Why I Changed How I Practice Psychiatry: A Framework Beyond Overprescribing
Between 2015 and 2022, U.S. antidepressant prescriptions rose more than 30% — and we are not a less anxious society. Here's the framework I use with every patient before we discuss medication.
The Patient Who Changed How I Practice
Years ago, a patient came to me after seeing three psychiatrists in five years. She had been diagnosed with major depressive disorder, then generalized anxiety, then adult ADHD. She was on three medications. She was not better. She was more confused about herself than when she started.
When I asked her — not about her symptoms, but about her sleep, what she was eating, how she moved, whether she felt connected, whether she ever truly rested — what came back was a picture of five foundational systems all running on empty. She wasn't treatment-resistant. She was under-resourced at the most basic biological and human levels, and no one had looked there.
The Overprescribing Problem in Modern Psychiatry
Between 2015 and 2022, antidepressant prescriptions in the United States increased by more than 30%. Anxiety medication prescriptions have followed a similar trajectory. By no meaningful measure are we becoming a less anxious or less depressed society. Something about the current approach is not working.
I am not anti-medication. I prescribe it. I have seen it change and save lives. But I have also watched it used as a first answer when it should have been a last resort — or, at minimum, not the only answer.
The Five Pillars: What We Look At First
At Bryn Mawr Mental Health and Wellness, and through The Pillars Project, we evaluate five foundations before — and alongside — medication:
- Sleep — the neurological state that clears metabolic waste and regulates the amygdala
- Rest — deliberate parasympathetic downregulation, distinct from sleep
- Nutrition — the gut-brain axis, where roughly 90% of serotonin is produced
- Movement — 150 minutes weekly of moderate activity, often more effective than medication alone
- Connection — the felt experience of being genuinely known, not merely socially active
What This Looks Like in Concierge Care
In a concierge model, we have the time to actually ask these questions. A first evaluation runs 90 minutes, not 15. We can look at your sleep architecture, your nutrition, your rest patterns, and your relational world before defaulting to a prescription pad.
Dr. Raena Khorram is a board-certified psychiatrist, founder of Bryn Mawr Mental Health and Wellness, and founder of The Pillars Project. She is licensed in Pennsylvania and New York and sees patients in Bryn Mawr and virtually throughout Greater New York State.
