It is not uncommon to see patients who are taking a long list of medications, some for which there isn’t a clear indication for ongoing use. This occurs for medications for physical health as well as mental health. It is important for a prescriber of any medication to assess in a thoughtful manner if it is necessary to continue prescribing that particular medication. There are many reasons to discontinue a medication, but the focus of this article is on the decision making process to discontinue a long-term medication for mental/behavioral health concerns.
Deprescribing is a systematic approach to identifying and discontinuing medications when existing or potential harms outweigh existing or potential benefits. The steps include (1) establishing a current and comprehensive medication list including the reason for each medication; (2) assess each medication for discontinuation with a risk: benefit analysis and order the priority for discontinuation; and (3) implement and monitor patients during taper off medication(s). Important considerations when deciding on which medications can be discontinued include: if there is no clear indication for use; if the medication is ineffective; if the original symptoms have resolved and stayed in remission; and if there are significant side effects that outweigh the benefits. It can be challenging to determine why a medication was started if it was started by another provider, and it is reasonable in those situations to take some time to get to know the patient and his symptoms and develop a case formulation prior to making a decision to stop a medication. Safety is maximized when medications are prescribed at the lowest effective dose with systematic reassessment of the need for continued use. The principle of sufficiency is that patients are only taking the medications necessary to meet their treatment needs and no more. If a decision is made to discontinue a medication, it is important to do it one medication at a time with close follow up and a plan in place for how to manage if it does not go well.
Here are some general deprescribing principles for the primary classes of psychiatric medications that are used long-term: antidepressants, antipsychotics, mood stabilizers and stimulant medications. When a patient is started on an antidepressant for a single episode of depression or for PTSD, the goal is to reach remission and maintain it for 6-9 months and then taper off the medication. When a patient has had multiple episodes of depression or more of a chronic PTSD, it is important to have a discussion with the patient about maintaining on the lowest possible dose of the antidepressant to help prevent future episodes of depression. When antidepressants medications are being used for anxiety disorders, it is reasonable to periodically try to reduce or taper off the medication to determine if it is still needed, especially once the patient has pursued therapy to help develop coping skills to help manage anxiety symptoms.
Regarding antipsychotic medications, in the case of a patient with a primary psychotic disorder, it is important to have the patient maintain on the lowest possible dose of their medication to prevent future psychotic breaks. This class of medication is used for other indications as well (adjunctive for depression and anxiety, sleep disturbance, aggression, irritability in autism) and for those uses, it is very important to continue use at the lowest dose and for as short of a time period as clinically reasonably to avoid long-term metabolic and involuntary movements side effects, which are more likely to occur the longer a patient is on an antipsychotic medication. It is also important to limit the length of time that one of these medications is used at a high “loading” dose (for example, in a manic state or to get control of intense aggression).
The general principles for the mood stabilizer medications are similar to the antipsychotic medications. For patients with true bipolar disorder, maintenance on the lowest possible dose of the least harmful mood stabilizer is important and indicated. When a medication in this class is used for other indications (adjunctive for depression, impulsivity, aggression) it is important to limit long-term use and reassess ongoing use given the risk for significant side effects for this class of medication.
When stimulant medications are prescribed for ADHD, the goal is to help with impulsivity, hyperactivity and inattention. It is known that the symptoms of hyperactivity and impulsivity dissipate as a child gets older and ideally a child starts learning executive functioning skills to help with inattention. It is reasonable to consider trials off medication (during a school break and non-intensive period of school) to determine if the mediation is still needed. The nice thing about the stimulant class of medication is that, because of the “in and out on the same day” mechanism, one knows fairly quickly what the effects of stopping the medication are.
It is our hope that this article helps answer some questions about when and how to consider deprescribing psychotropic medications. The article is a general overview. Please feel free to call SmartCare Behavioral Health with specific questions about particular cases.