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Too many pills, not enough questions
Polypharmacy is one of those interesting concepts which is basically unknown outside of small niche, who understand the area, whilst actually being of importance to potentially nearly everyone.
It is the technical name for the situation in which patients prescribed five, six, or even ten medications simultaneously, often by a series of doctors whose lines of communication are nonexistent, with no one bothering to ask whether the cocktail is beneficial or harmful. The plain English term would be over-medication. And the scale of it is staggering.
Inappropriate prescribing of medicines causes falls, confusion, memory problems, and in some cases kills people. Hospital admissions tied to this problem run to an estimated 8.6 million a year across the EU, roughly half of which could have been avoided. Non-adherence, because patients cannot keep track of what they are supposed to be taking and when, drains an estimated €125 billion from health budgets annually. These are enormous numbers and they describe a failure that is almost entirely self-inflicted.
What Ireland’s CAMHS report exposed
Over-medication among the elderly is bad enough, but what’s been happening in child mental health services is worse, and more urgent. The HSE’s Final Recall Stage Report on the National Kerry CAMHS is not easy reading. Psychotropic medications were being prescribed to 79% of children in the cohort they examined. The national average is 39%.
More children were on two or more such drugs than were on a single one, which runs contrary to what standard prescribing practice for minors looks like pretty much everywhere else in Europe.
Some of the drug combinations detailed were also highly unusual, and many were prescribed at rates well above national benchmarks, often without consideration of the child’s weight or height, as the BNF for Children requires. Risperidone, an antipsychotic, was given for an average of 22 months, far longer than the 6 weeks usage recommended to manage irritability in children with autism.
Amongst children with intellectual disabilities the numbers were even worse. Prescribing rates reached 94%, including neuroleptic use at 80% and a high prevalence of multiple concurrent drugs. No recorded baseline physical health assessment existed in over 90% of these cases. These are very much not the sorts of drugs which you fire and then forget, but Ffllow-up monitoring was negligible.
The report clearly stated that high rates of psychotropic prescribing, seemingly as an alternative to actual talk therapy, was a key failing, resulting in moderate to major harm in 89% of intellectual disability cases reviewed. That finding deserved headline status. It largely did not get any.
A problem that spans countries, not just Kerry
Individual clinicians bear some responsibility in the Kerry case, obviously. The NKCAMHS report found psychiatry was delivering triple the interventions of the rest of the multidisciplinary team put together, not because psychiatrists were doing anything wrong as such, but because the psychologists and OTs and speech therapists simply weren’t there in sufficient numbers. When the waiting list for CBT is six months long, the prescription pad is what you’ve got.
The same thing plays out in elderly care across the continent. A GP with a patient on medications from three or four different specialists doesn’t really have the time, and often doesn’t have the training or the systems, to sit down and work out whether all of those prescriptions still make sense as a package. Any one of them might be perfectly reasonable on its own. Five of them together might be doing damage. But there’s no one whose job it is to check, which is really the heart of the problem.
And the health records situation makes it worse again. In plenty of member states a hospital consultant can’t see what a GP has prescribed, and neither of them can see what the community mental health team has put the patient on. So you end up with a situation where nobody has the full picture and the patient is the one carrying the risk.
What the EU funded, and what happened next
There have been EU-funded efforts to tackle this, and some of them actually worked. OPERAM and SENATOR had a go at building software that could flag dodgy prescriptions based on established clinical criteria, and in some settings they managed to cut inappropriate prescribing by 37%. Fewer bad drug reactions, fewer people ending up in hospital for no good reason.
The problem, as is so often the case with EU-funded health research, is what happened when the money stopped. The projects wound down. The reports got written. Policymakers referenced them in speeches. And very little changed at the level of actual clinical practice, which is the bit that matters. Pharmacogenomics – the idea that you could use someone’s genetic profile to predict how they’ll react to a particular combination of drugs – sounds great, but it needs integrated electronic health records to work, and most member states don’t have those yet. At this point it’s like buying a radar system but not trusting the software and so not being able to turn it. Something which of course an EU member state would never do. The investment required to build them has not been forthcoming and, honestly, there’s not much sign that it will be.
The WHO set itself the target of halving medication-related harm by 2030. On current form, that’s not happening.
What could actually change things
Some of what needs to happen here wouldn’t require years of legislative wrangling, just the political will to actually do it and some relatively modest investment.
For a start, mandatory annual medication reviews in primary care, for anyone on five or more prescriptions, run by a pharmacist sitting alongside the GP. We know this works because the EU already funded projects that proved it.
Then there’s deprescribing — the structured process of actually reducing or stopping drugs that aren’t needed anymore. That needs to become routine, not something a handful of enthusiasts do on the margins. Doctors, both in hospitals and in general practice, need proper training in recognising when a pile of medications has crossed the line from helping to harming. And patients themselves need to be told, in plain language, what they’re on, why, and what the alternatives are. Most of them aren’t getting any of that at the moment.
What happened in Kerry is, when you strip it back, a story about medication filling the gap left by therapy services that aren’t funded well enough. More multidisciplinary teams and shorter waiting lists for psychological treatment would do more to fix inappropriate prescribing in mental health than any amount of retrospective auditing. And for children with intellectual disabilities specifically, specialist consultant oversight of what’s being prescribed should be compulsory. Not optional, not recommended
This matter now because it raises clear concerns regarding the treatment of children in care, but we must also consider that Europe is aging – by 2050 one in four Europeans will be over 65 – and an aging population is a population which is increasingly using multiple medications. The NKCAMHS report is a cautionary tale about what happens when prescribing practices outpace oversight, and its lessons apply well beyond child mental health services in one Irish county.
Making medicines available is necessary – and god knows Europe is struggling at that – but ultimately it may be ensuring they are used well is the more difficult part.