Why Do I Write This With Confidence, And Why Now?

A decade ago, I researched and co-authored a peer-reviewed paper for Brain Stimulation titled How Mental Health Is Shortchanged by Lack of Reimbursement for Vagus Nerve Stimulation (VNS). The piece examined how the U.S. mental health system overlooked strong real-world evidence in patients suffering from the most severe form of depression, Treatment Resistant Depression (TRD), largely because medication-based treatment models which were deeply embedded financially and institutionally. The research supporting VNS therapy was compelling, but the resistance to adopting innovative non-pharmaceutical interventions was entirely foreseeable and is ever-present today.

An Explanation Of Traditional Antidepressants Versus VNS

Vagus nerve stimulation (VNS) is an implantable device therapy that delivers intermittent electrical impulses to the vagus nerve, influencing brain regions involved in mood regulation. Unlike traditional antidepressants, it works through neuromodulation rather than neurotransmitter manipulation, offering a distinct pathway for patients who have not responded to pharmacologic treatments.

For decades, antidepressants have remained the cornerstone of treatment for major depressive disorder. Many patients experience substantial benefit. However, a large segment of patients continue to struggle despite repeated treatment attempts. Research has shown that a significant percentage of patients who can tolerate initial antidepressant therapy still fail to achieve meaningful improvement or full remission, ultimately falling into the category of treatment-resistant depression.

What follows often exposes the limitations of the modern psychiatric care framework.

Patients who do not respond to an initial antidepressant are frequently shifted from one medication regimen to another, sometimes for years at a time. Treatment intensification often includes antipsychotics, benzodiazepines, or complex combinations of medications that carry considerable neurological, metabolic, and cognitive risks. Over time, medication management can become extraordinarily complicated, particularly for elderly individuals already managing diabetes, cardiovascular disease, chronic pain, or sleep disorders.

At the same time, the long-term effectiveness of antidepressants remains an important concern. In our Brain Stimulation paper, we discussed evidence showing that many antidepressants gradually lose effectiveness over extended periods of use in portions of the patient population. Additional analyses examining FDA-submitted antidepressant trials have also suggested that, particularly in milder forms of depression, the measurable separation between medication response and placebo response is often narrower than many assume.

Which is why the newly announced HHS initiative aimed at curbing psychiatric overprescribing and encouraging more holistic approaches to mental health treatment is so important. The agency specifically emphasized “informed consent, deprescribing when clinically appropriate, psychotherapy, family support, nutrition, and physical activity as alternatives or complements to medication-centered care.”

That announcement reflects a broader realization emerging within healthcare: the United States has steadily evolved into a medication-centric mental health system that is becoming increasingly costly, inconsistent in outcomes, and, in some cases, counterproductive.

The causes of psychiatric overprescribing are deeply embedded within the structure of the healthcare system itself. Psychiatry now operates under immense strain. Demand for mental health services accelerated dramatically following the COVID-19 pandemic, while the number of psychiatrists, psychologists, and behavioral specialists failed to expand at a similar pace. In many regions of the country, patients wait months for evaluations, leaving primary care physicians to manage growing psychiatric burdens.

Primary care physicians now write a substantial share of antidepressant and anti-anxiety prescriptions in the United States. Most are acting responsibly within an overburdened system. They are trying to manage overwhelming demand in clinical environments where brief appointments have become the norm. Faced with patients experiencing chronic stress, panic attacks, insomnia, grief, burnout, or depressive symptoms, medication often becomes the most immediate and accessible intervention.

Financial incentives reinforce the pattern. Insurance companies routinely reimburse medication management efficiently, while psychotherapy and integrated behavioral care frequently remain expensive, difficult to access, or poorly covered. The economics of healthcare favor treatments that can be delivered rapidly and repeatedly.

As we observed a decade ago, this imbalance has become particularly pronounced in depression treatment. Despite the limitations of existing therapies, the healthcare system continues to default toward escalating pharmaceutical intervention.

Part of the explanation is cultural. Beginning in the 1990s, public messaging and pharmaceutical advertising promoted the idea that depression was primarily the result of a “chemical imbalance” that medications could correct. That framework helped reduce stigma for many patients, but it also simplified an extraordinarily complex condition. Trauma, social isolation, economic instability, substance use, sleep deprivation, poor nutrition, and chronic stress were often pushed into the background of the conversation.

Children and adolescents have become an especially sensitive area within this debate. HHS specifically highlighted concerns regarding psychiatric overuse “especially among children” in its May 2026 announcement. Federal agencies are now encouraging pediatric-specific prescriber education, deprescribing initiatives, and greater access to psychotherapy and family-based interventions.

Those concerns are understandable. Developing brains remain highly dynamic, and long-term exposure to psychiatric medications raises important questions regarding cognition, emotional maturation, dependency, and metabolic health. Yet the shortage of child psychiatrists has forced many pediatricians and family physicians to manage increasingly complicated psychiatric cases without adequate specialist support.

The larger issue is not whether psychiatric medications should exist. They unquestionably should. Severe depression, bipolar disorder, schizophrenia, obsessive compulsive disorder, PTSD, and ADHD are legitimate and potentially devastating medical conditions. Properly prescribed psychiatric medications save lives every day.

The deeper question is whether the United States has become overly dependent on medication because it has underinvested in nearly every other dimension of mental health treatment. That failure becomes especially visible when examining innovative non-pharmacologic therapies.

One of the enduring frustrations within psychiatry is how uncommon long-term outcome studies remain, particularly studies demonstrating sustained remission over periods measured in years rather than months. From a healthcare economics perspective, insurers and government programs routinely absorb the enormous cumulative costs associated with antidepressants, antipsychotics, emergency interventions, hospitalizations, and disability support, while alternative therapeutic approaches frequently encounter reimbursement barriers.

That contradiction highlights one of the fundamental weaknesses within American psychiatry: the healthcare system readily finances chronic medication management while often failing to support durable, multidisciplinary, and preventive strategies.

Even lifestyle-oriented mental health interventions remain poorly integrated into standard care. Exercise, sleep optimization, nutrition, substance-use reduction, psychotherapy, and social engagement all demonstrate measurable psychiatric benefits for many individuals. HHS itself now openly encourages these non-medication approaches. Yet many patients still struggle to access such services consistently through insurance networks.

Psychiatric overprescribing is therefore not simply the result of individual physician behavior. It is the predictable consequence of a healthcare system designed around efficiency, reimbursement flow, and rapid symptom control.

The downstream effects are becoming increasingly difficult to ignore. Polypharmacy continues to rise. Withdrawal syndromes remain poorly understood. Long-term benzodiazepine dependence persists across large patient populations. Metabolic complications associated with antipsychotic use continue to expand. Many patients spend years cycling through medication combinations without achieving lasting stability.

Mental health cannot be restored entirely through pharmaceuticals because many of the forces fueling modern depression are not exclusively biological.

That reality is finally beginning to shape public policy discussions. HHS’s new deprescribing initiative may ultimately matter less for the regulations themselves than for what it symbolically acknowledges: America’s mental health strategy requires meaningful re-calibration.

The future of psychiatry should not involve rejecting medication altogether. It should involve restoring balance — using medication carefully and appropriately while rebuilding the psychological, behavioral, social, and preventive foundations that mental healthcare gradually lost during decades of pharmaceutical dominance.

Otherwise, the nation risks continuing down a path where millions of Americans remain heavily medicated, but never fully restored.