for those in-depth conversations that we’ve all been skipping for far too long.

Muhamad Aly Rifai, MD

Exactly. It’s not an overhaul we need—it’s a revolution in care, Teresa. And while it’s a steep climb, I’d say this conversation today is a pretty good first step.

Teresa Baron

Couldn’t have said it better myself. Here’s to the start of something meaningful.