The Vital Role of Pharmacists in Polypharmacy Management

For patients with complex behavioral health conditions, such a bipolar I disorder complicated by anxiety, substance use, or metabolic issues, taking multiple medications is often unavoidable. However, what needs to be considered is not just the number of prescriptions but the purpose behind each one.

As medication regimens become more complex and patients transition between prescribers, settings, and systems, pharmacists are increasingly vital and best positioned to see the full picture and keep care on track.

“Pharmacists, especially those in community settings, are often the frontline interaction for patients on multiple medications,” Michael McGuire, PharmD, BCPP, professor of pharmacy practice, psychiatry, at Belmont University College of Pharmacy and Health Sciences in Nashville, Tennessee, said. “In many cases, we may be the only ones who see a patient’s entire medication profile in real time because they might be missing their medical appointments, but they do go to the pharmacy and pick up their medications.”

McGuire has been on faculty at Belmont since 2012 and maintains an active clinical practice in behavioral health. From this dual vantage point, he noted that polypharmacy often develops not because of bad intentions but because no single provider is positioned to see everything a patient is taking.

“When someone is seeing multiple prescribers, each focused on their own specialty, it is very easy for unnecessary therapies to slip through the cracks,” he said. “In community pharmacies, we routinely catch early warning signs, whether that is overlapping therapies, medications that have not been reassessed, or adherence issues that could destabilize a patient.”

Seeing What Others Miss

Visibility into all prescriptions is one of the primary reasons pharmacists play a crucial role in polypharmacy management, according to Quynh Bui, PharmD, a clinical pharmacist at First Databank. First Databank provides drug knowledge and medication decision support to health systems, pharmacies, and clinical software platforms worldwide.

“Polypharmacy refers to the use of multiple medications taken by a patient and is generally defined as 5 or more medications,” Bui said. “It often occurs in the elderly or in patients under psychiatric care. Pharmacists, especially community pharmacists, are positioned to play an important role because they have visibility into all the medications prescribed from multiple specialists.”

She added that community pharmacists are uniquely positioned to become trusted partners in optimizing therapy.

“They can identify duplications of therapy, assess [adverse] effects, speak directly with the patient, and then communicate with prescribers when something does not make sense,” Bui said.

Another important component that makes pharmacists so effective in this space is continuity.

“A mental health provider may only see a patient every few months, but the pharmacist may see that same patient 2 or 3 times in between when they come in for refills,” McGuire said. “When you see someone that often, you start picking up on changes and can tell when something is off before anyone else notices.”

Collaboration Across Care Teams

For polypharmacy to work safely, pharmacists must be fully integrated into care teams and empowered to communicate directly with prescribers. That communication, the experts note, must be deliberate and ongoing.

“When you are working with patients who are on multiple medications, especially those with serious mental illness, communication [among] pharmacists, psychiatrists, primary care providers, and other mental health providers has to be intentional,” McGuire said. “Right now, too much of our mental health system is disjointed.”

That’s why pharmacists need to be viewed as clinical partners trained to deliver comprehensive medication management.

“We can verify whether each medication still makes sense for the patient, flag outdated or interacting therapies, and make evidence-based deprescribing recommendations,” McGuire said. “But that only works if we are given both the access and the authority to participate in those conversations.”

From a technological perspective, Bui noted that collaboration often begins with patient conversations.

“Pharmacists can best collaborate with providers through direct conversations with patients,” she said. “They can assess how well patients understand their medication regimen and identify [adverse] effects. If patients are unsure about their medications, pharmacists can reach out to the prescribing providers for clarification and additional information.”

After all, collaboration ensures that each component of the regimen is evidence-based and appropriately indicated for the patient’s care.

Weighing Benefit vs Burden

Evaluating whether a complex regimen still serves the patient requires constant reassessment, and it’s important to ask the right questions.

“When I am evaluating complex cases with multiple medications, I always start by asking whether each drug continues to serve a clear clinical purpose,” McGuire said. “If a medication is on the profile simply because it has always been there, that is a red flag.”

From there, he assesses the risk to determine whether the potential benefit is worth the chance of introducing medication errors, toxicity, or excessive treatment burden that would cause the patient to stop taking it altogether. He also evaluates whether the regimen is realistic in the long term.

“If someone does not have a strong support system, adding more medications may be overwhelming,” he said. “I constantly ask whether the regimen is sustainable without causing more harm than good.”

Bui noted that community pharmacists take a similar approach by ensuring there is a clear indication for every medication and avoiding unnecessary duplication.

“They can help avoid unnecessary duplications of mechanisms of action and ensure appropriate refills to assess adherence,” she said. “Another strategy is to encourage patients to speak up and communicate with their providers about the goals of their therapy.”

Deprescribing Without Destabilizing

Although simplifying regimens is often beneficial, McGuire cautioned against treating deprescribing as a purely numerical exercise.

“When I am reviewing a patient’s medication list, the first thing I look at is stability,” he said. “If a patient is managing their symptoms well, I do not immediately dismantle the regimen just because it looks complex, since sometimes that complexity is what is holding everything together.”

Once stability is confirmed, he looks for medications that no longer have a clear indication.

“I pay particular attention to drugs that often become drugs without an indication, such as anticholinergic medications and proton pump inhibitors,” McGuire said. “I also look for overlapping [adverse] effects and pharmacodynamic and pharmacokinetic interactions.”

Additionally, some medication categories require particular caution.

“Deprescribing can be particularly challenging with medications like opioid pain relievers or benzodiazepines,” McGuire said. “We often discuss the long-term risks, such as falls, cognitive impairment, and worsening trauma symptoms, especially as patients age.”

Leadership Through Monitoring and Education

Pharmacists are not only medication reviewers; they are also educators and often oversee laboratory monitoring for high-risk behavioral health therapies.

“This includes ensuring that baseline and ongoing assessments such as weight, fasting lipids, glucose, and [hemoglobin] A_1c are obtained and reviewed,” Bui says. “They can also advocate for renal and hepatic function testing.”

In McGuire’s opinion, leadership often begins with speaking up.

“If we see a patient with schizophrenia who keeps missing doses of their daily oral medication, we should bring that to the prescriber and say, ‘Have we thought about a long-acting injectable?’” he said. “Those products can improve adherence and reduce relapse risk.”

Education is just as important, which is why when he walks people through what a medication does, why it is part of the regimen, and how it keeps them stable, they are more likely to stay engaged in their treatment.

Technology as a Tool

Data analytics, medication review software, and electronic health records now play a major role in identifying potential polypharmacy risks. Bui noted that decision-support technology can be very effective when systems communicate accurately.

“Technology-driven medication decision-support programs can help pinpoint patients who may benefit from pharmacist intervention by flagging those prescribed multiple high-risk medications,” she said.

However, McGuire warns that disconnected systems can still allow errors to slip through.

“The tools we have now can be incredibly helpful when they talk to each other,” he said. “The problem is that they often do not.”

Even with the most advanced software, he stressed that clinical judgment remains essential.

“You still need a pharmacist to look at that data and say, ‘Does this make sense for this patient right now?’” McGuire said. “We cannot automate clinical judgment. Data should support that judgment, not replace it.”

Operational and Systemwide Impact

From a fulfillment and pharmacy operations standpoint, Tom Utech, CEO of iA, a pharmacy fulfillment company that supports large-scale dispensing and coordination, noted that pharmacists are central to managing medication complexity across the system.

“Community pharmacists monitor medication safety, help prevent duplicate therapy, and improve adherence through comprehensive reviews and patient education,” Utech said. “They are just one piece of the overall care team, but they have the most education and expertise in the medications themselves, which makes their role crucial.”

The use of shared electronic records and centralized fulfillment can maintain a comprehensive view of a patient’s total medication profile across multiple points of care. But even then, pharmacist oversight remains critical.

“Technology can help flag problems, but it is the pharmacist who ultimately reconciles medications and ensures that the therapy is accurate and appropriate,” Utech said.

What Comes Next

Looking ahead, McGuire noted the profession must move toward earlier and deeper integration into behavioral health care.

“If we are serious about advancing pharmacist-driven medication management, pharmacists need to be recognized and used as clinical providers,” he said. “Without provider status, we are limited in how much we can formally intervene.”

Bui emphasized the need for standardized deprescribing pathways and collaborative practice agreements.

“Collaborative practice agreements are necessary to empower pharmacists to order laboratory tests and adjust doses within defined clinical parameters,” she said. “This helps ensure safe, efficient, and coordinated patient care.”

Utech points to reimbursement and workflow reform as key to unlocking the capacity of pharmacists.

“The next priorities include expanding reimbursement for direct patient care services provided by pharmacists, strengthening EHR [electronic health record] integration, and advancing collaborative care models,” he said. “Incorporating centralized fulfillment can free up pharmacist time so they can focus on direct patient care and counseling.”

Polypharmacy will continue to be a reality for patients with a serious mental illness, complex chronic disease, and overlapping prescribers. The challenge is not how to eliminate it, but how to manage it intentionally.

“What truly matters is not the polypharmacy itself but the intentionality and purpose behind each prescription,” McGuire said.