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Phelps, 2019 Deprescribing in Psychiatry - Psychopharmacology Institute


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SA mention by Dr. Phelps.


Phelps J. Deprescribing in Psychiatry - Psychopharmacology Institute.

Psychopharmacology Institute, https://psychopharmacologyinstitute.com/section/deprescribing-in-psychiatry-2330-4422

(2019, accessed 12 February 2020).




For our next Quick Take, let’s look at the concept of deprescribing in psychiatry.


I was somewhat surprised to discover that there’s actually a small literature on this, led by a 2016 paper from Yale University’s Drs. Gupta and Cahill. I found that there are actually 2019 guidelines from the journal American Family Physician. The authors of that letter or article are actually part of a Canadian initiative that has led to a website called deprescribing.org. We’ve even reached the point here of having a website about deprescribing and a Canadian initiative for it! We’re going to look at some of the recommendations from that group, and then look at a specific example for stopping an antidepressant.


These recommendations for deprescribing have mainly targeted geriatric psychiatry, where it’s common that multiple medications have accumulated over time. But I think the principles of this process apply to every psychiatric medication, as we start thinking, “How will this medication be stopped someday?” It’s pretty unlikely that our medications are going to continue forever, even though at the time we start them many of them seem like they will be indicated thus. At some point, the patient will reach the geriatric age range, and we will need think about trying to take something out.


What is the general process of discontinuing a medication from the point of view of this initiative? It begins with a review of all current medications, including those that are prescribed by others, and then targeting a specific one and having a strong rationale for why it’s that one, including, “What will be the impact of this discontinuation on the other medications?” And it's not just kinetic effects, like carbamazepine, where you would have drug interaction changes, but also dynamic effects, like increased anxiety from discontinuing an anxiolytic that could then affect asthma or COPD. The process of starting with a careful review and targeting one medication at a time sounds great academically, but I think you all know from experience that this can be really challenging in the real world. They emphasized planning this discontinuation in partnership with the patient and in the geriatric setting with caregivers as well.


Regarding the planning, let’s look at some of the details of what’s recommended. First of all, I think the following questions are very useful: What is the patient’s perception of this medication? What does she or he think is its role? What does she or he think is going to happen when it is tapered off? What is the relative risk and relative benefit of getting rid of this medication versus continuing it?


You’ll discover, of course, when you do this that the whole process is intimately related to your treatment alliance in that this is much easier when alliance is good and much more difficult when it's hard. So, sometimes you have to begin with working on the treatment alliance itself. You have to have buy-in from the patient, someone who understands the rationale for stopping this medication. And I regard this as a negotiation process in many cases, where there may be some resistance in this idea and we need to sell the idea and gradually work it out with the patient before we get underway. If you don’t, you can imagine that you’ll just get spring back to where the patient says, “See, that was a bad idea. I knew we shouldn’t have done this, and I want to go back to my previous dose.” In that case, the patient is now even more stuck on that medication than before.


In terms of planning, you can think about timing like the season of the year. Don’t finish an antidepressant taper in November in the Northern Hemisphere. And consider things like relationships and work. Is there something coming up concerning the patient's finances or interpersonal issues that makes now not such a good time for this?


Also really important is making in advance a game plan for when problems come up during this taper. If symptoms recur, are we going back up on this medication, or are we moving on to alternatives? Can we add them on during the taper? What’s the plan? And for withdrawal symptoms, what’s the game plan there? Can we slow down? Can we back up a step? Having that mapped out in advance can really smooth the course when these things come up.

Let’s take an example of an action plan for an antidepressant. With a recurrence, rather than going right back up, which locks the patient in on that medication to an extent, we could consider augmentation with psychotherapy, light therapy, physical activity, or fish oil. These are all the low toxicity, low-risk interventions that buy us time for that antidepressant taper. In extreme cases, one might even consider transcranial magnetic stimulation or ECT. But it’s really a question of, “How determined are you to avoid going back up? How serious is the need to get off?” Note that before you go down, you have to mention to the patient that going back up is not guaranteed to work the way that it did before this process began.


Finally, regarding withdrawal symptoms (like for antidepressant withdrawal), in my view, you should be able to avoid these by laying out a taper process that simply keeps them from happening in the first place. But when they do, I think it’s important to provide support, and see if you can buy time with interventions like with fish oil, for example, and avoid going back up. Now, in extreme cases, I would simply refer the patient to survivingantidepressants.com and say, "Study up on what patients have done there", while trying to maintain my treatment alliance.


In summary, deprescribing is a process. It needs to be considered in advance of getting things underway. It is involved critically with your treatment alliance and setting up a game plan for the process and what to anticipate. Good luck with that process!



Edited by Altostrata
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I am here as a supporter to certain individuals undergoing withdrawal, and to learn from and contribute to the forum where possible.
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