The Department of Health and Human Services recently announced a federal action plan to curb psychiatric overprescribing. Secretary Robert F. Kennedy Jr. framed the initiative as a response to a national mental health crisis, calling for informed consent, shared decision-making and a shift toward nonpharmacologic treatments. The American Psychiatric Association (APA) responded with a statement that supported more research and clinical training, but pushed back against framing mental health primarily as a problem of overmedicalization or overprescribing.
That exchange is now shaping a broader public debate. One side warns that we are overmedicating Americans, especially children. The other cautions that abrupt deprescribing can endanger patients who genuinely need treatment. Both sides have a point, but each is also describing the wrong patient.
The overprescribing crisis is real. But the gravest harms do not fall on middle-class adults on antidepressants like Lexapro. It is a crisis of antipsychotics prescribed for foster children, polypharmacy in jails, sedation in nursing homes and long-acting injectables in group homes.
The Americans most overmedicated are the ones whose distress the system reads as primarily biological — even when its causes are largely structural — and they are invisible to both the Make America Healthy Again movement and the APA pushback.
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I am a psychiatric mental health nurse practitioner who has provided care to justice-involved individuals and other vulnerable populations. The patients I evaluate are not the audience Kennedy’s announcement seems targeted at, and they are not the engaged outpatients whose suicide risk the APA rightly urges us to protect. They routinely take five, six or seven psychiatric medications at once, often without a health care provider’s explanation of why.
The pattern is well documented. A 2017 Government Accountability Office (GAO) review noted that children in foster care were prescribed psychotropic medications at rates significantly higher than other Medicaid-enrolled children. It also documented prescribing patterns unsupported by research, including these vulnerable children taking five or more psychotropic medications at the same time. Studies on correctional psychiatric prescribing have documented rising psychotropic medication use and raised concerns about overuse, polypharmacy and off-label prescribing. In nursing homes, antipsychotics are routinely used for dementia-related agitation despite mortality warnings.
What the deprescribing debate misses is not just that these patients exist, but how they ended up on the medications in the first place. A foster child whose nervous system is dysregulated after a fourth placement in two years presents with restlessness and difficulty concentrating. The system diagnoses ADHD. An unhoused man presents with a low mood and lack of pleasure. The system calls it depression. Those assessments might be correct, but each might also be a structural problem that gets a biological label because that’s what the system can document, bill and treat. The medication is prescribed, but the conditions that produce the distress don’t improve, so the problem isn’t solved.
This is what overprescribing looks like within the populations that neither HHS nor the APA are talking about. It is not the so-called worried-well adult asking for Prozac or the distracted teen taking Adderall. It is the slow translation of social, developmental and environmental distress into psychiatric diagnoses, and drugs prescribed in settings where the alternatives — stable housing, family continuity, therapeutic relationship, time — are not on the menu.
Pharmacology is not the enemy here. But in most cases, it is not the hero either. Prescribing pills takes 10 minutes. Housing takes years. The system reaches for what it has, not for what would work. The result is predictable: The unhoused man with depression is still depressed five years later, and now takes three medications, because nothing about his life has changed except his care providers and his pill bottles.
Pharmacology is not the enemy here. But in most cases, it is not the hero either.
The substance of the federal action plan is not the problem. Informed consent — the right to understand and agree to your treatment before it begins — and nonpharmacologic options should be standard, reimbursed and supported. So should be appropriate deprescribing. These are uncontroversial principles in any other area of health care. The problem is that both framings, Kennedy’s and the APA’s, assume they’re talking about a patient with voice, agency and a sound relationship with the healthcare system. The patients I see often have none of those things.
What we need is a third conversation that asks where psychiatric medications are doing the most harm, who is bearing it and what structural changes — not just clinical guidelines — would be required to reduce it. These questions cannot be answered by a Health and Human Services press release or an APA statement.
I have evaluated patients who have been on so many medications for so long that no clinician can reconstruct why. I have evaluated adults who were started on antipsychotics at age 7 and have been on medications ever since. No provider along the way ever stopped to ask whether they still needed them, or ever had.
The question worth asking is not whether Americans are overmedicated. It is which Americans, with which medications, in which settings and with how much genuine choice and agency. We owe the foster child, the incarcerated person and the sedated grandmother more than a prescription for problems that were never medical to begin with.
