Uncertainty may be a hidden driver of overprescribing
STUDY: De las Cuevas C, Actas Esp Psiquiatr 2026
STUDY TYPE: Editorial
FUNDING: Independent
Background
Psychiatry lacks the biomarkers that anchor decisions in other medical specialties. Diagnoses are probabilistic, outcomes are hard to predict, and the line between disorder and normal variation is often blurry.
This editorial by Carlos De Las Cuevas argues that prescribing sometimes serves the clinician as much as the patient: a way to resolve the discomfort of not knowing, rather than a response to clinical need.
Summary
Dr. De Las Cuevas identifies four forces that lower the prescribing threshold:
- Intolerance of uncertainty: the tendency to experience ambiguity as aversive and to favor actions that resolve it quickly, even without clear evidence.
- Action bias: the preference for doing something over waiting, especially when outcomes are unpredictable.
- Need for closure: the drive toward definitive answers that can lock in early diagnoses and block reconsideration.
- Anticipated regret: fear of a bad outcome if nothing is prescribed, which amplifies the perceived cost of watchful waiting.
External forces add to the problem. Time-pressured visits leave little room for longitudinal observation. Patients often expect a prescription. Medico-legal culture penalizes undertreatment more visibly than overtreatment. And healthcare metrics reward treatment initiation over clinical restraint.
The cumulative result is overprescription, polypharmacy, and medications that persist by default without a clear plan for starting and stopping.
Practice Implications
- Before starting a new medication, ask “Am I prescribing because the patient needs this, or because I’m uncomfortable not prescribing?”
- Share your uncertainty in a therapeutic way, and have a ready source of non-pharmacologic solutions (I’ve gathered 30 here).
- Stay within the maximum effective doses, and avoid med strategies that failed to work in trials (that starts on slide 16 here). There are exceptions to this rule, but they are at the tail of the bell curve, not the majority.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
