Deprescribing Psychotropic Medication 2/7/24

Medication regimens that were once good, might not be the best choice now.

While psychotropic medications can be remarkably helpful in the management of many behavioral health disorders, it is not infrequently the case – particularly with children and adolescents— that revisions in established medication regimens are appropriate as the patient goes through the developmental process and as symptoms and diagnostic understandings evolves.  While is can be very difficult at times to achieve optimized symptom relief, it is critically important for prescribers to carefully assess the ongoing appropriateness of a youngster’s medication regimen and one of the important opportunities to consider may well be to reduce dosages and or discontinue medications over the course of time.

There is a natural tendency for providers to add medications to fine tune treatment as doing so reaffirms prior decisions to start a medication and there is a natural bias against reducing interventions that previously were deemed to be highly appropriate.  Today’s edition of the SmartCare newsletter speaks to the processes and considerations that need to be considered over time to refine care by reducing the medication burden by lowering dosages or eliminating medications.

Deprescribing can be a vital part of managing conditions, avoiding adverse effects, and cautiously challenging prior clinical assumptions that can ultimately improve outcomes and improve a patient quality of life.   Particularly in complex and clinically challenging cases, there is often a tendency for what has been described as “prescribing cascades” that results in unnecessary polypharmacy as when a drug administered causes subtle adverse signs and symptoms, that may be misinterpreted as a new condition, resulting in a new medication being added, when the prior prescribed regimen may more appropriately be better managed by dose reduction or drug discontinuation.  In other circumstances, the utility of a previously prescribed medication may be marginal and the patient may better be served with a less complex regimen.   In other circumstances stopping medications can sometimes produce withdrawal effects that may be difficult to interpret, so deprescribing needs to be done carefully in partnership between a patient, their caregiver and their healthcare provider.

Deprescribing psychopharmacologic medications should entail a careful tapering or discontinuation of a psychiatric medications that may no longer be necessary or beneficial for a patient. This process requires a thorough assessment of the individual’s mental health status, current medication regimen, and any potential risks or benefits associated with deprescribing.

  1. Assessment: The first step is to assess the patient’s current mental health status, including symptoms, functioning, and any changes in their condition since starting the medication.
  2. Review: Conduct a comprehensive review of the patient’s medication history, including the indication for each medication, previous response(s), side effects, and any attempts to taper or discontinue medications in the past.
  3. Risk Benefit Analysis: Evaluate the potential risks and benefits of continuing each medication. Consider factors such as the severity of the underlying condition, the potential for relapse, the presence of side effects, and the patient’s preferences and goals of care.
  4. Shared Decision-Making: Engage the patient in shared decision-making regarding the deprescribing process. Discuss the reasons for considering deprescribing, the potential benefits and risks, and alternative treatment options.
  5. Tapering: Monitor the patient closely during the tapering process and after discontinuing the medication. Regular follow-up appointments allow for ongoing assessment of symptoms, monitoring for any adverse effects or withdrawal symptoms, and adjustments to the tapering plan as needed.
  6. Monitoring: Monitor the patient closely during the tapering process and after discontinuing the medication.  Regular follow-up appointments allow for ongoing assessment of symptoms monitoring for any adverse effects or withdrawal symptoms, and adjustment to the tapering plan as needed
  7. Supportive Interventions: Offer supportive interventions to help manage any withdrawal symptoms or rebound effects that may occur during the tapering process. This may include psychotherapy, lifestyle modifications, or non-pharmacologic treatments.
  8. Reevaluation: Periodically reevaluate the patient’s mental health status and medication regimen to ensure that the deprescribing process is proceeding safely and effectively.  Adjustments to the treatment plan may be necessary based o changes in symptom or other clinical factors.

It is important to approach deprescribing with caution and to involve the patient/caregiver as an active participant in the decision-making process. Consultation with behavioral health professionals including both psychotherapist and psychiatrists can help ensure that deprescribing is done safely and in line with the individual’s and the family’s treatment goals and preferences.

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