Psychiatric medication deprescribing has gained significant attention in recent years as healthcare professionals recognise the importance of optimising medication use and minimising potential harms associated with long-term use. Historically, there has been little attention paid to deprescribing in psychiatry, and the focus of research had been on prescribing.
Psychotropic medications play a crucial role in managing mental health conditions. While these medications can be effective in alleviating symptoms and improving quality of life, they also come with potential side effects, especially with long-term use.
Deprescribing psychiatric medications involves a careful and gradual reduction in dosage or discontinuation of medications with the goal of minimising adverse effects, optimising therapeutic outcomes, and promoting overall well-being. This process requires a collaborative approach between doctors and patients to ensure safe and effective deprescribing.
A variety of clinical scenarios warrant deprescribing. For example, a patient’s medication regimen comprising high doses of medication and polypharmacy with associated drug interactions leading to medical risk, patient preference, risk of continuing medications outweighing benefits (although this may not have been the case when the medication was initially instituted), or the condition has remitted.
Some adverse effects of psychotropic medications that lead to considerations of deprescribing include weight gain and other metabolic consequences, impaired capacity for feeling (emotional flattening), sexual side effects (anorgasmia and delayed arousal), effects on memory and concentration (cognitive fogginess), and extrapyramidal side effects, particularly from first-generation antipsychotics, and tremor from lithium.
Furthermore, as the patient’s age increases, the psychotropic medication side effect profile may increase due to impacts on drug metabolism, leading to reduced tolerance.
The Maudsley Deprescribing Guidelines 2024 provides evidence-based recommendations and practical guidance for deprescribing psychiatric medications. These guidelines are designed to assist healthcare providers in making informed decisions about when and how to deprescribe medications based on individual patient factors, medication characteristics, and treatment goals.
Key Principles of Deprescribing include:
- Patient-centred care – where patients are actively involved in shared decision-making regarding their medications to ensure that patient preferences, values, and goals are considered, coupled with detailed psychoeducation regarding the deprescribing process and potential risks.
- Risk-benefit assessment of each medication considering efficacy, side effects, potential drug interactions, and the patient’s psychological status.
- Gradual reduction in dosage over time to minimise withdrawal symptoms and monitor for any recurrence of symptoms.
- Monitoring and support for patients during the deprescribing process.
While psychiatric medication deprescribing offers significant benefits, it also presents challenges and considerations that must be addressed such as:
- Withdrawal symptoms during the deprescribing process, including rebound anxiety, insomnia, mood fluctuations, and physical discomfort.
- Relapse risk of illness recurrence when reducing psychiatric medications.
It is also important to distinguish deprescribing-related withdrawal symptoms from a relapse of a psychiatric condition. Withdrawal symptoms (including poor mood, anxiety and insomnia) can sometimes be mistaken as a relapse of the underlying disorder. A careful history can help distinguish withdrawal from a relapse of illness.
Key points of the history include the re-onset of symptoms, the presence of distinctive (physical and psychological) symptoms of discontinuation, and a response of those symptoms after a reinstatement of the previous dose for a short period of time.
Therefore, medication deprescribing is an important part of psychiatric pharmacology, and the approach of listening to the patient’s concerns and proceeding cautiously with appropriate rationale in deprescribing is in keeping with good clinical practice.
Key messages
- Deprescribing involves an individualised approach based on factors such as patient diagnosis, treatment history, current symptoms and shared decision-making
- Risk-benefit evaluation is essential in deprescribing with a focus on the patient quality of life
- A gradual reduction rather than an abrupt discontinuation is preferred to minimise risk of withdrawal symptoms and to monitor any risk of relapse of symptoms.
Author competing interests – nil