Overprescribing and the "Do Something Imperative"

The intense situation where decisions are made

There you are, a doctor wrapping up a routine 15-minute visit to review blood pressure medications, when the patient suddenly starts sobbing. “It’s hopeless. I can’t go on. There’s no point to anything.” Your next patient is waiting. Psychotherapy appointments are available in a month. The earliest available psychiatric assessment is two months out. You went into medicine to help people. This person is desperate for help. The pressure to do something is intense. Your prescription pad is ready. You reach for your pen.

The “Do Something Imperative” is at the root of over-prescribing but it hardly gets mentioned in the current public debate. The debate got louder after the May 4^th summit on mental health and over-medicalization organized by HHS Secretary Robert F. Kennedy. The antiscientific tenor of the conference is illustrated by his statement that stopping SSRIs is “ten times harder than quitting heroin.” The event encouraged anti-psychiatry advocates to amplify patient testimonials about withdrawal symptoms. Organized psychiatry responded by describing the benefits of medications. Commentators on all sides found targets to blame: clinicians, corporations, and conspiracies. However, the interaction between a patient and a clinician where prescription decisions are made was ignored.

Many people think that antidepressant prescriptions are mostly written by psychiatrists who have spent an hour taking a careful history and establishing a relationship with the patient. However, a 2026 analysis by the Health Care Cost Institute found that 75% of all psychotropic prescriptions are written by primacy care physicians, nurse practitioners, internists, and other medical specialists (Gordon & Martin, 2026). The patient’s account of despair, sleeplessness, and hopelessness often arrives in the last three minutes of an appointment booked for something else. The next patient is waiting. The wait for a psychiatric consultation is two months.

Even in appointments specifically booked to deal with anxiety or depression the “Do Something Imperative” looms. Most people who ask for help with depression have already tried yoga, meditation, self-help books, herbal remedies, and advice from their minister and/or bartender. They have gathered the courage, the money, and the time to ask a professional for help. All of that interact with a clinician’s training, identity, and expectations to create intense pressure to do something. Writing a prescription is often the only action that feels adequate to the situation.

Research confirms what clinicians experience. A study identified three factors that consistently push primary care physicians toward prescribing medications even if they are unlikely to be effective: clinical uncertainty about what to do, social pressure from patients and the system, and above all, “a desire to do something for the patient” (Tingström et al., 2020). When standardized patients present with symptoms of adjustment disorder (a condition not helped by antidepressants), the percentage who depart with a prescription goes up from 10% to 55% if the patient mentions a specific antidepressant (Kravitz et al., 2005). Clinicians tend to be unaware of the effect, but pharmaceutical advertising relies on it. Also, the bias towards action increases towards the end of a long medical workday (Linder et al., 2014).

In a study of 130 primary care physicians given clinical vignettes of patients with unexplained symptoms, 87% chose to prescribe, test, or refer rather than simply follow up — a pattern the authors call “action bias” (Kiderman et al., 2013). The bias to action is the predictable outcome when compassionate professionals are in a pressured situation with someone who is suffering. No specialist is available, but a prescription pad is. Telling clinicians “Quit prescribing so much” has little effect. Erecting bureaucratic obstacles can decrease prescribing, but at the expense of decreasing the availability of treatment for patients who would benefit and wasting precious minutes that could be spent with patients.

An obvious solution would be to provide longer appointments and make psychiatric expertise more readily available. Both are unrealistic. RVUs and cost containment are the focus of managers whose promotions depend on profits, and adequate resources are rarely available in any case. However, many clinicians, most in my experience, try hard to provide the best help possible whatever the situation. They would welcome deeper understanding about the situation in which they make prescribing decisions are made and how to help patients to understand the rationale.

Secretary Kennedy has the resources to get to the root of the overprescribing problem. He could instruct HHS to fund research on the interactions of doctors with patients in the crucial moments when decisions are being made. They would be glad to share what it is like to experience the “Do Something Imperative” and their strategies for dealing with it. They would also be glad to describe other related challenges including two that help to account for overprescribing: the tendency to give credit to a new medication whenever a patient improves, even when symptoms would have eased on their own; and the tendency to blame symptoms during a drug taper on the lower dosage even when they may be unrelated.

The doctor reaching for a pen at the end of a 15-minute visit is not the problem and summits are not the solution. Understanding the “Do Something Imperative” from the inside in the moments when it operates offers an opportunity for real change.

Gordon, B. S., & Martin, K. (2026, March 31). Primary Care Providers Prescribe the Majority of Antidepressants and Anxiolytics for People with Employer Sponsored Insurance. Health Care Cost Institute. https://healthcostinstitute.org/all-hcci-reports/primary-care-providers-prescribe-the-majority-of-antidepressants-and-anxiolytics-for-people-with-employer-sponsored-insurance/

Kiderman, A., Ilan, U., Gur, I., Bdolah-Abram, T., & Brezis, M. (2013). Unexplained complaints in primary care: Evidence of action bias. The Journal of Family Practice, 62(8), 408–413.

Kravitz, R. L., Epstein, R. M., Feldman, M. D., Franz, C. E., Azari, R., Wilkes, M. S., Hinton, L., & Franks, P. (2005). Influence of patients’ requests for direct-to-consumer advertised antidepressants: A randomized controlled trial. JAMA, 293(16), 1995–2002. https://doi.org/10.1001/jama.293.16.1995

Linder, J. A., Doctor, J. N., Friedberg, M. W., Reyes Nieva, H., Birks, C., Meeker, D., & Fox, C. R. (2014). Time of Day and the Decision to Prescribe Antibiotics. JAMA Internal Medicine, 174(12), 2029–2031. https://doi.org/10.1001/jamainternmed.2014.5225