DEPRESCRIBING

IN PSYCHIATRY

Swapnil Gupta | Rebecca Miller John Cahill

OXTORD
Deprescribing in Psychiatry
Deprescribing in Psychiatry

SWAPNIL GUPTA, MBBS, MD

REBECCA MILLER, PHD
JOHN D. CAHILL, BMBS, PHD
Yale University School of Medicine
Department of Psychiatry
New Haven, Connecticut
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Library of Congress Cataloging-in-Publication Data

Names: Gupta, Swapnil, author. | Miller, Rebecca, 1974- author. | Cahill,John (John D.), author.
Title: Deprescribing in psychiatry / Swapnil Gupta, Rebecca Miller, John Cahill.
Description: New York, NY : Oxford University Press, [2019] |
Includes bibliographical references.
Identifiers: LCCN 2019012605| ISBN 9780190654818 (pbk.) |
ISBN 9780190654825(UPDF) | ISBN 9780190654832 (ePub) |
Subjects: | MESH: Mental Disorders—drug therapy | Deprescriptions |
Psychotropic Drugs—adverse effects | Inappropriate
Prescribing—prevention & control | Mental Health Recovery
Classification: LCC RC483 | NLM WM 402 | DDC 616.89/18—dc23
LC record available at https://lccn.loc.gov/2019012605

This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the
conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate
information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical
and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and
accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-todate
published product information and data sheets provided by the manufacturers and the most
 To Gyan, SSJ, and Rajo. SG
To JR — thank you for sharing the decision with me. RM
To V (and all others with the wisdom and courage to have more questions than answers). JC
 Contents

Preface
Acknowledgments

I. THE CONTEXT FOR DEPRESCRIBING

1. Deprescribing in Psychiatry: An Introduction
2. Decision-Making in Deprescribing
3. Barriers to Deprescribing: Origins and Solutions
4. Nonpharmacological Aspects of Deprescribing

II. THE INTERVENTION OF DEPRESCRIBING

5. Wellness Approaches I: Self-Determined Strategies
6. Wellness Approaches II: Collaborative Strategies
7. The Process of Deprescribing
8. Deprescribing Antidepressant Medications in Major Depressive Disorder
9. Deprescribing Antipsychotic Medications
10. Deprescribing Mood Stabilizers
11. Deprescribing Benzodiazepines, Z-Drugs, and Stimulants
12. Concluding Thoughts and Future Directions

Appendix

Index
 Preface

Many of us also know what it means to be buried under an avalanche of psychiatric drugs. We know what it means to have the
treatment be worse than the disorder. We know what it means to be in a chemical tomb, where we feel so drugged we are neither
alive nor dead; when we are so drugged that our bodies are stiff and slow and lifeless; when our faces become expressionless
masks; when our eyes stop dancing and, instead, glaze over into a petrified stare; when our passion is neutered under powerful
pharmaceuticals; and when we are, quite literally, disappeared within a chemical coma.

—Deegan (2004)

This provocative and disturbing description of one person’s experience of taking an excess of psychiatric
meds is, unfortunately, not a unique experience. With the growth of pharmaceutical approaches to treating
psychological distress and psychiatric symptoms, psychiatric prescribers are more equipped to add,
rather than take away. Without sounding overly ambitious, this book aims to take a step toward
rebalancing the scales by promoting the innovation, implementation and study of rational deprescribing
as an intervention for psychiatry. We, the authors, do not approach the topic lightly, having seen the great
benefits of awakening a person’s spirit when medications address signs and symptoms appropriately and
allow a person to regain or establish a life they love. We do not profess to have the singular algorithm for
determining who needs what medication and when (i.e., who would benefit from what medication at what
dose and for what length of time). We do not presume that the individual prescriber reading this should
necessarily be prescribing fewer medications, nor do we consider deprescribing a panacea. Furthermore,
deprescribing should not be regarded as a movement or a fad.
Instead, our more modest proposal is to offer a pragmatic starting point; and to stimulate open
conversation among patient, prescriber, the clinical team, and friends and family in order to support the
option of decreasing or stopping psychiatric medications through a process of shared decision-making:
the intervention of deprescribing. While Deegan’s quoted description may seem extreme, it is not an
uncommon experience, particularly for those with psychotic disorders. Many of our own patients and
many patients across the country are prescribed multiple psychotropic medications, especially during a
hospital stay, with varying degrees of follow-up evaluation of their purpose and ongoing necessity.
Polypharmacy is prevalent, carrying numerous often underconsidered risks.
This book and we the authors are not “anti-psychiatry”. In fact we view deprescribing as a tool with
which psychiatry might remain most relevant and effective moving into the future. Two of us are
practicing psychiatrists (SG, JC) who make ample use of medications in their practice, and the other is a
practicing psychologist (RM), all working in an active urban community mental health setting. Instead we
might consider ourselves “anti-irrational prescribing”. To put it in a more strengths-based frame, we
consider ourselves interested in promoting a person’s best life by using the tools to support that objective
in the most reasonable way, tools that include medications and psychotherapy along with a whole host of
others. At the same time, we look to collaborating and leaving appropriate room for individual testing to
see if medications are useful tools for the person in this pursuit, and if so, which and how much. It comes
from a place of humility rather than hubris that we imagine this book as in its first edition. Our hope is that
a seed has been planted and that, with time, the field’s experience and evidence base will grow—and so
too will this volume. Part 1 reflects context, selected background and rationale that drives this work for
us. Part 2 proposes a starting point for the development of deprescribing clinical guidelines in psychiatry.
We focus on key areas and applications of the clinical intervention and, for scope of this book, are far
from exhaustive. To account for the perhaps inevitable diffusion of a clinical intervention, as it flows
along the pipeline of implementation, we have deemed it necessary (and justified) to orient at times
around both available clinical efficacy and effectiveness literature as well as what we perceive is real-
world, common belief and practice. Elsewhere, we offer possible alternative interpretations of
established findings in order to remind the reader of the potential for subjectivity when drawing clinical
inference from certain study designs. We suggest that it is what we hold true as field at large, not the raw
sum of the literature, that principally drives real-world patient outcomes. We nevertheless trust that the
reader will critically consider the evidence and assertions in this work through their own lens of
experience and expertise.
Writing this book has itself been an exercise in shared decision-making. The process sparked numerous
controversies among the three of us, followed by discussions that led us to repeatedly reexamine our own
prescribing behaviors and identities as mental health professionals. It facilitated a consideration of the
wide socioeconomic context of the practice of psychopharmacology as well as the individual patient’s
experience. Most importantly, it led each of us down an inward path that was defined by our individual
culture, upbringing, belief systems, and medical, psychiatric, and psychological training. Rather than
attempting to expunge these differences and present this book as a standard, uniform guideline, we briefly
elucidate our individual training and the experiences that affect our understanding and practices around
psychopharmacology.
Swapnil Gupta was born and brought up in the small town of Pondicherry, in Southern India. She went
to a medical school that highlighted critical engagement with the pharmaceutical industry, close
examination of evidence-based treatments, and rational use of medical testing, medications, and other
interventions. In her psychiatric residencies in both India and the United States, she encountered patients
whose psychological suffering was equally related to economic, sexual, racial, and various forms of
disenfranchisement as it was to diagnosable mental disorders. In her clinical practice, she attempts to
maintain a complex, biopsychosocial view of her patients’ experience, at every stage of their treatment.
For her, this book is a combination of rational medication use, critical evaluation of the available
evidence base, parsimonious and equitable use of resources, and, finally, making the patient’s voice
heard.
Rebecca Miller grew up in New Jersey, in the United States, as part of a white, upper middle-class
protestant family. Her quest to understand her own experiences with mental illness and the mental health
system led her to obtain a degree in clinical psychology and to work in community mental health in order
to help create a more equitable mental health system. She directs peer support and trains psychiatry
residents and psychology interns, incorporating her lived experience into her efforts to improve mental
health care. The effort around deprescribing is, for her, a civil rights endeavor, in support of others
interested in trying the “experiment” of reducing or stopping medications in an empowered, collaborative
way.
John D. Cahill was raised in the United Kingdom and has a bi-cultural background, having been
exposed to both Western and Eastern perspectives on wellness. He felt a calling as a physician from a
young age, attended medical school during the ascent of evidence-based medicine, biological psychiatry
and community-based mental health care, and moved to the United States for specialty training, drawn by
opportunities for innovation of psychiatric care. His work spans biomarker and new drug target
development, the psychotherapeutic aspects of prescribing, and building learning healthcare systems. His
principle occupation remains the care of individuals with both emerging and persisting serious mental
illness. Struck by the inherent (and at times meaningful) uncertainty and imprecision within psychiatric
care—and the range of reactions (for better or for worse) one might manifest to this challenge (from
patients, caregivers, providers, academia, care systems, government, and society as a whole), he is
honored to contribute to this book principally to illuminate the issues, offer a starting point for
deprescribing practice and frame questions for future research and debate. John does not presume that
deprescribing will result in psychopharmacology becoming less prominent in psychiatry, but that
deprescribing represents a meaningful construct for all stakeholders to consider in order to ensure
minimum-effective dosing of medications and robust therapeutic alliance.
—SG, RM, JC
New Haven, CT
April, 2019
 Acknowledgments

This book acknowledges our patients - past, present and future - who teach us so much. It is also the
culmination of influences from so many teachers, mentors, family, and friends, each of whom added their
voice in different ways to the thinking represented in this book. We wish we could acknowledge each of
them individually as they have contributed so much to the development of this book and provided the
support to allow for the time it took in the writing.
The work described in this book was funded in part by the State of Connecticut, Department of Mental
Health and Addiction Services (DMHAS), but this publication does not express the views of DMHAS or
the State of Connecticut. The views and opinions expressed are those of the authors. We are grateful to
DMHAS for the support it provides for this work.
In particular we want to express gratitude to Michael Sernyak, Robert Cole and Jeanne Steiner at the
Connecticut Mental Health Center (CMHC) for providing the space and support to work in innovative
ways; the people receiving services at CMHC, who inspire us with their strength and courage and honor
us by sharing their stories with us; Megan Katz, for her keen editorial eye and broad vision for the
organization of the book; Yaara Zisman-Ilani, John Strauss, and Vinod Srihari, for comments on the
manuscript; and Sandy Steingard and Tamar Lavy, who have shared countless thoughts, ideas, and stories.
Thank you to our editors at Oxford University Press; Andrea Knobloch and Lani Oshima, as well as
assistants Allison Pratt and Ann Sanchez, for their patience and support in this process.
In addition, SG owes a debt of gratitude to her parents (Yogi and Alka), teachers at JIPMER and
PGIMER, Stephen Goldfinger, Nina Schooler, Mohini Ranganathan, and Deepak Cyril D’Souza, her
wonderful team of clinicians at CMHC (Candace, Dorothy, Laurie, Melissa, Molly, Monica, Terri). RM
would like to acknowledge and thank Erika Carr, Allison Ponce, Michelle Silva, and Christy Olezeski for
stalwart support and positive peer pressure; the peer support team at CMHC; Larry Davidson, Janis
Tondora, Chyrell Bellamy, Michael Rowe, Anthony Pavlo and others at Program for Recovery and
Community Health, for their inspiring work; and family ASM, KSM, DHM. JC would like to specifically
acknowledge the mentorship of the late Ralph Hoffman, whose brilliance and humanity was a shining
example for the field. JC is indebted to collaborators and mentors at the University of Nottingham, the
University of Huddersfield, and Yale University, and for funding support (of separate, but informing
work) from the National Institutes of Health, the Brain & Behavior Research Foundation, the Rabinowitz
family, and the Patrick and Catherine Weldon Donaghue Medical Research Foundation.
—SG, RM, JC
 PART 1

THE CONTEXT FOR DEPRESCRIBING

 1
Deprescribing in Psychiatry
An Introduction

This chapter provides the foundation for the rest of the book, defining the concept of deprescribing and
relating it specifically to working with the deprescribing of medications in psychiatry. It provides a
rationale and history of the concept of deprescribing, outlines the potential benefits of adapting
deprescribing to psychiatry, and orients the reader to the rest of the content of the book.

Goal and Learning Objectives

After reading this chapter, the reader will be able to:
1. Define the concept of deprescribing
2. Give three justifications for its application in psychiatry
3. Identify three ways in which deprescribing is congruent with recovery- oriented care

Deprescribing as a Critical Intervention in Psychiatry

Psychiatry is at a crossroads, one where the overmedicalization of distress, economic interests of ‘Big
Pharma’, and soaring health care costs intersect with the promise of more effective and precise biological
treatments. Although the introduction of newer psychotropic medications has expanded the treatment
options in psychiatry, there is a risk of overprescription and unrealistic expectations in terms of risk–
benefit ratios. For instance, psychotropic medications such as fluoxetine (Prozac), quetiapine (Seroquel),
and aripiprazole (Abilify) have made the blockbuster medication list on several occasions in the past two
decades. However, they have also been the subject of scrutiny around side effects, resulting in major class
action lawsuits against their manufacturers. This warrants careful reexamination of current prescription
practices and a recalibration of our understanding of the potential risks and benefits of prescribing
psychotropic medications for a given condition or symptom.
Every individual is a stakeholder in the public debate surrounding the issue of psychiatric medications,
but this debate is exceptionally significant to individuals experiencing distress, their families, and the
people who work in mental health, including psychiatrists, nurse practitioners, pharmacists,
psychologists, social workers, allied caregivers and physicians in other specialties.
Alongside this is the emergence of the voices of people with the illness, including radical groups who
contend that the experiences termed mental illness are an extension of the range of human experience and
not to be pathologized. The social contexts of community breakdown, poverty, racism, and discrimination
against a range of identity markers, along with the resultant trauma, can feed a widespread rejection of
strict biological explanations for the psychological distress that the individual faces.
Deprescribing is one avenue for addressing this expansion of drug prescription and the medicalization
of distress. While certainly not a panacea, we believe that the expanded deprescribing intervention
described in this book has the potential to help shift practice by acknowledging the inherent uncertainties
in psychiatric treatments and by guiding prescribers in working collaboratively in (de)prescribing
psychotropic medications. We use the structure of deprescribing to frame and address the questions of
balancing risks with benefits, patient autonomy with community interests, and medical expertise with
experiential expertise.

A Definition
Scott et al. (2015) defined “deprescribing” as the “reduction or cessation of potentially inappropriate
medications in situations where existing or potential risks outweigh existing or potential benefit, taking
into consideration the patient’s medical and functional status and preferences”. In this way it can be
regarded as a collaborative inquiry, within a shared decision-making framework, toward the goal of
minimum effective medication usage. It is neither an “anti-prescribing” stance, nor a denial or
invalidation of suffering, nor a rejection of evidence-based treatment. The term “deprescribing” was
originally coined in geriatric medicine, where patients are at greater risk for serious consequences of
polypharmacy due to side effects, additive effects and ensuing drug–drug interactions. This risk escalates
in patients as they age, in part because of altered metabolism of medications as well as because of the
increasing incidence of polypharmacy. In the geriatric population, the potential negative consequences of
polypharmacy have included increased falls, altered mental status, and cardiac arrhythmias (Woodward,
2003). The highly visible impact of polypharmacy in geriatric patients may have functioned as the
proverbial “canary in the coal mine,” making the danger readily apparent and visible to all. This most
vulnerable population inspired a movement toward reevaluating medication regimens, one that has pushed
the field of geriatric medicine into defining prompts, protocols, and guidelines for implementing
deprescribing (e.g., the Beers Criteria; Fick & Semla, 2012).
Since then, deprescribing is increasingly emerging in other medical specialties, including cardiology,
in which, recently, the idea of the long-term use of various medications including aspirin, statins, beta-
blockers, and angiotensin converting enzyme inhibitors following a myocardial infarction has also been
called into question (Rossello, Pocock & Julian, 2015). The lack of clear evidence for guidelines around
their continued use, along with concerns regarding polypharmacy and a lack of trials on drug withdrawal
have continued to motivate this work. In primary care, proton pump inhibitors have become a target of
deprescribing as the data on long-term efficacy are increasingly being recognized as inadequate
(Boghossian et al., 2017; Reeve et al., 2015; Walsh et al., 2016). In neurology, research in epilepsy has
established the feasibility and advantages of discontinuing anticonvulsant medications, particularly for
those who have not had seizures for a given period of time (Aktekin et al., 2006; Dash et al., 2015).
Guidelines have now emerged to specify those patients for whom deprescribing antiepileptic drugs is
recommended (Beghi et al., 2013). Our work takes this argument forward into the mental health realm,
where the serious potential consequences of long-term psychotropic usage (such as increase
cardiovascular mortality) need to be weighed against benefits and patient preference (Parks et al., 2006).
The limited frequency of review of risk/benefit ratios in chronic pharmacotherapy is an unfortunate
result of real-world practice across all medical specialties. Factors influencing this may include an
inadequate evidence base for the required duration of pharmacotherapy and an absence of trials on how to
discontinue a medication. Furthermore, adjusting or reducing medications may provoke fear of “rocking
the boat” if a patient has attained medical stability with some difficulty (Steinman & Landefeld, 2018).
Prescribers may also feel an obligation to do “something” when faced with a person’s suffering, biasing
them toward continuing to prescribe the same or additional medications. Although well-meaning, this
risks violating the basic tenet of “first, do no harm,” when the continued use of a medication results in
more negative than positive effects.
Medicine has been said to be vulnerable to the “therapeutic illusion,” which is a tendency to attribute
improvement or recovery to medical interventions even though there may be other factors that may
partially or completely explain an improvement (Casarett, 2016; Thomas, 1978). For instance, a
physician who prescribes an antidepressant to a depressed patient may attribute any resulting
improvement in symptoms to the medication. The reality may be that the patient presented toward the tail-
end of the natural course of the episode (an untreated episode of depression is expected to last 6–9
months); that the patient stopped drinking alcohol at the same time as starting medication; or that the
patient experienced a significant social context change (such as getting a new job or starting a new
relationship).
Although the concept of deprescribing can easily become entangled in deep philosophical, social,
political, and ethical debate, at the core of deprescribing (and this work) is a structured, multifaceted
clinical intervention warranting further development, study, and dissemination. While relatively well-
developed in geriatric medicine, this intervention has only recently emerged in psychiatry. It is crucial to
differentiate the intervention of deprescribing from the mere act of ‘discontinuation’ or ‘withdrawal’ of
psychotropic medications which have been variable defined, implemented and studied in psychiatry.

Why Psychiatry Needs Deprescribing

The concepts of shared decision-making, minimum effective dosing, and medication discontinuation
research are not new to psychiatry. However, with the relatively greater emphasis on medication initiation
and continuation in clinical literature, guidelines, and training, the option of medication reduction may be
easily overlooked. Organizing the approach and furthering research around the construct of deprescribing
may help to redress this imbalance. We elaborate reasons why deprescribing is critical to psychiatry,
focusing on the preservation of patient autonomy, minimization of polypharmacy, and the contextualization
of reductionistic biological models.

Patient Autonomy

The topic of the ethics of psychiatry has been extensively written about in books, papers and the like.
Patient autonomy is particularly pertinent to deprescribing due to its foundation in shared decision
making. Psychiatry’s past may continue to reverberate in negative ways and psychiatric providers would
do well to acknowledge the past history of the field, which has included the implementation of later-
proven-ineffective or even harmful treatments prior to the more wide-spread adoption of medical
research ethics committees and evidenced-based medicine. Included in these are such practices as cold-
packing, lobotomy, and insulin-induced coma—the images of which contribute to current stigmatization of
both the field and our patients. Some of the patients currently seen in our mental health systems have had
personal experiences with these therapies. Could deprescribing be an opportunity to heal the iatrogenic
trauma and mistrust which lingers from not too distant past? Whilst being a far from straightforward issue,
involuntary commitment, the use of restraints, and legally mandated medication continue to be regular
practices in the face of emergent or imminent risk, along with more subtle forms of coercion which erode
patient autonomy. Practices that undermine trust and decrease perceived and actual patient autonomy
around treatment decisions become especially problematic if procedural justice is not served.
Deprescribing, as an intervention in psychiatry, is conceptualized as one that stands to increase patient
autonomy.

Deprescribing as a Biopsychosocial Intervention

Although the psychiatry mainstream has prided itself on maintaining a “biopsychosocial” approach to its
disorders and treatment, biomedical explanations and treatments have overshadowed psychological and
social interventions in recent decades. With its greater emphasis on psychotherapeutic and social
supports, deprescribing offers an opportunity and framework to rebalance the biopsychosocial approach
to the treatment of psychiatric disorders while bringing together key care stakeholders in a collaborative
mode. For example, when an antipsychotic medication is reduced to a minimum effective dose within the
framework of deprescribing, this may lead to an increased investment in social supports, lifestyle
changes, and psychotherapeutic interventions. Ensuring that treatment does not become “toxic help” is an
imperative in providing responsible, ethical, and effective care in psychiatry (Deegan & Drake, 2006).
The availability of deprescribing could serve as a safeguard to ensure that the use of medications are
limited to situations in which they are clearly indicated; to reorient and rebalance the focus of treatment to
psychological and social factors (see Figure 1.1); and to promote collaboration with the patient as an
equal partner in his or her own care.

Figure 1.1 Increased integration and balance of bio-psycho-social approaches as a collateral benefit of deprescribing. The scenario on the left
represents a patient’s treatment, where a prescriber is addressing some medical health factors and prescribing several medications. The
prescriber is working in relative isolation from a therapist who is addressing both psychological and social factors with the patient (however,
overall, and in the eyes of the patient, the major focus is on the pharmacotherapy). The prescriber and patient initiate a deprescribing of one
medication—involving the therapist from the outset. This promotes the scenario on the right, where there is increased collaboration between
providers and psychosocial factors become more prominent in the patient’s treatment.

Nonconcordance
Many patients already seek to discontinue their medications and may do so on their own regardless of
their prescriber’s advice or involvement. The adherence rates to medication in schizophrenia provides
one illustration, with reported rates ranging from 42% to 95% (Sendt et al., 2015). Could proactively
addressing the option of reducing or stopping medications preempt risks surrounding patient-initiated,
abrupt medication discontinuation? When requested by a patient, who with capacity, is aware of the risks,
the outstanding question for the prescriber becomes not whether to guide a therapeutically optimal
discontinuation, but instead determining how. The focus on the doctor–patient relationship, building trust,
and maintaining communication and connection is an essential element of all medicine but becomes
particularly highlighted in deprescribing. In this way deprescribing can promote concordance between
prescriber and patient.

Deprescribing as a Recovery-Oriented Practice

Our understanding of recovery-oriented practice does not mandate the universal deprescribing of
psychotropic medications. However the rationale for deprescribing in psychiatry fall within the related
overarching concept of recovery-oriented care that links them philosophically. The idea that someone
with a mental illness can live a meaningful life, pursuing important life goals, was seen as a somewhat
radical notion in the late twentieth century but has since taken hold as a dominant paradigm in the United
States and internationally in recent years. The idea that people can live with and live beyond their
psychological symptoms provides a challenge to previous conceptualizations of mental illness as a sort of
“life sentence.” Deprescribing (like de-institutionalization and de-hospitalization) seems like a natural
progression in the evolution of thinking about mental illness—one that takes into consideration the lived
experience of those of us (including co-author RM) who live with mental illness or experiences of
extreme emotional distress. Baker et al. (2013) argue for the reorganizing of the psychiatrist–patient
relationship to better orient medication prescribing with recovery-based principles. In line with person-
centered principles, the patient is encouraged and educated about being a full partner in decisions around
medication and other treatments (see Figure 1.2).

Figure 1.2 Deprescribing is well-aligned with recovery-oriented principles.

Shared decision-making has been identified as one of the key practices in deprescribing (cf. Miller &
Pavlo, 2018). Principles such as respect for patient autonomy and viewing the person as an expert in his
or her own experience, including that of illness and health, support the conceptualization of deprescribing
as a recovery-oriented practice. In addition, the focus of treatment shifts from clinical recovery to
personal recovery, which means that, instead of having a specific symptom-related goal, treatment is
modified to suit the patient’s attitudes, values, and life goals. Deprescribing, with its focus on the patient’s
values, attitudes, and preferences, is an intervention that espouses personal recovery. Table 1.1 identifies
specific recovery-oriented practices and how they apply to deprescribing.
Table 1.1 Some recovery-oriented practices in mental health and their application to deprescribing
Practice Description Application to deprescribing
Shared decision-making SDM is a process of collaboration to arrive at a mutually Collaboration, provision of education, and
(Davidson, Tondora, Pavlo, acceptable plan for moving forward in the treatment process. solicitation of the patient’s preferences and
& Stanhope, 2017; Deegan It involves two experts: the physician with scientific and values at every step are essential components
& Drake, 2006) clinical knowledge, and the person who knows his or her own of deprescribing
preferences, values, and subjective experiences.
Person-centered care Person-centered care puts the person receiving care in the Deprescribing aims to increase quality of life
(Davidson et al., 2017; driver’s seat, and focuses on life goals vs. treatment goals. It via reducing use of medications as applicable.
Stanhope, Ingoglia, is a highly individual comprehensive approach to developing a Person-centered care offers a framework in
Schmelter, & Marcus, 2013; care plan for achieving life goals rather than a problem focus which individualized tapering plans as well as
Tondora, Miller, Slade, & or strictly symptom relief. psychosocial supports are nested.
Davidson, 2014)
Hope (Jacobson & Hope is the belief that recovery is possible. High expectations With its emphasis on individual goals and
Greenley, 2001) and a belief that a person can achieve goals is crucial to preferences, deprescribing potentially instills
recovery. hope.
Empowerment (Jacobson & Empowerment may be viewed as a corrective for learned Engaging in the process of deprescribing may
Greenley, 2001) helplessness and low self-efficacy that may have been empower the individual by encouraging them
instilled by the mental health system. It includes autonomy, to take charge of their treatment and providing
courage and responsibility. the space for them to take risks, should they
choose to do so.

A key element of recovery-oriented care is the use of person-first language and descriptions that are
empowering. Referring to someone as “noncompliant” or “lacking insight” (1) is not behaviorally
anchored, (2) suggests judgment of behavior (as opposed to value-free observation), and (3) implies a
lack of autonomy on behalf of the patient. We encourage paying special attention to the language used
while discussing and documenting deprescribing. In the spirit of recognizing patients’ expertise and their
right and ability to make decisions (whether we agree or not) for themselves, it is essential to use
respectful, recovery-oriented language.

Deprescribing Provides a Systematic Way to Address Irrational Polypharmacy

Polypharmacy (both rational and irrational) has increased in a substantial way over the past decade.
When defined as the use of five or more prescription drugs, polypharmacy across all drugs increased
from an estimated 8.2% in 1999–2000 to 15% in 2011–2012 in the United States (Kantor et al., 2015).
Although some data support the use of combinations of individual antidepressants and antipsychotic
medications, the duration for which combinations should be used is unknown (Dodd et al., 2005;
Freudenreich & Goff, 2002). In their review, Stahl and Grady (2004) observed that most investigators did
not try to discontinue one of the drugs after the combination proved beneficial to establish a true need for
the combination. This practice of continuing medications unchanged without a clear understanding of their
necessity can lead to drug interactions and serious side effects, often without any benefit. Deprescribing
prompts prescribers and patients to periodically reassess the risks and benefits of each medication and
provides a framework within which to implement reduction and/or cessation of medications considered
redundant or for which the risks may outweigh the benefits.

Prescribing and Deprescribing as a Complex Intervention

Prescribing and deprescribing medications, despite mechanistic models would have us believe, are not
simple endeavors; they qualify as complex interventions for complex problems, particularly in psychiatry.
Glouberman and Zimmerman (2002) compare and contrast approaches to simple, complicated, and
complex problems in health care, using the respective metaphors of cooking a recipe, launching a rocket,
and raising a child (see Table 1.2). A simple problem can be addressed with a basic set of procedures
with predictable results; a complicated problem requires more expertise, but results nevertheless have
high degree of certainty. When addressing complex problems, however, formulas, procedures, and
expertise do not guarantee success and uncertainty abounds. This distinction can be usefully applied to
prescribing and deprescribing in psychiatry.

Table 1.2 Comparing the approach to simple, complicated, and complex problems
Approaching Simple, Complicated, vs. Complex Problems
Simple: Following a recipe Complicated: Sending a rocket to the Complex: Raising a child
moon
The recipe is essential Formulas are critical and necessary Formulas have a limited application
Recipes are tested to assure easy replication Sending one rocket increases assurance Raising one child provides experience but no
that the next will be OK assurance of success with the next
No particular expertise is required. But cooking High levels of expertise in a variety of Expertise can contribute but is neither
expertise increases success rate fields are necessary for success necessary nor sufficient to assure success
Recipes produce standardized products Rockets are similar in critical ways Every child is unique and must be understood as
an individual
The best recipes give good results every time There is a high degree of certainty of Uncertainty of outcome remains
outcome
Optimistic approach to problem possible Optimistic approach to problem possible Optimistic approach to problem possible
From Glouberman & Zimmerman (2002) and University of Toronto Press (2004). Reprinted with permission of the publisher.

Despite what our neurobiological models would have us believe, the act of prescribing a medication is
best regarded as a complex intervention. Effecting antagonism at dopaminergic D2 receptors in the
mesolimbic pathway with haloperidol, on a receptor level, could indeed be regarded as a simple
problem. However, when the problem is framed on the level of attempting to care for an individual’s
experiencing a psychotic disorder with said medication, the picture becomes more complex. Individual
differences in pharmacokinetics and dynamics, nonlinear dose–response effects, heterogeneity, and
uncertainties in the pathoetiology of the psychotic experiences, the level of the patient’s concordance,
sense of meaning and understanding of the recommended prescription and access (e.g., insurance
coverage) to the medication potentially interact to confound the desired result. The interacting factors
grow exponentially when adding in the psychosocial context, culture, history of the individual, and
relationship between prescriber and patient—to identify a few, but certainly not all, confounding
variables.
For better or worse, trials of drug efficacy attempt to render this complexity more manageable with
stringent research methods (e.g. study protocols, the checking of drug levels, and objective markers of
target engagement). However, when generalized into real-world effectiveness, the waters are inevitably
muddied, and implementation science readily recognizes the resultant gap in knowledge translation.
Accordingly, while engaging a patient in shared decision-making around pharmacotherapy, it is vital to
also engage in an individualized, flexible, responsive, multiperspective approach, one that optimistically
acknowledges uncertainty and ever-changing bio-psycho-social-cultural factors.
To use the aforementioned metaphor, a parent persisting with the same child-rearing strategies
successful at 2-year-old when the child is 15 may be disappointed. To assume (without confirmatory
evidence) a static system (i.e. a given pharmacotherapy will continue to work indefinitely for an
individual) may be over-simplifiying. In this way, psychiatry must be armed with research and guidelines
for both starting and stopping medications until we have clear justification to the contrary.
 Settings for Deprescribing
In today’s health care systems, primary care physicians are especially well-positioned to implement
deprescribing as they coordinate with different specialties for a given patient. Typical settings in which
psychiatric medications are prescribed include primary care, geriatric clinics, nursing homes, public
sector or community mental health centers, private practices, intensive outpatient programs, and inpatient
services (acute and long-term). These may include state-funded agencies, nonprofits, Veterans Affairs
(VA) hospitals, private clinics, and combinations of these. Ideally, deprescribing would require
infrastructure that would facilitate reliable communication between providers from different specialties.
This would include electronic medical records (EMR) with updated medication lists accessible by
multiple providers and secure messaging facilities. Accessibility to other supports, such as groups and
individual therapy and drug and alcohol treatments, may be necessary in certain cases. For instance, the
VA hospital system has patients seeing multiple medical specialists at the same location with a single
medical record containing a consolidated list of medications. In this situation, the primary care physician
is well-placed to initiate a conversation about deprescribing, both with the providers from various
specialties and with the patient; although the deprescribing should ultimately be conducted by the
prescriber who initiated and manages the target medication.
In public-sector agencies, the coordination of treatments for mental and physical disorders has been a
challenge when such services are obtained at different locations and sometimes even when they are co-
located at the same facility. To address this issue, the Substance Abuse and Mental Health Services
Administration and the Health Resources and Services Administration (SAMHSA-HRSA) Center for
Integrated Health Solutions has developed one version of what has become known as a behavioral health
home, with the goal of coordinating all health services that a given individual needs either in-house or
using a co-located partnership model (Alexander & Druss, 2012). Two of the core principles of effective
care at these health homes are patient-centered care and evidence-based care. As the goal of these health
homes is coordination and patient-centered care, with decision support as a core principle, they may form
an ideal location for the implementation of a deprescribing initiative. On inpatient psychiatric units,
patients who have not responded to various combinations of medications may be deprescribed all their
medications to make a “fresh start”—something not always feasible on an outpatient basis, especially for
those with a history of severe illness and high potential for imminent risk. In this setting, deprescribing
may be carried out more rapidly because the purpose is not merely the reduction of side effects but the
identification of a helpful medication.
Deprescribing may also be offered as a “consultation service” to the primary treating team. A
consultation team that is able to conduct detailed history and medication review, assess the likelihood of
relapse, measure and treat withdrawal symptoms, and suggest alternatives to medication as part of a
detailed deprescribing plan may be a more feasible way of implementing deprescribing in large systems.
The team would ideally include a pharmacist and an internist who could weigh in on side effects and
interactions. This process may be conducted as a quality-improvement or utilization review initiative.

The Ethics of Deprescribing

It is unfeasible in this intended pragmatic book to adequately review the ethics of deprescribing.
Autonomy and non-maliference have already been mentioned. Nevertheless, it is easy to imagine the
relevance of all ethical prinicples to a given deprescribing decision. Repeated reviews of medication
lists ensure that medications do not end up causing more harm than good (nonmaleficence) and that the
treatment that is offered is truly beneficial (beneficence). In mental illness, the struggle between
individual (autonomy) and societal (justice) interests risks being resolved at the expense of the
individual’s autonomy. Mandated and coercive treatments are justified by citing poor insight and/or
judgment in combination with perceived risk to or even burden on society. There is a risk that
deprescribing may be viewed as an error of omission or as a withholding of appropriate services. To
offset this risk, it is crucial to remain aware of potential ethical dilemas related to deprescribing, both as
prescribers and as a field.

Conclusion
This chapter presents the initial description of how to conceptualize and begin thinking about the issues
related to the implementation and study of deprescribing in psychiatry. We see this intervention as more
than just medication adjustment; it is a holistic expansion in approach and techniques relevant to both
the reduction and initiation of medications, one geared toward promoting recovery for individuals
diagnosed with mental illness.
While in other medical conditions the reduction or elimination of medication use may be more
straightforward, we contend that mental illness is not “an illness like any other,” does not yet neatly map
onto a clear pathophysiology like diabetes or hypertension, and does not equate simply to something like
the reduction of a statin for hypercholesterolemia. For historical, cultural, and inter- and intra-personal
reasons, psychiatric medications have a much greater meaning, impact, symbolism, and potential risk
related to their reduction or discontinuation. Mental illness affects one’s core sense of being, one’s
interpersonal relationships, and one’s potential ability to move forward in life. Along with a history of
psychiatry that has more recently heavily emphasized the medical model over social or alternative
explanations of illness, each of these sociocultural factors highlights the need for a more complex and
multifaceted approach to pharmacotherapy. Drawing from and complementing the recovery literature in
mental health, deprescribing in psychiatry is a potential venue for achieving the ultimate goal of
psychiatry: decreasing human suffering.
Our audience for this book includes interested professionals who prescribe psychiatric medications,
including primary care physicians, psychiatrists, advanced practical nurses, psychologists, physician
associates and others. Interested allied professionals including pharmacists, social workers, peer support,
administrators, and policymakers may find the ideas useful in helping to reorganize existing services to be
more recovery-oriented. We also imagine that patients and their friends and family may be interested in
using the book to think through their own process of taking medications, although the intended audience is
primarily professionals and more specifically prescribers.
On this note, we wish to address the use of the term “prescriber” in this book. Despite some
controversy over the use of the term, we chose “prescriber” to refer to the person prescribing the
medication, including psychiatrists, nurse practitioners, psychologists, physicians’ associates, trainees,
and physicians in other specialties. We decided to use this term to describe the person writing the
prescription for both expediency and inclusivity. We clearly advocate that the value of a “prescriber” not
be reduced to the act of writing a prescription.
This book is geared to support learning about the considerations to address when introducing
deprescribing. The next chapter discusses the complex process of decision-making in psychiatry and how
that relates to deprescribing process. Chapter 3 identifies and describes barriers to deprescribing and
what can be done to overcome them. Chapter 4 addresses some of the psychological considerations when
deprescribing, identifying the meaning of the medication and other factors that demand to be addressed.
Chapter 5 outlines the various supports and strategies that a patient can access on his or her own in order
to support deprescribing. Chapter 6 continues in this vein, discussing interventions that a prescriber or
clinician may recommend adding to a range of services in order to best support deprescribing. Chapter 7
outlines each step of deprescribing and elaborates on considerations for decision-making. Chapters 8–11
address specific classes of psychotropic medication (antidepressant, antipsychotic, mood stabilizers,
benzodiazepines, and stimulants) and the considerations around deprescribing these. Chapter 12 is a
summary and offers future directions for this emerging and important area of psychiatric practice.
Each chapter contains specific learning objectives, case examples, and a self-assessment to monitor
reader understanding. We hope this book provides guidance and thought-provoking ideas around the
concept of deprescribing as it relates to the broader trajectory of transforming mental health care to be
recovery-oriented and person-centered.

Self-Assessment
1. Deprescribing as an intervention can encompass

a. Medication reduction and/or discontinuation

b. Consultation with primary care physicians, pharmacists, and specialists
c. Consultation with the patient and his or her support system
d. The medication regimen ultimately remaining the same
e. All of the above

Correct answer: e.
2. Which of the following is not an indication for initiating deprescribing in psychiatry?

a. Patient preference
b. Side effects and drug interactions
c. No clear demonstration of therapeutic benefit
d. Request from the patient’s significant other

Correct answer: d.
3. Which of the following is a recovery-based practice espoused by deprescribing?

a. Beneficence
b. Empowerment
c. Autonomy
d. Nonmaleficence

Correct answer: b.

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 2
Decision-Making in Deprescribing

The process of making prescribing decisions in psychiatry can be challenging. From equivocal diagnoses
and prognoses, to a shifting array of treatment options (with limited precision), all contextualized by a
plethora of differing values, preferences, and standards. Both prescriber and patient must face, and
operate under, much uncertainty. These decisions are especially difficult when prescriber and patient
disagree, when values or preferences conflict with standard guidelines, or simply when no guidelines are
available. Looking more closely at how to make decisions, and what might support this process, is the
focus of this chapter, specifically as it relates to prescribing or deprescribing.

Goal and Learning Objectives

After reading this chapter, the reader will be able to:
1. Better understand a framework for psychopharmacological decision- making
2. Explain a model for the decision-making process in the context of prescribing and deprescribing
3. Gain and apply a greater understanding of one’s own decision-making process to provide care that is more sensitive to both scientific
evidence and patient preferences
4. Identify the steps of shared decision-making (SDM) and how to create an environment conducive to such

Decision-Making and Decision Analysis

Decision-making is a well-developed science in business management and in medicine. By integrating
elements of decision analysis and SDM, this chapter provides us with frameworks to understand why we
prescribe what we prescribe, how we reached that decision, and how we can apply this to deprescribing.
Understanding some basic concepts and frameworks in decision-making will enable us to examine our
own use of decision-making and to contrast a traditional paternalistic approach with the SDM approach.
Traditional decision-making trees end up having limited use in psychiatry due to the relative lack of
prediction tools. Even in other branches of medicine where predictive tools, and therefore
recommendations, are clearer, there is still growing interest in SDM and greater collaboration towards
better person-centered outcomes. We start by reviewing more traditional approaches followed by an
expansion on SDM as it specifically applies in psychiatry and deprescribing.

Traditional Decision-Making

A decision is defined as a conclusion or resolution reached after consideration. Janis and Mann (1977)
defined decision-making as a “cognitive process resulting in the selection of a belief or course of action
among several different possibilities” or “the process of identifying and choosing alternatives based on
the values and preferences of the decision-maker”. Decision analysis is an explicit, quantitative approach
to examining difficult decisions about a course of action. It involves the steps of defining the problem,
structuring the problem in the form of a decision tree, estimating the uncertainties, and, finally, estimating
the relative value of different outcomes - as illustrated in Figure 2.1.
Figure 2.1 Example decision analysis tree schematic.

Decision analysis has been applied in medicine to structure and estimate the probability of possible
outcomes to a given decision point. In the traditional medical setting, the prescriber–patient interaction
entails the patient coming to the prescriber with a complaint that they expect the provider to evaluate,
understand, and treat. In general, the prescriber is expected to generate diagnostic possibilities, conduct
an interview and examination, and order tests that help narrow down the possibilities and then
recommend a treatment that is most likely to address the diagnosis. The process demands the ability to
understand (prior) probabilities and make best estimates at several steps, including as it relates to the
focus and extent of the history, examination, blood work, and other tests, and hence impacts the
recommended treatment. In this way, multiple, parallel decisions are being made implicitly throughout the
provider–patient interaction, limiting this kind of single decision analysis.
The preceding clinical process has roots in a traditional paternalistic stance in which the provider is
seen as the expert who assesses, analyzes, and decides on the course of treatment, including medications,
independent of the patient’s values and preferences—to a large degree, unilateral decision-making. The
provider has the obligation of keeping a patient’s best interest in mind as an ethical imperative, but not
necessarily including the patient explicitly in the process. While patient preferences may be considered to
some extent, there may be little active collaboration, and the provider may still make the decision
independently. A medical paternalism model has increasingly lost favor as patients demand more choice
and medical information is more widely available and consumed; furthermore, there is a growing body of
evidence showing that collaboration between providers and patient can actually improve certain
outcomes (Adams & Drake, 2006; Hamann et al., 2003; Wilson et al., 2010).

Facets of Decision-Making

The process of medical decision-making therefore has many facets. The process for both provider and
patient often begins before they meet. A prescriber may be influenced by years of training and experience,
social and cultural influences, demographic factors, and both conscious and unconscious individual
biases. Patients, on the other hand, may have past experiences with certain medications, advice from
friends and family, and information about medications through various sources, including advertisements
and, increasingly, the internet. The issue of patient complexity, including co-occurring conditions and
other variables, has been outlined in a recent model attempting to define this complexity. Through
comparing the demands on the patient (e.g., illness burden, socioeconomic factors) with capacity for
managing these demands, this newer conceptualization may provide a way of conceiving of patient
complexity, but it has not yet been broadly adopted (Shippee, Shah, May, Mair, & Montori, 2012). When
patient and provider come together, there is a sharing of information, reasoning, values, and preferences.
This sharing is an ongoing process, and prescriber and patient gradually develop a collaborative
relationship in the setting of which medication prescriptions can be more finely tuned. It is important to
remember that both prescriber and patient have their individual cognitive processes that influence each
other and are influenced and refined by the outcome of previous decisions, as illustrated in Figure 2.2.

Figure 2.2 Influences on decision-making in the prescriber–patient relationship.

Applications to Psychiatry

Although extensively used in other fields of interventional medicine, the applicability of decision analysis
to psychiatric medication management is limited because of many reasons (summarized in Figure 2.3).
Decision analysis and decision-making in psychiatry is challenged by the absence of etiology-based
diagnostic systems, lack of diagnostic tests, and imprecision of available treatments. It involves a number
of stakeholders, including the prescriber and the patient, but also often family members, spouses, and, in
some instances, society in general. In addition to providing relief to the patient, the provider is charged
with minimizing risk, both to the patient and to the community. Minimization of risk to the community may
come at the expense of violating individual rights, thus generating tension within the prescriber
themselves and affecting the alliance between the prescriber and the patient.
Psychiatric diagnoses and treatments are uniquely sensitive to sociocultural settings and often bear the
burden of a long history of stigma, discrimination, and the history of co-option of psychiatry for social
control: for example, the inclusion of homosexuality in the Diagnostic and Statistical Manual of Mental
Disorders (DSM) or the misuse of psychiatric hospitalization in the oppression of women or political
dissidents (Faraone, 1982). Thus, both the macro- and micro-contexts of psychiatric decision-making are
composed of constantly changing layers.

Figure 2.3 Decision analysis in psychiatry.

Additionally, attaching values to certain outcomes may be complicated. A given patient may highly
value being medication-free but may also value staying out of the hospital. Finally, both clinical problems
and interventions in psychiatry can be individual, and the evidence base may not have clear answers.
Despite these limitations, decision analysis may prove valuable in structuring the problem and
systematically examining options, including the evidence base, outcomes, and values, with the
overarching goal of minimizing bias toward one course of action (Tavakoli, Davies, & Thomson, 2000).
In general though, the movement in medicine more broadly is toward an SDM approach, as outlined in the
next section.
 Beyond Decision Analysis: Shared Decision-Making
More and more in medicine and in psychiatry, the trend is toward orienting patients and prescribers
around collaborative, SDM (Edwards & Elwyn, 2009). Providers are increasingly realizing that the
transformation of the patient from a passive recipient of treatment to an active planner and partner in
treatment is more likely to lead to outcomes that are desirable to the prescriber–patient team. Shared
decision-making is considered a person-centered intervention that respects patient autonomy and self-
determination and is a trend going back decades in medicine, while the actual implementation has been
slower than hoped (Coylewright et al., 2012; Strull et al., 1984). In the salient scenarios where serious
mental illness drives imminent risk, the power to make decisions regarding psychiatric treatments has
remained with the prescriber or, in certain cases, with the judicial system. However, this should not
impede the default decision-making process moving from “unilateral” to newer models of SDM.

Stages of Decision-Making
The basic framework of SDM identifies three stages during deliberation before a decision: choice,
option, and decision talk. The first stage, choice talk, identifies that there is a choice to be made, and the
provider conveys this to the patient. This may be clear to the patient prior to meeting (e.g., a patient
comes in looking to reduce medications). The second stage, option talk, provides further details of
treatment options tailored to the patient. The final stage, decision talk, encourages an exploration of what
matters most to the patient in order to facilitate a decision (Elwyn et al., 2012; Figure 2.4).
Figure 2.4 Framework of decision-making.
From Elwyn et al. (2012).

Defining the Problem or Identifying a Goal?

In decision analysis, the first step involves identifying a problem and then listing possible treatment
options and outcomes. Typically, the problem is formulated in terms of a diagnosis from which the
treatment options and outcomes follow. For example, the problem may be hypertension, and the possible
treatment options are medication, lifestyle changes, no treatment, or combinations thereof.
An attempt at defining the problem for decision analysis quickly takes us to the heart of the challenge in
its application to psychiatry. Is the problem, for instance, treating schizophrenia (or hallucinations) or
supporting the person in pursuing a job which they cannot seem to hold on to? What are the barriers to life
goals being addressed by the treatment? Ideally, treatments in medicine are expected to be etiology-based:
for example, treating tuberculosis with rifampicin, an antibiotic that kills the mycobacteria that cause
tuberculosis opposed to a cough suppressant that merely addresses a symptom. Psychiatry is challenged
by a lack of treatments that definitively and directly address a defined pathoetiology. Hence, rather than
impose presumed treatment/illness-based goals associated with a patient’s psychiatric diagnosis, it is
prudent to look to the patient to set treatment goals and then present possible treatment options. Literature
and the shared expertise of provider and patient can then to some extent inform the possible outcomes.
Drawing from person-centered approaches to care, we can reconceptualize interventions as moving
from solely focused on “addressing the problem” to a more positive approach of supporting life goal
attainment. Traditionally, care planning starts with the development of a problem list. In person-centered
approaches to care, instead, the broader life goal is the focus, with an identification of the barriers
standing in the way of goal attainment (Adams & Grieder, 2004; Tondora, Miller, Slade, & Davidson,
2014). These barriers may equally be symptoms treatable by, or side effects caused by, medications.
Listening to the functional specifics of each of these barriers is essential in getting a sense of what could
be the targets of potential intervention and support.
The first step is hence supporting the person in identifying what they want to change, improve in their
life, or move toward. This can be a challenging task for some, as in this chapter’s case example of Cindy
with her ambivalence about her ability to pursue a job. Other patients may be accustomed to defining their
future plans around the circumscribed, institutionalized goals of patienthood, “going to group” and “taking
my medications.” These are easily spotted as goals imported from previous treaters or, at the very least,
the patient’s interpretation or internalization of the treaters’ expectations. Thus utilizing different and more
evocative questions and supporting an exploration either done with the prescriber or allied professional
(such as a social worker, peer support specialist, etc.) can better support a fuller understanding of the
potential goal and, from that goal, what the choice points may be in terms of treatment.
The SDM stage of choice talk helps the patient realize that there are choices available to potentially
address identified barriers to achieving their life goals—something that cannot be taken for granted. For
example, a patient may be unaware that the fatigue interfering with his job performance could be
alleviated by lowering a dose of medication or changing the medication to one that might treat the
symptom equally well without causing fatigue. Often, in practice, patients may misattribute a disturbing
side effect to one medication and may ask to switch that medication, when the problem may lie with
another medication or be an impact of the medication combination. Identifying the choice point and
clarifying it to the patient is the first step in deliberations in shared decision-making.

Identifying Alternatives
Once a mutual understanding is reached about what is being addressed and what the hoped outcome will
be, the next step is the discussion of possible treatments—options talk. As long as a patient is not at
imminent danger to themselves or others, and/or is not under legal mandate, the option of not taking any
medications is the person’s right and needs to be considered as a possible choice even if it may not seem
to be the best decision from the prescriber’s or others’ perspective. For a given symptom configuration,
there might be a range of medications available, each in various formulations and doses. When we add
medication combinations to the equation, the permutations increase exponentially. Hence, adjustment of
doses, formulations, and combinations may be framed as a secondary tool for “fine-tuning” after the initial
choice of medication and starting dose is made. In some scenarios this can be overwhelming to both
patient and prescriber, who are then at risk of colluding around over-simplified, singular, binary choices.
For example, if a patient is doing generally well, the option of increasing dose may be weighed purely
against remaining at the same dose, and the option of reducing dose is not generally considered. For
patients who have been on the same medication regimen for years, the process of shared decision-making
may not have advanced to the stage of identifying all alternatives.
 Using decisional support tools such as the Decisional Balance Worksheet (Collins, Carey, & Otto,
2009), the Payoff Matrix from Integrated Treatment for Dual Disorders (Brunette, Drake, & Lynde, 2002),
or others can help. These can be completed by either the prescriber and the patient in collaboration, or by
the patient prior to an appointment with other clinical staff, peer support staff member, or a family
member. Relying on the team approach can increase efficiency and decrease anxiety for the patient as time
may be limited in the encounter with the prescriber. Such decisional tools assist people in clearly
outlining the cost–benefit ratio or the pros and cons of each decisional option, taking into account a
person’s values, goals, and preferences.

Choosing Between Alternatives

When the patient–prescriber team generates a set of alternatives, the next step is to zero in on a single,
most-valued alternative. This may involve a review of benefits and side effects and viewing those
benefits and side effects in the individual patient’s context. While choosing between alternatives, the
prescriber may use a number of concepts to evaluate and present the information to the patient. The most
common framework used to decide on a course of action is the Benefit–Risk Assessment (BRA). BRA is
a common decision-making tool employed in medicine. The potential risks of an intervention are weighed
against the potential benefits to yield a rough estimate of the risk–benefit ratio. In pharmacoepidemiology,
there are several quantitative and qualitative approaches to assessing the BRA but clinically, only a few
can be used: Mt-Isa et al. (2014) classify the methodologies as those based on frameworks (such as
decision analysis), metric indices (such as quality of life, number needed to treat, tradeoff indices),
estimation techniques, and utility survey techniques. It is also important to remember that the relationship
between the concepts of risk and benefits is inherently contextual.
In psychiatry, the first difficulty in estimating the risk–benefit ratio is the absence of sufficient
information. An attempt at a risk–benefit analysis for a given medication for a given patient at a given
point in their life serves to highlight several facts: risk may be dependent on time (a factor that might
place a person at risk for an adverse outcome at timepoint A might not do so at timepoint B in the same
person); the effect of a risk factor may depend on the person in question (the risk factor may produce an
adverse outcome in person A but not in person B); some risk factors are modifiable and can be mitigated
by interventions. The existing literature is limited in providing us with precise, definitive, and
generalizable information to assess these potential risks. Furthermore, perception of risk may be different
from actual risk. The differing perception of risk can influence how prescribers present information to a
patient, and how patients assimilate the information presented.
The process of choosing between treatment alternatives requires an assessment, acknowledgement,
tolerance, and communication of the inherent uncertainty of the choices. Although empirical studies can
inform estimates of treatment outcomes in certain situations, the generalizability and applicability of such
data have limitations. For instance, the rate of relapse in the first year following the discontinuation of an
antipsychotic medication in a patient with chronic schizophrenia has been reported as significantly higher
than if the medication is continued (Leucht et al., 2009; Leucht et al., 2012). However, relapse rates are
not 100% and we do not yet know how to confidently differentiate between patients who might relapse
without medications and those who might not. Furthermore, we have limited confidence around what
factors (besides medications) may impact the risk of relapse.

Creating a Constructive Environment

Ideally, decision-making is conducted in an environment where both patient and prescriber feel
comfortable expressing their thoughts, wishes, and fears; sharing all relevant information including values
and preferences; and interacting to reach a creative, individualized, and workable plan. When a
discussion is personal and multifaceted, it is important that the persons concerned are able to express
their opinions freely, without fear of rejection or ridicule. Questions like “What would you like the
medication to help you with?” or “What do you think about taking this medication?” or “What about this
medication makes you nervous?” may encourage patients to talk more in depth about their assumptions
and experiences around taking medications. A plan of action arising from such a discussion will enlist the
increased commitment of both prescriber and patient and may lead to a better outcome than a unilateral
decision on either the patient’s or the prescriber’s part.
There are situations where the prescriber may agree to prescribe a medication that is not medically
indicated largely because the patient’s demands for it are perceived as unrelenting. Prescribers may want
to avoid confrontation and increase trust, making it easier at times to prescribe what is not going to be a
helpful medication but is one that will satisfy the patient (Brett & McCullough, 2012). A study measuring
the effects of patient and prescriber expectations on prescribing behavior found that patients were more
likely to receive a medication when the practitioner judged the patient to want the medication than when
the practitioner ascribed no expectation to the patient (Cockburn & Pit, 1997). One way to address the
effect of expectations on prescribing is to solicit them at the very beginning and clarify what medications
can and cannot do.
Table 2.1 notes some of the important basic facets of creating an environment conducive to having
initial discussions around the possibility of deprescribing medications.

Table 2.1 Creating an environment conducive to shared decision-making regarding deprescribing of

medications
Timing
If the symptom or problem being treated is not acute, take time before deciding whether or not to lower or stop medications, including
adding psychosocial interventions if indicated
Attention
Avoid answering the phone or using the computer (unless sharing information with the patient) during the appointment
Frame a time and quiet setting dedicated to the conversation
Communication
Use the “talk back” method to assess for understanding (Karen & Alan, 2017)
Avoid discrediting or ridiculing patient sources
Avoid interrupting the patient
Ask questions to indicate that the patient is an equal partner in this decision (“What do you think?” “Do you have any suggestions about
this?”)
Effects and side effects
Inquire actively about concerns about side effects, including sexual side effects
Ask what the patient hopes the medication reduction will do
Attitude and approach
Be flexible. Emphasize that medication decisions are not a “one size fits all.”
Emphasize that the decision about medications is not binding and the medication can always be changed, adjusted or restarted
If the patient prefers it, include friends or family in the discussion
Tailor your approach to the patient. Patients expect and prefer varying degrees of involvement from their doctors. Even the same patient
may want a different approach from their doctor at different points in their life

Evidence for Shared Decision-Making in Psychiatry

While there is strong evidence for SDM approaches improving certain outcomes and that it is desired by
both patients and prescribers it is not yet ubiquitous (Davidson, Tondora, Pavlo & Stanhope, 2017).
Certain concerns on the part of providers and psychiatrists may contribute to this, such as that, if left up to
the patient, the decision will be a bad one (Beitinger et al., 2014; Hamann & Heres, 2014). In addressing
this, the authors offer an outline to differentiate between different kinds of decisions that might call for a
modified version of SDM, in particular issues more commonly faced by people with serious mental
illness (see Figure 2.5.

Figure 2.5 Modified shared decision-making (SDM) model.

From Hamann & Heres (2014). Reprinted with permission from the Psychiatric Services. American Psychiatric Association. All Rights
Reserved.

The figure points to the differential decision-making approach depending on the type of decision.
Deprescribing generally would fall into “best-choice” or “preference-sensitive” categories. At times
deprescribing is actually the “best-choice” option but the patient still declines, with reasons including
fear of relapse or other psychological factors discussed further in Chapters 3 and 4. Approaching these
situations with care and utilizing methods like motivational interviewing or other approaches can slowly
move a patient in the direction of considering a trial of deprescribing. Especially when the risks of
polypharmacy are clear, a slow and careful discussion over a longer period of time (months or even
years) is the indicated approach from our experience.
In psychiatry, and different from other specialities of medicine, it is important to keep in mind the
extreme power differential represented by the power of the system to involuntarily commit someone. A
patient’s previous traumatic experiences with the mental health system may make having a real
collaboration much more challenging.

Use of Language Around Medication

The movement toward recovery-oriented care and SDM is also reflected in the evolution of the
terminology used to describe the degree of a patient’s agreement and participation in the treatment.
Accordingly, the terms used have changed from “compliance” to “adherence” and, more recently,
“concordance” (Gutheil, 1982). Compliance is the extent to which a person’s behavior (in terms of taking
medications, following diets, or executing lifestyle changes) coincides with medical or health advice
(Haynes et al., 1979). At times, courts and providers in mental health have used coercion to promote
compliance, including such measures as involuntary hospitalization or outpatient treatment, threats of
withholding resources (such as money), or lack of full disclosure of options or side effects (Corrigan,
Kosyluk, & Kottsieper, 2015). Adherence is often used interchangeably with compliance but it is
considered to be a more multidimensional phenomenon, one that may be influenced by patient- and health
care provider–related factors, the therapy itself, education, and socioeconomic aspects. In some
nonpsychiatric settings adherence is defined as filling prescriptions on time and compliance as taking
medications as prescribed (Aronson, 2007). Generally, in mental health, the terms have both been used to
describe taking medications as prescribed. “Persistence” is another term that is commonly used in time-
limited fixed medication therapies such as cancer chemotherapy, although it has not been adopted in
mental health (Andrade, Kahler, Frech, & Chan, 2006).
In psychiatry, the recovery model has suggested moving away from the word “compliance” because it
implies that the patient is passive and unengaged. The more recent term in vogue, “adherence,” has been
used as a relatively less value-laden term with greater empowerment and active involvement of the
patient. Most recently, the term “concordance” has been suggested as a less power-driven term and to
represent the collaboration between prescriber and patient, although others have criticized the term as not
capturing the patient behavior of following through with a prescribed course of medications (Aronson,
2007; Osterberge & Blaschke, 2005; Jordan, Ellis & Chambers, 2002).
In this book, we made the decision to use the term adherence because it describes the behavior of
following a prescription made by the provider; although we agree that the term could be accused of not
fully capturing the patient’s participation in decision-making or the active nature of taking a medication as
a means for desired life outcomes. The assumption is that the prescribed plan of care was a result of
appropriate SDM.
A model for the continuum of decision-making from paternalism to collaboration is illustrated in Figure
2.6.

Figure 2.6 The continuum of decision-making in the prescriber–patient interaction.

Some Additional Considerations

An important caveat in discussing a collaborative or shared decision-making model is that patients must
retain the choice to have the decision made by the prescriber. Many patients, or even the same patient at
different points in time, may prefer less information, less choice, and to rely on the prescriber’s expertise
without the burden of making the decision on their own. This may seem contradictory to the idea of
empowerment and choice, but it is an expression of choice in another way; to give up that choice and
defer to another. The desire to have the prescriber be the decision-maker may also be culturally linked,
where being able to rely on the prescriber to make the decision increases the comfort level of the patient.
In more collectivist cultures, it may be essential and even the basic expectation for the family to be
involved or for the parents of an adult child to make the decision for the child.
Regardless of one’s personal feelings about the importance of patient involvement and collaboration,
the decision to not make a decision is a valid one that also needs to be respected (Tondora et al., 2014).
An insistence on the patient being “in the driver’s seat” and making independent decisions in the name of
person-centered care when that is not the preference of the person actually ends up contradicting these
values instead of upholding them and errs toward forced consumerism. At the same time, it is essential to
consider the previous messages and experiences that the person has been privy to within the mental health
system. There may be significant learned helplessness and passivity within the “sick role.” These
attitudes may take time to shift and be unlearned, and they may appear to be the true “choice” of the
person, but, with a bit of investigation and discussion, it can become clear that these choices are limited
by the perceived expectations of the provider and the system.

Case Example
Cindy, a 57-year-old woman with a long history of schizophrenia, comes to the mental health center often.
She has expressed occasional interest in reducing the dose of clozapine (she has been taking 500 mg each
night for the past 8 years with good symptomatic control) due to the sedation that it causes. She would like
to return to work and feels that she will likely fall asleep on the job with her current regimen. When the
prescriber approaches her about potentially trying a slight reduction in her medications to address the
fatigue, she says, “I don’t know Doc, I’ve always been told staying on the meds is the most important
thing. I probably shouldn’t work anyway, it might stress me out even more. And I remember at the state
hospital how many times they said I needed to reduce stress. So maybe it doesn’t make sense for me to
have a job. But I’ll let you decide that, Doc.”
Here it becomes clear that while the patient has a goal in mind—to get a job—she is conflicted due to
messages she has received for many, many years about her vulnerability to stress. Cindy is reluctant to
some extent to change anything about her medications due to the many years of messages regarding the
importance of staying on them consistently and the metaphor ingrained in her—comparing the chronic
management and prognosis of her mental illness to that of diabetes (which, as it was for her mother, she
perceives to be progressive and incurable).
One way to handle this sometimes implicit or unconscious bias toward continuing medications
unchanged is by asking questions such as, “What is the role of the medication in preventing a relapse for
this particular patient? Does this patient place an equally high value on preventing relapse? What
constitutes a relapse for this individual patient, and what else might prevent this? What else matters to the
patient, and what are his or her preferences?” A summary of some possible questions as well as the
associated framework is shown in Table 2.2.
Table 2.2 Questions that might help uncover and address the bias toward continuing medications
unquestioned
Question Framework
What is the role of this medication in preventing the relapse and/or treating Biopsychosocial perspective on relapse prevention
symptoms?
Does the patient value relapse prevention as much as I do? Patient life goals and preferences
What does it mean to the patient to continue to be on medications? Patient life goals and preferences
To what extent do these medications reduce risk? Evidence for risk prevention (violence and self-
harm, violence to others)
What does it mean to provide treatment in a situation where none might be The value of empirical evidence in treating the
needed? individual patient
What is the strength of the evidence that ongoing treatment is needed? Critically evaluating existing evidence
What are the risks associated with continued medication treatment (and the Risk–benefit analysis
benefits of potentially discontinuing)?

Investigating potential implicit and explicit assumptions and beliefs around medication reduction may
not change the ultimate course of action, but can be useful in decision-making. This is especially relevant
when external factors (e.g., systemic pressures, family disagreement, fear of reprisal, fear of patient
relapse, and liability issues) may ultimately be in conflict with patient preference and clinical judgment.

The Decision-Makers

The Prescriber as Expert

The prescriber is considered the expert on medical knowledge and is expected to make well-intentioned
and informed treatment recommendations to the patient by integrating scientific knowledge and clinical
experience. However, the prescriber’s thinking process is not free of influences, internal and external, as
well as conscious and unconscious. Prescribers unavoidably have their own values and preferences that
affect their decisions and the parts of the evidence to which they pay attention. Different prescribers
possess different abilities with respect to decision-making and integrating different kinds of information.
A popular Oslerism calls medicine a science of uncertainty and an art of probability. Acknowledging and
tolerating uncertainty is an important skill and essential to minimizing biases. An inability to acknowledge
and tolerate uncertainty may cause us to ignore some therapeutic options, thereby allowing our biases to
play a stronger role in our decision-making (Simpkin & Schwartzstein, 2016).
Often, providers may themselves find it difficult to assimilate outcomes of clinical studies expressed as
complicated statistical parameters, much less communicate them effectively to a nervous and unwell
patient. However, should the patient prefer, this information should be communicated in an understandable
and effective way. For example, a study of women in cancer treatment found that they experienced less
immediate satisfaction with the decision when the uncertainty of outcome was communicated clearly. The
authors concluded that there was a tradeoff between the acknowledgment of uncertainty and decision
satisfaction (Politi et al., 2011). The tradeoff may be well worth it if the final action is aligned with the
patient’s wishes, goals, and values after they have understood the available evidence for a course of
action rather than a premature decision taken merely to allay anxiety as soon as possible.

The Patient as Expert

The patient is increasingly and perhaps controversially called an “expert by experience” or at a minimum,
“an expert on their own experiences.” This focus is to illustrate the importance of the person’s
perspective, as well as to serve as an empowering stance to decrease the power differential inherent in
the prescriber–patient relationship (Gabbard & Nadelson, 1995). The patient brings an intimate
knowledge of the conditions of their symptoms, the specific manifestations of such in the context of their
daily life, and the goals and values that are important and have an impact in their decision-making
process. This intersecting matrix of experience, goals, and values results in a unique configuration for
each individual of how treatment would best suit the situation. Without full exploration and comfort in
sharing these factors with the prescriber in a forthright way, the decision-making process may collapse
from lack of clear understanding of an important factor or factors. Creating a trusting environment and a
strong working alliance is therefore essential.

Conclusion
Decision-making in psychiatry is a complex process that is influenced by systemic and individual factors,
both within the patient and the provider. Decision analysis consists of stages of defining the problem,
identifying alternatives, and choosing between them, while SDM extends the more traditional medical
approach to be a collaborative endeavor between prescriber and patient. Looking closely at the process
of decision-making may help us identify our unconscious biases toward one course of action thereby
encouraging evidence-based practice. Some common sources of biases in prescribers might be past
experience; preferences of colleagues, mentors, and the institution at which one practices; advertising;
and personal experiences. Viewing the deprescribing process as an opportunity to collaborate around an
endeavor that can improve quality of life, physical health, and well-being means communicating clearly
about preferences and values and taking time to planfully engage the patient in the process.

Self-Assessment
1. Alex is a 25-year-old man who dropped out of college 5 years ago because of a first episode of psychosis. He responded very
well to risperidone long-acting injectable 50 mg every 2 weeks that was started within 3 weeks of his diagnosis. Three years
ago, he dropped out of treatment for 4 months but returned when he started experiencing severe insomnia and anxiety
again. He was restarted on the same medication and responded well to it again. Today, he is here to ask you about stopping
the medication. He says that he doesn’t feel like he is “normal” if he has to take medications to stay well. He also wants to
go back to college and does not think that he can study while he is taking medication because it slows him down and makes
his hands shake.

a. What are the treatment options you would consider in this scenario?
b. What are the treatment options you will offer Alex?
c. If Alex asks you “what do you think would be best, doctor?” what would you say and why?
d. What would your concerns be if you discontinued Alex’s medications?
e. What would your concerns be if you continued Alex’s medications?
f. Identify the source of these concerns and group them:

i. Scientific literature
ii. Past experience with similar patients
iii. Intuition

2. Angela is a 35-year-old woman working as a teacher. She lives with her husband and her son who is 6 years old. She had a
first episode of moderate major depression last year that responded well to sertraline 200 mg, and she has continued taking
it for the past 18 months. She is thinking about having another child but is nervous about getting depressed again and does
not want to stop the sertraline.
a. What are the treatment options you would consider in this scenario?
b. What are the treatment options you will offer Angela?
c. If Angela asks you “what do you think would be best doctor?” what would you say and why?
d. What would your concerns be if you discontinued Angela’s medications?
e. What would your concerns be if you continued Angela’s medications?
f. Identify the source of these concerns and group them:

i. Scientific literature
ii. Past experience with similar patients
iii. Intuition

3. Stages of shared decision-making include:

a. Choice talk, options talk, decision talk

b. Assessment, alignment, agreement
c. Explanation, discussion, decision
d. Sharing, conflating, consensus

4. A prescriber and patient meet, and the patient says, “Doc, please, don’t tell me more, just tell me what to do.” The treater,
after some further discussion of the request, offers no further information to support the patient’s decision-making and
makes a recommendation. This is:

e. Authoritarianism
f. Consistent with a person-centered approach
g. Typical paternalism that is destructive to a collaboration
h. A culturally insensitive approach

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 3
Barriers to Deprescribing
Origins and Solutions

The goal of this chapter is to assist the reader in identifying potential barriers and solutions to the process
of deprescribing. Deprescribing has the potential to streamline medication regimens, minimize side
effects, and cut costs; the process also intends to improve patient adherence and strengthen the
relationship between the patient and the prescribing professional. However, the patient–prescriber team
may encounter numerous barriers while attempting this endeavor. Barriers may originate from the patient,
prescriber, and/or the institution, both local and the larger medical system. This chapter frames potential
general barriers and proposes ways to address them, with the caveat that any given prescriber–patient
team may encounter context-specific barriers which need to be explored and addressed on a case-by-case
basis.

Goal and Learning Objectives

After reading this chapter, the reader will be able to:
1. Recognize three prescriber-related factors that might bias against recommending deprescribing in any given scenario
2. Identify three barriers stemming from the patient and their environment that may be encountered when implementing deprescribing
3. Consider strategies for overcoming these barriers

Potential Pitfalls of Deprescribing

Risk of Relapse

In discussing deprescribing, one of the biggest fears for providers, patients, and family alike is that
symptoms will reoccur in such a way to affect quality of life and/or functioning. In a relapsing/remitting
illness (as many psychiatric conditions are regarded), there are specific clinical definitions. Relapse is a
return to full syndrome once remission has occurred and recurrence is a further episode occurring after
recovery as clinically defined across medical conditions. These have qualifications and thresholds based
on the diagnostic criteria of the condition in question, and this will be discussed in more detail in each
related chapter. Yet, between clinicians and among people with lived experience of mental illness, these
terms are not commonly defined nor understood and often conflated as a single, colloquial construct of
“relapse.”
In other medical conditions, such as heart disease, another heart attack can be clearly delineated as a
relapse of the underlying coronary disease. In mental health however, experiences considered to be a
relapse by the patient can be quite individualized. For those who experience ongoing voices for example,
and who consider those voices as symptoms, a relapse might be more usefully defined as an increased
difficulty coping with voices (and subsequent hindering of work performance, for example) than an
increase in the frequency of the voices themselves. The functional impairment that results from an
increase in symptoms may be more relevant than an actual increase in and of itself. The relative
difference and degree of difference from one psychological state to the next is important in this more
personalized definition of relapse and may be conjointly agreed upon by prescriber and client in
discussions surrounding deprescribing.
The outcome of hospitalization has been widely used as a marker of relapse in mental health research.
Alternatively, Lader identifies two other general categories: a change in severity of psychopathology and
a deterioration in social functioning or social roles. A majority of published studies in schizophrenia use
hospitalization to define relapse, over clinical scales such as the PANSS and CGI (see Olivares et al.,
2013 for a review). Hospitalization represents a heterogeneous set of factors and may not capture the
experiences of people who might have an exacerbation of symptoms without hospitalization or may be
hospitalized strategically for a medication adjustment (which, in their experience, does not rise to the
definition of relapse per se). In other words, relapse is not a one-size-fits-all concept, can be individually
defined by the person, and may or may not denote an increase in symptoms.
We should be under no illusion - it is well-documented that discontinuation of psychotropic agents
increases the risk of relapse in recurrent depressive disorder, bipolar disorder, and schizophrenia. The
caveats are that discontinuation studies in all three disorders have methodological limitations (as
discussed in further chapters), and crucially, we argue that discontinuation (as is has been variably
implemented thus far in psychiatric research) is not an equivalent intervention to deprescribing. Instead,
deprescribing is a holistic intervention looking at the possibility of reducing or stopping medication while
engaging in extensive preplanning, prevention, and possibly the addition of other interventions and
supports. Nonetheless, the risks of deprescribing must be discussed clearly with the patient to the extent
that those risks can be assessed. Factors to consider include experiences of past attempts at medication
reduction, current substance use, psychosocial stressors, and levels of support. Although for some people
relapses and rehospitalizations can be disruptive to employment, relationships, and stable housing, it may
be important to consider that a patient may choose to risk a relapse or rehospitalization rather than
continuing to take a medication that presents for them a more insidious and chronic biological (e.g., side
effects), psychological (e.g., meaning of the medication or impact on self-efficacy), or social (e.g., cost or
stigma) burden.

Deprescribing and Stigmatization of Mental Illness and Its Treatment

One of our goals in arguing for deprescribing in psychiatry is to promote individualized medication
treatments at minimum effective doses integrated into a multi-dimensional care plan, thus promoting and
furthering the idea of using medication as one of many tools in the recovery process. If deprescribing is
applied indiscriminately and is viewed as endorsing “anti-psychiatry” perspectives, then such application
will defeat our fundamental purpose of maximizing the benefits of medication while minimizing harm in
order to promote better quality of life for each individual, considering his or her unique set of
circumstances. If deprescribing is misinterpreted or misused, it could also serve to reinforce the stigma
associated with appropriate treatments for psychiatric disorders. The intent of deprescribing is not to
demonize the use of medications, nor to send a message that medication use is problematic. Many people
with mental illness describe wanting to discontinue their medications because this will somehow prove
that they are ‘well’ or that they don’t have mental illness after all (see Roe, Goldblatt, Baloush-Klienman,
Swarbrick, & Davidson, 2008). While the approach of deprescribing is value-neutral on these ideas and
does not take a universal stance regarding the meaning of medications, it is essential to consider these
feelings and associations in the process of deprescribing in order to best support the intervention on an
individual, a systems, and a societal level (see Chapter 4 for further discussion).
 Physician-Related Factors
Large surveys conducted among geriatricians and primary care physicians identified the following
barriers to deprescribing: uncertainty over why drugs were prescribed in the first place, concern over an
increased workload (including the time required), and a fear of not following accepted guidelines and the
potential consequences of such, including but not limited to litigation (see Reeve et al., 2013). We suggest
that these, as well as other reasons, can readily arise in the practice of deprescribing as applied to
psychiatry.
The lack of a clearly identified purpose by the original prescriber of the medication can introduce
doubt and concern for the current prescriber (e.g., “Is there something another provider saw that I am
missing? Has the patient underreported their symptoms and there is a compelling reason for this
prescription after all? What negative consequence might there be if the medication is reduced or
discontinued?”). These doubts and uncertainties can result in faltering, if not wholly rejected, attempts at
deprescribing.
It is important to reflect on what stops prescribers from considering the option of medication reduction
despite the standard guidelines recommending the use of minimum effective doses (as described in Table
3.1). Physicians, in general, have been reported to be perfectionistic, harm-avoidant, and risk-averse
(Eley, Young, & Przybeck, 2009; Kluger, Laidlaw, Kruger, & Harrison, 1999). Reduction or
discontinuation of medications may mean increasing the risk of symptoms, relapse, or even the need to
hospitalize a patient—a result that is often viewed as a failure by the prescriber and the system. The drive
to prevent a relapse can be so strong that medication reduction and/or discontinuation might not occur to a
prescriber, missing an opportunity for improvement of quality of life for the patient. Furthermore,
managed care limits the time afforded to the prescriber and the patient to adequately devote to the process
of shared decision-making, and continuing medications unchanged is thus incentivized as a ‘safe’ default.

Table 3.1 Reasons why prescribers might hesitate to consider medication reduction or discontinuation
when a patient is well
Reasoning Cultural, personal, or professional value attached to this reasoning
• Symptoms may reappear • We want to reduce suffering, not increase it
if medication is reduced
• The patient may relapse if • Understanding relapse as failure of treatment and we don’t want to fail
medication is reduced
• Absence of guidelines for • We don’t want to do what we haven’t been trained to do; nobody has taught us how to do it
medication reduction
• Absence of indications for • There’s no immediately apparent reason to do it; nobody has told us to do it
medication reduction
• Minimize risk to the • Prescribing is less risky than deprescribing, continuation of medications is the most efficient way to
patient and society minimize risk, sociocultural incentivization of medication prescribing over deprescribing
• The patient may relapse if • Avoiding blame/litigation for a relapse
medication is reduced
• Psychiatric diagnoses are • Professional training highlights this statement as a fact
lifetime diagnoses

“If It Ain’t Broke, Don’t Fix It”

Nonmaleficence is a deeply rooted ethical principle in medicine, but when unbalanced by other
principles, could validate unnecessary, prolonged medication regimens. Indeed, errors of omission may
seem more forgivable than errors of commission. Framing this sentiment more emphatically is the phrase
“never change a winning team,” which evokes a metaphor to imply that victory serves as an indicator that
a particular combination of players (or medications) functions optimally and indefinitely (Nüesch &
Haas, 2012). While ‘never changing the winning team’ may be a compelling approach for a college
football coach for the season, over the years, as the average age of the team approaches 90 (let us say),
lesser success may be enjoyed. A similar distinction may be applied to prescribing, where what works
initially may not necessarily bear out through the entire natural course, or indeed life of the patient.
Complicating factors might include normal aging, co-occuring medical conditions, psychosocial
conditions, and stakeholder preference. For instance, infectious disease consultants have reported that
many primary treatment teams tend to prefer continuing the original antibiotic therapy if they have
obtained desirable results, despite specialist recommendations for a streamlining of antibiotic therapy
(Van der Meer & Gyssens, 2001).
Overapplication of this rubric can manifest in many different ways in psychiatric prescribing, for
example (1) in extended treatment with anticholinergics in the absence of proven risk of antipsychotic-
induced extrapyramidal symptoms (Marsden & Jenner, 1980); (2) in persistence with higher doses of
antipsychotic medications (where lower dose antipsychotic treatment can be a viable option in the
maintenance phase; Schooler, 1993, 1991); and (3) in the continuation of polypharmacy without
establishing each individual medications’ ongoing need (Stahl & Grady, 2004). That being said, Onder,
Nobili, and Margenoni (2016) add a cautionary note about disparaging this ethical principle and
excessive enthusiasm for deprescribing in geriatrics where, in complex patients, medical stability may be
precarious and hard-won after several combinations have been already tried. This argument, too, can be
easily applied to psychiatry where rational polypharmacy (e.g. antidepressant augmentation and specific
combinations of mood stabilizers and antipsychotics) has a steadily growing evidence base.

What To Do About It
It behooves the prescriber to remember that the decision to continue a medication regimen unchanged
remains a decision made. Ethical practice and sound clinical decision-making demand representation
from and weighing of multiple perspectives. A prescriber must remain mindful of whether one’s practice
could be biased in one direction or another (i.e., more prone in general to suggest a change or promote
continuation relative to peers). The simplest and most acceptable approach to challenging blinkered
nonmaleficence is the use of credible evidence from sources such as national guidelines that, for example,
recommend the active seeking of minimal effective doses as standard practice. It might also be
worthwhile to remind ourselves that, in addition to allaying symptoms at the current time, we bear the
responsibility of minimizing the potential for serious side effects that may occur in the future. The latter
involves maintaining a balance between an active treatment approach and a preventive approach in the
management of medications. For instance, it is known that the incidence of antipsychotic-induced tardive
dyskinesia increases with age and the duration of antipsychotic treatment. Similarly, the rate of lithium-
induced permanent tubule-interstitial renal disease has been reported to increase with the duration of
treatment. Remaining mindful of the accumulating risk of these serious side effects while renewing these
medications may help in overcoming any fears regarding considering a deprescribing process and thus
“rocking the boat.”

Limited Guidelines on Deprescribing

Training and guidelines in psychopharmacology are largely focused on the initiation, continuation, and
monitoring of medication treatment and do not equally describe the process of medication withdrawal
and/or discontinuation, which are typically only mentioned in the context of switching from one
psychotropic to another (i.e. cross-titration). For instance, standard guidelines for the management of
depression address the use of “washout” and cross-tapering when switching from one antidepressant to
another but offer relatively fewer suggestions for when a patient may want to collaborate around stopping
an antidepressant drug and not replace it with another. Guidelines for management of schizophrenia
recommend the use of minimum effective doses of antipsychotics in the maintenance phase of treatment
but do not outline a tapering schedule or what to do when a patient wishes to collaboratively try a
medication-free period. In these situations, a novice prescriber, by virtue of their training experiences,
may be disincentivized towards change. Until more formal training and guidelines exist, prescribers might
reassure themselves that their training offers relevant and translatable knowledge and skills. To further
provide perspective (although not yet formally studied, but drawing on universally-reported high rates of
non-adherence) one might posit that the majority of medication tapers and discontinuations undertaken are
in fact instigated and ‘managed’ by patients alone.

What To Do About It
Lack of current guidelines around deprescribing requires the prescriber to take a more creative and
innovative approach. Gaining comfort with this experience may necessitate additional peer and team
support for the prescriber. Providers might draw on the past experiences of the patients themselves, as
patients are likely to have had past experiences with discontinuing medications without informing their
prescribers. Hence persons with relevant lived experience may be considered a valuable partner. As the
literature addressing optimal medication withdrawal strategies still grows, persons with lived experience
of self-managed discontinuations, perhaps guided by online resources such as consumer forums, may
arguably hold the majority of the collective expertise on the topic. Of course, utmost caution and scrutiny
should be exercised when integrating anecdotal evidence (particularly from patient forums) into one’s
understanding. Beyond the limited published literature, discussions with more experienced colleagues can
also prove to be an invaluable resource. The peer-reviewed publication of anecdotal evidence, such as
case reports, can lay the foundations for the generation of higher levels of evidence. All readers are
encouraged to contribute to this effort. Currently, there is a wealth of untapped clinical experience among
colleagues, patients, and other care providers that can be informally tapped for potential guidance. By
drawing on these various resources, the application of fundamental priniciples and listening to one’s
patient, the novice deprescriber can be better equipped and feel more confident in their approach to
deprescribing.

Fear of a Bad Clinical Outcome and Potential Litigation

In a nationwide survey of barriers to deprescribing among psychiatrists, a fear of relapse and

rehospitalization emerged as a central concern (Gupta, 2018). Given the mixed results of numerous
observational as well as randomized controlled trials of medication discontinuation in patients with
schizophrenia, bipolar disorder, and recurrent depression, and the subsequent guidelines that have
emerged from these trials, this concern is more than valid. This fear is intensified when considering
patients with past histories of suicide attempts, violence, and criminal justice system contact.
Furthermore, an attempt at deprescribing may be perceived as flouting standard guidelines or not
providing best common practice, leaving the prescriber potentially vulnerable to litigation.

What To Do About It
An awareness of the “therapeutic illusion” or the “illusion of control” may help mitigate the fear of
relapse to some extent. The therapeutic illusion has been defined as a situation where physicians believe
that their actions or tools are more effective than they actually are and is based on the tendency of human
beings to overestimate the effect of their actions (Casarett, 2016; Langer, 1975; Thomas, 1978). This
perpetuates the idea that withdrawal or change in a medication (as the more salient action) will
destabilize a patient, which in turn causes the prescriber to keep the medication unchanged. Casarett
(2016) recommends two questions to ask ourselves in helping to dispel or challenge our innate tendency
toward the therapeutic illusion. First, “before you conclude that a treatment was effective, look for other
explanations,” and, second, “if you see evidence of success, look for evidence of failure.” Applying these
principles to psychiatry may reveal, for instance, that what we perceived as a good response to an
antipsychotic was actually explained by the patient simultaneously securing disability benefits. This
relates as well to the statistical adage “correlation does not equal causation,” another useful maxim in
potentially dispelling the illusion. One might accordingly also question why our patients who continue to
accept their prescriptions unwaveringly still end up having relapses.

Patient-Related Factors
Reeve et al. (2013), in their review of 21 articles, identified three themes within the potential barriers to
and enablers of deprescribing in older individuals. These were disagreement or agreement with
“appropriateness” of cessation, absence or presence of a “process” for cessation, and negative or
positive “influences” to the idea of ending the use of a particular medication (Reeve et al., 2013).
Numerous other potential reasons prevent people from asking their physicians to reduce the number of
medications. Patients may fear a relapse of illness, fear being denied the ability to resume medication, or
even fear provoking disapproval or abandonment by their treaters, especially if they have previously had
negative reactions to the suggestion of decreasing medication. Avoidance of the issue may lead some
patients to discontinue medications unilaterally—which may deprive the prescriber of the opportunity to
collaborate and gain experience with this process.

Fear of Relapse

Patients have often worked hard to achieve symptom control with the right combination of medications. It
is understandable that a person may be reluctant and even strongly opposed to any change in medications
because of the fear of the return of symptoms or a concern about being rehospitalized. This fear may be
reinforced by shared feelings in treaters, by institutionalizing attitudes that equate clinical status solely
with medication adherence and by repeatedly-heard advice to stay on their medications in order to stay
well.
At the same time, although a useful tool, the process of self-monitoring can have the unintended
consequence of developing hypervigilance in the person with mental illness; a constant watching of the
self for any emergence of symptoms. This can lead to anxiety regarding mood fluctuations, for example,
that may be “within normal limits” or not really a concern. In this way the anxiety triggered by the fear of
relapse can contribute to a self-fulfilling prophesy. Therefore, as Gumley puts it, there is a need to “de-
catastrophize relapse” (Gumley & Schwannauer, 2006).
One useful scale for assessing fear of relapse is the Fear of Recurrence scale (FORSE; Gumley &
Schwannauer, 2006), which assesses the concerns of a person regarding recurrence (used interchangeably
with relapse in reference to this scale). The scale includes three subscales: fear of relapse, awareness of
thoughts, and intrusiveness. This is based on research evidence that the appraisals and increase in focus
and self-consciousness about experiences and bodily sensation actually contribute to the increase in
distress and an acceleration of potential relapse (Gumley, White, & Power, 1999). The “fear of relapse”
subscale had strong correlations with anxiety and depression further supporting the idea that concerns
about relapse may further speed symptom onset.

What To Do About It
Listening to and validating the patient’s concerns about relapse may be the first step in addressing them.
Of note, it may take months or even years to consolidate an alliance sufficiently secure for a patient to
even consider changing a medication. The prescriber should strive to minimize unaddressed issues that
might bias a collaborative weighing of the risk–benefit ratio for a medication. This might include
proactively educating against the barriers outlined in this chapter as well as modeling acceptance of
uncertainty. Development of a detailed plan to identify relapse or symptom return early on may be a useful
step in reassuring the person about their ability to decrease medications in a safe, controlled way. For
someone accustomed to being sedated and having their moods and distress muted, the return of intense
emotional experiences may be both a delight and contain an element of terror, for fear that these
experiences are the harbinger of a relapse. Expanding the definition of health by shrinking the idea and
definitional boundaries of relapse may be useful in the process of deprescribing a medication.
Normalizing variations in mood and experiences of distress can be seen as important targets in supporting
a person to weather the potential of increased variation of experiences as the effect of medications are
lessened.

Impact on Family, Friends, and Caregiver Relationships

Sometimes, the relationships that patients develop feel as if they may be (or are) contingent on the patient
continuing to take medications. For instance, a spouse may have already threatened divorce unless
medications are taken, or the patient may fear that friends will abandon a patient if they become
symptomatic. Some relationships may have been initially forged around having a psychiatric treatment in
common (e.g. meeting a friend at clozapine group). Treatment relationships (prescriber, therapist,
clinician, case manager) as well as those stemming from treatment (e.g. friends met at the mental health
center) can be significant, and a desire to please, or at least not risk disappointing a caregiver may
discourage a patient from instigating a change in a prescribed treatment. Many patients are socially
connected to their visiting nurse who administers medications; discontinuing medications might end these
twice daily visits to their home. A patient may fear that deprescribing might mean less frequent contact
with a prescriber to whom they are attached and from whom they have received significant support.

What To Do About It
If the patient feels comfortable and wishes to, the easiest way to address pressure from family, friends, or
even wider treatment team members, is to engage them, at some stage, in the decision-making and
implementation process of deprescribing. Involving significant social supports and allaying their anxiety
may be as or more important as allaying the patient’s anxiety. More specific interventions, such as couples
therapy or family therapy, may be indicated. Deprescribing may be framed in a positive light, as a routine
treatment option from the outset, without threat of diminishing or jeopardizing the therapeutic relationship.
Patients may also feel as if their prescriber is abandoning them during deprescribing or even at the
suggestion of deprescribing, making it essential to address these concerns immediately and even if they do
not come up directly. One might frame the importance and utility of continuing (and even more frequent)
periodic followup irrespective of prescribing. When it is the case, i.e. routine follow up with the
psychiatrist will continue, it may be useful to explicitly state that this relationship, at least, is not
contingent on taking medications.
 Fear of Losing Benefits

It is commonly perceived that applications for benefits such as social security disability income (SSDI)
and other services such as in-home care, individual or group therapy, or rehabilitation services are
strengthened by listing medications in the application form. Indeed, the psychosocial interventions
patients engage in to sustain their recovery can be more challenging to quantify and articulate. A long list
of medications at high doses may paint an individual as being very ill and therefore highly deserving of
disability benefits. Although perhaps not accurately reflecting the decision-making process of any
adjudicating body, the potential role of medications as “badges of illness” may lead a patient to imagine
that they are at risk of losing their benefits if their application is weakened by a diminished medication
list.

What To Do About It
Effective and direct communication of the patient’s clinical and functional status (including documentation
of nonpharmaceutical strategies) with the concerned authority may be needed. Reasons for medication
discontinuation (e.g., ineffectiveness or side effects) may have to be noted in the supporting
documentation. While reassuring the patient directly may be tempting, it is important to temper this with
the realistic possibility that benefits may be cut or lost, and that as the prescriber or clinician it is
impossible to provide any true guarantee. Just as patients assume that a long list is supportive of more
serious impairment, it is not clear that the assessors may not have similar assumptions. Providing detailed
rationale and accurate current functioning, and being transparent with the patient about the framing and
even sharing the document with the patient, can help reduce anxiety and support the alliance in the worst
case scenario in which benefits are denied.

Withdrawal or Rebound Symptoms

Although medications such as benzodiazepines and opioids (causing tolerance and dependence) are most
notable for their classic withdrawal syndromes, serotonergic antidepressants such as selective serotonin
reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs) and serotonin and norepinephrine reuptake
inhibitors (SNRIs) are also associated with clinically salient discontinuation (or withdrawal) syndromes.
Furthermore, these serotonin withdrawal symptoms may resemble the underlying illness (mood lability,
transient depression, severe anxiety), and both patient and prescriber may become concerned about a
relapse. Patients may change their mind about deprescribing because of how difficult it can be to tolerate
and manage these distressing, yet transient symptoms. Hopefully less relevant to a well-implemented
deprescribing, abrupt discontinuation of other psychotropics (e.g. lithium and antipsychotics) have been
linked to rebound symptoms resembling a recurrence of the underlying condition. Withdrawal syndromes
are discussed in more detail in the relevant chapters that follow.

What To Do About It
Just as transient, ‘initiation’ side effects should be mentioned when prescribing a new medication,
preparation for withdrawal symptoms while deprescribing is crucial. Preparation may involve creating
expectations and providing information about the nature and potential duration of withdrawal symptoms,
along with a plan of management. Reassurance that withdrawal symptoms can be effectively managed and
are time-limited may be very helpful in averting the patient’s conclusion that they have become forever
reliant on the medication to feel well. A plan to manage rebound symptoms or recurrence may include
close surveillance, a planned response and apriori acceptance of the possibility that it may become
necessary to slow the taper or even retitrate to a higher dosage in order to regroup and reassess the
deprescribing plan.

Deprescribing and Identity Disruption

Some individuals receiving long-term services within large, encompassing institutions such as the public
mental health system become socialized into an identity of “being a patient.” This identity is constructed
around a core self-perception through the lens of psychiatric diagnosis and treatment. Withdrawal of
medication, or even a suggestion thereof, could threaten a potential loss of identity. Patients may even
have daily or weekly routines (yielding collateral benefits such as structured social contact) constructed
around obtaining and filling prescriptions as well as taking the drugs themselves. These routines for many
people include having developed strong social relationships with those care providers involved in
medication administration. For example, a patient’s brief daily interaction with their visiting nurse may
represent their most significant social contact. Alternatively, a periodic visit to the friendly local
pharmacy might prompt another patient to treat themselves to some new toiletries or self-care items each
month. The idea of discontinuing medications may trigger both a loss of identity (whether it be socially
valued or devalued) as well as the loss of corresponding everyday social interactions and ritual which
are associated with accessing and administering the medication.

What To Do About It
Appropriate framing of the place of medications in treatment at the time of prescribing may help patients
‘let go’ of them when they are not needed anymore. A discussion on what it means for the person to be on
a psychotropic medication can be a rich area for discovery of meaning and associations that the person
may not be fully aware of initially. Following this discussion, exploring what it might mean to lead a life
without medications may be helpful. Exploration of the practical activities surrounding the regimen,
collateral benefits, and what they stand to lose presents an opportunity to find alternatives to relationships
mediated by medication tasks. Increasing other social supports can assist the person in thinking through
deprescribing. The recovery literature has suggested that one of the challenges associated with recovery
may be the task of accepting oneself as an ordinary agentic (having agency) human being, a task that may
very well emerge during deprescribing as well.

Systemic and Cultural Factors

Association of Medication with Health Rather than Disease

With the commodification of health, supplements; screening tests; provider visits; and to some degree
medications have come to be associated with health and maintenance of health rather than treatment of
disease. Instead of assuming the baseline of a healthy body that does not require any medications,
consumers may feel like they are missing out on health if they are not taking a certain number of
medications. This can be problematic when this attitude disincetivizes more favorable wellness strategies
(such as decreasing alcohol use, or getting more exercise). In such a societal climate, an intervention such
deprescribing may be easily perceived as withdrawal of care or deprivation. Garfinkel (2017) stress that
the concept of deprescribing may be automatically perceived as a negative approach, one interfering with
“good health.” For instance, in Ireland, when the health service incentivized the reduction of antibiotic
prescriptions it was perceived by the public as inadequate care for patients (see Wise, 2016).

Pressure from Direct-to-Consumer Advertising

“Ask your doctor today, if drug x is right for you” is a commonly heard phrase on television. When
patients are bombarded with commercials and printed advertisements eulogizing the benefits of a
particular brand of medication, they may view the receipt of the free samples as a boon and subsequent
discontinuation as deprivation. Direct-to-consumer advertising may influence prescribers to offer
medications they may not have otherwise prescribed (due to relative appropriateness, confidence, or
experience). In a recent survey, more than 33% of participants said that they asked their prescribers for
information about a drug they had seen or heard advertised, and almost 25% asked for a prescription of
that drug. Seventy-five percent of these individuals reported that their prescribers gave them the requested
drug (American Pharmaceutical Association, 1997).

What To Do About It
At the time of writing, the United States is only one of two countries that allows direct-to-consumer
advertising (the other being New Zealand—although this is under review as the medical community
lobbies against potential detrimental effects). On the level of the individual patient–provider relationship,
all sources of information can be acknowledged, contextualized and integrated. The appeal from
marketing can be acknowledged and weighed within the risk–benefit calculation as either positive or
negative. For some patients, a marketing campaign may bring value in the form of buy-in or alternatively
create unrealistic expectations for results; checking in with the patient as to the source of their information
can help clarify and contribute to a conversation that is forthright and respectful.

Time Constraints and Absence of Coordinated Systems of Care

Deprescribing is a time-intensive intervention requiring detailed review of the risks and benefits of each
medication, coordination with other prescribers, and the development of a multidisciplinary plan for the
prevention of relapse. In the age of ‘15-minute medication checks’ (Torrey, Griesemer, & Carpenter-Song,
2017), most psychiatrists merely have sufficient time to review changes in symptoms and side effects,
order refills, and complete the patient record. Support from pharmacists, primary care providers, and a
good communication network are all essential for supporting effective deprescribing. Attempts at
coordinating care with other prescribers may not always prove successful, especially in the absence of
common electronic health record systems. When this infrastructure is unavailable, well-meaning
prescribers who would otherwise support deprescribing may be feel daunted by the time investment
required and feel compelled to abandon it as a nonessential or unfeasible intervention.

What To Do About It
Although cultures of practice can be gradually influenced, systemic barriers can warrant interventions at
the level of the agency and institution, as well as looking at broader mental health and healthcare policy
change. This might include advocacy at the state and federal levels. The specific issue of insufficient time
for pursuing a deprescribing intervention may be addressed in at least two ways. At the systems level, in
most instances it is the insurance carriers that influence the level of detail/complexity and/or duration of
the physician–patient encounter through economic incentives and disincentives. One potential avenue for
change in this area would be providing, via billing parameters, evidence for the overall long-term cost-
effectiveness of deprescribing and creating a set of billing codes or bundled payment specific to this
intervention. At the individual patient level, with limited available duration or frequency of visits, time
costs may be defrayed longitudinally. Alternatively, a long-term therapeutic relationship with a prescriber
can be leveraged. The strength of the therapeutic alliance may provide a safety net in a sense, allowing the
patient to take more risks because of confidence in their relationship with the provider. Typically
deprescribing is not something that needs to, or should, be rushed. Spreading the process over multiple
meetings allows for intersession assignments for both patient and prescriber. Written information and
other materials (such as specialized decision support tools) may be reviewed at a patient’s leisure. The
assumption that deprescribing requires a prohibitive amount of time and effort within our current systems
of care should be countered.

Conclusion
Deprescribing can be challenging to implement due to factors stemming from prescribers, patients,
caregivers, and the surrounding cultures and systems of care. Prescribers may be disinclined to
deprescribe due to relative lack of time and/or training, concern of violating standard guidelines, and
concerns of “causing” a relapse or risk-taking behavior (i.e., harm to self or others). Patients, on the other
hand, may resist deprescribing due to a fear of symptom recurrence; pressure from family, friends, or
mental health staff; and concern for other collateral consequences such as losing valued resources.
Systemic and institutional factors such as a societal “pressure to prescribe” and brief medication
management visits may further dissuade providers from altering the status quo. Barriers can be addressed
through the better training of prescribers, both at the level of core and specialty training; ongoing
education of patients about their medications; dynamic updating of the risk–benefit calculation; and further
influencing public attitudes to health as a process and lifestyle and not an “off the shelf” commodity
merely to be consumed.

Self-Assessment
1. Joe is 40-year-old single unemployed man receving social security disability who lives with his elderly mother. He was
diagnosed with schizoaffective disorder in his 20s and takes haloperidol 5 mg twice a day, olanzapine 30 mg at bedtime, and
benztropine 2 mg in the morning (without which he experiences extrapyramidal side effects). Between the ages of 25 and 31
he had eight hospitalizations for threatening behavior toward his mother. You look at his medication regimen and wonder if
he might still do well without the haloperidol. When you broach this question with Joe and his mother, they are immediately
reluctant.

a. How might you engender further discussion about attempting to deprescribe the haloperidol and what would be the indication?
b. Speculate on three reasons which Joe might be declining a reduction in this medication.
c. What kind of psycho-social interventions may support deprescribing in this case?

2. Mary is a 67-year-old woman who lives in a rest home. She was diagnosed as having schizophrenia in her 30s and has taken
clozapine 200 mg twice a day for 15 years. She also has type 2 diabetes and hypertension and has suffered two strokes. You
suggest a slow reduction in dose, to which she is amenable, but she struggles to relate back the rationale during your initial
discussion. She is not conserved, but her family heavily influences her care at the home. That evening her nurse from the
rest home calls, incredulous, wondering whether what Mary is relating to her about today’s appointment is true, “Her
daughter will never allow this!”

a. What are the potential risks of reducing Mary’s dose?

b. Speculate on three potential concerns that the nurse might have.
c. How will you address the nurse’s concerns regarding deprescribing?

3. Tim is a 29-year-old man who has continued escitalopram following two major depressive episodes. He has been seeing you
monthly since he had his first episode at age 23 and the second at 26. Both episodes were in the context of major life
events. Although he believes the medication was helpful in remitting his depression, he is wondering whether he should
 stop the escitalopram, with his fiancée often telling him that “it is a sign of weakness.”

a. What are the risks of engaging in a deprescribing of escitalopram?

b. Speculate on three possible reasons driving Tim’s ambivalence about stopping the medication.
c. How might you overcome these barriers and proceed with a deprescribing?

References
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1203–1205. doi: 10.1056/NEJMp1516803
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Rural Health, 25(1), 43–49.
Garfinkel, D. (2017). Overview of current and future research and clinical directions for drug discontinuation: Psychological, traditional and
professional obstacles to deprescribing. European Journal of Hospital Pharmacology, 24(1), 16–20.
Gumley, A., & Schwannauer, M. (2006). Staying Well After Psychosis: A Cognitive Interpersonal Approach to Recovery and Relapse
Prevention. New York: John Wiley & Sons.
Gumley, A., White, C. A., & Power, K. (1999). An interacting cognitive subsystems model of relapse and the course of psychosis. Clinical
Psychology & Psychotherapy, 6(4), 261–278. doi: doi:10.1002/(SICI)1099–0879(199910)6:4<261::AID-CPP211>3.0.CO;2-C.
Gupta, S., Miller, R., Montenegro, R., Pavlo, A., Cahill, J.,D. (2018). Survey of Practices, Attitudes and Barriers to Deprescribing Psychiatric
Medications. Poster presented at: Annual conference of the American Psychiatric Association, New York.
Lader, M. (1995). What is relapse in schizophrenia? International Clinical Psychopharmacology, 9, 5–10.
Langer, E. J. (1975). The illusion of control. Journal of personality and social psychology, 32(2), 311.
Marsden, C., & Jenner, P. (1980). The pathophysiology of extrapyramidal side-effects of neuroleptic drugs. Psychological Medicine, 10(1),
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und Statistik, 232(3), 247–257.
Olivares, J. M., Sermon, J., Hemels, M., & Schreiner, A. (2013). Definitions and drivers of relapse in patients with schizophrenia: A systematic
literature review. Annals of General Psychiatry, 12(1), 32. doi: 10.1186/1744–859x-12–32.
Onder, G., Nobili, A., & Marengoni, A. (2016). Potentially inappropriate drug prescribing and the “never change a winning team” principle.
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systematic review. Drugs & Aging, 30(10), 793–807.
Roe, D., Goldblatt, H., Baloush-Klienman, V., Swarbrick, M., & Davidson, L. (2008). Why and how people decide to stop taking prescribed
psychiatric medication: Exploring the subjective process of choice. Psychiatric Rehabilitation Journal, 33(1), 38–46.
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Supplement, 22, 58–65.
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 4
Nonpharmacological Aspects of Deprescribing
Deprescribing, like prescribing, can be regarded as a multifaceted intervention, and hence this chapter
focuses on the major, anticipated nonpharmacological considerations. As touched upon in chapter 3, this
may include real and imagined consequences for a patient, family and friends, treater, and systems (such
as altered access to resources/entitlements). Lastly, this chapter will provide a method for anticipating,
eliciting, and systematically addressing these concerns to prevent them from undermining the process of
deprescribing.

Goal and Learning Objectives

After reading this chapter, the reader will be able to:
1. Outline the psycho-social-cultural factors and dynamics that underlie deprescribing
2. Identify patient roles, relationships, and resources that are need to be considered within a deprescribing plan
3. Describe strategies and a therapeutic stance for optimally managing these dynamics

The Psychological Meaning of Medications

The prescribing and ingestion of drugs is embedded in a matrix of cultural values and assumptions.

—Helman, 1981

We propose that deprescribing medications in the field of psychiatry requires the prescriber to consider
not just the biological but also the psychological factors involved. Thus, a useful framework to apply is
the psychodynamic meanings of medications as they relate to both the patient’s inner and outer worlds.
This outer world is constituted by significant others, friends and family, the prescriber and other mental
health professionals, and even systems of care. A pill is not just a pill; the psychological meaning of
taking the medication—or not taking the medication—must be incorporated into the deprescribing
process. Failing to do so places the endeavor at risk of being undermined by unaddressed fears, concerns,
needs, and associations. The symbolic meaning of medications, not only for the patient but also for the
prescriber, the team, the family and broader society, should not be underestimated.
Rates of nonadherence to medications have been estimated at about 50–70% of patients with
schizophrenia who do not take medication as prescribed (Bellack et al., 2009). Earlier research on what
has been previously termed “noncompliance” to medication regimens provides some initial thoughts about
the relationship of patient to medication. The issue of patients not taking medications as prescribed was
first understood as a problem in the prescriber–patient relationship and/or problems in the patient’s
understanding of the illness (David, 1990). This has relevance to the “health belief” model, first
suggested by Becker (1974), that suggested that patients are more likely to comply with a doctor’s orders
when they feel more at risk or susceptible to illness. However, on a more practical level, compliance is
also found to increase when there are fewer perceived barriers such as cost or side effects.
The person-centered perspective on treatment considers patients to have a more active role in
decision-making and is less focused on the “compliance” of the patient to the “orders” (Tondora, Miller,
Slade, & Davidson, 2014). This perspective sees the patient as actively making decisions about what they
feel is best for their body and their illness and focuses on an increase in self-determination and choice
(Corrigan et al., 2012). The movement toward self-determination relates to an evolution in attitudes about
the use of medication within the recovery movement. Within the recovery movement, medications are one
of many possible tools in addressing mental illness, and their use relies on an authentic collaboration
between prescriber and patient.
Perceived, intuited, or assumed biases on the part of the prescriber about medication may sway the
patient’s decision-making in either direction. A patient intent on pleasing the prescriber, or one who feels
subjugated by, and fears retribution from, the prescriber, may superficially decide on a course of action
with medication based on a wish to please. In other cases, psychological reactance (Brehm, 1966; Miron
& Brehm, 2006), or a perceived threat to one’s psychological autonomy in the face of requests or
demands, may lead to a negating of any suggestions only out of a need to maintain a sense of coherence
and personal will, rather than stemming from what is in the person’s best interest.
Recent research into the impact of alliance and trauma further add to this picture. Tessier and
colleagues (2017) found a correlation between higher levels of trauma in the psychiatric system and
lower rates of adherence toward psychiatric medications. Adherence was increased by higher rates of
alliance with the provider. This points to the importance of addressing traumatic experiences regarding
the mental health system and could speak to the development of an “institutional transference” (Martin,
1989). With greater association of the medication to a perpetrator of trauma, if the medication in some
way symbolizes the offending health care system, it would be intuitive to predict lower rates of
adherence.
Medications act as symbols in cultural, economic, and psychic ways (Metzl & Riba, 2003).
Antipsychotic medications, for instance, carry a cultural resonance related to controlling the behavior of
those diagnosed with schizophrenia or other psychotic illnesses, based on assumptions regarding self-
control and/or dangerousness. Some authors have suggested that medications themselves can be seen as
entities that represent the sociocultural, economic, and technological trends of a given time period
(Cohen, McCubbin, Collin, & Pérodeau, 2001). There is a “public protection” aspect to adherence with
these medications, which may be reflected in discourse in the media. For example, an individual who
presents as angry or uncontrolled may be referred to as “off their meds” in relaying a news story. This is
an experience endorsed by patients who perceive medications as symbolizing a form of social control, as
outlined in one study looking at those with schizophrenia (Rogers et al., 1998). From a psychoanalytic
perspective, some writers have characterized medication as a third person in the therapeutic work, with
patients’ feelings about the therapist projected onto the medication (Tutter, 2006).
Even the act of taking a psychiatric medication for the first time is imbued with meaning and personal
importance. Davidson (2001) describes his experience of first taking antidepressant medications as “a
watershed event . . . [m]y hands shook as I opened the bottle for the first time”. This intensity can be seen
as representing a threshold crossing, from an identity as a ‘well person’ to that of someone with mental
illness, with the medication acting as the vehicle for this transformation. Thus, stopping the medication
can represent the return to health, if only symbolically. For some, stopping medication can feel like an
important marker of recovery (Roe, Goldblatt, Baloush-Klienman, Swarbrick, & Davidson, 2008); this
finding is important for its potential implications when returning to medications, as it may be challenging
to restart a medication if it is seen as a “failure” or back-sliding from the patient’s perspective. Taking a
psychiatric medication can imply or confirm for some that they are truly ill; the medication is conflated
with a diagnosis, and the message to one’s self might be “if I’m taking medications, I must really be
[crazy/sick/ill/insane]” (Swarbrick & Roe, 2011). Reversing this logic can be a motivator to stop
medications, and understanding this motivation is crucial in providing accurate and specific support to a
patient interested in deprescribing.
Mintz and colleagues have utilized the term psychodynamic psychopharmacology (Mintz, 2011; Mintz
& Belnap, 2006) to describe the psychological aspects of the therapeutic relationship in reference to the
use of medications. Mintz (2011) defines it as identifying the “central role of meaning and interpersonal
factors in pharmacological treatment.” In the description of resistance to taking medications, Mintz et al.
say that it may be related to an unheard communication of the symptom and, with that, a reluctance to have
it be silenced by the effects of medication. In extending this hypothesis to deprescribing, one can replace
the symptom with the medication—if taking the medication symbolizes illness for a person, removing the
medication may mean wellness or perceived wellness and a subsequent loss of care and concern by the
prescriber, other caregivers, family, and friends.
These common dynamics identified in relation to medications and their meaning can provide insight
into the reluctance to initiate deprescribing and help the prescriber to anticipate and understand
unexpected or perplexing behavior. Box 4.1, excerpted from Mintz, Seery, and Cahill (2018), outlines
some possible sources of harm from the meaning medications.

Box 4.1 Examples of potential adverse effects from medications that are mediated by meaning

• Medications used to avoid responsibility or self-knowledge

• Medications used to avoid appropriate affect or healthy developmental steps
• Medications used to avoid acknowledgment of appropriate limitations
• Medications used to act out a traumatic scene
• Medications used to replace people
• Medications used to replace internal controls
Excerpted from Mintz et al. (2018).

Patients may turn to medication as a way to avoid feeling or confronting difficult emotions. They may
use medications as a way of pushing through and continuing on in situations that are untenable. For
example, a person who becomes depressed and anxious in the context of an abusive romantic relationship
may use antidepressants and anti-anxiety medications to avoid addressing the real context of a
problematic relationship. Instead of approaching the situation head on, the medications are used as a way
of addressing the distress without changing the situation. This form of resistance risks reducing potentially
rich therapeutic encounters to simple transactions of symptom and dose.
Strategies to consider when approaching a situation that seems to be influenced by the
countertherapeutic effects of medication are listed in Box 4.2 (Mintz et al., 2018).

Box 4.2 Deprescribing Strategies when Medications Have Meaning-Based Countertherapeutic

Effects

• Develop an “overall diagnosis” that considers psychological aspects of treatment.

• Focus on the therapeutic alliance.
• Ameliorate harm by addressing pathogenic meanings.
• Consider countertransferential contributions to the impulse to deprescribe.
• Approach deprescribing as an interpersonal process.
• Attend to the treatment context.
• Deprescribe in a planful way that maximizes patient learning and authority.
• Consider that it is better to give no treatment than bad treatment.
Excerpted from Mintz et al. (2018).

Moving from a stance of dependence to autonomy, from patient to person, from consumer to
independent actor—these shifts in self-perception and subsequent role changes are filled with meaning,
ambivalence, and, at times, terror. While this often relates to fear of relapse or rehospitalization, these
dynamics cut much deeper, potentially accessing historical roles and relationships such as being the
identified patient in the family or social group. With this role unconsciously playing out, the
deprescribing process may be unsuccessful due to unacknowledged feelings of betrayal on the part of the
patient: “If I’m not sick, who will my mom have to take care of?” These dynamics that are often
unconscious, require a significant trust in the relationship with the prescriber or other clinical provider to
be comfortably explored in the process of deprescribing, and point to another reason why the process of
deprescribing may need to take place over a significant length of time, with potentially several “false
starts” and reconsiderations as these dynamics begin to emerge more clearly.

How to Elicit Significant Psychological Factors when Deprescribing

Eliciting concerns about deprescribing needs to be done carefully and with the consideration that patients
may not be consciously aware of the meanings they ascribe to the use of medication, and, even if they are
aware, it might be less acceptable to acknowledge these meanings. Approaching these questions in a
gentle and nonjudgmental way, and within one’s own psychotherapeutic frame and proficiencies, is of
essential importance. A focus on the relationship and addressing any ruptures in the alliance as the
conversation moves forward provides a good foundation.
As much as possible, the idea that the patient is using the medication as a way of avoiding strong
emotion must be approached in a strengths-based way; for example, by framing this use of medications as
an adaptation to a difficult circumstance when no other tools were available to the person. A nonshaming
approach, contextualizing the history and social dynamics of a person’s life, can place the use of
medications in a temporal context that serves to explain their previous usefulness and potential loss of
such function in the present day. This is similar to any coping skill or defense once utilized successfully
and that now, having outgrown or outlived its use, needs to be shifted and exchanged for something else.
The use of medications may be a way of reinforcing “patienthood” (Mintz, 2011). The idea of
medications being a message that a person is ill and perhaps not responsible for their actions or behaviors
can be a barrier to deprescribing, depending on the dynamic functioning of this stance in a person’s life.
There may be certain fears associated with being something other than a “patient,” - fears that have been
reinforced over the years due to the negative consequences of previous deprescribing trials or other
negative experiences of trying to venture out beyond patienthood. Particularly vulnerable are those who
have been institutionalized or part of the mental health system for a long period of time. Even when the
prescriber sees the medications as potentially more harmful than beneficial and may be interested in
starting a conversation about the reduction of one of these medications, the patient may be opposed for
reasons not initially clear; this is an important prompt for further exploration.
Attending to the alliance and therapeutic relationship is a crucial element in understanding meaning and
laying foundations for moving forward with any deprescribing effort. The alliance is considered the best
predictor of outcomes in therapeutic efforts (Martin, Garske, & Davis, 2000). Adherence studies have
identified the relationship with the provider as a positive predictor of adherence to prescribed regimens
(Day et al., 2005) and perceived coercion as a negative predictor of adherence. Focusing on identifying if
any dynamics (perhaps related to power differentials, early parental relationships or past history in the
present relationship) are playing out around the medication is important to consider in the process. In
addition, it is important to acknowledge that there may be multiple and potentially contradictory dynamics
playing out, without becoming wed to a single understanding, as relationships are changing and context-
dependent.
 The Sociocultural Significance of Medications
As discussed briefly in Chapter 3 around identity disruption as a barrier to deprescribing, a medication
regimen may be perceived by patients or social supports as a “badge of illness” or indeed as
“membership” in social groups from which patients derive significant support and enjoyment. For
example, a patient with schizophrenia who attends weekly clozapine medication group as one of their
most significant social interactions, and who deeply values the camaraderie she experiences there, may be
reluctant to give up that particular medication due to the medication-specific social benefits. Similarly, a
patient who has grown fond of their visiting nurse, who they have seen daily for medication
administration for the past several years, may do poorly in a deprescribing effort solely due to a
nonpharmacological effect—the significant loss of social contact through nursing visits. Efforts may be
made to identify the potential for support and to grieve any losses. Alternative supports may be found, or
advocacy for exceptions/policy change in local care systems, may be appropriate. Systems and payers of
care might consider reframing group membership and eligibility for services to better acknowledge those
in recovery without medications.
The simple ritual of periodically refilling and taking a medication may be significant to some patients.
Social interactions, prompts for general wellness maintenance (e.g., personal hygiene or flu vaccination),
and earlier detection of burgeoning medical illness may be collateral benefits of a monthly visit to the
pharmacy. These effects may be difficult to detect in advance; strategies might include a detailed step-by-
step walk-through of a patient’s everyday activities or asking them to imagine impacts on their routine if
no longer taking the medication.
Cultural differences in attitudes and practices related to medications have been reported but should not
be assumed solely based on group membership. An exploration (involving collaterals) may illuminate
relevant factors in an individual culture or subculture biasing toward or against a deprescribing.
Medication side effects may be experienced as meaningful or a marker of efficacy. Depending on cultural
factors, a patient revealing multiple prescriptions may elicit increased concern and caregiving as readily
as being perceived as inferior and ostracizing. The relationship between the allopathic prescription and
alternative, natural, or traditional remedies should also be considered. The response in a patient’s cultural
environment to a deprescribing might include the reciprocal refocusing on such remedies for better or for
worse.
On a systems level, risks of losing entitlements or resources, either real or perceived, may undermine
deprescribing. These risks may be mitigated with time as deprescribing becomes more prominent as a
treatment intervention. Until then, however, it is easy to imagine that a reviewer of a disability application
might more readily associate an applicant with an extensive list of high-dose medications with greater
severity of illness (and therefore disability) than an individual on a single minimum effective dose
medication who preferentially leverages psychosocial treatments. If a valid presumption, this will likely
be amenable to education and advocacy.

Conclusion
Considering the psychological meaning and sociocultural significance of medications is an important part
of prescribing but can be especially salient when deprescribing. Previously incomprehensible behaviors
may become clearer and more understandable when seen through the lens of psychic meaning and the
polarities of care versus neglect, health versus illness (and other identity markers or role designations).
Group memberships, entitlements, and access to resources may be challenged.
Nonpharmacological concerns, once elicited and examined, may contribute positively to the process of
deprescribing and may have the unintended positive result of identifying previously unaddressed
dynamics and opportunities for further social recovery for the patient. Approaching these questions with
care, concern, and attention to the alliance will best support this exploration of often difficult dynamics. If
a prescriber identifies limitations due to time or training/supervision, it would be appropriate to engage a
psychotherapist to collaborate in support of deprescribing.

Case Examples

Case Example 1
Josh is a 55-year-old, single, unemployed man taking haloperidol decanoate injections, divalproex,
gabapentin, and benztropine. He has a history of drinking heavily and using crack cocaine in his 30s,
following which he was admitted to a long-term state hospital for more than 2 years. He has no
complaints except for a generalized tremor that subsided after discontinuing divalproex. Following this,
the gabapentin and benztropine were also slowly discontinued as the indication for their use was unclear.
He seemed slightly more talkative but not disruptive. Several months into the deprescribing trial, he lost
his temper with his case manager, after realizing that she had been skimming money from his slim
disability income, and yelled at a neighbor because of his smoking crack in Josh’s apartment building.
These outbursts caused Josh to be hospitalized, following which the divalproex was restarted. On return
to the outpatient clinic, he declined the divalproex and had the support of his psychiatrist and therapist to
stay off the medication. In subsequent sessions with his therapist, he revealed for the first time, an
instance where he was sexually abused by the family pastor. This revelation, when shared with his
brother, led to an altercation between the two of them and, eventually, to another hospitalization. This
time, however, Josh did not return to the outpatient clinic after discharge and was not in contact for more
than 4 months. When he did return, Josh said that he had spent the summer in a larger, nearby city and was
feeling quite well. He had, however, lost his subsidized apartment, lost any contact with his brother, and
lost contact with a visiting nurse whom he cherished. He admitted to having drank alcohol but had not
used crack. He had been to the emergency room of a hospital in the nearby city and had been given a large
dose of haloperidol decanoate on one occasion. Josh also added that he was afraid he would lose his
disability income if he was not prescribed enough medication. He also wondered if divalproex was
actually “good for him,” and he was placed on haloperidol and divalproex again. Interestingly, the level
of divalproex was found to be very low every time it was subsequently measured. Over the next year,
Josh asked for the divalproex to be stopped and asked for a higher dose of haloperidol. During this
period, he used crack cocaine a few times, was hospitalized twice, but was more engaged in both group
and individual therapy. He referred to the sexual trauma a few times and seemed to be on his way to
eventually processing it.
This example illustrates the numerous identity and social issues that may arise during deprescribing
(indeed as they can during prescribing). These issues, such as being taken advantage of by his case
manager, and the revelation of the sexual trauma, were not immediately obvious in the manner in which
this individual’s life progressed, but seemed to underlie some of his actions and those of the people
surrounding him.
The first issue that arises is his relatively desirable response to the deprescribing of the divalproex,
gabapentin and benztropine. He seemed more cheerful and happier. For an individual who has been
“awarded” a lifetime diagnosis of schizophrenia and thus been “sentenced” to a lifetime of medication,
what did it mean that, to Josh, he was well, and even better, without many of his medications? Along with
feeling less sedated overall, he seemed to have reconnected with an identity that had presumably diffused
at the start of his psychosis, and been reconstituted as that of a “schizophrenic” and as a “consumer” of
medications. This illness identity seemed to diffuse again with the suggestion that he may not need that
many medications after all.
The second phenomenon that emerged was a realization of a sense of agency and that Josh recognized
himself as a potential source of action and as the recipient of the consequences of his actions. This
manifested itself in Josh addressing his difficulties with his case manager and his neighbor, and
subsequently, in one interpretation, being punished (with a hospitalization) for exercising his right to
defend and protect himself. While his reactions may have not been the most socially acceptable, the
reaction (of being hospitalized) to his increase in agency may point to lingering stigma and discrimination
within the mental health system, where healthy agency among someone diagnosed with schizophrenia can
be construed as symptomatic and requiring treatment. The uncovering of the sexual trauma and the ensuing
shame and anger led to altercations with his brother and another visit to the hospital. The hospitalization
could be considered an illustration of the mobilization of social forces, including his brother, his housing
agency (that placed the emergency call), and mental health professionals to “keep Josh in his place.”
In this example, divalproex, in Josh’s mind, had become the ticket to retaining his disability income and
perhaps even retaining a relationship with his brother. He, however, disliked feeling affectless and sleepy
and did not wish to take it. This conflict about divalproex appeared in his requesting a prescription but
not really consuming the medication. The concern over losing his benefits and his brother was heightened
by the advice from friends and his brother’s refusal to see him “without your meds.”
Similar to shifts in family dynamics when an identified “alcoholic” first enters recovery, Josh’s family
role, as passive ‘schizophrenic’, was shifting with his reduction in medication, causing ripple effects in
other relationships including that with the mental health system. The question around the flexibility of the
mental health system itself to be able to support a patient as their role and identity shifts also emerges in
this scenario. This is something to be sensitive to within the context of deprescribing; that, despite the
prescriber’s best efforts to flexibly and individually conduct a deprescribing trial, larger systems (e.g.
familial or social) may push back against these changes if only as an attempt to reestablish equilibrium.

Case Example 2
Gina is a 57-year-old heterosexual woman, divorced, unemployed, living alone in an apartment. She was
taking risperidone, benztropine, occasional diphenhydramine, and a small dose of lithium that could be
considered subtherapeutic based on blood level. Gina was assigned to a prescriber who had newly joined
the practice following the retirement of a colleague. She appreciated the new prescriber, who she felt was
not very focused on medication but who wanted to talk to her. On one visit, the prescriber mentioned to
her that she didn’t need the lithium and was discontinuing it. After 2 weeks, Gina informed the office that
she was having anxiety and that she needed to take lithium. The prescriber offered to increase the dose of
diphenhydramine and pointed out several ways in which the lithium was not suitable for her anymore, but
she would not agree and continued to be determined to restart the lithium. She had mentioned several
times to the new prescriber that Dr. James had prescribed the lithium more than 20 years ago and that her
ex-husband frequently taunted her saying “are you off your lithium again?” whenever she lost her temper
or laughed loudly.
Gina’s attachment to the lithium and refusal to stop taking it, despite a low possibility of therapeutic
benefit (or withdrawal symptoms) indicated that there were unidentified factors at play that were
mediating her anxiety. Although she did not make the connection between the two, her anxiety over the
discontinuation of lithium could be related to the departure of Dr. James who had treated her for more
than 20 years. Discontinuing the lithium, to her, was like severing her last connection with a prescriber
whom she trusted and valued. Further, her ex-husband’s repeated taunts led to a conclusion about herself
that “unmedicated Gina” was intolerable and deserved to be mocked or punished. She had internalized the
idea that the only way to be acceptable to society was to take lithium. With this hypothesized link between
the medication and the relationship with her previous doctor, addressing the grief over losing Dr. James
and what it means to now “go against” his recommendations may free Gina to try reducing the lithium. The
treatment team may also assist Gina in seeing herself as a person of worth even without the lithium,
supporting her in beginning to undo the damage caused by her husband’s comments. Both these issues if
addressed before the medication itself is changed will likely promote a more successful trial off the
lithium. Furthermore, the unilateral decision to stop the lithium made by her new prescriber may have
triggered psychological reactance; the sense that her autonomy was compromised may have foreclosed the
deprescribing option for Gina. Including Gina in the initial decision-making and eliciting these concerns
about loyalty to her previous doctor and the characterization of her by her ex-husband may have better
allowed Gina and her prescriber to better understand and therefore address these concerns and dynamics
on the front end.

Self-Assessment
1. Which of the following dynamics may become activated by a suggestion of deprescribing?

a. Relinquishing the role of the “identified patient”

b. Fears around a greater sense of agency
c. Fear of repercussions on relationships with significant others
d. All of the above

Correct answer: d. All of the above.

2. Which of the following may compel a patient to decline changes in medication?

a. Fear of relapse/rehospitalization/incarceration
b. Ritualization of the process of obtaining and consuming medication and building a social circle around it
c. Fear of not looking ill enough on an application for benefits
d. All of the above
e. None of the above

Correct answer: d. All of the above.

3. Which of the following may be a social implication of deprescribing?

a. Threat of divorce from spouse

b. Family cutting off communication
c. Kidney problems
d. Only a
e. A and b

Correct answer: e. A and b.

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 PART 2

THE INTERVENTION OF DEPRESCRIBING

 5
Wellness Approaches I
Self-Determined Strategies

It is important for deprescribing not to be experienced as a withdrawal of treatment per se and certainly
not withdrawal of care or concern on the part of the treater. A key element of this is acknowledging and
bolstering of existing strategies or the introduction and development of new strategies for maintaining
wellness. These can come solely from the patient and their social supports or in collaboration with
treaters. This chapter addresses wellness supports that may be suggested by the prescriber but are
essentially put in place by the patient to support a deprescribing process. These strategies are not being
proposed here as replacements for the indicated pharmacotherapy, or as standalone treatments for any
given diagnosis as a multi-dimensional approach remains key. In the same way we neither encourage, nor
recommend, flight to these non-pharmaceutical strategies to justify a reactive abandonment of
pharmacotherapy.
This chapter discusses the management of one of the major concerns about deprescribing raised by
patients, prescribers, and family members alike—namely, relapse, or a return of symptoms that can
impact a person’s quality of life. While a return of symptoms may or may not necessitate a return to
medication, other alternative strategies put in place might prevent or best manage an increase in distress.
The focus is on a wellness approach and personal wellness strategies. These include two well-
recognized self-management strategies: the development of a Wellness Recovery Action Plan (WRAP),
which is an evidence-based practice that includes a person’s own identified “toolbox” of daily self-
management strategies, and the use of “personal medicine,” which is a group of strategies that are self-
initiated, nonpharmaceutical self-care activities. Even if the prescriber is not participating directly in
these activities, we argue that it is beneficial to show interest and awareness of these strategies in order
to support the alliance and avoid reinforcing mind-body splits which may occur for the patient, projected
between members of the treatment team. Potentially detrimental, these mind body splits could hinder the
integration of care/‘work’ the patient undertakes alone, with their therapist or with their prescriber, for
example. Assuming some readers will be less familiar with this area, we include in this chapter a targeted
review of the literature.

Goal and Learning Objectives

After reading this chapter, the reader will be able to:
1. Name at least five personal supports to consider for someone interested in deprescribing
2. Identify two benefits of implementing self-management strategies
3. Describe WRAP and personal medicine as they can be used to support deprescribing.

Adopting a Wellness Approach

Using Swarbrick’s (2006) definition of a wellness approach, the deprescribing provider will benefit
from taking a holistic, multidimensional look at the patient, with the focus being on areas of strength,
health, and vitality in order to maximize the effectiveness of deprescribing and to collaborate with them
from a recovery-oriented perspective. Moving away from a strict focus on symptoms and instead adopting
a stance of what best supports a person’s quality of life and pursuit of valued life goals can change the
focus on symptom and illness to a more pragmatic “what works” stance. Increasingly in health care, and
especially in psychiatry, there is growing evidence and support for “self-management” strategies to
support an individual’s own role in staying well.
This focus on progress in important areas of a person’s life includes identifying things such as purpose,
friends and family, work, hobbies, and other valued actions (including giving back to the community and
contributing to family and organizations). In fact, a recent study looking at patients’ stated reasons for
seeking medications showed that 51% identified “social relationships” as the goal for their medication
use, and they saw medications overall as a support toward pursuing valued life goals. Interestingly, in this
sample of patients, 31% also identified reducing or stopping medications as their goal in meeting with
their prescriber (Deegan et al., 2017). Increasing this focus on wellness is an important element in starting
a deprescribing trial.
It is especially important to keep a wellness approach in mind when thinking about deprescribing
because, within this process, the fear of “relapse” or return of psychiatric symptoms can be a terrifying
notion for all involved (including the patient and their family as well as the care team and the prescriber),
as discussed in Chapter 3 when considering barriers to deprescribing. Through various adjunctive
supports and approaches, including preplanning and crisis planning, peer support, social support, and
other forms of “personal medicine,” adjunctive avenues can decrease the need for pharmacological
intervention and support the process of deprescribing. What follows briefly outlines each of these
categories and how each might be integrated on an individual basis for persons interested in
deprescribing.

Planning Ahead for Relapse

Identifying the early warning signs of relapse is particularly important when initiating a deprescribing
process. Even if we are successful at redefining relapse, expanding the notion of health, approaching a
person in a recovery-oriented manner, and destigmatizing hospitalization; these experiences are still
potentially best avoided not only because of the distress they cause, but also for the potentially major life
disruption and loss of time and income for the person. Identifying early warning signs or predictors of
relapse is not clear-cut from a research perspective, but scales such as the Early Symptom Scale can
reliably predict a relapse and facilitate effective secondary prevention (Birchwood et al., 1989).
One of the key practices, therefore, in deprescribing, is creating a plan in advance that describes how
the prescriber, patient, and other identified members of the team will respond when there is an increase in
distress or symptoms or a significant change in functioning. This team may include family members;
friends; the pastor, imam, or other spiritual leader; the visiting nurse; a peer support staff; or someone else
named by the person as vital to their path to recovery and wellness. A plan may be formalized, written,
and contain many detailed specifics and steps. Alternatively, the plan may be more straightforward, with
only a few key actions to be taken. Legal and quasi-legal documents, including advance directives and
documents of treatment preference, can set out in advance a roadmap to guide the person and their team
when symptoms increase and/or health and function declines.

Psychiatric Advance Directive

There are a number of existing treatment planning tools to help patients articulate preferences during more
difficult times (i.e., when preoccupied by symptoms or unable to competently make or indicate choices).
At one end of the spectrum is a psychiatric advance directive (PAD), which is a potentially legally
enforceable documentation of a person’s preferences, wishes, and choices (O’Connell, 2015). This is
particularly important for those people who, when more symptomatic, may become unable to express their
wishes or may behave in ways that would be distressing to them in other nonsymptomatic states. In order
to construct such a document, a person must do so at a time when they are considered capable of making
decisions and articulating preferences for treatment.
For example, a 32-year-old woman with bipolar disorder, when depressed, also becomes psychotic
and virtually mute. She communicates only in metaphor and is unable to express her needs. When well,
she clearly knows her preferences for which hospital, medication, and course of treatment she finds
acceptable or unacceptable. For example, she consents in her PAD to electroconvulsive therapy only in
the instance that (1) alternative indicated approaches have been unsuccessful and (2) she is actively
suicidal with imminent risk. These specific wishes are clearly articulated and include great detail, such as
stating that she is willing to take trifluoperazine but not haloperidol for psychotic symptoms due to prior
experience with those medications (a history of side effects).
The detailing of these preferences is important for several reasons. In relation to deprescribing,
patients may leave an inpatient admission prescribed multiple new medications with which they do not
have buy-in and that future prescribers are reluctant to change. A detailed plan can include which
medications are preferred and have been useful in the past, as well as those which are not preferred due
to either side effects or being ineffective in the past. This may prevent unnecessary medications from
being initiated at times of crisis and thereby circumvent the need for a deprescribing intervention down
the line.
In addition, creating such a plan can help the person with mental illness to feel more in control and
empowered around the experience of hospitalization or the experience of an increase in symptoms. PADs
have been shown to reduce the number of coercive interventions in a crisis, which can in turn lead to less
trauma and greater trust and empowerment in the person with mental illness (Swanson et al., 2008).
Other planning tools to support a person in outlining preferences are readily available as templates and
guidelines to help a person catch, as early as possible, a serious symptom recurrence. One example is a
crisis planning tool from the State of Maine Department of Mental Health (State of Maine Substance
Abuse and Mental Health Services, 2016) and a tool used in behavioral health services in Oregon
(Oregon Behavioral Health Network, 2016). As a more progressive and sociocultural focused example,
the Icarus Project has developed what they term “Mad Maps,” which include identifying sources of
oppression and creating a self-directed wellness and empowerment tool (DeBrul & The Icarus Project,
2015). In the United Kingdom, the National Institute for Health and Care Excellence outlines what it has
identified as the key elements of any crisis plan, as listed in Box 5.1.

Box 5.1 Guidelines for Advance Plan Development

1. Possible early warning signs of a crisis and coping strategies
2. Support available to help prevent hospitalization
3. Where the person would like to be admitted in the event of hospitalization
4. The practical needs of the service user if they are admitted to hospital (e.g., childcare or the care of other dependents, including pets)
5. Details of advance statements and advance decisions
6. Whether and the degree to which families or carers are involved
7. Information about 24-hour access to services
8. Named contacts

From National Institute of Health and Care Excellence (2016).

These guidelines can serve as an outline for information and decisions that are helpful to make in
advance of any deprescribing intervention.

Wellness Recovery Action Plan

Another evidence-based intervention related to planning ahead is that of the Wellness Recovery Action
Plan (WRAP; Copeland, 1997), a peer-led or individually implemented intervention which grew out of
Copeland’s research with people who mobilized wellness strategies to maintain health either on or off
medications. Copeland interviewed a number of people to categorize helpful approaches to living with
mental illnesses; from this work, she created a now world-recognized curriculum to support people in
identifying their own key strategies for staying well. Based on the lived experience of people with mental
illness, the WRAP curriculum guides one through identifying what one needs to do on a daily basis to stay
well (the wellness toolbox), including basic self-care approaches like, “get 8 hours of sleep,” “eat
breakfast,” and “talk to a friend.” These simple but powerful strategies support people in taking control of
their well-being and having lists and ideas on hand to refer to when things are not going well. Along with
the wellness toolbox, WRAP assists in identifying “early warning signs”; those small but important
behavioral markers that a relapse may be more likely. These signs are highly individualized; for example,
one person identified that when she stopped looking to cross the street, she knew that she needed to do
more to take care of herself. Identifying these signs can be a collaborative process with the prescriber and
the patient, particularly around deprescribing interventions.
Identifying early warning signs can also be done with peer support or a friend or family member.
Having a sense of what to look for, and what others should look for, can again help empower the person,
allow them to feel more in control of their symptoms, and have the sense of having a “safety net.” WRAP
also includes a crisis planning tool, similar but potentially more detailed than a PAD. The crisis planning
tool guides the identification of specific preferences around medications, hospitals, and any other
instructions designed to support a person in crisis when they may not be able to articulate their own
wishes. WRAP is generally conducted in groups led by peer support staff but can be done individually
and online. The WRAP plan should never be required to be shared with the prescriber nor other clinical
team members as this goes against the ethos of a self-determined and -owned wellness plan (Copeland,
1997). But encouraging the person to share aspects of the plan, if not the whole plan, can be beneficial
because it contains rich clinical material. The early warning signs can be crucial in identifying and
potentially averting relapse during the deprescribing process. The prescriber may be able to discern some
of these from previous episodes and from discussion with family and other clinical providers, as well as
(and most importantly) through discussion with the patient herself.
Research evidence regarding WRAP shows that it produces significant symptom reduction, increases
hope and recovery, and has a positive impact on perceived physical health. Counter-intuitively however,
empowerment scores appeared to decrease in this study (Cook et al., 2009). A randomized clinical trial
found similar results, including an overall reduction in symptom severity, an increase in hope, and an
increase in quality of life (Cook et al., 2011). WRAP is based on principles of empowerment theory and
self-efficacy (Bandura, 1977).

Personal Medicine
Another useful concept to introduce in the context of deprescribing, and particularly for those patients
who may be attached to the idea of medication, is “personal medicine,” a term coined by Deegan (2005).
As a psychologist who identifies as having schizophrenia, she has worked to develop tools to support
greater empowerment of people around their treatment. Personal medicine comprises strategies that are
“self-initiated, non-pharmaceutical self-care activities that served to decrease symptoms, avoid
undesirable outcomes such as hospitalization, and improve mood, thoughts, behaviors, and overall sense
of wellbeing” (Deegan, 2005, p. 3). Identifying these strategies and supporting people in practicing them
can be a role played in part by the prescriber as well as by other members of the clinical team and/or
family and friends. Gaining a sense of control or increasing self-efficacy can be an empowering
experience, supporting increased self-esteem and confidence in the process of managing illness. For the
prescriber in their collaboration with the patient, support around identifying these strategies is essential to
providing additional personal resources and strategies to manage the potential psychological stress
arising from reduction of medication (i.e., fear of relapse) and to manage a possible increase in symptoms
resulting from the reduced use of medication.
In deprescribing, advance directives and other planning tools can be helpful not only in providing
concrete suggestions for action and specific preferences for treatment that are in line with the person’s
wishes, but the planning itself also provides somewhat of a psychological safety net for the person:
having these things spelled out and having the document (whether it be a PAD, a crisis plan, or a WRAP)
in the hands of natural supports (such as family, friends, the prescriber) can act as reassurance that things
are in place in case something does happen. The process of creating an advanced plan can also be
empowering for the person and stimulate previously undiscussed topics with friends and family about
what the person would prefer to have happen in the case of a reemergence of symptoms. For many people
with serious mental illness, as with anyone, having something in place to take care of children, pets, or
plants that depend on them is essential. Patients may refuse inpatient care because, for example, there may
be no one in place to take care of their beloved dog or to water their prized plants. With a plan in place, a
person can feel freer to address their own needs and go into the hospital if needed without the added
stress of worrying about their children, companion animals, or plants.
An important critique about the use of WRAP and other self-management strategies is the commentary
by Scott (2005), which states that these strategies continue to promote a deficit-based identity despite
their potential usefulness. This is important to consider when promoting something such as WRAP,
because a patient may need to process the idea that being able to control the illness does not also imply
that they are somehow responsible for causing it. Self-management approaches can also inadvertently
have the unintended consequence of leading to a kind of hypervigilance around any change in mood or
thoughts. The fear of relapse and the promotion of self-monitoring for any signs of this can lead to a
foreclosure of natural mood variation and a limiting of experience in order to maintain a kind of ill-
conceived sense of “stability.” Instead, the goal of recovery-oriented approaches such as WRAP and
other self-management strategies is to promote a sense of hope, empowerment, and reduction of distress
in order to allow the pursuit of valued life goals and to increase meaning and purpose in life.

Meaning and Purpose

Meaning and purpose in life is considered a valued aspect of recovery-oriented care and is a well-
researched aspect of well-being. The positive psychology field lends support to the importance of having
meaning and purpose in one’s life. One early study confirmed this association between purpose in life and
psychological well-being (Zika & Chamberlain, 1992). The literature on stress resilience also supports
finding and pursuing meaningful life activities as a way to moderate and manage stress.

Exercise

The literature supporting exercise as an intervention, particularly in affective disorders, continues to grow
(see Greer & Trivedi, 2009). Despite the caveat that rigorous studies of more controlled samples of
subjects are warranted, current evidence supports exercise as a treatment for mild to moderate
depression, as confirmed in several meta-analyses (see Cooney, Dwan, & Mead, 2014; Knapen,
Vancampfort, Moriën, & Marchal, 2015).
There is also a growing literature supporting the adjunctive use of exercise in schizophrenia. Exercise
may contribute to a reduction in symptoms of schizophrenia (Scheewe et al., 2013). Another review of
three randomized controlled trials showed significant reduction of negative symptoms, but not positive
symptoms, when looking at the effects of exercise (Gorczynski & Faulkner, 2010). A meta-analysis found
exercise benefits for people with schizophrenia in reducing symptoms and improving functioning and
neurocognition with a dose of at least 90 minutes of moderate exercise a week (Firth, Cotter, Elliott,
French, & Yung, 2015). A more recent meta-analysis found that exercise reduced symptoms and improved
quality of life in those with depression and schizophrenia (Dauwan, Begemann, Heringa, & Sommer,
2016). Evidence for exercise continues to grow and can be recommended as a possible addition to a
deprescribing endeavor.

Family Support

Strong evidence for the contributions of family therapy to the multi-dimensional care of schizophrenia
comes in particular from McFarlane’s studies on multifamily groups (McFarlane, 2002). There is some
evidence for relapse prevention particularly with single family therapy (Pilling et al., 2002).
One long-validated predictor of relapse in people with bipolar disorder and schizophrenia has been the
concept of expressed emotion (EE) in families. EE is defined as emotional overinvolvement and critical
communication from family members or significant others. A meta-analysis identified levels of EE as a
robust predictor of relapse in schizophrenia, mood disorders, and eating disorders (Butzlaff & Hooley,
1998). A recent 20-year follow-up study found higher rates of relapse and hospitalizations as well as
positive symptoms in those people with families high in EE (Cechnicki, Bielańska, Hanuszkiewicz, &
Daren, 2013). Family interventions, therefore, are strongly recommended to support family education
around mental illness and particularly to assist families in reducing levels of EE (Pharoah, Mari,
Rathbone, & Wong, 2010). This is particularly relevant in deprescribing and may be an adjunctive
component to add to the treatment and supports needed to help prevent increases in symptoms that may be
exacerbated by family dynamics. Family therapy is especially a consideration for those patients living at
home, younger adults, and those with family members serving as legal conservators.
In a review of family-based strategies in preventing relapse for people with mental illness, Falloon
(2003) analyzed 50 studies from 1980 onward. Studies were diverse in their interventions, but findings
indicated that in those studies combining medication management and case management with or without
family stress management, those with stress management showed clinical improvement in 14 out of 18
studies. One meta-analysis found that critical comments by caregivers (negative expressed emotions)
increased the likelihood of relapse by 2.2 times in first-episode psychosis (Alvarez-Jimenez et al., 2012).
In a unique book, Mackler and Morrissey (2010) detail recommendations for “dealing with your family
after you’ve been diagnosed with a psychiatric disorder.” This brief, practical book covers family roles,
boundaries, family conflict, and other areas vital to address for the person in recovery, along with
personal accounts of family experiences. Each chapter also includes questions for self-reflection that
encourage a critical and thoughtful approach to self and others. This is one example of using what is
sometimes termed bibliotherapy: using books as tools in managing mental health. Personal accounts (cf.
Jamison, 1995; Saks, 2007) are also useful for some, serving as inspiration and role modelling around
living with a mental illness.
 Novel and Progressive Approaches

Emerging paradigms such as the Hearing Voices movement (see Corstens, Longden, McCarthy-Jones,
Waddingham, & Thomas, 2014; Styron, Utter, & Davidson, 2017) and other alternative views of
psychopathology as “extreme states” would challenge the designation of an increase in symptoms as a
relapse per se. In this paradigm, an increase in voices or other “symptoms” (in quotes to emphasize the
paradigm’s ambivalence if not rejection of this term) might be seen as important data about life
circumstances (unaddressed anger, problematic relationships) that need to be addressed or changed, in
contrast to being seen as a flare up of an underlying autonomous disease process. In qualitative research,
people who hear voices identified the personal context and understanding of such (the personal meaning
and understanding of voice hearing) to be most beneficial to coping with and adapting to hearing voices
(Corstens et al., 2014).
Alternative views of psychopathology can be accessed in mutual support groups. In particular, the
Alternatives to Suicide and the Hearing Voices Network groups are two to highlight as innovative and
potentially not as well-known to providers. Hearing Voices groups do not necessarily characterize these
experiences as symptoms to reduce or eliminate. Instead, the groups and the philosophy of the approach,
conceptualize voices as part of the continuum of human experience and as experiences with meaning to
potentially be understood by the voice hearer. One facet is that many, if not most, people who hear voices
have experiences of trauma and that understanding the voices can be helpful in reducing distress (Dillon
& Longden, 2013). Groups provide a sense of containment, new relationships, and greater understanding
of voice-hearing (Payne, Allen, & Lavender, 2017). Learning from others’ personal stories and
experiences is an essential part of the approach, and some of these stories were put together in a volume
Living with Voices: 50 Stories of Recovery (Romme, Escher, Dillon, Corstens, & Morris, 2009) that
provides a diverse range of accounts. Research on Hearing Voices groups is in preliminary stages, but
initial studies and reports from the field indicate that this is a promising approach (Dillon & Hornstein,
2013; Longden, Read, & Dillon, 2018) and may thus also have potential to support the deprescribing
process when patients seek this out. It is perhaps premature for providers to recommend progressive
approaches such as this, for example in schizophrenia, as an evidence-based alternative to gold standard
care. Although participation can derive significant benefits for those inclined, potential risks must also be
considered—including disincentivizing to avail of (other) evidence based treatments where indicated.
Alternatives to Suicide groups, developed by the Western Massachusetts Recovery Learning
Community, provide spaces for people to talk openly about their thoughts and feelings about suicide.
These are groups where discussions of suicide take place without a clinical staff member present, making
open conversation possible without the potential of involuntary commitment (WMRLC, 2018). Another
example of peer and mutual support, these group seem well-suited to supporting people interested in a
deprescribing trial.

Conclusion
Addressing potential reemergence of symptoms is a key practice in deprescribing, especially as the
anticipatory anxiety around this possibility is hypothesized to potentially precipitate the feared outcome.
Preplanning tools such as a PAD, WRAP, or other personally identified strategies for catching and
addressing early warning signs are perhaps most successful when done in close collaboration with
treatment team members and other significant people in the patient’s life. Also, family education and
involvement can provide a further dimension of support. Patient-determined wellness strategies offer
additional treatments to ameliorate specific symptoms, improve social supports, and enhance the potential
for finding meaning and purpose during deprescribing.
 Self-Assessment
1. Relapse in psychiatry is:

a. Easily definably and measurable using biological markers

b. Personally defined by the patient
c. Marked by reduction in functioning
d. Often defined by proxy using hospitalization as the marker
e. A and b
f. B and d
g. B, c, and d

Correct answer: g
2. WRAP plans must be shared with the clinical team as part of the philosophy of the approach.

a. True
b. False

Correct answer: b
3. Personal medicine is defined by Pat Deegan as:

a. Individualized dosing of psychotropic medications

b. A sugar pill designed to elicit the placebo effect
c. Personal nonpharmacological approaches such as exercise
d. Medicine not legal in all 50 US states

Correct answer: c

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 6
Wellness Approaches II
Collaborative Strategies

When considering a course of deprescribing, in addition to the personal, self-determined strategies

addressed in Chapter 5, it is essential to evaluate the person’s interest in and potential benefit from
specific modalities of psychotherapy, symptom support, and other clinical interventions. This chapter
covers some of the more commonly used approaches as well as briefly discussing emerging and
progressive practices. As in Chapter 5, we reiterate our advocacy, in general, for a multi-facted treatment
approach considering multiple dimensions. In comparison to chapter 5, the evidence base for the
effectiveness of some of the following strategies in certain conditions is more developed, however we
again caution against using the promise of such interventions to justify a reactive abandonment of
pharmacotherapy. We again encourage prescribers to actively discuss (if not deliver themselves) non-
pharmacological treatment options to build alliance and allow the patient to integrate all facets of their
treatment. Similar to Chapter 5 we also include a targeted review of the literature for the relatively
uninitiated reader.

Goal and Learning Objectives

After reading this chapter, the reader will be able to:
1. Identify two evidence-based psychotherapies to consider adding during deprescribing
2. Identify two benefits of peer support
3. Describe the importance of sleep management as part of a deprescribing trial

Additional Clinical Strategies

Depending on the condition, several specific psychotherapies may be considered as adjunctive, or even
primary, modalities of treatment to add when considering a course of deprescribing. In this section, we
will describe several key therapies that may be useful adjuncts (e.g., CBT and Acceptance and
Commitment Therapy), the importance of addressing sleep issues, and progressive and emerging
approaches including online and mobile technologies.

Acceptance and Commitment Therapy

One evidence-based adjunctive psychotherapy that cuts across symptoms and conditions is Acceptance
and Commitment Therapy (ACT, Hayes, Strosahl, & Wilson, 1999). Considered a third-wave cognitive
therapy, it focuses on the pursuit of valued goals, the increase of psychological flexibility, detachment
from language as fact, and use of mindfulness. ACT is considered an evidence-based practice (SAMHSA,
2010) and an approach to alleviating human distress and suffering with underlying mechanisms that are
transdiagnostic (Hayes et al., 1999). Evidence for its use with obsessive compulsive disorder (OCD),
depression, rehospitalization due to any reason, psychosis, and general mental health are validated by
SAMHSA, although other clinical trials show promise for its use in chronic pain (see Powers, Zum Vorde
Sive Vording, & Emmelkamp, 2009, for a meta-analysis) and voice hearing (Bach & Hayes, 2002;
Gaudiano & Herbert, 2006). Growing evidence for its use with schizophrenia is emerging (Shawyer et
al., 2017), but further trials are needed to confirm greater efficacy over the comparison condition of
befriending. In serious mental illness, ACT can be integrated within a multi-dimensional treatment plan,
including the consideration of pharmacotherapy.
ACT’s grounding theory is not disorder-specific but is instead aimed at reducing suffering through
experiential and mindfulness approaches, with a focus on values-based living, thus making it a promising
treatment modality for people with a complex constellations of problems and in line with recovery-
oriented approaches to care (Davidson, Rowe, Tondora, O’Connell, & Lawless, 2008; Tondora, Miller,
Slade, & Davidson, 2014). ACT works to change one’s relationship with distress, regardless of etiology,
as opposed to necessarily trying to change thoughts or feelings. Instead, the focus is on accepting
thoughts, feelings, and experiences and finding ways to still work toward valued life goals through
increasing psychological flexibility (Ciarrochi, Bilich, & Godsell, 2010). ACT is one modality to
consider adding for someone interested in initiating a course of deprescribing.

Cognitive Behavior Therapy

Traditional CBT has a strong evidence base in treating anxiety (Stewart & Chambless, 2009), depression
(Cuijpers et al., 2013), OCD (Öst, Havnen, Hansen, & Kvale, 2015), and other conditions. A preliminary
meta-analysis found that CBT for depression showed equivalent efficacy to pharmacotherapy, with long-
term gains better maintained via CBT than medications (Gould, Otto, Pollack, & Yap, 1997). A recent
meta-analysis looking at depression and anxiety disorders found combination therapy most effective, with
both pharmacotherapy and behavioral interventions providing independent and long-lasting effects
(Cuijpers et al., 2014). As an adjunct, CBT-informed treatments have also been shown in a recent meta-
analysis to help prevent the transition into psychosis (Hutton & Taylor, 2014), and is a recommended
treatment for schizophrenia as part of a multi-dimensional plan of care including pharmacotherapy (Dixon
et al., 2009).
More recently, adjunctive CBT for psychosis (CBTp; Turkington & Kingdon, 1998) has shown positive
results for those with psychotic experiences, however meta-analysis level evidence remains inconclusive.
This modification of traditional CBT directly addresses positive and negative symptoms by widening
coping strategies, reducing distress caused by voices or other positive symptoms, and increasing
understanding of the problems in the person’s life. It is goal-focused, meant to be collaborative, and is
focused on improving quality of life. Therapist and client come to an understanding together of what is
leading to the identified problems—and they come to a mutual formulation of such. It also involves
evaluating the evidence for and against beliefs, including delusional ones, and indicating how likely these
beliefs are true (Hagen, Turkington, Berge, & Gråwe, 2013; Turkington, Wright, & Tai, 2013). More
recent iterations of CBTp have shifted to an even more strengths-based and values and goals focus, one
consistent with recovery-oriented care (Anthony, 1993; Turkington et al., 2013). It remains likely that
antipsychotics would continue to play a vital role in psychotic disorder treatment and towards the optimal
delivery of CBTp, however combined strategies may help support minimum effective dosing.

Sleep

Patients may rightly fear the reemergence of sleep disturbances when starting a reduction of medications.
One of the most significant predictors and risk factors in schizophrenia, mood disorders, and other
psychiatric disorders is that of sleep changes. In a recent meta-analysis, people with schizophrenia who
were not taking medications had significantly shorter total sleep time, sleep onset latency, and sleep
efficiency, and those who had been withdrawn from medications had a similar profile for those three
variables (Chan, Chung, Yung, & Yeung, 2017). Sleep changes have moderate predictive validity of
relapse in psychotic disorders (Eisner, Drake, & Barrowclough, 2013).
Sleep disturbances in affective disorders has been well-documented, both via self-report and through
objective study, and they carry an increased risk of suicidality (Rumble, White, & Benca, 2015). Relevant
disturbances include shorter total sleep time, greater sleep onset latency, and decreased sleep efficiency.
Sleep disturbance and insomnia have also been found to be independent predictors of depression (Rumble
et al., 2015). Therefore, addressing sleep is a major focus area for deprescribing psychotropic
medications overall and in particular for antipsychotic medications (Klingaman, Palmer-Bacon, Bennett,
& Rowland, 2015), due to the common collateral sedative effects of these medications (Rumble et al.,
2015).
Sleep disturbances have been found to have moderate predictive value in relapse for psychotic
disorders (Eisner et al., 2013). In another review looking at predictors of relapse in schizophrenia,
increased emotional sensitivity was found to be moderately predictive (Gaebel & Riesbeck, 2014), but
overall there were few specific and sensitive signs that accurately predicted relapse. An increase in
anxiety has also been identified as a moderate predictor of relapse (Eisner et al., 2013). One meta-
analysis found that critical comments by caregivers (negative expressed emotions) increased the
likelihood of relapse by 2.2 times in first-episode psychosis (Alvarez-Jimenez et al., 2012).
Sleep emerges as a particularly important focal point in a recent study of people discontinuing a range
of psychiatric medications (Ostrow, Jessell, Hurd, Darrow, & Cohen, 2017). The first study of its kind,
the research found that sleep was the most important factor in helping cope with potential withdrawal
effects. Recent recommendations for treatment of sleep disturbances in general regard behavioral and
psychological treatments as first-line and more effective long-term than pharmacological interventions
(Morgenthaler et al., 2006; Morin, Culbert, & Schwartz, 1994). These treatments include CBT for
insomnia (CBT-I), relaxation training, and stimulus control therapy (reassociating the bedroom with
sleep), as well as using paradoxical intention (setting the goal as staying awake) to reduce performance
anxiety (Morin et al., 1994). These treatments have also been found to be effective for those with co-
occurring psychiatric disorders and insomnia (Taylor & Pruiksma, 2014). Treating other causes of sleep
disturbance is also important, and patients should be assessed for sleep apnea or other obstructive
disorders which can greatly impact sleep quality and duration. This is especially true for those patients on
antipsychotic and other medications that might have contributed to the development of metabolic
syndrome, with the associated weight gain contributing to sleep apnea (Rumble et al., 2015).

Peer Support

Peer support is another adjunctive support to consider in the process of deprescribing. Peer support is
defined as “a system of giving and receiving help founded on key principles of respect, shared
responsibility, and mutual agreement of what is helpful” (Mead, 2003). It is the provision of support from
those with “lived experience” of mental illness and/or substance use disorders. As a growing field and
discipline, research shows that outcomes from working with peer staff are equivalent to non-peer staff,
with some studies showing slightly better outcomes with peer staff (Solomon, 1995; Davidson, 2004).
Patients experienced longer community tenure when receiving peer support in one randomized controlled
trial (Min 2007). Peer staff also show an ability to reach people who are difficult to engage (Rowe, 2007;
Sells, 2006). Working with peers contributes to increases in empowerment (Corrigan, 2006; Resnick,
2008) and an increased sense of independence for both peer staff and the person receiving services, as
well as role shift (Ochocka, 2006). Those patients working with peers also showed increased hope
(Sledge, 2011). The overall evidence base for adjunctive peer support is considered moderate (Chinman,
2014). Peer support provides a unique opportunity to show that recovery is real through living examples.

Novel and Progressive Approaches

Behavioral management techniques can be used to cope with voices, including listening to music,
distraction, physical exercise, and other techniques. Such strategies can be taught prior to or in the
process of deprescribing, where appropriate, in order to build the repertoire of coping for the person
experiencing (or fearing the experience of) distressing voices. The theory is that subjective fear as well
as the actual risk of relapse are reduced (Deegan & Affa, 1995).
Towards normalization of patient experiences, one can potentially generalize the idea of redefining
symptoms as “extreme states” to psychiatric hospitalization. As previously noted, relapse is often defined
by hospitalization (Lader, 1995), but if we can work to destigmatize the idea of hospitalization as
something that is less of a “failure” and characterize it more as another tool in the coterie of possible
strategic ways to take care of oneself, perhaps better use can be made of our inpatient facilities. This may
be a challenge for many patients because their hospital experiences may have been traumatic—another
reason to work to avoid returning to the hospital. Use of alternatives to hospitalization (e.g., peer run
respites, intensive outpatient services, and other crisis intervention residential services) may be options
to identify ahead of time for when a person needs more support but not necessarily inpatient
hospitalization.
Another progressive approach gaining recognition is open dialogue. Open dialogue is an approach
developed in the mid 1990s in Finland using a multifaceted conversation to prevent relapse, particularly
in first-episode psychosis (Seikkula, Alakare, & Aaltonen, 2001). The intervention begins within 24
hours of onset and includes bringing together the person’s social network and providers in conversation.
The intention is to provide words and description to the experience and to reconnect the person with those
important others in their life (Seikkula et al., 2006). Several important principles of the approach include
continuity of care, involvement of family and caregivers in dialogue together with the person, and
tolerance of uncertainty as more important than change (Pavlovic, Pavlovic, & Donaldson, 2016). A
recently published 19-year observational study from Finland showed that open dialogue reduced the need
for neuroleptics and improved social and occupational outcomes (Bergström et al., 2018). However, a
review of the evidence on open dialogue concluded that although it appears promising, the current
evidence base in its support is of low quality and weak (Freeman, Tribe, Stott, & Pilling, 2018). Although
open dialogue may offer some useful principles which, relevant to deprescribing, may have potential to
support minimum effective dosing of medications, it cannot currently be recommended in place of gold
standard treatments for psychotic disorders.

Online Resources and Apps for Therapy and Support

Increasingly, online resources and smartphone applications are being utilized for both therapy and
adjunctive support of deprescribing and addressing particular symptoms. The Veteran’s Affairs
department has sponsored the development of several useful apps to supplement posttraumatic stress
disorder (PTSD) treatment and CBT for insomnia treatment (Kuhn et al., 2016). An initial RCT for the
CBT-I coach app for mobile phones found good acceptability and positive outcomes in veterans also
enrolled in a CBT-I therapy (Koffel et al., 2018). Similar positive results for the PTSD Coach app have
been found, with strong acceptability (Miner et al., 2016) and initial positive evaluation results (Kuhn et
al., 2014; Owen et al., 2015). A recent RCT showed significant effects on PTSD and depressive and
anxiety symptoms (Kuhn et al., 2017).
Internet-based CBT interventions have shown increasing promise across a range of symptoms and
conditions in recent years. A meta-analysis of 19 RCTs showed support for clinical improvement in
depression, with those interventions that provided additional supportive interventions having a greater
effect size (Richards & Richardson, 2012). Guided therapies, those using the support of a therapist either
in person or by phone, have shown greater effectiveness than those without. However even without this
therapist interaction, internet-based interventions show a significant impact on depression, as analyzed in
another review of 22 studies (Iakimova, Dimitrova, & Burté, 2017). A recent study comparing internet-
based CBT to face-to-face delivered interventions showed no difference in overall effects, although there
was a limited pool of studies to draw on, indicating more research needed in this area (Andersson,
Cuijpers, Carlbring, Riper, & Hedman, 2014).
An ever-evolving array of wellness-related apps are becoming increasingly accessible, and these also
leverage multiple modes of passive data collection/sensing built into mobile devices and wearable
technology. While at the disposal of the interested and informed individual as tools to maintain wellness,
the clinical effectiveness of these applications warrants rigorous ongoing study.

Conclusion
A brief summary of recommendations for supporting deprescribing using wellness strategies (drawn from
the content of Chapters 5 and 6) is provided in Table 6.1. In short, individualizing and tailoring a patient’s
particular plan to his or her particular needs and concerns stands the best chance of preventing or
foreshortening feared outcomes. For some people, there may not be a need to add any additional supports;
this should be assessed very carefully and with the consideration that adding supports may also signal a
concern on the part of the prescriber to the patient regarding their worry or level of confidence in the
deprescribing process. Similar caution should be taken in making recommendation of non-evidence based
strategies—or at least providing clear caveats and limitations when drawing a patient’s attention to a
progressive or self-directed strategy. If not framed in a balanced way, the process of introducing
alternatives to pharmacotherapy risks having these novel, non-threatening and compelling strategies over-
valued, at least beyond their current evidence base. In this way therapeutic alliance may be weakened,
rather than strengthened. Therefore, acknowledging the potential usefulness and eliciting the patient’s own
preferences is an important step in conveying confidence in the ability of the patient to embark on the
deprescribing process, but our expertise and value as prescribers (and deprescribers) should not be
relinquished. At the same time, it is important to look closely at possible additional supports that will
decrease the likelihood of a negative impact of a reduction in medications.
Overall these additional supports should be seen in the context of empowering the person to find new
ways of supporting their recovery and learning strategies for managing symptoms, or, put more
colloquially, live the life that they want to live without (or with a reduction of) medications. Framing
the whole deprescribing intervention in these terms is important (and not just lip service) as it promotes a
certain responsibility and interdependence in the person. Learned helplessness, dependency, and lack of
trust in oneself are some of the possible relics of the paternalistic approach to prescribing medications,
and being aware of these dynamics is essential in thinking about “prescribing” other interventions for the
person.
Table 6.1 Identifying adjunctive wellness strategies to support deprescribing
Concern or area Consider adding or recommending:
of need
Clinical supports and Cognitive behavioral therapy (ACT, CBT, CBTp) Sleep hygiene/CBTi Exercise Peer support/mutual support groups
specific symptoms Using technology to supplement these supports
Concerns regarding Psychiatric Advance Directive (PAD) Wellness Recovery Action Plan (WRAP) Other preplanning tools Normalizing
relapse and decatastrophizing relapse and hospitalization Assessing level of fear via dialogue or use of FORSE
Social support Family psychoeducation Family therapy Social skills or supported socialization Incorporating friends and
acquaintances into the deprescribing plan
Meaning and Identifying interests, hobbies and values Referral to employment support Finding a job or starting volunteer work
purpose
ACT, acceptance and commitment therapy; CBT, cognitive behavior therapy; CBTb, cognitive behavior theory for psychosis; CBTi, cognitive
behavior theory for insomnia; FORSE, fear of recurrence scale.

Self-Assessment
1. One of the key symptoms to address in order to help prevent relapse is:

a. Auditory hallucinations
b. Anxiety around the deprescribing process
c. OCD-like symptoms that emerge within the discontinuation process
d. Lack of sleep/insomnia

Correct answer: D
2. You are working with a 45-year-old woman who has a 15-year history of schizoaffective disorder and is interested in
decreasing her haloperidol and sertraline due to feelings of sedation and emotional dulling. She is currently living alone in
her apartment and tends to come out only to see you for monthly appointments. Which of the following would you
recommend to her to support her interest in deprescribing?

a. Completing a values survey to identify what is most important to her and start with the first ranked value
b. Refer her to the local psychosocial clubhouse to get more friends
c. Refer her to employment support so she can begin looking for a job
d. Discuss a range of options and elicit her thoughts, values, and preferences, utilizing a shared decision-making approach

Correct answer: D
3. Acceptance and Commitment therapy is focused on:

a. Changing negative thoughts to positive ones

b. Identifying cognitive distortions
c. Increasing psychological flexibility
d. Pinpointing core beliefs

Correct answer: C

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 7
The Process of Deprescribing
Minimum effective dosing and discontinuation of psychiatric medications are neither new nor foreign
concepts. “Deprescribing,” however, as a relatively recently coined term, could represent several
advancements for psychiatry as: (1) a rallying call to the field to more concertedly examine the factors
that influence and inform our prescribing both on an individual and system levels; (2) an expanding area
of research seeking answers to questions around medication reduction and guidance for interested
prescribers; and (3) perhaps most importantly, a structured, multi-facted intervention for optimizing the
collaborative and concerted reduction of a chosen medication.

Goal and Learning Objectives

After reading this chapter, the reader will be able to:
1. Identify three scenarios in one’s past or current practice where deprescribing might be considered
2. Define and differentiate a paternalistic, consumerist and shared decision-making stance as they might pertain to deprescribing
3. Outline the seven steps of deprescribing in psychiatry

Deprescribing as an intervention is much more than a trial of discontinuation or withdrawal of

medications. Its development as an intervention has so far been led by pharmacists (see Farrell et al.,
2015; Reeve, Thompson, & Farrell, 2017). Reeve and colleagues (2014) reviewed the available
literature on the deprescribing process and identified five essential key elements. Of note, only one is the
actual discontinuation. These elements are:
1. Obtaining a complete medication history.
2. Identifying medications that are potentially inappropriate.
3. Evaluating the possibility of reducing and/or discontinuing the medication.
4. Implementing a plan for reducing and/or discontinuing the medication.
5. Ongoing monitoring, documentation and support.

When attempting to adapt this work, which has principally thus far in primary care and geriatric and
palliative medicine, to psychiatry, we propose some additional considerations. These are by no means
unique to mental health, but perhaps more salient because of previously discussed sociocultural and
individual factors which have a particular impact in the practice of psychiatry. These include:

• A greater focus on the therapeutic alliance and the psycho-socio-cultural context

• The risk of faddism, pendulum-swinging, and the unintentional creation of stigma
• The broader context and timing of the intervention
• Opportunities for leveraging nonpharmacologic strategies and treatments
• The psychodynamic meaning of the medication (and diagnosis)
• Managing the illusion of diagnostic and therapeutic precision
• Tolerance of uncertainty and ambiguity
• Working within legally mandated treatment stipulations
• Broadening the group of stakeholders involved
• Scenarios in which a patient’s capacity is impacted or a surrogate decision-maker is appointed
• Limitations and realities of current resources (e.g., scope and duration of appointment or access to
nonpharmacological treatments)
In light of these additional considerations for deprescribing in psychiatry, we have therefore expanded
Reeve’s five steps to seven. We have added these steps in order to reflect an extended preparatory phase
which puts additional focus on the timing of the intervention, inclusion of significant social supports, and
bolstering of psychosocial and clinical supports that clinical experience indicates are essential to safely
reducing and discontinuing psychotropic medications (Gupta & Cahill, 2016). These additional steps
reflect the multidimensional nature of recovery and provide an opportunity to explore and bolster the
therapeutic relationship and plan of care as well as empower the patient. In fact, we propose that this
phase may stand alone as a valuable exercise even if it does not immediately or ever lead to a plan to
alter a person’s medication regimen. The proposed seven steps of deprescribing in psychiatry, split into a
“preparation” and an “action” phase (in respect to medication dosing), are described in Table 7.1. For
each step, the main, intended aims and outcomes are listed to offer a starting point for the practitioner.

Table 7.1 Proposed steps for deprescribing in psychiatry

Step Aims Outcomes
Preparation phase
1 Assess the timing and • Be planful to optimize chances of success • Detailed bio-psych-social-cultural assessment
context • Remain alert to periods of, and factors driving, higher with focus on factors known to drive relapse
risk of relapse • Gain alliance around disclosure and monitoring
• Reinforce that deprescribing is an option (if not now, in of substance use
the future) • Anticipate stressors (next 6 months)
• Proceed now or postpone for later date
2 Medication • Compile a detailed list of all current medications (from • A complete list of all medications taken
reconciliation all providers) • An opportunity for further psychoeducation
• Include alternative remedies • Gain and document permission to
• Elicit specific, underdisclosed side effects (e.g., sexual, communicate with other prescribers
check renal function) • Gain access to relevant medical records
• Facilitate the patient articulating associated pros and • Develop a common appreciation and language
cons of taking each medication around the ongoing benefits and risks of each
• Acknowledge (and communicate acceptance) that medication
conflict and ambivalence around treatment is expected • Uncover ambivalence and actual level of
adherence
• Reveal undisclosed experiences/side effects
3 Explore patient’s • Explore the patient’s thoughts and feelings around their • An opportunity to bolster therapeutic alliance
experience, attitudes and condition and its treatment as a whole and empower patient
meaning around • Detect potential nonpharmacological effects of • Learn patient’s learning style preference and
treatment medications (i.e., meaning-based) assessment of current understanding
• Explore experience of existing treatments and previous • Appreciate patient’s frame of reference and
attempts at deprescribing core values relevant to treatment decisions
• Consider with patient whether to proceed to
action phase now, or cycle back to Step 1 at
later date
Action phase
4 Set frame for the • Discuss with patient possible outcomes (including • Gain informed consent around next phase of
deprescribing adverse outcomes/relapse) the intervention
intervention • Elicit their hopes, ideas, concerns and expectation for • Engage and secure two-way line of
the process communication with key supports
• Have patient identify key supports and treaters they • Understand how patient likes to make
wish to involve in process decisions
• Demonstrate interest, optimism and expertise in the • Gain mutual respect for each other’s
process expertise/experience
5 Decide which medication • Exam benefits and risks of deprescribing up to three • Document shared decision-making process
to deprescribe medications (involve key supports as needed) • Agree upon medication to deprescribe (may
• Provide decision support tools to patient as desired and take several meetings)
useful • Further develop therapeutic alliance and a
• Engage in shared decision making to choose 1 to spirit of collaborative investigation (within safe
deprescribe now bounds)
6 Develop the specific • Identify established and new nonpharmacological • Document expected and possible effects with
deprescribing plan treatments and strategies to treat emergent effects of guidelines for responding to each
 reduction and maintain wellness • Construct a detailed step-by-step dose
• Set clear expectations and action plan, including reduction plan with schedule of monitoring
wellness/crisis planning • Share a copy with key supports
• Identify early warning signs of relapse • Confirm understanding of deprescribing plan
• Use existing clinical evidence/experience to plan rate • Ensure full access to necessary, expanded
of taper and identify pharmacological strategies for nonpharmacological treatments and wellness
emergent effects (i.e., short-term adjunctive drugs) strategies
• Engender broad buy-in and optimism around
plan among key stakeholders
7 Implement, monitor and • Implement changes and monitoring according to plan • Deprescribing may be completed as planned
adjust plan (according to • Remain open to need for adjusting the plan • May need to adjust (e.g., slow the rate of, or
response) • Monitor mental and physical status reverse the taper)
• Monitor occupational and social functioning • May need to manage a relapse/adverse event
• Loop back to Step 6 as necessary • Patient hopefully gains a deeper understanding
• Be able to accept failure of the intervention without of themselves and empowered management of
reproach their condition (whatever the outcomes)
• Therapeutic alliance and treatment is enriched
and knowledge is gained (and ideally shared)

As mentioned, the initial preparation phase can stand alone as a periodic medication review process,
perhaps done every 6 months or annually whether or not it leads to a formal deprescribing of a chosen
medication. The intervention proper begins in the second “action” phase with Step 4. A deprescribing
effort may be initiated by the patient, prescriber, or another stakeholder. One of the aspirational, collateral
benefits of this deprescribing intervention (specifically the preparation phase) is to illuminate and
normalize previously undisclosed ambivalence and ‘true adherence’ to current prescribed medication
regimens. Taking this further, and in order to avoid precipitous, patient-initiated discontinuations, we
recommend that, as part of the process of prescribing, providers also consider setting parameters and
expectations around the option of deprescribing. Deprescribing may therefore be more than just a tool to
be used as the circumstance arises.
There are potential risks as well as benefits with deprescribing as with any other intervention, and
informed consent is paramount. To truly engage our patients in shared decision-making we also
potentially engage them in shared risk-taking. It remains the duty of each provider to weigh the balance of
evidence in any individual case when deciding whether or not to recommend deprescribing. This includes
remaining reflective and observant of their practice (and that of their immediate colleagues), as well as
staying up to date with the clinical evidence and guidelines. However, it is not and should not be the sole
responsibility of the prescriber to initiate, gather additional information and resources, and “manage” a
deprescribing process.

Step 1: Assess the Timing and Context

This stage is predicated on having an up-to-date, bio-psycho-social-cultural formulation, medical, and
psychiatric assessment as well as a strong therapeutic alliance. It is crucial to develop an open line of
communication around substance use, whether it be direct disclosure from the patient or indirect via
periodic urine toxicology if warranted by a recent history of substance use disorder. Although current use
of substances would not automatically preclude deprescribing, it is best to have a clear sense of the
current use of substances, and to be thinking of past use as a potential risk factor for the person, who may
turn to restarting or increasing substances in response to a decrease in prescribed medications.
Stress commonly exacerbates many psychiatric disorders (Lex, Bäzner, & Meyer, 2017). Though
impossible to anticipate all potential psychosocial stressors, there are circumstances that the patient
and/or therapist may assume will be stressful, such as a change in employment, housing, relationships,
therapist, or psychiatrist. An attempt at medication reduction would be least risky when the patient has a
relatively stable psychosocial situation. For example, the immediate posthospitalization period is known
to carry higher clinical risk and planned medication reductions should be implemented cautiously (Olfson
et al., 2016). Well-intentioned prescribers may need to carefully balance the need for postdischarge dose
reductions, which, although they may be clearly warranted after acute stabilization, other psychosocial
circumstances may point to waiting before beginning deprescribing. This may be when collateral
tranquilizing effects are no longer needed, psychosocial factors have improved, or simply due to the
natural course of the illness episode.
Medication reduction may be easier and safer in a patient who is able to gauge their emotional state
and communicate either directly with the prescriber or through family and friends. Past experiences with a
patient around life events and the demonstrated ability of the patient to reach out for additional support
from treaters and others, is a positive sign for this ability to be used during deprescribing. The use of
tracking tools such as symptom scales or daily recording of moods, etc., can be useful in this area. At the
same time, a patient who is less able to identify and clearly report changes should not be excluded from
consideration, particularly if there is a clear rationale (e.g., metabolic syndrome, sedation) that more
clearly points to deprescribing as an important intervention in mitigating risk. Impending significant life
events or logistical barriers should be planned around (e.g., moving or a transition to college). The
prescriber will need to thoroughly evaluate past responses to medication reduction and evaluate risk (past
attempts at suicide, homicide, legal involvement) in considering deprescribing for a given patient. The
outcome of this step may be to postpone the deprescribing until later while reinforcing that it is an option
and laying any necessary groundwork in the meantime (e.g., treat an active substance use disorder).

Step 2: Medication Reconciliation

The major outcomes of this step are a complete and detailed list of medications that the client is currently
taking, access to appropriate records and providers, and gaining a deeper appreciation of the individual
effects of each medication for the patient. This may likely include uncovering ambivalence or actual
adherence to the prescribed regimen around certain medications or dosages—which should be met with
acceptance and understanding. This step will likely require liaison with the primary care provider and
other specialists. Ask explicitly about nonprescription, over-the-counter medications; medications used
on an as-needed basis; additional doses taken outside of how the medication was prescribed; and
alternative, natural, and traditional remedies (in order to consider potential pharmacologic or
nonpharmacologic effects and interactions). The list should ideally describe each medication in a manner
identifiable to the patient—strength and dosage form, for example “20 mg enteric-coated tablet” may be
paired with “small white pill with 57 on it.” The list should also be assessed for possible drug–drug
interactions, additive side effects, and disease–drug interactions (ideally in collaboration with a
pharmacist and informed by the patient’s latest health status).
It can be challenging to deduce the original therapeutic target or intent when a medication (and dose)
was initiated by a prior provider—it cannot be assumed that the medication was prescribed for the
principal US Food and Drug Administration (FDA)-approved indication, for example. The original
indication for a medication may not be clearly documented and may require extensive record-searching
(Plakiotis et al., 2015; Reeve et al., 2014; Scott et al., 2015). Real-world practice dispels the illusion of
therapeutic precision; for example, a change in prescriber may interrupt plans for cross-titration of
antipsychotic medications or discontinuation of an anticholinergic during antipsychotic titration, thus
leading to inadvertent and irrational polypharmacy. Similarly, an antipsychotic initiated at higher doses
for the treatment of acute mania with psychotic features and severe agitation during an inpatient
admission, if unexamined, may cloud the clinical picture either by implying the definitive diagnosis of a
primary psychotic disorder or causing secondary negative symptoms.
Once the list is compiled, conduct a systematic reexamination of the pros and cons of continuing each
medication at all, and at its current respective dose. It is advisable to neither constrain this discussion to
what the prescriber would consider conventional therapeutic and adverse effects, nor be too exhaustive in
listing all the rarer potential side effects per package insert or case report-level evidence—as always, the
process should be tailored to the patient according to good clinical judgment. Thus, for the prescriber, this
step provides an opportunity to learn and reconcile an individual patient’s experience with a given
medication (perhaps even idiosyncratic beliefs) with their existing knowledge base.

Step 3: Explore Patient’s Experience, Attitudes, and Meaning About Medication

A patient’s experience of a medication is his or her own. Effects of the idiosyncratic “meaning” of a
medication can present consciously and unconsciously. Furthermore, attitudes toward taking or not taking
medications may vary with culture, personality, and specific relationship with the prescriber (Jonsdottir
et al., 2013; Lanouette, Folsom, Sciolla, & Jeste, 2015; Misdrahi et al., 2012; Sylvia et al., 2013). In the
same way that providers offer their perspectives on etiology and mechanisms of action (invited or not), it
is valuable to gain an understanding of the patient’s perspective on the source of their distress and how
they maintain their wellness. This can lead to useful elucidation of the concepts of symptom management,
diagnosis, prognosis, and phases of illness/recovery.
Power struggles and transference-based issues may manifest in discussions surrounding medication
(Mallo & Mintz, 2013), and the prescriber should maintain a psychotherapeutically informed stance
within the scope of their training and treatment frame while exploring these issues. Collaboration with a
patient’s therapist may help. As discussed in Chapter 6, medication may hold psychodynamic meaning for
a patient (e.g., representing the prior treater who originally prescribed it and thus representing a symbolic
loss of the relationship to give it up), be viewed as a “badge of illness” (e.g., evidence of a medical
explanation for their struggles), or as vital to their accessing resources (notably entitlements).
The outcome of Step 3 (and hence the preparation phase) of deprescribing may equally be the decision
to cycle back around at a later date than to proceed with a deprescribing trial—but it should always result
in a deepening of the patient’s understanding, empowerment, and ownership of their recovery and the
treatment relationship.

Step 4: Set the Frame for the Deprescribing Intervention

Step 4 begins the “action phase” of the deprescribing intervention proper and therefore should begin with
a process of informed consent. Solicit patient preferences on receiving and manipulating information (i.e.,
verbal, written, or digital) and who they would like to include in the decision-making process. Provide an
overview of deprescribing as a potential treatment direction in order to solicit ideas, concerns, and
expectations from the patient, their family, and even the clinical care team. It is important to acknowledge
the potential risks (including adverse outcomes, symptom increase, and relapse) as well as differentiating
these risks in the context of a slow process of deprescribing with increased attention in contrast to
unsupported or even precipitous medication discontinuations.
The patient may receive pressure and mixed messages from their key supports around their interest in
deprescribing. This can contribute to stress and undermine an attempt at deprescribing; therefore, it is the
responsibility of the prescriber to identify these supports and assist the patient to engage with and involve
them at their comfort level. Expectation of a relapse or a negative outcome can actually increase the
possibility of a negative outcome and hence it is especially important to elicit potential concerns from the
patient and their key supports and to address all possible (Colloca & Finniss, 2012). Despite these
challenges it is possible to generate buy-in, optimism, and enthusiasm for a deprescribing process, so
long as realistic expectations are set, concerns are addressed, and opportunities for meaningful growth
through collaborative inquiry are well-articulated.

Step 5: Decide Which Medication to Deprescribe

This step involves a concerted, shared decision-making process. While acknowledging the potential for
differing opinions on which medication should be deprescribed (e.g., the prescriber might prioritize a
reduction in the benzodiazepine, but the patient might elect to start with the antipsychotic), we suggest
limiting the medications discussed in detail at this stage to no more than three. Systematically weigh
together in greater detail the risks and benefits, this time, of deprescribing each option (this inversion
from Step 2, may yield further and confirm previously acquired data). Specifically raise adverse effects
that may be initially asymptomatic (such as early chronic renal impairment); tend to be underreported
(such as sexual side effects); or can be associated with lesser subjective distress than functional impact
(such as tardive dyskinesia). The principal outcome of this step is agreement around a single medication
to be deprescribed—this may be an important exercise in balancing power dynamics in the therapeutic
relationship and might raise ethical issues. As stated earlier, shared decision-making is neither
paternalism nor consumerism, and both patient and prescriber should have their voices present in the
room. It may be helpful to consider more diffuse or downstream therapeutic gains in addition to the
specifics of the task in hand. The prescriber might seek peer supervision or local ethics committee
consultation in acknowledging how challenging—but meaningful—this process can be.

Step 6: Develop the Specific Deprescribing Plan

The foundations of a good deprescribing plan include setting clear expectations, bolstering alternative
coping and wellness strategies, and fostering an acceptance of the inherent uncertainty of the process.
The deprescribing plan therefore draws on the best available clinical evidence and knowledge of and
from the individual patient to determine a “good enough” initial rate of taper, establish a robust safety net
for emergent effects and burgeoning relapse, and a clear rationale for attempting the deprescribing
regardless of the eventual outcome. The chosen medication may be tapered to a new target, gradually
discontinued, or, perhaps in other cases, switched to an alternative with more favorable side-effect
profile but lesser expected efficacy.
The deprescribing plan should integrate features and language specific to the individual patient and
context, pitched at an appropriate level of education and insight. Psychotropic medications can produce
distressing withdrawal symptoms (Dilsaver & Alessi, 1988; Tamam & Ozpoyraz, 2002; Wyatt, 1991),
and it is important to generate realistic expectations, assess for them at every visit, and offer in advance,
management strategies. This may take the form of wellness recovery action planning (WRAP; Copeland,
1997); a psychiatric advance directive or other preplanning tools described in Chapter 6; or our
Collaborative Deprescribing Worksheet (proposed below). Specify new and existing alternative
treatments as well as early warning signs of relapse, using the patient’s own words (reflecting together on
the time course of prior episodes of illness may be useful in this respect). Additionally, deprescribing
studies in geriatric medicine suggest a role for family (Plakiotis et al., 2015), and interventions such as
family therapy and relapse prevention strategies may be beneficial (Emslie et al., 2015; Hasan & Musleh,
2017; Pitschel-Walz, Leucht, Bäuml, Kissling, & Engel, 2015). Wellness strategies should draw from the
patient’s own ideas and methods (even if initially regarded by the provider as idiosyncratic). There may
be further opportunity here to reconcile countertherapeutic behaviors with available clinical evidence.
Wellness strategies may be collaborative (with supports or providers) or be self-directed (in which case,
they may not be discussed in detail or at all with the prescriber).
More frequent clinical encounters and/or the provision for additional ad hoc sessions may be planned
(within the limitations of available resources and the patient’s schedule). Providers should remain
mindful, make good use of their own reactions, and recognize the potential for altering the frame (i.e.,
duration and frequency of visits) based on countertransference (e.g., increased contact due to unfounded
anxiety, or diminished contact due to discomfort sitting with emerging symptoms, loss of control, or
increased risk).

Step 7: Implement, Monitor, and Adjust Plan

It is crucial for both prescriber and patient to be flexible and view medication changes as “trials” (Reeve
et al., 2014) that can be adjusted as needed. Once again, framing the patient’s recovery as a complex
system, and deprescribing as a complex intervention, this process can be regarded as “probing and
monitoring response,” or “safe to fail” collaborative inquiry. As for safety, a measured and feasible crisis
plan should have been well-articulated in Step 6, setting the bounds within which adaptations to the plan
would be acceptable in Step 7. Modifications may include slowing of the taper; introducing a short-term,
as-needed medication for emerging symptoms; or even re-titrating the medication and reassessing.
Periodic monitoring of all aspects of a patient’s health and functioning is indicated, with particular
focus on the anticipated effects. Both prescriber and patient take joint responsibility in this plan. In all
cases, fostering a stance of optimism and acceptance in the patient and the potential outcomes is key.
Ensure that the patient remains empowered in process, is utilizing their strengths, and is deriving the
intended benefit from new and supplemental strategies and supports. As part of the monitoring process,
providers should also consider the meaning of the deprescribing intervention itself to the patient and to
themselves, meanings which can shift and evolve. For example, overinvestment (e.g., due to a patient’s
desire to please the prescriber) may extend a deprescribing past a shift in the risk–benefit ratio.
Alternatively, intolerance of anxiety or a residual difference in opinion on which medication to
deprescribe might drive the premature abandonment of an otherwise potentially successful
discontinuation.

Documentation of Deprescribing
Accurate documentation of a deprescribing intervention is essential for several reasons. Because
deprescribing may not adhere to standard guidelines, documenting clear rationales and plans may help
allay any potential medico-legal issues. Furthermore, the patient–prescriber team may need to repeatedly
refer to a plan during the process. Finally, because guidelines and published clinical evidence are
currently lacking, a detailed case history (used locally or published) may help accumulate knowledge and
guide deprescribing interventions for other patients. The structure of the clinical instrument we in this
chapter below (if with the proper consent, appropriately de-identified and incorporated into a suitable
platform) may serve as a means of recording and sharing the process and events of deprescribing towards
generating a database for continuous learning and innovation (akin to a Learning Health System).
Electronic medical records, progress notes, or medication order forms are typically not set up for the
documentation of process and are meant mainly for recording of observations, diagnoses, and orders. We
recommend a more holistic documentation of medication lists, with due attention being paid to the
understanding and value that the patient attaches to each of the medications. Box 7.1 shows an example of
such a medication list. Collateral information on the effects of specific interventions applied can
additionally add context and guide the deprescribing.

Box 7.1 Example Format for Collaboratively Documenting Medication Lists

Patient’s name: John Smith
Date: 10/20/2018
Sources of information: John and his wife (Tina), pharmacy, psychiatric records, primary care records
Participants: John and Tina, therapist (via phone)

Medication Started Clinical Indication for medication Side Patient/caregiver Perceived usefulness
and dose on effects
Depakote 1,000 Apr Mood stabilization Hair loss John thinks it is “useless.” Tina thinks John gets angry if he
mg BID 2008 misses morning doses.
Risperidone 4 mg Apr Psychotic symptoms None Both John and Tina agree that risperidone keeps him
HS 2008 “even.”
Cogentin 2 mg Jun Risperidone-induced EPS None “Don’t know.” “Haven’t taken it at times.”
HS 2008
Wellbutrin 400 May Depressive symptoms in the context None “Really helped back then.” Therapist thinks it helped him
mg daily 2011 of bereavement quit smoking.
Protonix 40 mg Jan Heartburn None “I can’t stop this one. I get chest pain without it.”
daily 2012
Lipitor 80 mg at Jan High cholesterol None “The doc said I need it to keep my cholesterol down.”
bedtime 2018

The authors offer the reader a collaborative deprescribing worksheet (Appendix 1). This document is
designed to be completed and maintained by both the patient and prescriber as a framework to help guide,
promote, and document a person-centered collaborative deprescribing process (it should not be
overvalued as the core intervention in and of itself). There are three parts, which can be used
independently or together as one document: Part A documents information gathering and sharing, Part B
documents a shared decision-making process, and Part C documents details and implementation of the
deprescribing plan (while allowing for flexibility). The patient and prescriber are both invited to sign
their names on this document to reflect the collaborative nature of the process. The authors encourage
practitioners to consider adopting the worksheet as is, or adapting it to their needs. A digital version can
be readily developed and integrated into electronic medical records.
Part A: Reviewing the medications
In Part A, the patient and prescriber gain a shared understanding of all current medications taken (this
may include alternative remedies if relevant). Collaborate on listing both the current and potentially future
“pros versus cons” of taking each medication in commonly understood language. These may include
pertinent positive and negative effects as well as other factors like cost and convenience that emerge from
your discussion. Potential side effects should be curated to those most relevant (avoid simply listing all
possible associated side effects of each medication). You should extend into further rows of the
worksheet (and an additional side) if needed. As you work through, flag up to three medications that
either patient or prescriber wishes to consider further together for deprescribing. As mentioned earlier, a
prescriber and patient may undertake Part A periodically, whether or not intending it to lead to a
deprescribing. Part A encompasses the previously detailed deprescribing Steps 1 through 3.
Part B: Choosing a medication
In Part B, the patient and prescriber (soliciting additional input from key supports and additional
resources as appropriate) engage in shared decision-making around which medication to deprescribe at
this time. First, the patient identifies what factors/values are most important to them when making this
decision (responding to the four direct questions). The patient’s ideas, concerns, and expectations are
elicited. The provider may assist the patient in identifying who else might be appropriate to involve in the
deprescribing decision process—this may include key supports, peers, other providers, or consultants
(such as pharmacists or other specialists). Once these foundations are in place, up to three medications
(as identified in Part A) are examined in detail, asking the question: What are the potential benefits and
risks of deprescribing the medication? Please note that, by contrast, in Part A the pros and cons of
continuing each medication are examined. Part B refers to deprescribing Steps 4 and 5 and similarly
concludes with the definitive agreement on one medication to deprescribe.
Part C: The deprescribing plan
In Part C, the specifics of the deprescribing plan are articulated, implemented, monitored, and adjusted
as necessary. The workflow references the field of management’s Plan-Do-Study-Act construct to capture
the complexity of the process, the importance of starting somewhere, and learning and adapting, as well
as balancing inherent elements of certainty and uncertainty. Expectations around anticipated emergent
effects (such e.g., as insomnia) as the taper ensues are listed, with suggestions (from the prescriber,
patient, and key supports) of what to try in response. This can include pharmacologic as well as
nonpharmacologic strategies (such as, e.g., short-term use of a hypnotic agent, sleep hygiene practices, or
cognitive behavior therapy). The prescriber also has the opportunity to stipulate scenarios in which they
would like to be updated or consulted. Although taking a more directive stance here, this can be well-
pitched to communicate an ongoing interest and concern for the patient, a “leaning in” and offering of a
clear safety net. Similarly, circumstances that would constitute an emergency are listed. The log section
offers a rolling audit trail of clinical events, which might include dose decrements, initiation of
alternative treatments, or follow-up contacts. The patient has the opportunity to document any changes
they notice at these time points and what strategies they employed in response, all of which will be
available for discussion at the next review. At the end of each subsequent clinical encounter, the event log
may be updated with agreed recommendations (and a copy made to chart). On a point of practicality, if
plans need to be changed and a series of proposed actions are not implemented, they might be negated
(with a single line) and the series continued in the row beneath from that point. Part C refers to
deprescribing Steps 6 and 7.

Conclusion
This chapter has described an expanded process for deprescribing specifically adapted to psychiatry. The
considerations and strategies are humbly offered serve as a starting point for the interested prescriber and
what we hope will remain a burgeoning field. The principal addition to existing guidelines is a
preparation phase that gathers further information on the wider context of the medication regimen and lays
firm foundations for the intervention proper. As a complex intervention for a set of complex problems
(which mental health conditions invariably represent), a commensurate approach finds a “good enough”
starting point, probes and monitors closely (with multiple, iterative “safe to fail” trials), and accepts
uncertainty while maintaining optimism. These principles may be equally relevant in treating an
individual patient and in innovating in the field as a whole.

Self-Assessment
• Identify 3 cases from your past of present practice where deprescribing might have been/be relevant.
• With a colleague, role play the completion of the 7 steps of deprescribing using the instrument
provided.
• Provide and receive feedback on how it felt in both roles (patient and prescriber), what went well,
and what could be improved. Pay particular attention to dynamic shifts along the “continuum of
shared decision-making”.
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 8
Deprescribing Antidepressant Medications in Major Depressive
Disorder
In this chapter, we discuss specific context, considerations and clinical decision-making relevant to
deprescribing antidepressants. As in the subsequent medication class- and condition- specific chapters,
we feel it justified to orient around both the available clinical efficacy and effectiveness literature, as
well as what is (in our experience), real-world clinical practice and usage. Elsewhere, we raise possible
alternative interpretations of established findings in order to remind the reader of the potential for
subjectivity when drawing clinical inference from certain study designs. As stated previously, we
propose that it is what the field at large holds true, not the raw sum of the clinical literature, that has
greatest impact on real-world patient outcomes. We nevertheless trust that the reader will consider the
literature and this work through their own critical lens of knowledge, experience and expertise. We
include here proven, as well as hypothesized, potential adverse effects of extended AD use to promote
inquiry by the individual prescriber and the field. Further, we discuss the clinical presentation and
management of antidepressant discontinuation syndromes which may be encountered. Finally, we integrate
pharmacological and non-pharmacological strategies that may support deprescribing ADs.

Goal and Learning Objectives

After reading this chapter, the reader will be able to:
1. Outline a framework for risk–benefit calculation for ongoing prescriptions of ADs
2. List common signs and symptoms of AD discontinuation syndrome and their management
3. Feel more empowered in developing an AD deprescribing plan for a given clinical scenario

Case Example
Joan is a 50-year-old woman who has had three episodes of depression and has been doing well on
sertraline 100 mg/d for the past 3 years. She recently came across a newspaper article that questioned the
efficacy of antidepressant medications and says that she may want to try stopping sertraline and managing
any depressive symptoms through exercise and yoga. She brings this up with her prescriber at their next
session. The prescriber advises that standard guidelines recommend indefinite continuation of
maintenance treatment following three episodes of major depression, and that if Joan is interested in
attempting to discontinue them, alternative strategies should be planned. Joan’s prescriber choses to
validate, that in addition to her personal preference here to not take ADs, growing numbers of reanalyses
of data have questioned the efficacy of ADs for moderate depression. Before the tapering of sertraline is
started, Joan realizes the need to consolidate her engagement in psychotherapy and making positive
lifestyle changes (such as ensuring optimal sleep, diet and exercise, or minimizing unwarranted sources of
stress in her environment). Education is provided about potential discontinuation symptoms, including the
chances of feeling like she is experiencing a recurrence of depression. Other strategies for managing
discontinuation symptoms, such as reducing the rate of taper, or a cross-taper to fluoxetine, are framed as
potential options if necessary. Joan opts to start yoga and join a gym, and she and her prescriber decide to
plan to start the taper in 1 month’s time.

As debate questioning the use of antidepressants increasingly pervades public consciousness,

psychiatric and primary providers may find themselves facing situations like Joan’s with increasing
frequency. ADs are a very commonly prescribed class of medication and are the first line treatment for
most anxiety and depressive disorders, whilst being an adjunct for other conditions. It is particularly
important to learn how to deprescribe ADs, firstly, because of how commonly they are prescribed and,
secondly, because there are viable, evidence-based, nonpharmacological treatment alternatives in many
situations. This chapter is intended to provide an approach to addressing such clinical scenarios. Table
8.1 lists the more commonly prescribed antidepressants and their indications.

Table 8.1 Commonly used antidepressant (AD) medications

Medication Common medications Common indications
class
SSRIs Fluoxetine, paroxetine, sertraline, citalopram, Depressive disorders, anxiety disorders, OCD, eating disorders, enuresis,
escitalopram, fluvoxamine neuralgia, migraines, smoking cessation
Tricyclic Imipramine, amitriptyline, nortriptyline,
ADs desipramine
SNRIs Venlafaxine, duloxetine
Others Bupropion, mirtazapine
OCD, obsessive compulsive disorder; SNRI, selective serotonin norepinephrine inhibitors; SSRI, selective serotonin reuptake inhibitor.

Potential Effects of Extended Use of Antidepressants

Weight Gain

ADs belonging to the class monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs)
may contribute to weight gain both in the short- and long-term. Selective serotonin reuptake inhibitors
(SSRIs), in contrast, vary in their effect on weight; fluoxetine and paroxetine are more often associated
with the potential for weight loss, whereas citalopram and sertraline are thought of having lesser weight
gain effects. Among the newer ADs, mirtazapine is widely associated with weight gain (often used an
intended collateral effect), most of which occurs in the first 4 weeks. This topic is reviewed in more
detail in the article by Fava (2000).

Sexual Dysfunction

ADs generally (excluding bupropion and mirtazapine) carry risk of causing a range of sexual side effects,
including reduced libido, difficulty in arousal, erectile and ejaculatory dysfunction, and anorgasmia.
Particularly problematic is the relative reluctance (potentially from both patient and provider) to raise the
issue and the conflation or misattribution of effects being from the illness itself. Sexual side effects in turn
can negatively affect a person’s self-esteem, quality of life, and relationship with a partner.

Tardive or Withdrawal Dysphoria

Although not a well-established or accepted syndrome, it has been hypothesized that prolonged use or
abrupt withdrawal of an AD can itself induce dysphoria. Equivalent phenomena are more established in
antipsychotic treatment with the examples of tardive and withdrawal dyskinesia. To further explore the
idea of tardive dysphoria, El-Mallakh et al. (2011) conducted a systematic review of existing long-term
studies of AD treatment of recurrent depression. They concluded that while there was reliable evidence
for AD efficacy in treatment of depressive episodes and preventing relapses of the same episode, the
evidence for prevention of recurrences was less clear. Could some of the observed recurrences with AD
maintenance represent tardive dysphoria?
El-Mallakh et al. (2011) identified 18 studies whose duration was more than 18 months and found that
patients taking placebo were more likely to have recurrence of depression as compare to those taking
ADs. However, results indicated that most of these recurrences occurred within the first 6 months of
discontinuating, raising the possibility that AD withdrawal was responsible for the recurrence rather than
the underlying disorder itself.

AD Tachyphylaxis or “Poop Out”

The reappearance of depressive symptoms when an AD is taken for maintenance, has been reported in
some samples in over half of patients initially responding to an AD. This phenomenon (or group of
phenomena) has been framed by some as AD tachyphylaxis or others, colloquially as “poop out”. Some
candidate mechanisms speculated to explain these clinical observations include a loss of placebo effect,
pharmacokinetic changes, change in disease severity or pathogenesis, and ineffective prophylaxis. One
question raised here is the whether the pathogenesis of a recurrence in a patient taking ADs is different
from a person who has never taken an AD (see Byrne & Rothschild, 1998). Further research is needed in
this area to better understand the relative contribution of underlying illness and medication effects to these
scenarios.

Antidepressant Prescription in Primary Care

Primary care providers effectively screen for and manage a large proportion of major depressive
disorder. ADs are prescribed commonly in primary care settings but unfortunately may be initiated and
continued inappropriately (Baumeister, 2012). Primary care providers may only consider referring
patients to specialist psychiatric providers if symptoms do not respond to a first or second trial of an AD,
or striking behavioral side effects emerge (such as apparent activation of suicidality or mania). Without
the support and input of specialists, recommendations for discontinuation may not be made and even when
made, may not be followed as written. For instance, in a study targeting inappropriate AD prescription in
primary care settings (e.g., using an AD for several years after remission of a single episode of major
depression), it was found that only 6% of patients who were subsequently advised to discontinue their
AD actually successfully followed through with the recommendation (Eveleigh et al., 2017). This study
has important implications; first, when indicated, expectations for deprescribing should be established at
the time of prescription (possibly with the input of specialists). Second, it suggests that AD
discontinuation is not a simple matter of making a recommendation to discontinue a medication, and
points to the need for the development and dissemination of complex, multi-faceted deprescribing
interventions. Important for further research in this area is an exploration of the reasons behind the low
percentage of follow through on the patient’s part, which would further inform recommended interventions
that might be particular to the primary care setting.

Relapse and Recurrence Prevention: The Role of ADs

In recurrent depressive disorder, a relapse is defined as the reappearance of depressive symptoms within
the same episode of depression, whereas a recurrence is defined as the occurrence of a new episode of
depression (Frank et al., 1991). Accordingly, continuation therapy with ADs would prevent relapse
whereas maintenance therapy would prevent a recurrence. The Collaborative National Institute of Mental
Health (NIMH) study recommended 16–20 weeks of continuation therapy based on the rationale that ADs
merely suppress symptoms of a depressive episode rather than shortening its natural duration. Hence,
treatment is needed for the entire natural duration of an episode, 6–8 weeks of acute treatment followed
by 16–20 weeks of continuation; take for example work by Prien & Kupfer (1986). This study found that
38% of individuals assigned to placebo treatment in the continuation phase of treatment (after remission
of acute symptoms with active treatment) relapsed as compared to 5% patients who were assigned to
treatment with imipramine. However, notably, the AD used in the acute phase was discontinued abruptly
with no washout period, risking a discontinuation syndrome and subsequent unblinding. Interestingly, rates
of relapse for the placebo group and the imipramine group became almost equal after a further 8 weeks.
An extensive review of maintenance therapy with AD stated that “far fewer data exist on maintenance
therapy and recurrence than is commonly thought” (Keller & Boland, 1998). The same review also
concluded that maintenance therapy was recommended for anyone who had more than three episodes of
depression, that tapering an AD was preferred to abrupt discontinuation, and that, although unexplored,
psychotherapy was a promising intervention for prevention of recurrences. Since the publication of this
review, there have been several longer term (varying between 1 and 5 years) trials of the efficacy of ADs,
various psychotherapy modalities, and combinations thereof. However, reviews indicate that the average
duration of trials still continues to center around 1 year (see Clarke, Mayo-Wilson, Kenny, & Pilling,
2015; Geddes et al., 2003).
Finally, in a recent commentary, Fava has raised the notion of a reconceptualization of some depressive
recurrences as iatrogenic (secondary to AD treatment) and recommends a sequential model of treatment
where the use of ADs is limited to the shortest period of time and then followed by the use of alternate
strategies (Fava, 2018).

Risk of Recurrence

While considering deprescribing an AD, it is important to make a reasonable estimate of the risk for a
recurrence of depression. If the risk for recurrence is high and the past episodes have been severe and
disruptive to the patient’s life, this needs to be weighed carefully. Contextualizing this is important,
including looking at the patient’s values regarding the use of psychotropic medications, the reported
efficacy of the AD in preventing depressive recurrences, and the availability of alternate strategies for
prevention of recurrences, as well as the person’s willingness and access to these strategies.
Berwian and colleagues (2017) conducted a systematic review of 13 studies that identified predictors
of a depressive relapse after AD discontinuation. They concluded that there was some evidence that the
number of previous episodes and a true treatment response could predict a depressive relapse but that
there was a critical need for further research in this area.

Planning Deprescribing of Antidepressants

After considering the risks of recurrence, side effects, patient preferences, and alternative maintenance
treatments, the patient and prescriber may decide to attempt deprescribing. In planning AD deprescribing,
as listed in Box 8.1, it is important to consider withdrawal symptoms and their management and the
implementation of psychotherapeutic and behavioral interventions for prevention of recurrences.

Box 8.1 Major Steps Involved in Deprescribing Antidepressant (AD) Medications

 • Weigh risks of recurrence, efficacy of AD, side effects, availability of alternatives and patient
preferences.
• Initiate psychotherapy and behavioral measures before AD reduction.
• Monitor factors that may increase a risk for recurrence (e.g. substance use or stress)
• Educate about, monitor, and manage AD withdrawal symptoms.

Figure 8.1 lists key factors one may need to consider before making a decision about deprescribing
ADs.

Figure 8.1 Some factors influencing the decision to deprescribe antidepressant medication in major depressive disorder.

Antidepressant Discontinuation or Withdrawal Syndromes

Although ADs have never been termed addictive and do not strictly meet criteria for such, discontinuation
or withdrawal syndromes have been characterized. It is important to recognize and manage these transient
symptoms of withdrawal as they can be misconstrued as a recurrence of the underlying depressive illness.
In addition, the symptoms of withdrawal are reported as ranging from mild to very distressing to the
patient. Numerous authors have reviewed clinical manifestations, mechanisms, and management strategies
(see Haddad, 2001; Lejoyeux, Adès, Mourad, Solomon, & Dilsaver, 1996; Warner, Bobo, Warner, Reid,
& Rachal, 2006). We have summarized the most relevant clinical information here.

Clinical Symptoms

Withdrawal symptoms have been described with all classes of serotonergic ADs including MAOIs,
TCAs, SSRIs, and newer ADs such as the selective serotonin norepinephrine inhibitors (SNRIs) and
noradrenergic and specific serotonergic antidepressants (NASSAs). Some withdrawal symptoms
occurring after the abrupt discontinuation of tricyclic ADs however, have been attributed to a cholinergic
rebound and have been treated with anticholinergic medications (see Dilsaver, Feinberg, & Greden,
1983). Symptoms of SSRI withdrawal are characteristic of the group and an SSRI discontinuation
syndrome has been specifically named and described (estimated to occur in a third of individuals
abruptly stopping). It is characterized by dizziness, fatigue, myalgia, paraesthesias, nausea, and vomiting
(see Chouinard & Chouinard, 2015; Therrien & Markowitz, 1997). Mirtazapine withdrawal can cause a
range of symptoms including insomnia, restlessness, nausea, vomiting, dizziness, agitation, panic attacks,
mood swings, irritability, mania, or depression. These symptoms have been treated symptomatically with
olanzapine, clonazepam, or fluoxetine depending on the presentation (see Cosci, 2017). Among SNRIs,
venlafaxine has been shown to cause electric shock–like sensations similar to those described by patients
withdrawing from SSRIs (see Reeves, Mack, & Beddingfield, 2003). In a study that pooled data from 553
patients, discontinuation of duloxetine was seen to most commonly cause dizziness, nausea, headache, and
paraesthesia (Perahia, Kajdasz, Desaiah, & Haddad, 2005).

Variables Affecting Withdrawal Symptoms

Half-life, duration of treatment, dosage, and drug-drug interactions are to be considered when assessing
likelihood of withdrawal symptoms. The half-life of the AD influences the likelihood of a patient
developing withdrawal symptoms following AD discontinuation. ADs such as venlafaxine and paroxetine
that have a half-life of less than 12 hours are more likely to cause withdrawal syndromes than fluoxetine,
which has a half-life lasting days. ADs are unlikely to cause withdrawal if the duration of treatment was
less than 5 weeks. Broadly, this may be reflective of intracellular changes induced by or adaptive to ADs
over these initial weeks which become unopposed when the AD is abruptly removed. It is unclear if the
dose of the AD influences the withdrawal symptoms. Additionally, there is some evidence to suggest that
concurrent treatment with antihypertensives, anticonvulsants, and antihistamines is associated with a
greater frequency of AD withdrawal symptoms (see Lejoyeux & Adès, 1997). Therefore, taking each of
these variables into consideration is important when looking at rate of taper in ADs.
Differentiating withdrawal from a relapse or recurrence is important, as the management and prognosis
of each differs, but clearly distinguishing each presents challenges. Antidepressant withdrawal typically
begins a few days after the discontinuation of the medication and may be accompanied by numerous
physical symptoms in addition to mood disturbances. Although a relapse may occur within a few days to
weeks after AD discontinuation, it typically does not present with the physical symptoms characteristic of
withdrawal syndromes. The distinction between AD withdrawal and major depressive relapse/recurrence
may hold a different significance if some recurrences are indeed reformulated as being a function of AD
use (see Fava, 2018). Adding to the conundrum of distinguishing the two (recurrence and withdrawal) is
the common occurrence of patients skipping doses or taking brief ‘holidays’ from the medication. This can
further muddy the picture, especially if the patient does not fully share the extent to which they have not
adhered to the prescribed regimen.
An additional variable in depression treatment and subsequent AD withdrawal is hormonal variations
and their effects on mood for women. Some pre-clinical evidence points to differential response to
classes of ADs based on progesterone levels (Li et al., 2012). Also to be considered is stage of life (i.e.,
pre- peri- or post-menopausal) and relative contributions of the menstrual cycle on hormone and mood
fluxuations. Although beyond the scope of this text, we encourage the reader to consider these as
additional variables requiring consideration in the consideration of withdrawal symptoms and the
differentiation between recurrence and withdrawal.

Managing AD Withdrawal
Unexpected and unmanaged withdrawal symptoms could easily prompt the abandoning of a deprescribing
plan. Some of the most common strategies to address these symptoms include reducing the rate of taper of
the AD or switching to long-acting agents such as fluoxetine. Consumer forums (uncontrolled, testimonial
evidence) have described ways to take smaller doses of medication than are commercially available by
crushing tablets or removing the contents of capsules to create smaller doses. Most recently, AD
‘withdrawal strips’ allow the patient to control the dosing in much smaller progressive decrements.
Liquid preparations of many ADs are also available, but are not as commonly prescribed. Such extended
taper strategies have been shown to reduce the incidence of withdrawal symptoms (see Groot & van Os,
2018). However, the judicious reader should use caution in interpreting these mixed levels of evidence
when attempting to infer the potential benefits and risks of this approach. Although is could be argued that
both physiological and psychological aspects could be at play, a person-centered approach that accounts
for non-pharmacological effects of medications (such as ‘meaning’) would accept value from so-called
placebo effects. Further research in this area is much needed.

Psychotherapeutic and Behavioral Interventions to Support AD Deprescribing

Numerous psychotherapeutic approaches have shown efficacy in both the treatment of interepisodic
residual symptoms and in the prevention of relapses and recurrences of major depression (see
Nierenberg, Petersen, & Alpert, 2003). Psychotherapeutic interventions may very well become the
mainstay of maintenance therapy in recurrent depression, especially if evidence for the iatrogenic theory
of depression recurrence grows (see Fava, 2018).

Cognitive Behavior Therapy for Depression

Cognitive behavior therapy (CBT) is the most well-established psychotherapeutic treatment for major
depression both as an adjunctive to ADs and as a stand-alone treatment (for less severe episodes). A
systematic review and meta-analysis of a comparison of second-generation AD (SSRI, SNRI, and other
receptor-specific ADs) treatment versus CBT for a single episode of depression concluded that there was
no difference in treatment effects, either singly or in combination (Amick et al., 2015). Cognitive therapy
(see Paykel et al., 2005), including mindfulness-based cognitive therapy (see Ma & Teasdale, 2004;
Teasdale et al., 2000), has also been shown to prevent relapses and recurrences in recurrent major
depression. A recent 2-year follow-up study of 289 individuals with recurrent major depression did not
find continued AD treatment superior to preventive cognitive therapy provided while tapering AD in
terms of risk of relapse and recovery (Bockting et al., 2018). Well-being therapy, a modification of CBT,
was also shown useful in preventing relapses (see Fava, Rafanelli, Cazzaro, Conti, & Grandi, 1998).

Behavioral Activation

Behavioral activation is a well-recognized addition to treatment for depression. In a four-arm,

randomized controlled study of 241 patients with major depression (mean Hamilton Depression Rating
Scale [HAM-D] score was 20.74) it was found that behavioral activation and AD had equal efficacy and
both were more efficacious than cognitive therapy or placebo at initial treatment (Dimidjian et al., 2006).
An extension of this study examined the efficacy of the same interventions for preventing recurrences and
found that both behavioral activation and cognitive therapy were as efficacious as AD (Dobson et al.,
2008). Adding behavioral activation as an intervention may prove to be a key intervention in
deprescribing ADs.
 Exercise Training

Exercise has emerged as a close-to-equivalent treatment for depression. In a randomized controlled trial
of 156 depressed individuals aged 50 or older, treatment with AD was compared to exercise or a
combination of the two. All three groups showed a similarly significant drop in HAM-D scores at the end
of 16 weeks (Blumenthal et al., 1999). The same participants were reevaluated at 10 months, and it was
seen that the exercise group had a lower recurrence rate than the medication group (Babyak et al., 2000).
A consideration with exercise is level of motivation and follow through—developing an consistent
regimen is a challenge for most people without depression, and additional symptoms could present
difficulties with follow through in the implementation for the person. At the same time, the side effects of
this intervention cross multiple domains, making it an appealing option as a supplemental intervention.

Conclusion
In the past decade, AD medications have been mired in controversy over their effectiveness as well as
more recently their potential contribution to the pathophysiology of some recurrent depressive episodes.
The deprescribing of ADs requires thorough planning and preparation for management of potential
withdrawal symptoms and prevention of future recurrences of depression by using slow tapers, AD
switches, and psychotherapeutic interventions. Primary care physicians, who constitute the bulk of AD
prescribers, must be educated about the degree of distress that withdrawal symptoms can produce. Future
research focused on elucidating the long-term side effects of these medications and neurobiological basis
of withdrawal syndromes could assist in the further development of deprescribing protocols.

Case Examples

Case Example 1
Joe, a 25-year-old single white man, has taken escitalopram 20 mg/d for more than 6 years following a
single major depressive episode precipitated by a relationship break-up (during which he had suicidal
ideation). He currently lives in his own apartment, has a part-time job, and is taking online classes. He
smokes marijuana once a week but does not drink alcohol or use any other recreational drugs. He has had
no depressive or anxiety symptoms for 3 years. He is asking about discontinuing escitalopram.
Guidelines of the American Psychiatric Association suggest that a patient can attempt discontinuation of
the AD after 9 months of treatment if they have had only one episode of depression. In Joe’s case, this
guideline is applicable. The risks of ongoing escitalopram use for Joe, are mainly related to sexual
dysfunction which can be very distressing for a 25-year-old man, while the continued benefits are unclear.
The main risks of discontinuation are the withdrawal symptoms and a potential future recurrence that
might have been prevented by escitalopram. Although his initial episode was severe, the risk of
recurrence for Joe is not clearly known. Joe’s consent around this risk/benefit calculation should be
obtained, along with a plan for the management of withdrawal symptoms and a personalized list of
symptoms and strategies to identify and manage a recurrence (see Table 8.2).
Table 8.2 Decision-making grid for case 1
Decision-making grid
Risks Benefits
Continuing Long-term side effects including sexual dysfunction Possible prevention of recurrence
escitalopram
Deprescribing Withdrawal symptoms Time and labor-intensive process Development of non-pharmacological strategies
escitalopram Possible recurrence of depression Patient wishes to deprescribe
Patient values/preference: Patient prefers to risk a recurrence of depression rather than continue escitalopram at this point
Plan: Deprescribe escitalopram
Interventions: Psychoeducation about withdrawal symptoms, bolstering social support, lifestyle changes, CBT, cessation of marijuana,
developing a relapse prevention plan

Case Example 2
Jill, a 34-year-old white woman, is on venlafaxine for management of recurrent major depression. She
has had three episodes in the past, the last one (a year ago) causing her to be hospitalized due to an
overdose of 10 pills of aspirin. She says that she has weighed the benefits of continuing venlafaxine
against the risks and side effects and feels like she does not want to take any medication for depression
anymore.
Jill has had three episodes of depression, including one severe enough to cause hospitalization.
Guidelines would clearly indicate that she should continue taking ADs (see Table 8.3) and this needs to
be clearly communicated to Jill. This is an opportunity to engage in exploration of undisclosed side
effects and the meaning of medications (and diagnosis) for Jill. Non-pharmacological strategies can be
added either way to ensure minimum effective dosing. Psychoeducation can be provided and the alliance
bolstered, even if Jill accepts your recommendation not to change the regimen. Careful attention should be
paid to the possibility that Jill will decide to discontinue the medications on her own, and clear
messaging to Jill that rather than discontinue on her own, there is a possible reduction strategy with which
she can collaborate on. The risk-benefit of medication discontinuation without prescriber knowledge,
versus non adherence to guidelines and supporting a collaborative trial of medication reduction, should
be thoroughly explored. If necessary, seeking peer consultation and identifying prescriber biases will be
useful in decision making here.

Table 8.3 Decision-making grid for case 2

Decision-making grid
Risks Benefits
Continuing Patient may drop out of treatment if she feels that Prevention of recurrence (she is at a high risk for recurrence as she
venlafaxine her thoughts are being disregarded Side effects has had three past episodes and has been suicidal in at least one)
Deprescribing Withdrawal symptoms Time and labor-intensive Increased focus on other contributors to depression Patient prefers to
venlafaxine process Recurrence of symptoms deprescribe
Patient values/preference: Patient has strongly expressed a preference for not taking AD
Plan: Further exploration of meaning of medications and of the patient’s decision-making process
Interventions: Psychoeducation about withdrawal symptoms, bolstering social support, lifestyle changes, CBT, developing a relapse
prevention plan or WRAP plan

Case Example 3
Jack, a 37-year-old man with bipolar depression and alcohol use disorder, takes lithium 1,500 mg a day
(level 1.00 mEq/L) and amitriptyline 100 mg qHS, continues to drink, and has ongoing mild to moderate
depressive symptoms. He says that he does not want to be on two medications.
Since Jack has bipolar disorder, the use of an AD is controversial (see the STEP-BD
recommendations). Furthermore, he continues to have symptoms even though he is taking an AD (albeit at
a low dose). To add to this, Jack continues to drink alcohol daily, which could be significantly
exacerbating his depressive symptoms. In this situation, Jack might be advised to taper amitriptyline, start
CBTi for predicted emergent insomnia, and assess Jack’s stage of change around his alcohol use in order
to decide on possible interventions. Distinct from serotonergic effects, he may experience symptoms of
cholinergic rebound that could be managed by either slowing the taper of the primary medication or
adding a pure anticholinergic agent (such as benztropine) for a short taper (see Table 8.4). In addition,
doing a thorough assessment of Jack’s current life situation and looking at contributing contextual factors
will inform recommendation of other possible adjunctive supports.

Table 8.4 Decision-making grid for case 3

Decision-making grid
Risks Benefits
Continuing Conversion to rapid cycling Anticholinergic side effects Some improvement in depressive symptoms Management of
amitriptyline neuropathic pain
Deprescribing Withdrawal symptoms Time and labor-intensive Increased focus on other contributors to depression including
amitriptyline process Increase in depressive symptoms alcohol use Patient prefers to deprescribe
Patient values/preference: Patient prefers to take only one medication
Plan: Deprescribe amitriptyline
Interventions: Psychoeducation about withdrawal symptoms, bolstering social support, lifestyle changes, CBT, cessation of alcohol use,
developing relapse prevention or WRAP plan

Case Example 4
Anna, a 78-year-old woman who lives with her family, ambulates on a scooter due to osteoarthritis, has
chronic obstructive pulmonary disease, and is taking multiple medications. She was given mirtazapine
30mg QHS 7 years ago, which was augmented with bupropion 150 mg 3 years ago, and she has continued
the combination since then.
There are no guidelines for the duration of treatment with an AD that has been added to augment an
initial. In this case, the prescriber might initiate a discussion recommending the deprescribing of
bupropion to minimize drug interactions and side effects (see Table 8.5).

Table 8.5 Decision-making grid for case 5

Decision-making grid
Risks Benefits
Continuing Long-term side effects including lowering of seizure threshold and No evidence for benefits of continuation
bupropion increased blood pressure Drug interactions
Deprescribing Withdrawal symptoms Increase in depressive symptoms Reduced side effect Reduced risk of interactions
bupropion leading to adverse outcomes
Patient values/preference: Patient prefers fewer medications but leaves the decision up to you
Plan: Deprescribe bupropion
Interventions: Psychoeducation about withdrawal symptoms, monitor for recurrence

Self-Assessment
1. Joan is a 56-year-old married woman who has taken duloxetine 60 mg twice a day for more than 6 years. Before she started
taking duloxetine, she had three episodes of mild to moderate depression in a span of 5 years. She has never been actively
suicidal or hospitalized and is otherwise healthy. She is asking about the possibility of discontinuing duloxetine.
a. What are you most inclined to recommend?
b. If Joan asks for more information, what are the factors you will consider and advise her on?
c. If Joan decides that she wants to discontinue duloxetine, what are the withdrawal symptoms you will warn her about?

2. Tim is a 30-year-old single man who experienced a severe episode of depression 3 years ago following the death of his best
friend. He was neither experiencing psychosis nor hospitalized, but he had suicidal ideation. He has been taking citalopram
20 mg and is doing well. Would you suggest tapering off citalopram?

a. What would you recommend and why?

b. What will you do if Tim refuses to taper off citalopram despite your suggestion?
c. What will you do if Tim insists on stopping the medication despite your suggestion?

3. Karen is a 40-year-old woman who continued to have depressive symptoms despite taking sertraline 200 mg for over 12
weeks. You give her bupropion 300 mg as augmentation, and the symptoms subside over the next 6 weeks. She is now
asking about how long she needs to take the medications.

a. Would you recommend continuing both medications? Justify your recommendation.

b. If you recommend tapering, which medication would you recommend and why?

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 9
Deprescribing Antipsychotic Medications
In this chapter, we present specific context, considerations and clinical decision-making relevant to
deprescribing antipsychotics. We apply the same caveats found in the introduction to chapter 8 and urge
the reader to consider this work through their own critical lens of knowledge, experience and expertise. A
specific challenge for this class of medications is the broad receptor profiles, growing set of clinical
indications, considerable off-label use and diagnostic uncertainty that dispels all but the most robust
fantasies of therapeutic precision. The principal focus of deprescribing in this chapter may well be the
pursuit of minimum effective dosing more than complete discontinuation, excepting the case of multiple
antipsychotic medications. Issues of shared decision making and informed consent are particularly
pertinent when working with vulnerable populations such as those experiencing psychotic disorders. We
discuss here factors that might recommend for and against deprescribing antipsychotic medications (APs).
We also describe the clinical presentation and management of related rebound and discontinuation
syndromes. Finally, we integrate some nonpharmacological interventions that may support deprescribing
these medications when indicated.

Goals and Learning Objectives

After reading this chapter, the reader will be able to:
1. Frame a risk benefit calculation for ongoing prescriptions of APs for a given clinical scenario
2. List common symptoms of AP and anticholinergic discontinuation syndromes and their management
3. Develop an AP deprescribing plan for a given patient

Case Example
Graham is a 49-year-old white man who lives with his elderly mother in a third-floor walk-up apartment.
He has been diagnosed with treatment refractory schizophrenia, and his chart indicates he was prescribed
five different antipsychotic medications (with an unclear adequacy of trials) before being initiated on
clozapine 1 year ago in addition to continuing haloperidol 10mg at bedtime which he states helps with
sleep. Although the combination of clozapine and haloperidol provided him the best response in terms of
further reducing his subjective distress around auditory hallucinations, these experiences continue on a
daily basis, and he has learned to cope with them to a degree. Graham has gained more than 100 pounds
since starting clozapine and has developed type 2 diabetes, heart disease, and osteoarthritis in his knees,
limiting his ability to leave home.

The discontinuation of APs is one of the more contentious issues in psychiatric deprescribing (see Table
9.1 for common AP medications and their indications). The level of uncertainty that surrounds the etiology
and heterogeneity of the condition(s) of schizophrenia spectrum disorders, the often chaotic and
functionally impactful presentations of illness, the prevalent stigma and misconceptions that surround
them, the increasingly burdensome long-term side-effect profiles (notable metabolic side effects of
atypical APs), the cost of care and related disability, and lack of cohesiveness and clarity in the research
literature, among countless other factors, confound the best-intentioned prescriber embarking on a shared
decision-making process.
Table 9.1 Commonly prescribed antipsychotic medications
Class Common medications Common uses
Atypical Risperidone, paliperidone, Schizophrenia (and some: bipolar disorder and unipolar depression) Some: acute agitation,
antipsychotics olanzapine, quetiapine, behavioral disturbances associated with dementia, Parkinson’s disease, behavioral
clozapine, ziprasidone, dysregulation in children and adolescents, problems with impulse control
aripiprazole
Typical Haloperidol, fluphenazine, Psychotic disorders H: Tourette’s, second-line for severe behavioral problems in children
antipsychotics perphenazine, chlorpromazine C: nausea/vomiting, acute intermittent porphyria, mania, tetanus, intractable hiccups,
combativeness in children. Bipolar disorder, acute agitation
Anticholinergics Benztropine, trihexyphenidyl Parkinson’s disease, extrapyramidal symptoms (related to antipsychotic use)

Deprescribing offers a framework for the periodic reassessment of medication risk–benefit ratios and
for their optimal, collaborative reduction to the minimum effective dose and discontinuation when
indicated. Current guidelines for the treatment of patients with schizophrenia and other chronic psychotic
disorders state that APs are critical to controlling symptoms of psychosis and preventing relapse
(emphasis added, APA, 2006). The evidence base for APs is strongest in favor of treatment of acute
agitation (hence APs are also known as “major tranquilizers”) and positive symptoms (such as auditory
hallucinations), but unfortunately less so for addressing the negative and cognitive symptoms which more
closely predict functional impact. The prevailing evidence demands APs be started and specialized care
be sought as quickly as possible after psychotic symptoms emerge with the goal of reducing duration of
untreated psychosis, associated with worse prognosis. When schizophrenia is (often later) diagnosed,
large retrospective epidemiological studies support the notion that APs need to be continued indefinitely
at the minimum effective dose to prevent relapse of this commonly relapsing and remitting condition.
However, diagnostic uncertainty can persist, with those who may not need continuous maintenance
treatment difficult to identify. Consider for example Ian, a 21 year old man who remains well 1 year
following his initial, and only, 2 month episode of psychosis with some features of mania and coincident
cannabis use and faithfully continues maintenance treatment with an AP. He reports some decreased
motivation and difficulty concentrating preventing him from returning to college. His affect is constricted.
Does Ian suffer from schizophrenia? Could this have been a prolonged cannabis-induced psychosis?
Could this be a primary bipolar I disorder? Could his apparent negative and cognitive symptoms be
purely side effects of the AP? We may not have a definitive answer until the AP is withdrawn—but at
what risk?
Although the field has characterized and coalesced around a prevailing model for psychosis and its
treatment (i.e. mesolimbic hyperdopaminergia driving aberrant salience, tempered by D2 receptor
antagonism), exceptions such as the relatively low D2 receptor affinity of our most effective AP,
clozapine, and the burgeoning glutamatergic model of psychosis, muddy the waters. Uncertainty further
abounds when considering that a recommendation to continue APs indefinitely is typically predicated on a
phenomenological diagnosis of schizophrenia—currently best understood as a syndrome without a
universally accepted pathoetiology or diagnostic test. Indeed, psychosis as a symptom can occur in a
range of conditions with vastly varying etiologies and prognoses. For example, a substance-induced
psychotic episode may remit spontaneously within a week or so with cessation of the substance. Newer
clinical guidelines speak to continuing APs for at least 6 months to a year after a first episode of
psychosis before reviewing; however, the largely longterm, retrospective, observational studies generally
showing discontinuation after 1 year as being detrimental are limited by potential confounds such as
illness severity, changing environmental factors (such as potency of cannabis), limited inference of
causality and lack of agreement on most meaningful patient-centered outcomes. We further cannot yet
confidently predict those individuals who will benefit from continued prescription and those who would
benefit from deprescribing. These reflections are not intended to undermine the value of our diagnostic
classifications, nor the research methods currently at our disposal which have been put to good use
providing illuminating clinical research and new treatments providing life-altering benefits. However, we
do intend to highlight the need for further work in this area, as well as our responsibility to acknowledge
and address the uncertainty and imprecision that remains at this time inherent in the holistic management
of any individual presenting with psychotic experiences.
Specific guidelines for treatment of schizophrenia show more concordance in the acute than in the
maintenance phase of treatment. This might reflects, in part, the relative glut of short-term efficacy trials
over long-term effectiveness data. The American Psychiatric Association (APA, 2006) and the World
Federation of Societies of Biological Psychiatry (Hasan et al., 2012) recommend continuing the same
regimen to which the patient has responded for at least 6 months, and the International
Psychopharmacology Algorithm Project (Takeuchi, Suzuki, Uchida, Watanabe, & Mimura, 2012;)
recommends maintaining the dose that was effective in the acute phase during the first few months.
Maintenance dosing guidelines recommend chlorpromazine equivalents of 600 mg/d or less (see Hasan et
al., 2012; Kreyenbuhl, Buchanan, Dickerson, & Dixon, 2010) or haloperidol equivalents of 8 mg/d or less
(roughly equivalent to a chlorpromazine-equivalent dose of 400 mg).

Potential Consequences of Long-Term AP pharmacotherapy

AP Polypharmacy

Rates of AP polypharmacy have risen over the past two decades (see Essock, Covell et al., 2009;
Ganguly, Kotzan et al., 2004)—arguably ahead of the evidence supporting potential benefits (i.e. in
treatment refractory cases) over the risk of additive side effects. There are other examples in medicine,
where clinical practice has led the clinical research, though the approach has benefits and drawbacks.
Although the literature supporting rational AP polypharmacy does continue to grow, the evidence remains
circumscribed. Due to lack of guidelines for AP polypharmacy, AP combinations are at risk of being
continued indefinitely (see Stahl & Grady, 2004). Encouragingly for example, some studies have shown
that a large proportion of patients can be safely transitioned from multiple APs to a single AP without
incident (e.g. Borlido, Remington et al., 2016), although others report worse outcomes (e.g. Katona,
Czobor et al., 2014). At this point in time, with limited evidence for the use of multiple APs for extended
periods it is incumbent to carefully consider the risks as they apply to each individual patient.

Risk–Benefit Ratios Shift with Increasing Age and Duration of Illness

The margin of error in our risk–benefit calculation increases with duration of treatment largely due to a
lack of longer-term effectiveness studies. Without clearly reliable predictors of relapse, deprescribing
guidelines, and tenable alternatives, well-intentioned prescribers may be biased towards recommending
longer courses and higher than necessary doses than may be necessary. From a public health perspective,
the conservative position, risking ‘over-treating’ may be defended if it were not for the crisis of increased
metabolic syndrome and cardiovascular mortality in this population linked to continued atypical AP use.
Murray (2016) proposes the controversial hypothesis that treatment with APs may compound the
primary hyperdopaminergic state in psychosis by producing a secondary dopamine supersensitivity. This
mechanism has been propose to explain the construct of withdrawal/rebound psychosis (upon abrupt AP
discontinuation) which some authors argue is a potential iatrogenic concern requiring attention (see
Moncrieff, 2006). Although some experts conclude that there is insufficient evidence of significant
neurological sequelae (see Goff, 2017), the metabolic and cardiovascular consequences are indisputable
(see Saha et al., 2007). As age and medical comorbidities increase, the risks of indefinitely continuing
APs unchanged may begin to outweigh projected benefits, a concept well-addressed in geriatric
medication (see the Beer’s Criteria). Age-related changes in pharmacokinetics and dynamics warrant the
periodic review of medications and predict the need for the reduction of particular agents, such as
anticholinergics and sedatives which can lead to cognitive impairment and increased falls, respectively.
Some APs, with their broad receptor profiles (notably those with significant anticholinergic and
antihistaminergic) as well as central nervous system depressant effects, should be routinely considered
for deprescribing (dose reduction, switch, or discontinuation) with advancing age. The possibility of
remission of psychotic illness as patients age may also be considered and emphasizes the importance of
reviewing AP dosage and necessity on a regular basis.

Factors Contributing to the Extended Use of Antipsychotic Medications

The argument for deprescribing APs is more easily made when there is diagnostic uncertainty or a high
likelihood that the recent psychotic episode may have been a one-time event or secondary to a medical
cause, primary mood disorder or substance use. Schizophrenia, however, when apparent, is understood to
commonly take a life-long relapsing and remitting course that is amenable to management but not cure. A
key decision point, one potentially determining a patient’s longer term care, comes after remission of a
first episode of psychosis. A common belief is that life-long treatment with APs is needed and, indeed,
there is little evidence to support safe AP discontinuation after the first year of treatment (see Tihonen et
al., 2018). Several studies have demonstrated high rates of relapse following AP reduction (Chen, Hui et
al., 2010; Zipursky et al., 2014). Overall, the efficacy of APs for the initial treatment of psychosis is well
established, but more research is needed to determine whether some individuals may respond to
alternative pharmacologic or nonpharmacologic treatments and, if so, how to identify which treatments
and for which patients (Goff, Falkai et al., 2017). While this is a controversial area and a topic that
arouses strong sentiment on either side of the debate, the stance of embracing the possibility that each
patient’s individual circumstances, course of illness, preferences, and changing life circumstances may
not fall in line with guidelines and deserves consideration is in line with person-centered approaches.
Overall, studies show that discontinuation is associated with relapse in a significantly higher
proportion of patients diagnosed with chronic psychotic disorders than in those who continue medications
(Gilbert, Harris et al., 1995; Leucht, Tardy et al., 2012; Viguera, Baldessarini et al., 1997; Zipursky,
Menezes et al., 2014). However, these studies, other than having varying definitions of relapse, have
particular inferential limitations for deprescribing. Many do not individualize the medication taper, and in
some cases, stop the medications abruptly. Adjunctive psychosocial offerings are not a formal part of
protocols in these trials, differentiating them from a deprescribing effort as put forth here. To reiterate, AP
discontinuation is not equivalent to AP deprescribing.
The majority of AP discontinuation studies conclude that there is a subset of patients who may not
require indefinite AP treatment, and, although commonly understood, guidelines do not yet exist to support
practice for that subset. For example, one study reports that 40% of patients whose symptoms remit after a
first episode may have a good outcome with either no or minimal AP treatment (Murray, Quattrone et al.,
2016). An individualized risk calculator for predicting successful deprescribing of APs would be hugely
valuable to the field—one such tool has been developed to predict conversion to full psychosis in those
with clinical high risk syndrome (Cannon et al., 2016). A similar methodology could be employed here.
As noted in Table 9.1, the range of clinical indications for APs stretch beyond the treatment of
schizophrenia and continue to expand. Atypical APs are becoming first line for the acute, and even
maintenance, treatment of bipolar disorder and the treatment of bipolar as well as unipolar (adjunctive)
depression. Independent of an affective or psychotic disorder, APs are now widely prescribed for acute
agitation and behavioral problems in children and people with dementia (Findling, Steiner et al., 2004;
Park, Cervesi et al., 2016). The use of quetiapine for insomnia (Coe & Hong, 2012; Anderson, Vande, &
Griend, 2014) and atypical APs for posttraumatic stress disorder (Hermes, Sernyak et al., 2014) has
become more prevalent and provide further examples of real-world clinical practice advancing, for better
or for worse, ahead of research evidence. Again, with limited published guidance around AP use for these
burgeoning indications, discontinuation may be disincentivized. Whether the apparent versatility of
atypical AP justifies their broadening use remains to be proved empirically.
Another factor potentially driving indefinite use of APs is that management of schizophrenia has largely
focused on remission of symptoms rather than on functional recovery. This questions whether we are
targeting meaningful, achievable, and person-centered outcomes with our treatments versus strictly
symptom control. Definitions of remission refer to improvement in the core symptoms of psychosis such
that they no longer interfere with behavior (and are at a threshold lower than the one used for the initial
diagnosis of schizophrenia—e.g., on a rating scale such as the Positive and Negative Syndrome Scale
[PANSS]; Andreasen, Carpenter Jr. et al., 2005). Recovery, in contrast, is a fuller concept, reflecting a
person’s ability to lead a meaningful and fulfilled life and maximizing (1) autonomy based on that
patient’s desires and capabilities, (2) dignity and self-respect, (3) participation and integration into full
community life, and (4) resumption of normal development. The concept of recovery has been highly
endorsed by the APA (2005) as well as by the US federal government (New Freedom Commission on
Mental Health, 2003). Functional recovery takes time and may therefore pose a less attractive outcome
measure for clinical trials with follow-up durations limited by feasibility and cost.
Thomas Insel, former Director of the National Institute of Mental Health (NIMH), reflected that
“although these symptoms [of psychosis] can be frightening and dangerous for patients, family members,
and providers, APs safely and effectively help people through the crisis of acute psychosis. However, the
long-term management of chronic mental illness is another matter. Recently, results from several studies
have suggested that these medications may be less effective for the outcomes that matter most to people
with serious mental illness: a full return to well-being and a productive place in society.”
Focusing on a broader measure of recovery (encapsulating symptomatic and functional outcomes),
Wunderink et al. (2007) conducted a clinical trial in people in 6-month remission with APs following a
first episode of psychosis, randomized to maintenance treatment with APs or guided dose reduction or
discontinuation. Over the initial 18-month follow-up period the relapse rate in the dose reduction group
was twice that of the maintenance group; however, at 7 years, those persons in the dose reduction arm
showed greater functional recovery and comparable symptomatic recovery as compared to medication
maintenance (see Wunderink, Nieboer et al., 2013). Furthermore, the Chicago follow-up study for
example, which tracked individuals for 20 years after a first episode of psychosis, reported that those not
on APs had better functional outcomes than those who continued APs (Harrow & Jobe, 2013). Table 9.2
summarizes studies looking at relapse rates following AP discontinuation.
Table 9.2 Summary of systematic reviews examining relapse rates following antipsychotic (AP)
discontinuation in schizophrenia
Reference Methodology Findings Conclusions Limitations
1. Gilbert, Systematic review Over a mean follow-up period of 9.7 months Risk–benefit of AP withdrawn in 1 day in 42
Harris et of 66 studies of AP the relapse rate was 53% in patients who neuroleptic studies, 24 studies had a taper
al., 1995 withdrawal in discontinued AP and 17% in those who did continuation Vs taper duration between 2 and 60 days
schizophrenia not. must be considered 22 studies did not provide a
carefully. definition of relapse No
mention of psychosocial
interventions
2. Viguera, Systematic review After abrupt discontinuation, the risk of The risk of relapse In 1,006 of the 1,210 patients,
Baldessarini of AP relapse reached 50% within 6 months. was highest within 6 AP was discontinued abruptly
et al., 1997 discontinuation in months of No mention of psychosocial
studies 1,210 discontinuing AP. interventions
patients with Subjects who
schizophrenia remained stable in the
first 6 months were
more likely to remain
stable after
3. Chen, Hui 178 patients with Relapse at 12 months was 41% (95% Quetiapine treatment No mention of psychosocial
et al., 2010 first episode confidence interval, 29–53%) for the substantially reduced factors or treatments
psychosis quetiapine group and 79% (68–90%) for the the risk of relapse in
maintained on placebo group first episode psychosis
quetiapine vs. patients
placebo for 1 year
4. Leucht, Meta-analysis of APs significantly reduced relapse rates at 1 APs benefit patients The funnel plot was
Tardy et al., 65 trials involving
year (drugs 27% vs. placebo 64%). Fewer with schizophrenia. asymmetrical and may
2012 6,500 patients patients given APs than placebo were More data needs to be represent a small trial effect
readmitted (10% vs. 26%) but less than a obtained about the Time to relapse data was not
third of relapsed patients had to be admitted. long-term morbidity available for most studies
In a meta-regression, the difference between and mortality of APs. Method of PA withdrawal was
drug and placebo decreased with study not described No mention of
length. psychosocial interventions
5. Zipursky, Systematic review Recurrence rates in the AP discontinuation Trial off AP Three studies discontinued AP
Menezes et of six studies of AP group were 77% and 90% at the end of 1 medications in first- over a maximum of 3 months,
al., 2014 discontinuation in and 2 years. Recurrence rates in the AP episode psychosis two studies stopped depot AP,
first-episode continuation group were 3%. patients is not one did not specify the rate of
psychosis patients, recommended as the discontinuation Variable
after they had risk of recurrence is definitions of recurrence
achieved very high
symptomatic
remission

Discontinuation Syndromes
A special consideration when deprescribing APs is the reappearance of psychotic symptoms during the
process. This reappearance of symptoms can be understood as a rebound of the underlying illness but has
alternatively been hypothesized to represent a ‘supersensitivity’ or ‘withdrawal psychosis’ by some.
Supersensitivity psychosis has been defined as the appearance of new psychotic symptoms (or psychotic
symptoms of greater severity) in a patient who abruptly discontinues or reduces APs after chronic use
(see Chouinard, 1991). However, this concept does not have broad acceptance, and its mechanism has not
been elucidated (Goff, 2015). Another reported withdrawal syndrome attributable to dopaminergic
function is withdrawal-emergent dyskinesia (a subtype of TD) which typically resolves spontaneously
over 1–2 months after abrupt AP cessation. Reintroduction of the AP and gradual taper over several
months can help.
Abrupt discontinuation of an AP with high anticholinergic effects (such as clozapine) as well as the
anticholinergic agents commonly used as adjuncts to AP treatment may precipitate a cholinergic rebound
involving nausea, malaise, diaphoresis, and tachycardia. Although no specific guidelines exist, pure
anticholinergic agents may be (re)introduced and more slowly tapered. See Table 9.3 for a summary of
some discontinuation syndromes related to stopping AP medications and suggested management of them.

Table 9.3 Discontinuation syndromes related to antipsychotic prescription and suggested management
Symptom Mechanism Management
Nausea, malaise, diaphoresis, vomiting, insomnia (Lacoursiere, Cholinergic No specific treatment may be needed, continue
Spohn et al., 1976; Cerovecki, Musil et al., 2013) rebound anticholinergic medication for a week after discontinuing
AP
Withdrawal emergent dyskinesia (Dufresne & Wagner, 1988; Dopamine Lower the rate of taper
Chouinard 1991; Chouinard & Chouinard, 2008) supersensitivity
Decreased REM latency, REM sleep and total sleep time Dopamine Other measures for management of insomnia such as low
(Thaker, Wagman et al., 1989) supersensitivity dose benzodiazepines, antihistaminics or trazodone
Withdrawal akathisia (Dufresne & Wagner, 1988) Dopamine Slow the rate of taper
supersensitivity

Strategies to Support AP Deprescribing

When attempting to deprescribe an AP, consider using the seven steps outlined in Chapter 7 while paying
particular attention to (1) person-centered care and outcomes, (2) shared decision-making and informed
consent, (3) family involvement and other psychosocial interventions in psychosis, and (4) interactions
with physical health and wellness. Again, the more common goal of a deprescribing intervention may be
ensuring a minimum effective regimen rather than complete cessation of pharmacotherapy. As with other
conditions and medications, the patient and their immediate circle of support are critical to the success of
deprescribing through early identification of symptoms and establishing a range of nonpharmacologic
coping strategies to mitigate the risk of relapse. However, due to the social aspects of chronic psychotic
disorders like schizophrenia, baseline social functioning and resources may be more limited and further
bolstering required.
Although the reemergence of positive psychotic symptoms may constitute an emergency for some
patients, others may be quite willing and able to accept and cope with such an emergence as long as
functional gains are maintained. A patient with schizophrenia, within the shared decision-making model
and given adequate informed consent, should be allowed to embark upon an intervention that carries an
increased risk of symptoms, distress and possibly hospitalization. The issues of capacity around such
decisions may be more pertinent in psychotic disorders where symptoms such as psychotic ambivalence
and reality distortion can, at times and for some, impact the decision-making process. The use of
psychiatric advanced directives, more longitudinal assessment and decision-making processes, and the
involvement of trusted supports and surrogate decision-makers may help. For prescribers, the ethical
consideration here may warrant peer consultation and a second opinion. A particularly useful tool when
deprescribing in serious mental illnesses is a Wellness Recovery Action Plan (WRAP; Copeland, 1997)
which assists a person in identifying daily wellness strategies as well as early warning signs of relapse
and crisis planning. WRAP empowers a person to self-monitor and intervene or seek help early if
possible—however, it is noted that a “hypervigilance” to such signs of relapse can emerge.
Specific interventions might be employed to target factors such as substance use (e.g., cannabis),
environmental stress, and expressed emotion that predict relapse. Cooccuring substance use is one of the
strongest predictors of relapse in chronic psychotic disorders (Swofford, Kasckow et al., 1996) and its
treatment is critical for relapse prevention in schizophrenia. Naltrexone or disulfiram (Petrakis, Nich et
al., 2006; Petrakis et al., 2006) and motivation interviewing, cognitive behavior therapy (CBT), or family
interventions (Barrowclough, Haddock et al., 2001; Drake, O’Neal et al., 2008; Barrowclough et al.,
2001; Drake et al., 2008) have some evidence base. Psychotherapy such as CBT can ameliorate early
symptoms accompanying a relapse such as insomnia. anxiety, or depression. As for features of psychosis
itself, although a range of adjunctive psycho-social strategies have varied degrees of evidence (e.g.
CBPp), none can be considered as standalone treatments or adequate replacement for a multi-faceted care
plan including APs. Falloon (1982; Falloon, Boyd et al., 1982) showed that family therapy provided
some addition benefit at preventing relapse over a period of months. Similarly, Hogarty (1991)
demonstrated that both family psychoeducation and individual social skills training helped reduce relapse
over medications alone. The effect of family psychoeducation persisted for 2 years.
Open Dialogue (a progressive approach to crisis intervention and initial care of young people
experiencing psychosis) engages the individual, family, and other key supports in open discussions about
all aspects of the clinical situation and decision-making. Although the evidence base remains extremely
limited, this approach has been reported to provide good clinical outcomes, reduced medication
utilization, and higher satisfaction with care (Gordon, Gidugu et al., 2016) and warrants further study.
Table 9.4 summarizes psycho-social adjunctive interventions with some degree of evidence of benefit in
schizophrenia. None of these interventions has been tested against APs in head-to-head clinical trials, and
each has been trialed only in patients who were already stabilized with medications. While we suggest
using these interventions to support a process of deprescribing, they cannot replace and may infact require
to concomittent use of APs for optimal effects.

Table 9.4 Nonpharmacological Interventions with potential benefit as adjuncts to APs for functional
outcomes in schizophrenia
Type of intervention Level of evidence Reference
Cognitive behavior therapy Meta-analysis (Pilling, Bebbington et al., 2002)
Family therapy Meta-analysis (Pilling, Bebbington et al., 2002)
Cognitive remediation Controlled trials (McGurk, Twamley et al., 2007)
Psychoeducation Meta-analysis (McFarlane, Dixon et al., 2003)
Open dialogue Narrative reports (Seikkula 2001)
Hearing voices networks Narrative reports (Corstens, Longden et al., 2014)

There are limited, conflicting guidelines for AP discontinuation. A review of studies comparing the
rates of relapse with a slow versus rapid medication taper reported benefits for slow tapers (Viguera,
Baldessarini et al., 1997). However, this finding was not replicated by a more recent systematic review
and meta-analysis that concluded no difference in relapse rates between slow versus rapid tapers
(Takeuchi, Kantor et al., 2017). A significant methodological limitation of these studies, potentially
addressable by future effectiveness studies of deprescribing, was that AP tapers were not individualized.
Although, schedules may vary (being shorter or longer in response to specific patient and contextual
factors) a reasonable starting point for duration of AP taper is 6 months. Canadian colleagues in primary
care have published recommendations to deprescribe APs after 3 months when used for behavioral and
psychological symptoms of dementia (this indication carries a “black box” warning in the United States)
and for insomnia after any duration (Bjerre et al., 2018). This is accompanied by some guidelines for how
to deprescribe APs in this context (among other resources; publicly available at deprescribing.org at time
of writing). These authors suggest a 25–50% dose reduction every 1–2 weeks for the former indication
and immediate discontinuation for insomnia. A distinction is carefully and very appropriately made,
however, that these guidelines are not intended for AP deprescribing in the treatment of psychotic
disorders. The methodology these authors employed to create the guideline may be useful as this field
advances (see Bjerre et al., 2018).
 Conclusion
Psychotic disorders, despite some diagnostic uncertainty early in their course, emerge as schizophrenia in
approximately 1% of the world’s population and cause profound subjective distress and chronic
deleterious effects on function, with wide-ranging and significant impact on public health. Given such
high stakes surrounding treatment decisions involving psychotic disorders, the question of deprescribing
is contentious, and we look with urgency to a clinical literature that cannot yet provide clear guidance.
Despite some more robust pockets of evidence and lines of inquiry, there remains overall uncertainty
around the optimal management of psychotic disorders and the parsing out of encompassed syndromes.
The clinical literature is notably limited in guiding recommendations for the duration of AP use and the
proactive identification of individuals who might benefit from deprescribing. Caution should be used
when attempting to generalize findings from more heterogenous first-episode psychosis cohorts to more
chronic groups and vice versa. Similarly, the results of large retrospective, observational studies should
be considered within the inferential limitations (of cause vs. association) inherent in their methodology.
Some of these knowledge gaps may be addressed by increased interest in, and funding of, research on AP
deprescribing studies, perhaps employing structured, multidimensional interventions in contrast to
existing discontinuation studies. We acknowledge that this may necessitate novel research methodologies
that account for the complexity of the intervention, greater pragmatism of study design and increased focus
on patient-centered outcomes. Furthermore, new mechanisms of funding this research may need to be
incentivized. When seeking US Food and Drug (FDA) indications, pharmaceutical companies might offer
to conduct research and share data and guidelines on how to optimally discontinue (in addition to
initiating) a new medication. In the meantime, providers and patients continue to gain clinical and lived
experience, respectively, to share in their immediate circles and hopefully beyond.

Case Examples

Case Example 1
Graham’s prescriber raises a question around the pros and cons of continuing clozapine, to which Graham
agrees to a deprescribing trial. The patient chooses to include his primary clinician (who he meets with
weekly), who is initially reluctant to endorse the idea, citing his last inpatient hospitalization 5 years ago
when he self-presented with distress around egodystonic command auditory hallucinations to harm others.
Nevertheless, considering the uncertainty around the adequacy of past medication trials, potential gains of
reduced metabolic side effects and improved related function, collaboration around a structured
deprescribing plan (including WRAP) and continued contact with his weekly clozapine group (with
whom he has grown very attached), all stakeholders agree to gradually taper the clozapine over 9 months.
He remains on the haloperidol 10mg qhs with a provisional agreement to optimize this, in the next
instance, if necessary.
Graham begins to steadily lose weight, giving him a newfound enthusiasm for attending the gym and
making other lifestyle modifications, leading to further improvements in his cardiovascular risk factors.
Although the frequency of his voices have not increased, at month 5, Graham reports increased distress
and difficulty employing his established coping strategies, accompanied by insomnia. A short-term
hypnotic is prescribed, and he gains the motivation to attend a Hearing Voices Network meeting (which
was previously recommended by a peer and on his deprescribing plan as a potential future self-initiated
wellness strategies). At month 7, Graham becomes more internally preoccupied and reports increasing
paranoia. At 100 mg total daily clozapine and a serum level less than 150, Graham and his prescriber
agree to implement the backup plan to optimize the less metabolically impactful haloperidol (while
continuing the planned clozapine taper). Graham agrees to the convenience of a once-a-month haloperidol
decanoate depot injection and finally discloses to his prescriber that had actually only been taking his
haloperidol tablets intermittently, as needed for sleep. Graham in fact completes the clozapine
deprescribing as planned at 9 months; however, the original plan has been adjusted to include attendance
of Hearing Voices Network meetings and the addition of intramuscular haloperidol decanoate 100 mg
monthly, which he tolerates well (Table 9.5).

Table 9.5 Decision making grid for case 1

Decision-making grid
Risks Benefits
Continuing clozapine Weight gain Unclear/Due to poor documentation, the need for clozapine was not clearly
established
Deprescribing Relapse and Reduced side effects, more investment in non-pharmacological interventions
clozapine rehospitalization
Patient values/preference: Patient wishes to reduce and stop clozapine
Plan: Psychoeducation, WRAP, CBT, involvement of any significant others, replacement of clozapine with a medication with a more
acceptable side-effect profile; short-term management of symptoms such as insomnia
Interventions: Deprescribe clozapine and replace with haloperidol; WRAP;

Case Example 2
Jane is a 37-year-old woman who was initially prescribed haloperidol 5 mg along with an antidepressant
because she was paranoid about people at work staring at her and talking about her. She has never been
hospitalized. She still has similar thoughts occasionally but is able to dismiss them. She tells her doctor
that she has been well for 2 years and does not want to take medications anymore.
Jane presumably developed persecutory delusions in the context of a depressive episode. In this case,
it is appropriate to attempt deprescribing the AP after the depressive episode has subsided (Table 9.6).

Table 9.6 Decision-making grid for case 2

Decision-making grid
Risks Benefits
Continuing haloperidol Long-term side effects including tardive Lesser risk of reappearance of paranoia
dyskinesia
Deprescribing Reappearance of paranoia Development of non-pharmacological strategies Patient
haloperidol preference
Patient values/preference: Patient wishes to reduce and stop haloperidol
Plan: Psychoeducation, WRAP, CBT, involvement of any significant others
Interventions: Deprescribe haloperidol

Case Example 3
Tom is a 36-year-old man who carries a diagnosis of schizophrenia but has limited insight. He is
prescribed risperidone 4 mg at bedtime, but unbeknownst to his prescriber he only takes it approximately
3–4 times a week. He also smokes daily marijuana and asserts that he doesn’t really need the risperidone
because the marijuana helps with his anxiety (driven by positive symptoms) much better. Tom also asked
about a class action law suit advertised on TV in relation to potential side effects from this medication a
month ago. His records reflect that he has not had any hospitalizations related to psychosis since he
started taking the AP. Tom presents to the office more agitated than before and demands to stop the
risperidone, he demonstrates no positive symptoms or imminent risk.
Tom demonstrates little in the way of buy-in or perceived benefit from risperidone. He admits to
having been taking a lesser than prescribed dose and may infact have self-discontinued the medication
already. The prescriber suspects that recommending Tom continue the risperidone is unlikely to yield
positive results. Instead she maintains a stance of exploration and curiosity to ensure that Tom continues
to be engaged. Psychoeducation around the risks of abrupt discontinuation is provided and Tom accepts a
gradual taper instead alongside reduction in his marijuana use. By completing the deprescribing
worksheet together, it becomes clear that sexual side effects were a big issue for Tom and aripiprazole is
agreed upon as an alternative strategy for early warning symptoms (Tom identifies that paranoia drives
his anxiety). 2 months pass without AP prescription until Tom calls his prescriber to request initiation of
aripiprazole in response to growing paranoia (Table 9.7).

Table 9.7 Decision making grid for case 3

Decision-making grid
Risks Benefits
Continuing risperidone Long-term side effects, Tom doesn’t want to take it Prevention of rehospitalization
Deprescribing risperidone Risk of relapse and rehospitalization Patient preference
Patient values/preference: Patient wants to stop risperidone
Plan: Continue psychoeducation, further discussion to reach a decision that both doctor and patient can agree on
Interventions: Psychoeducation, exploration of why he wants to stop the medication

Self-Assessment
1. Amy has taken haloperidol 10 mg twice a day for more than 30 years. She has severe tardive dyskinesia (TD) and stays
home all the time because she is so embarrassed about the involuntary movements. She is asking if reducing the dose of
haloperidol will help with the movements. She and you decide to go ahead with reducing the haloperidol. When Amy’s older
son hears about this, he leaves a very angry message on your phone, threatening to sue you for reducing the haloperidol.

a. What will your next steps be?

b. How will you approach the threat of legal consequences?
c. Do you think that a reduction in dose may cause an improvement in the TD?

2. Ben is a 40-year-old man who has taken quetiapine and lithium for 3 years, following a severe manic episode in which he lost
his entire life savings. He is single and wants to find a partner but won’t try because he is ashamed of his weight. He is also
concerned about his inability to perform sexually. When you bring up the possibility of reducing quetiapine, he immediately
refuses.

a. How do you understand Ben’s reaction?

b. How will you approach his fear of relapse?
c. If Ben declines to reduce the quetiapine, what will your next steps be?

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 10
Deprescribing Mood Stabilizers
In this chapter, we present specific context, considerations and clinical decision-making relevant to
deprescribing mood stabilizers, particularly in the treatment of bipolar disorder. We apply the same
caveats found in the introduction to chapter 8 and trust the reader will consider the discussion through
their own critical lens of knowledge, experience and expertise. Again, deprescribing interventions in this
class will include the pursuit of minimum effective dosing as well as complete discontinuation when
appropriate. Issues of shared decision making and informed consent are again pertinent when dealing with
vulnerable populations such as those experiencing serious mental illnesses. Some distinguishing
challenges of deprescribing for bipolar disorder are addressed, along with specific adjunctive strategies.

Goals and Learning Objectives

After reading this chapter, the reader will be able to:
1. Describe three scenarios where deprescribing of mood stabilizers may be appropriate
2. List the particular considerations when deprescribing lithium (in correctly diagnosed bipolar disorder) and how the risks may be mitigated
3. Complete a formal risk–benefit analysis for deprescribing a mood stabilizer in a given patient

Case Example
Jane is a 36-year-old woman who was diagnosed as having schizoaffective disorder in her early 20s. She
suffered from what she described as “anger attacks” and mood swings with premenstrual worsening. She
was first hospitalized at age 21 with a mixed affective episode during which she heard voices telling her
to kill herself. This occurred following the death of a beloved childhood pet. She often hears her name
called when “stressed out”, however full positive symptoms have only fleetingly presented at the
extremes of her mood episodes. She has been in individual therapy and has consistently taken
carbamazepine for more than a decade with intermittent use of risperidone. She estimates that she takes
about a third of the prescribed risperidone standing bedtime doses, and only when she notices her
thoughts racing and “spiraling” and her mood being more irritable. She says that she has gained a better
understanding of her mood fluctuations over the years and how to manage them by adjusting her work
schedule or soliciting help from her significant other. She wishes to stop taking all medications.
Historically, the most significant improvement in symptom management occurred when she moved out of
her parents’ home 2 years ago.
Arguably Jane, warrants a re-formulation and possible ‘undiagnosing’ intervention before exploring a
deprescribing intervention. It is unlikely that she suffers from a primary psychotic disorder given only
spotty psychotic, and more prominent affective, symptoms. Furthermore, the improvement with therapy
and altering her social environment demonstrates a significant interpersonal and psychological component
to her condition. Jane is well supported by her significant other and her therapist, and is a candidate for
deprescribing carbamazepine. She agrees however around continuing the risperidone as needed. The dose
of as-needed risperidone is lowered as the carbamazepine is stopped (due to loss of enzyme induction;
see Table 10.1). In the course of an increased non-pharmacological focus during medication visits, Jane
eventually discloses to her prescriber that she suffered chronic sexual abuse as a child.
Table 10.1 Commonly prescribed mood stabilizers
Medication Common indications
Lithium Bipolar spectrum disorders
Lamotrigine Mood instability in personality disorders
Divalproex Schizoaffective disorder
Carbamazepine Augmentation in depressive disorders Schizophrenia

Potential Factors Contributing to the Extended Use of Mood Stabilizers

Deprescribing of mood stabilizers may involve a careful review of history and diagnosis before a
reestimation of the risk/benefit calculation. Limitations surrounding clinical documentation, retrospective
report, high rates of cooccuring substance use and lack of diagnostic tests can thwart the retrospective
confirmation of a diagnosis of bipolar disorder. While the effectiveness of mood stabilizers is well-
established in correctly diagnosed bipolar disorder, there is perhaps less certain evidence for their use in
schizoaffective disorder, in the augmentation of antipsychotic and antidepressant regimens, and in control
of mood lability in the context of personality traits or disorders. Mood stabilizers as augmenting agents
(especially lithium for major depressive disorder and valproate for psychotic disorders) have no
recommendation for the duration of use in these cases. Patients may continue to take these agents
indefinitely and without any clear indication because the only way to establish their ongoing need is by
evaluating how a patient does without them. Some critics question an ‘overdiagnosis’ of bipolar disorder
which emerged in the 1990s (in turn increasing the risk of over prescription of mood stabilizers).
Substance-induced mood disorders, affective instability and impulsivity in personality disorders, and the
expansion of the “bipolar spectrum” of disorders are some of the potential driving factors (see Ghouse,
Sanches, Zunta-Soares, Swann, & Soares, 2013; Zimmerman, Ruggero, Chelminski, & Young, 2008).
In bipolar disorder, the use of combinations of mood stabilizers has become increasingly common and
is recommended by some standard guidelines, in particular those by the American Psychiatric Association
(APA, 2006). Mood stabilizers may be prescribed in combination with second-generation antipsychotic
medications, which are themselves used as mood stabilizers. In both these situations, the duration of need
for combination treatments is uncertain.
Balancing the high risk of mortality and morbidity inherent in untreated bipolar disorder, the commonly
prescribed mood stablizers, lithium and divalproex for example, are known to carry risk of potentially
serious and persisting neurological, renal, and hepatic side effects. In patients with medical comorbidities
that affect renal or hepatic function (e.g. diabetes, hypertension, chronic hepatitis due to various
etiologies), these medications may need to be adjusted or eventually discontinued due to evolving
medical factors. Several common mood stabilizers (lithium, divalproex and carbamazepine) have routine
bloodwork monitoring including drug levels built into the accepted guidelines. The prescriber therefore
has the tools and imperative to remain vigilant for changes where a reduction and or discontinuation of
mood stabilizers may be warranted or unavoidable.

Lithium

Lithium has established efficacy in preventing relapses of (particularly euphoric) mania in bipolar
disorder although its efficacy in preventing bipolar depressive episodes is equivocal (see Geddes,
Burgess, Hawton, Jamison, & Goodwin, 2004). Although lithium is used to augment antidepressant
treatment of unipolar major depression (Bauer & Döpfmer, 1999), guidelines for the duration of use and
expected consequences of discontinuation in this scenario have not been as thoroughly explored for this
indication.

Antiepileptic Agents

Coincident with the construction of the expanded ‘bipolar spectrum’ of disorders and the kindling theory
of recurrence, the use of divalproex (introduced in 1995) and lamotrigine (introduced in 1994) exploded
(see Akiskal et al., 2000). Both these medications began to be used for the treatment of bipolar disorder,
especially type II, either singly, in combination, or in combination with lithium. Divalproex is used for the
rapid control of agitation which may stem from a range of etiologies on inpatient psychiatric units (see
Deltito, Levitan, Damore, Hajal, & Zambenedetti, 1998). Divalproex does not require the same slow
titration to an effective dose as lamotrigine, it acts faster than lithium, and hence it is often preferred in
acute settings. Divalproex may offer addition appeal when added to neuroleptic agents to augment their
acute tranquilizing effect, and to facilitate quick discharge for inpatient units for example. However, the
onus then falls to the outpatient service to re-evaluate (or perhaps decipher) the original indication for the
use of divalproex, making it a potential target for deprescribing. A related scenario occurs when a patient
experiencing a psychotic episode is prematurely discharged from an inpatient service as the sedation
induced by divalproex makes them appear calmer. The underlying psychotic symptoms remain
inadequately treated, and when divalproex is then deprescribed on the outpatient service, a florid
underlying psychosis may emerge. This scenario highlights the need for careful consideration, timing and
planning of a deprescribing even in the face of the most compelling of indications.
Divalproex, lamotrigine, topiramate, zonisamide, and gabapentin are being used increasingly for the
management of alcohol withdrawal (in lieu of benzodiazepines) as well as alcohol use disorders (see
Hammond, Niciu, Drew, & Arias, 2015). For alcohol withdrawal, it is intuitive that the medication be
tapered off after the risk for withdrawal-related seizures has passed. Unfortunately this literature does not
yet specify clear, evidence-based guidelines for duration of treatment.

Lithium Discontinuation Syndromes

There is an extensive literature on relapses, both manic and depressive, precipitated by withdrawal of
lithium. For example, as early as 1970, Baastrup and colleagues (1970) noted that both bipolar patients
and patients with ‘endogenous depression’ relapsed following lithium discontinuation. Symptoms of
lithium discontinuation typically include physical symptoms such as tremor, polyuria, muscular weakness,
polydipsia, and dryness of mouth. However, reported psychiatric relapses (within 4 days of lithium
discontinuation), supports the possibility of a rebound phenomenon (see Christodoulou & Lykouras,
1982). A review of 10 studies of lithium discontinuation in bipolar disorder concluded that lithium
discontinuation “increased the risk of recurrence which may exceed that predicted by the course of the
preceding untreated bipolar disorder” (Suppes, Baldessarini, Faedda, & Tohen, 1991). A systematic
review and meta-analysis concluded that the odds ratio for a recurrence following an interruption in
lithium treatment was 1.4 compared to continuous treatment (Vries et al., 2013). Studies have also
identified increased daytime motor activity (Klein, Lavie, Meiraz, Sadeh, & Lenox, 1992) and changes in
the sleep–wake cycle (Klein, Mairaz, Pascal, Hefez, & Lavie, 1991) as early signs of relapse following
lithium discontinuation. Even patients who did not relapse experienced anxiety, nervousness, increased
irritability, alertness, sleep disturbances, and occasionally an elated mood beginning several days after
lithium discontinuation and lasting 1–2 weeks (Klein et al., 1991). When lithium is used as an augmenting
agent in major depression, one study found that, in older individuals with major depression, abrupt
cessation of lithium could precipitate a depressive relapse (Fahy & Lawlor, 2001). This was followed by
a systematic review of three articles that reached a similar conclusion (Ross, 2008).
Reports like these provide sufficient doubt to question whether the relapses following lithium
discontinuation are a recurrence of the underlying illness or a withdrawal phenomenon. As the definitive
mechanism of action of lithium remains unknown, any theories about the neurobiological basis of lithium
withdrawal are speculative. Dopamine supersensitivity, cellular transport, and membrane changes are
some putative mechanisms and have been demonstrated in small animal studies (see Balon, Yeragani,
Pohl, & Gershon, 1988). Another reported concern surrounding lithium discontinuation is that when
restarted for a given patient, lithium would cease to be as effective as it had originally been—a
mechanism for this has not been established.
It is therefore warranted to determine if the risk of relapse following lithium discontinuation can be
mitigated by slowing the rate of taper. Interestingly, studies found that the early risk as well as the overall
5-year risk of recurrence was lower following gradual discontinuation (e.g. over 2–4 weeks) as
compared to rapid taper (e.g. less than 2 weeks; see Faedda, Tondo, Baldessarini, Suppes, & Tohen,
1993, Baldessarini et al., 1996; Baldessarini, Tondo, Floris, & Rudas, 1997).

Some Considerations when Deprescribing Mood Stabilizers

The deprescribing of antiepileptic drugs (AEDs) prescribed for psychiatric indications has not yet been
studied systematically. The only literature currently available is from discontinuation studies conducted in
patients with epilepsy (using seizure recurrences as the main outcome, and not commenting on mood
disturbances or sleep for example). A literature review of AED discontinuation in patients with epilepsy
(Vernachio, Lovett, & Williams, 2015) states that tapering schedules varied widely (ranging from 4 days
to 4 years) and that although there was a general agreement that AED discontinuation needed to be
considered, there was no consensus on which patients for whom it would be indicated. A single case
report describes a manic episode precipitated by carbamazepine withdrawal in a woman with epilepsy
(Scull & Trimble, 1995).
The process of deprecribing (as with prescribing) involves careful consideration of drug-drug
interactions and consultation with pharmacy as needed. One example is the loss of CP450 enzyme
induction when deprescribing. A case report describes the development of parkinsonian symptoms after
discontinuation of carbamazepine in a patient who was taking a combination of risperidone and
carbamazepine (see Takahashi, Yoshida, Higuchi, & Shimizu, 2001). Monitoring for emergence of
extrapyramidal symptoms has been recommended when carbamazepine is discontinued in patients who
are taking concomitant antipsychotic medications that are a CYP3A4 substrate (Strack, Leckband, &
Meyer, 2009). A review of AED discontinuation in patients with epilepsy cites several case reports of
withdrawal symptoms such as akathisia, agitation, nausea, insomnia, abdominal pain, and anxiety
following the abrupt withdrawal of high doses of gabapentin (see Vernachio et al., 2015).

Non-pharmacological Strategies to Support Deprescribing of Mood Stabilizers

So far, psychotherapeutic interventions have been relegated to adjunctive treatments in bipolar disorder,
and there are very few data to support the use of such interventions as the primary modality of treatment.
A review of psychotherapeutic interventions in bipolar disorder found that adjunctive family therapy,
interpersonal therapy, and systematic care improved outcomes immediately in an acute episode, whereas
cognitive behavior therapy (CBT) and group psychoeducation were more effective in improving
functioning and reducing rates of relapse (Miklowitz, 2008). Psychoeducation, CBT, interpersonal and
social rhythms therapy, and family interventions are commonly tested treatments both in short- and long-
term studies, are feasible for patients with more complex bipolar disorder (see Reinares, Sánchez-
Moreno, & Fountoulakis, 2014).
One small, but illuminating, qualitative study describes the decision-making surrounding mood
stabilizers and the strategies that patients use to keep themselves well without medications. The authors
developed a model in the form of a sequential process that is influenced by the concept of “ideas about
myself and my moods.” Strategies were highly individual and ranged from “taking time off work” to
“lighting scented oils” for example (see Cappleman, Smith, & Lobban, 2015). Further strategies and ideas
for additional non-pharmacological strategies are described in Chapters 5 and 6.

Conclusion
The predominant literature available to guide the pharmacological aspects of deprescribing mood
stabilizers in psychiatry comes from lithium discontinuation studies conducted between 1970 and 1990
and points to the possible existence of a lithium withdrawal syndrome that may be independent of
recurrence of the underlying bipolar disorder. No guidelines and limited studies are currently available to
inform the safe withdrawal of AEDs when used as mood stabilizers.

Case Examples

Case Example 1
Joe, a 30-year-old man has been taking aripiprazole 20 mg/d along with divalproex ER 1,500 mg at night
for the past 4 months. These medications were prescribed at his first hospitalization, in which he believed
with delusional intensity that he was a famous actor and was irritable and angry. He quickly returned to
his usual state of health and experiences no side effects except for some daytime sleepiness. He tolerates
the sedation, and has returned to work.
The current formulation is that Joe experienced a first episode of psychosis (with mania-like features)
that could differentiate into either primary bipolar disorder or schizophrenia. In either case, aripiprazole
was indicated to treat the episode and might provide some prophylaxis of further episodes (affective or
psychotic) . There is currently unclear indication for or benefit from continuation of divalproex. Even if a
clear indication such as the need for augmentation of aripiprazole was identifiable, there is no guideline
for how long divalproex should be continued as an augmenting agent. As Joe is not actively inquiring
about deprescribing, a first step in this case would be to opening explain the risks and benefits of
continued divalproex and obtain his opinion (see Table 10.2). With this initial discussion in place, there
may be no urgency to make a change in the regimen.

Table 10.2 Example Decision-making grid for case 2

Decision-making grid
Risks Benefits
Continuing lithium Nephrotoxicity Neurotoxicity Prevention of manic and depressive episodes
Deprescribing lithium Mania or depression Suicidality Possible treatment refractoriness Removes long-term risks of lithium
Patient values/preference: Patient has expressed an interest in discontinuing lithium
Plan: Explore reasons for enquiring about discontinuation; discuss risks and benefits of stopping lithium; provide alternate medication
strategies
Intervention: Switch to another medication; offer psychoeducation on early identification of relapse; develop a plan for management of
suicidality if it emerges during lithium discontinuation; slow taper of lithium; plan for resumption of lithium if needed

Case Example 2
Jack, a 45-year-old man has been taking lithium for more than 15 years for a diagnosis of bipolar 1
disorder. It was started when he was hospitalized for a manic episode in his late 20s. Since then, he has
had brief periods of hypomania and two depressive episodes, but none warranting hospitalization. He
experiences no side effects other than a fine hand tremor. He states, “I have done my time” and is asking
for your opinion on discontinuing lithium.
Guidelines dictate that lithium should be continued indefinitely, especially since there is demonstrable
benefit. However, if the patient is asking about discontinuation, this should be addressed by exploring the
reason for the inquiry. If it is due to side effects, this may be resolved by dose adjustments or other
strategies. If he wishes to begin a trial without lithium, it will need to be tapered slowly with supervision
and support from the care team to minimize chances of relapse (and missed opportunity for alternative
wellness strategies) that might occur if he initiates a discontinuation on his own.
The prescriber may find themself pulled in two opposite directions in this scenario—a duty to follow
standard professional guidelines, thereby reducing the perceived risk of relapse, and another: to respect
the patient’s autonomy and perhaps even “right to fail.” The prescriber must remember that this tension is
never fully resolved, whatever action they eventually recommend. Rather than resolution, the prescriber’s
responsibility in such a situation is to build tolerance for this tension, perhaps even to maintain it as they
work with the patient. They must also have honest discussions with the patient about justified concerns
regarding relapse and respect for the patient’s autonomy. This will hopefully reduce the chances that Jack
will abruptly discontinue lithium without telling the prescriber and will foster the therapeutic alliance. At
the same time, it is important to acknowledge that Jack may very well relapse even while continuing to
take lithium and that it may not be the only factor in his life that is preventing a relapse (see Table 10.3).

Table 10.3 Example Decision-making grid for case 2

Decision-making grid
Risks Benefits
Continuing lithium Nephrotoxicity Neurotoxicity Prevention of manic and depressive episodes
Deprescribing lithium Mania or depression Suicidality Possible treatment refractoriness Removes long-term risks of lithium
Patient values/preference: Patient has expressed an interest in discontinuing lithium
Plan: Explore reasons for enquiring about discontinuation; discuss risks and benefits of stopping lithium; provide alternate medication
strategies
Intervention: Switch to another medication; offer psychoeducation on early identification of relapse; develop a plan for management of
suicidality if it emerges during lithium discontinuation; slow taper of lithium; plan for resumption of lithium if needed

Case Example 3
Hamid is a 65-year-old man who was diagnosed with bipolar disorder in his early 20s. He has taken
lithium since then and has had three admissions for manic episodes and persistent low-grade depressive
symptoms thereafter. Quetiapine was added at a recent admission. He however experience an episode of
lithium toxicity soon after, ending up in the ICU. He says “this medication very nearly killed me. I am
never going to take it again.” See Table 10.4. The challenge here is to first acknowledge and process the
potentially traumatic event before attempting to engage around a more balanced weighing of risks and
benefits of the medication regimen. Buy-in may be able to build around the quetiapine as an alternative
mood stabilizer.
Table 10.4 Example Decision-making grid for case 3
Decision-making grid
Risks Benefits
Continuing lithium Long-term side effects such as nephrotoxicity Prevention of future episodes of mania or depression
Deprescribing lithium Recurrence of episodes Removes long-term risks Hamid refuses to take lithium anymore
Patient values/preference: Patient wants to discontinue lithium
Plan: Further discussion about risks and benefits with Hamid. If he continues to reduce lithium, plan on increasing quetiapine to the dose of
a primary mood stabilizer
Intervention: Offer psychoeducation on early identification of relapse; develop a plan for management of suicidality if it emerges during
lithium discontinuation; slow taper of lithium; plan for resumption of lithium if needed

Self-Assessment
1. Prakash is 25-year-old-man who has taken lithium since he was 16. He says that because he doesn’t use drugs anymore, he
doesn’t need to take lithium and is asking for your help to stop it.

a. How will you approach Prakash’s request?

b. What are your fears about reducing the lithium?
c. What will you recommend to minimize the risk of recurrence?

2. Jane is a 30-year-old woman who was prescribed divalproex on the inpatient service, where she was admitted for severe
depression and anxiety. She says it helps her sleep but has caused marked hair loss. She refuses to take it anymore.

a. What might be the indications for prescribing divalproex in this case?

b. What are your concerns in deprescribing divalproex in this case?
c. How will you allay your own concerns if you help Jane reduce divalproex?

3. Maritza is a 45-year-old woman admitted for treatment of alcohol withdrawal. She is detoxed from alcohol using gabapentin
and discharged on a dose of 800 mg three times a day. Four weeks later during a follow-up, she says she is sleepy and
gaining weight but doesn’t feel like drinking as much as before. She is asking for your opinion about the gabapentin.

a. What would you suggest to Maritza in this case?

b. What would be your concerns in continuing gabapentin?
c. What would be your concerns in deprescribing gabapentin?

References
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composition within the broad clinical spectrum of bipolar disorders. Journal of Affective Disorders, 59, S5–S30.
APA. (2006). American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2006.
Washington, DC: American Psychiatric Publishers.
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 11
Deprescribing Benzodiazepines, Z-Drugs, and Stimulants
This chapter frames challenges and discusses strategies for deprescribing medications that may exhibit
habit forming/rewarding properties, and hence additional investment in continuing or difficulty
discontinuing may exist for the patient. Medications that we will be discussing include BZDs, the z-drugs
(zolpidem, zopiclone, eszopiclone, and zaleplon), and stimulant medications used to treat attention deficit
hyperactivity disorder (ADHD) such as methylphenidate (e.g. Ritalin), methylphenidate extended release
(e.g. Concerta), dexmethylphenidate (e.g. Focalin), mixed amphetamine salts (e.g. Adderall), and
lisdexamphetamine (e.g. Vyvanse). The same issues of shared decision making and informed consent are
particularly pertinent here for example in scenarios where these medication are prescribed in the context
of polypharmacy for individuals with serious mental illness or more mild forms, who push the prescribing
relationship towards consumerism. Despite these challenges it is important to consider and discuss the
deprescribing of these medications due to their long-term risks, including tolerance and dependence.
Particular to this chapter, the prescriber may find themselves in a position of disagreement with the
patient, for example—asserting a need for deprescribing in the face of a request to refill or even up-
titrate. As these drugs can have varying degrees of addiction potential, we reference some strategies that
are used primarily in the treatment of substance use disorders. We suggest that such strategies and
interventions may be adapted when deprescribing these medications—as long as the treater remains
mindful of potential harm and monitors intended outcomes. Rigorous trials are warranted to validate this
approach. In this chapter we focus on the management of the medication regimen and the original
indication for the prescription. We do not dwell on the co-occurring substance use disorders (when
present in the case examples) as the treatment of addictions per se is beyond the scope of this book and
well-covered elsewhere. Throughout this chapter, we also subscribe to a “harm-reduction” approach,
now widely accepted in the treatment of addictions.

Goals and Learning Objectives

After reading this chapter, the reader will be able to:
1. Name three pharmacological management strategies for prescription benzodiazepine (BZD) dependence
2. Describe some the common reasons for deprescribing stimulants
3. Outline three strategies for deprescribing stimulants

Case Example
Jason is a 40-year-old man who has severe social anxiety disorder and alcohol use disorder. He stays
home all day watching TV and drinks 5–6 beers every night. He has also taken clonazepam 1 mg three
times a day for the past 7 years initiated by his now retired primary care provider. His new primary care
provider is concerned about the combination of alcohol and the benzodiazepine (BZD) and suggests
reducing the total daily dose by 0.5 mg. Jason loses his temper, declares he is not “an addict”, and leaves
the office angrily.
This is unfortunately not an uncommon scenario in clinical practice. The prescriber has the unenviable
burden of a clear rationale to deprescribe the BZD due to a risk of dependence and additive effects with
alcohol. The timing, however, is suboptimal. On the next visit, the prescriber suggests a consultation with
a specialist (an addictions psychiatrist) who validates that the clonazepam should be eventually
deprescribed but commits to preventing an abrupt withdrawal. This prescriber also manages to reflect
back and validate the patient’s anger and fear at this proposal as a first step. They next begin to explore
the history and meaning of alcohol use for this patient.

Deprescribing Medication with Abuse Potential or Rewarding Effects: Common

Challenges
This chapter combines a discussion of several medications that share common properties in terms of their
risk of dependence and tendency to be misused. Rewarding effects of medications may be mediated via
classic addiction pathways i.e. mu opioid receptor activation and activation of the nucleus accumbens. In
general the greater rapidity of onset of effects, the greater the liability of reward. The immediate relief of
an adverse emotional state (e.g. alprazolam for a panic attack) can be extremely reinforcing from a
learning theory standpoint. Reduction and/or discontinuation of these medications may involve particular
difficulties, including but not limited to (1) the patient being unwilling to discontinue them; (2) severe
withdrawal symptoms (e.g. seizures and delirium with BZDs); (3) other withdrawal symptoms including
depressive symptoms, persistent anxiety, and insomnia; and (4) an almost immediate reappearance of
symptoms that the medications were initiated for (such as lack of concentration, hyperactivity, anxiety, or
insomnia). These common challenges can be approached in a variety of ways, but there may be increased
risk of emergence of countertransferential reactions (e.g. based on a lack of hope of recovery, or past
breeches in alliance and perceived trust with former patients).
It can be challenging for prescribers to maintain a balanced therapeutic stance when consumeristic
patients request or even demand specific medications with abuse potential in lieu of discussing
reasonable alternatives. These dynamics can similarly present when attempting to deprescribe such
medications—with the added potential of having to simultaneously manage a withdrawal syndrome. Such
patients may intimidate prescribers, eliciting reactions of fear, helplessness, anger, and guilt. These
scenarios can be exceptionally anxiety-provoking for trainees. A useful question to ask when either
patient or prescriber proposes a prescription change is “what are the underlying reasons?” This allows
the prescriber to attempt to understand the manifest and latent content of the decision-making process for
the partnership. When managing potential countertransference, treaters should remain equally aware of the
risk of reaction formation and seek an neutral, balanced stance. Periodically assessing where the
collaboration sits on the continuum of shared decision making (from consumerism to paternalism) is a
useful grounding exercise here. Emotional reactions, for example, evoked by a patient’s demands to
continue or titrate a counter-therapeutic medication are normal, but may also be a worthy focus of peer
supervision or the prescriber’s own therapy.
Similarly, identifying and processing the patient’s feelings in a nonjudgmental fashion may help
maintain the relationship and prevent behaviors unconsciously motivated by negative reactions.
Scratching the surface of the patient’s request also helps the prescriber further develop empathy, which in
turn fosters the maintenance of a therapeutic approach. The prescriber would do well to be aware of the
power struggles and psychological reactance that may emerge when interacting with an assertive patient.
In a situation where a patient demands a BZD or a stimulant, the power balance may feel tilted as each
party tries to exercise its autonomy at the expense of the other. In this setting, patients may feel as if the
prescriber is “holding them hostage” by deliberately refusing medications. Prescribers, in turn, may feel
pressured because their medical knowledge and authority is being challenged.
Closely related to the idea of power struggles is the concept of psychological reactance—the tendency
to deny requests out of hand as a consequence of perceived threats to autonomy. This natural human
tendency can play out unnoticed in prescribing relationships. As mentioned in Chapter 3, the theory of
psychological reactance states that individuals have certain freedoms with regard to their behavior which,
when curtailed or threatened will lead to the individual being motivationally aroused to regain them (see
Brehm, 1966). An example of psychological reactance would be a situation where a patient comes into
the office requesting a prescription for alprazolam during a deprescribing effort of clonazepam. The
prescriber may have an immediate reaction such as, “I am the prescriber here and I decide on which
medication, when and how much. Why are you telling me how to do my job?”. This may be an
uncomfortable reaction to acknowledge because it is counter to the perceived identity of healer and
empathic provider. But in acknowledging this response (which is not to be judged but instead considered
as part of the range of human experience in such a scenario) the prescriber can question their own
reaction and potentially utilize it as data about the relationship with the patient.
When there is clear and persistent disagreement regarding a course of action, getting a second opinion
from another provider may be an option. Shared decision making does not mean that the prescriber will
not be held responsible for unsafe prescriptions, and it is completely acceptable—and indeed, expected
—that the prescriber will refuse to participate in a plan that is unsafe.

Deprescribing Benzodiazepines
BZD and related drugs (z-drugs) are widely used to treat anxiety disorders and insomnia. It has been
established that they can cause tolerance and physiological and psychological dependence as well as
serious side effects and interactions with alcohol and other medications (such as opioids). Some
recommendations advise they be prescribed only for short periods of time (e.g. up to 2–4 weeks, see
Ashton, 2005) due to a risk of dependence (Murphy & Tyrer, 1991), but, in real-world practice, these
drugs are often continued for much longer periods of time.
Long-term use of these medications can have negative effects beyond addiction and dependence
formation. For example the long-term use of BZDs into older adulthood has been shown to be associated
with a higher risk of cognitive decline and dementia (see de Gage et al., 2012; Pariente, de Gage, Moore,
& Bégaud, 2016). The overuse and abuse of prescription BZDs has received increased public health
focus more recently, being considered by some as the next wave of the ‘opioid epidemic’. At the same
time, these medications have largely unrivaled utility in the immediate management of anxiety, making the
dilemma of prescribing and deprescribing more challenging. Although numerous studies can be found to
guide deprescribing BZDs in older adults in either primary care or nursing homes (thanks to the field of
geriatrics), almost no literature exists in more general psychiatric populations.

Potential Indications for Deprescribing BDZs

The recommendation for time-limited use means the initial prescription of a BZD in itself demands an
expectation and plan in place for deprescribing them. There are however other situations where it may be
necessary to help the patient discontinue. Examples include additive or interactive effects of problem
alcohol use, or coincident use of prescription opioids such as methadone maintenance treatment—both of
which significantly increase the risk of respiratory depression and death (see McCance-Katz, Sullivan, &
Nallani, 2010; Tanaka, 2002). BZDs may interact with antihypertensive, antipsychotic, and certain oral
hypoglycemic agents for example, to increase the risk of falls in elderly individuals. Although it may be
appropriate to preemptively deprescribe BZDs to avoid the development of dependence and abuse, the
appearance of any sign of dependence (see Box 11.1) makes the discussion more urgent. On some
occasions, patient may themselves initiate the discussion about deprescribing BZDs out of related
concerns. Prescribers should also consider the potential construct of ‘pseudoaddiction’ where apparent
‘medication seeking’ and behavioral signs of addiction are a manifestation of undertreatment of the
underlying condition (such as an anxiety disorder).
Box 11.1 Possible Features of BDZ Dose Dependence

• Patient has taken benzodiazepenes (BZDs) in prescribed (usually low) doses for months or years.
• Patient has gradually begun to “need” BZDs to carry out normal, day-to-day activities.
• Patient has continued to take BZD although the original indication for prescription has disappeared.
• Patient has difficulty in stopping the drug, or reducing dosage, because of withdrawal symptoms.
• If on short-acting BZDs, they develop anxiety symptoms between doses or get a craving for the next
dose.
• Patient contacts their prescriber regularly to obtain repeat prescriptions and become anxious if the
next prescription is not readily available.
• Patient may have increased the dosage since the original prescription.
• Patient may have anxiety symptoms, panics, agoraphobia, insomnia, depression, and increasing
physical symptoms despite continuing to take BZDs.
From the “Ashton Manual,” C. H. Ashton (2002).

The approach to deprescribing BZDs will depend on whether the patient (1) is using prescribed doses
or overusing; (2) demonstrating features of dependence such as craving, tolerance, withdrawal (3)
demonstrating features of comorbid addiction such as drug-seeking, alternative sources, detrimental
functional impact related to use; or (4) is invested in deprescribing and using non-BZD strategies to
manage withdrawal. To gain a patient perspective, a qualitative study worthy of further reading, analyzed
internet forum discussions of former-BZD users and framed seven themes in the process of recovery from
BZD use: “hell and isolation, anxiety and depression, alienation, physical distress, anger and remorse,
waves and windows, and healing and renewal” (see Fixsen & Ridge, 2017).

Pharmacological Strategies

Tapering Schedules
Most guidelines for BZD discontinuation recommend a taper, the duration of which may range from a few
weeks to a year (see Ashton, 2005). Reminiscent of antidepressants, online forums of former-BZD users
mention strategies such as “micro-tapering,” which may involve tapering doses by as little as 5–10% a
month. These forums also use terminology such as “dry tapers” (referring to the pills being cut or crushed
using a pill-cutter) or “wet tapers” where the pills are dissolved in commercially available water-based
vehicles to dissolve them such as “OraPlus.”. In the context of established diagnosable longterm
benzodiazepine dependence longer tapers (last months) are indicated.

Treating Withdrawal Symptoms

BZDs can cause serious and life-threatening withdrawal symptoms including catatonia, psychosis,
delirium, and seizures (see Mackinnon & Parker, 1982; Schweizer & Rickels, 1998) in addition to intense
short-term anxiety and insomnia. Similar withdrawal symptoms have been reported with zolpidem
(Victorri-Vigneau et al., 2014) and zopiclone (Flynn & Cox, 2006). A protracted BZD withdrawal
syndrome that is proposed by some and reported in up to 10–15% patients is less well-known and studied
(see Ashton, 1995; Higgitt, Fonagy, Toone, & Shine, 1990). This syndrome is purported to last from
months to years and is characterized by persistent anxiety and insomnia due to receptor adaptation, as
well as psychological difficulties (such as poor coping).

Table 11.1 Examples of Commonly prescribed benzodiazepines, z-drugs, and stimulants

Medication class Common medications
Benzodiazepines Alprazolam, clonazepam, lorazepam, diazepam
Z-drugs Zolpidem, zopiclone, eszopiclone, zaleplon
Stimulants Methylphenidate, mixed amphetamine salts, lisdexamphetamine, dexamphetamine

Distressing withdrawal symptoms have been cited as the main reason for relapse to the use of BZDs or
an inability to stop using prescription BZDs; hence, the treatment of withdrawal symptoms is critical to
deprescribing BZDs. The first approach is typically tapering with medications within the same class—
typically those BDZs with longer half lifes such as clonazepam or diazepam. More rapid BDZ self taper
protocols do exist for the acute treatment of alcohol withdrawal (e.g. with chlordiazepoxide) in ER or
IP settings. However, without appropriate provision for continuing multi-dimensional care this arguably
reflects a suboptimal approach. Anticonvulsants such as carbamazepine (Denis, Fatseas, Lavie, &
Auriacombe, 2006) and pregabalin (Bobes et al., 2012) have been used to replace BDZs when managing
withdrawal. However, caution is advised with the use of pregabalin and gabapentin because they can
themselves cause dependence (see Schifano, 2014).
Less acute withdrawal symptoms such as insomnia may be management with alternative hypnotics
(such as low dose trazodone, over the counter sleep aids or melatonin). Anxiety may warrant the use of as
needed hydroxyzine or propranolol or a standing SSRI. Given the broad tranquilizing effects of BDZs,
during deprescribng, prescribers should remain vigilant to the possibility of uncovering a previously
unrecognized psychiatric disorder (such as a mood diathesis or even psychosis), previously masked by
the BDZ. In these scenarios more targeted pharmacotherapy may be necessary.

Psychotherapeutic Interventions

Cognitive behavior therapy for the management of insomnia (CBT-I) and for anxiety, when initiated before
a BZD taper may ease the distress from BZD withdrawal. Both these interventions have been discussed in
greater detail in Chapter 6. In addition to individual therapy, groups and communities of former-users can
prove to be valuable supports during BZD deprescribing.

Community Strategies, Population-Based Interventions and Education

In community-dwelling older adults direct-to-consumer educational interventions such as “EMPOWER”

have been shown to stimulate conversation and shared decision-making around the use of BZDs (see
Tannenbaum, Martin, Tamblyn, Benedetti, & Ahmed, 2014). Public education through advertising
campaigns, community forums, and reading materials about the dangers of long-term BZD use are
warranted to reduce the risk that this class follows the same path as prescription opiates in their
association with the opioid epidemic—a current public health crisis across the US and beyond.

Deprescribing Stimulant Medications

Deprescribing stimulants can be challenging because some effects are desirable and can in fact be
harnessed to enhance performance in the short term, rather than address a deficit (see Bossaer et al.,
2013). Stimulants are an evidenced based and life-changing treatment when prescriber appropriately for
the management of ADHD, ADD and some subtypes of depression. Therefore their therapeutic use should
not carry stigma. Given comorbid substance use disorders are an important factor when considering and
planning any deprescribing, treaters should remain mindful of the high rates of addiction reported in
patients with ADHD. Comorbid ADHD and substance use disorder is not considered an absolute
contraindication to prescribing stimulants.
Unfortunately, some reasons why stimulant medications are desirable to some individuals for non-
clinical use include:

• Immediate-release formulations produce a euphoric effect and an increase in energy and alertness.
• Oral preparations can be modified for more rapid onset (e.g. ground and snorted).
• They can be sold for money or bartered for other drugs, alcohol, or sex.
• Patients may have had prior experiences with them as pediatricians, primary care physicians, and
psychiatrists prescribe them therefore they are prevalent, commonly diverted and perceived to be
safe.
• They can improve performance at work or academics in a relatively short time.

As child psychiatry is beyond of the scope of this book, we will be discussing deprescribing of stimulants
only among adult patients. Stimulant medications are used for the treatment of ADHD in both children and
adults. A study on stimulant prescription patterns from 2006 to 2009 showed that the number of
prescriptions increased by 34% each year, with a disproportionate increase among women and adults
(Zetterqvist, Asherson, Halldner, Långström, & Larsson, 2013). In addition to ADHD, stimulants may be
prescribed for treatment-resistant depression (Stotz, Woggon, & Angst, 1999), in post-stroke depression
to enhance participation in physical therapy (Grade, Redford, Chrostowski, Toussaint, & Blackwell,
1998), as augmentation in geriatric depression (Lavretsky, Park, Siddarth, Kumar, & Reynolds III, 2006;
Lavretsky et al., 2015), and medically in patients for a variety of reasons (Masand & Tesar, 1996). As
with other classes of psychotropic medications, guidelines are provided for the initiation and continuation
of stimulants, regrettably (with the exception of temporary ‘drug holidays’ in ADHD treatment) with
relatively little information on how or when to discontinue them.

Potential Indications for Deprescribing Stimulants

Stimulants can have serious side effects such as increasing heart rate and blood pressure, cardiac events,
loss of appetite and weight, tics, obsessive-compulsive behavior, psychotic symptoms, and mania.
Although side effects may be managed through dose adjustment or by the addition of another medication
(such as a mood stabilizer or an antipsychotic medication) some situations may warrant discontinuation of
the stimulant itself.
As covered above with BZDs, if a patient shows signs of developing misuse/dependence efforts should
be made to prevent or manage this comorbidity. Furthermore, if prescribed medications are being
distributed or sold (“diversion”) or snorted, crushed, and injected intravenously, these are strong grounds
for discontinuation.
When stimulants are prescribed for short-term indications, such as for improvement of participation in
physical therapy following a stroke or for augmentation of Alzheimer’s disease treatment, plans and
expectations for deprescribing should be established at time of initial prescribing.

Stimulant Withdrawal Symptoms

There is a vastly greater literature describing withdrawal syndromes related to stimulant abuse than to
clinical use, suggesting that the former syndrome is more common and significant. Although generally not
considered life threatening (as compared to BDZ withdrawal), severe psychological discomfort is
reported during withdrawal from stimulant (i.e. amphetamine) abuse and can escalate to include
dangerous agitation or severe depression with suicidality. Commonly reported symptoms include:
dysphoria, fatigue, insomnia, hypersomnia, psychomotor agitation, increased appetite, unpleasant dreams,
irritability, aches and pain and social withdrawal.
In terms of withdrawal from appropriate clinical use, two case reports, both in children, have
described the appearance of depressive symptoms—with psychotic features in one case—following the
withdrawal of stimulant medication (methylphenidate and pemoline; see Brown, Borden, Spunt, &
Medenis, 1985; Rosenfeld, 1979). One case report describes the appearance of dystonia during
withdrawal in a man who had used up to 600 mg/d of methylphenidate (Grau-López, Daigre, Mercado,
Casas, & Roncero, 2017).
A small study of abrupt stimulant withdrawal in children with comorbid ADHD and tic disorder
showed that there was no worsening of tics, but the children who continued to take the stimulants did
better on measures of ADHD. The authors concluded that abrupt stimulant withdrawal was not deleterious
but that this “did not preclude the development of withdrawal reactions in susceptible individuals”
(Nolan, Gadow, & Sprafkin, 1999).

Pharmacological Strategies for Managing Deprescribing of Stimulants

A ‘stimulant holiday’ is a construct apparently more established in child than adult psychiatry, where, for
example a child’s ADHD medication is temporary suspended over the weekend or school break when
symptoms may be less problematic. Generally, tapers are not recommended. Withdrawal syndromes from
prescription doses of stimulants have not been heavily features in formal medical literature and there are
no established pharmacological strategies for management. Two randomized controlled trials have shown
the utility of bupropion in the treatment of mild methamphetamine dependence in conjunction with
behavior therapy (see Elkashef et al., 2008; Shoptaw et al., 2008). In adults who have used prescription
stimulants such as mixed amphetamine salts for long periods of time with signs of dependence (and risk of
major depression), it might be reasonable to trial bupropion in the peri-deprescribing period. Bupropion
offers the other potential benefits of treating emergent depression or recurrence of attentional deficits.

Conclusion
BZDs and stimulant medications may be priorities for deprescribing from the prescriber’s point of view
due to concerns about diversion, dependence and abuse; however they may be very desirable to the
patient. Due to these conflicts, it may be especially important to educate the patient about side effects and
maintain a strong alliance while also maintaining clear boundaries around safety. BZDs may have a
prolonged and distressing withdrawal syndrome that can be life-threatening in the acute stages, thus
necessitating a very slow taper that can run into years. Although stimulant withdrawal syndromes are not
well documented in literature, case reports indicate that depressive syndromes can develop during the
withdrawal which may warrant treatment.

Case Examples

Case Example 1
Jen, a 43-year-old woman, was prescribed citalopram and clonazepam to treat a generalized anxiety
disorder that emerged following a divorce. Her anxiety symptoms and sleep improved instantly, and she
continued to go about her daily routine. After 8 weeks, her prescriber suggested discontinuing the
clonazepam because of the risk of dependence. Jen agreed, and the medication was tapered over 4 weeks.
Jen remained asymptomatic until the dose was reduced to 0.5 mg twice a day. Any dose below that
produced severe anxiety. Eight weeks later, the dose was increased again to 1 mg twice a day by a
covering physician. When Jen was approached about reducing clonazepam a year later, she seemed very
conflicted because she recalled the side effects she had experienced and also feared withdrawal seizures
(see Tables 11.1 and 11.2).

Table 11.2 Decision making grid for case 1

Decision-making grid
Risks Benefits
Continuing Long-term side effects including dependence, memory loss, risk of falls, Treatment of withdrawal symptoms
clonazepam drug interactions
Deprescribing Withdrawal symptoms Time and labor-intensive process Development of non-pharmacological
clonazepam strategies
Patient values/preference: Patient prefers to continue clonazepam because the last experience of withdrawal was very distressing. At the
same time, the patient understands the risks of long term BZD use and wants to stop using them.
Plan: Deprescribe clonazepam
Interventions: Start psychotherapy for anxiety and insomnia before changing the dose of clonazepam, emphasize that the plan is flexible,
keep the rate of taper slow, allow for extended periods on the same dose if needed, delay the taper if there are stressors that the patient
finds distressing, discuss the possibility of small as-needed doses for “bad” days.

Case Example 2
Joe is a 56-year-old man with a history of cocaine dependence after which he developed a generalized
anxiety disorder. He also has hypertension, diabetes, and hepatitis C. He takes fluoxetine and clonazepam
1 mg three times a day. Every time his prescriber suggests reducing the BZD, he says that he cannot go
through withdrawal and that he would die without taking BZDs (see Table 11.3).

Table 11.3 Decision making grid for case 2

Decision-making grid
Risks Benefits
Continuing clonazepam Long-term side effects It is what the patient wants; no clinical benefit
Deprescribing clonazepam Withdrawal symptoms Time and labor-intensive process Development of non-pharmacological strategies
Patient values/preference: Patient does not want any change in the dose of clonazepam
Plan: Continue psychoeducation
Interventions: Psychoeducation, CBT for anxiety symptoms

Case Example 3
Dan is a 55-year-old man with severe depression and posttraumatic stress disorder (PTSD). He was
prescribed methylphenidate in addition to an SSRI on an inpatient service where he was admitted for
suicidality. He states that it really helps him get through the day and is asking you to increase the dose by
5 mg twice a day. He is unwilling to discuss any reduction in the dose. When informed about side effects
he says “My life is terrible already. I don’t care about a few side effects if it helps me get through the
day.” See Table 11.4.
Table 11.4 Decision making grid for case 3
Decision-making grid
Risks Benefits
Continuing methylphenidate Long-term side effects, risk of dependence It is what the patient wants; no clinical benefit
Deprescribing methylphenidate Patient will drop out of treatment Development of non-pharmacological strategies
Patient values/preference: Patient wants an increase in the dose
Plan: Continue psychoeducation

Self-Assessment
1. Tom has been taking clonazepam 3 mg total daily for the past 7 years. He came across an article in the newspaper that said
that he could develop dementia. He is terrified, abruptly stopped taking the clonazepam, and has a panic attack. Now he
refuses to “touch the stuff.”

a. What is your initial intervention with Tom?

b. What will you suggest as a long-term plan?

2. Tina was given methylphenidate by her roommate as a trial. She liked the effect and had her doctor prescribe it monthly for
the next 6 months. She now says that she finds it impossible to even make her bed if she doesn’t take it.

a. What do you think is the cause of Tina’s complaint?

b. What will you suggest to Tina?

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Bossaer, J. B., Gray, J. A., Miller, S. E., Enck, G., Gaddipati, V. C., & Enck, R. E. (2013). The use and misuse of prescription stimulants as
“cognitive enhancers” by students at one academic health sciences center. Academic Medicine, 88(7), 967–971.
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dementia: Prospective population based study. British Medical Journal, 345, e6231.
Denis, C., Fatseas, M., Lavie, E., & Auriacombe, M. (2006). Pharmacological interventions for benzodiazepine mono-dependence
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Fixsen, A. M., & Ridge, D. (2017). Stories of hell and healing: Internet users’ construction of benzodiazepine distress and withdrawal.
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Grade, C., Redford, B., Chrostowski, J., Toussaint, L., & Blackwell, B. (1998). Methylphenidate in early poststroke recovery: A double-blind,
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Grau-López, L., Daigre, C., Mercado, N., Casas, M., & Roncero, C. (2017). Dystonia in methylphenidate withdrawal: A case report. Journal
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Lavretsky, H., Reinlieb, M., St. Cyr, N., Siddarth, P., Ercoli, L. M., & Senturk, D. (2015). Citalopram, methylphenidate, or their combination in
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Nolan, E. E., Gadow, K. D., & Sprafkin, J. (1999). Stimulant medication withdrawal during long-term therapy in children with comorbid
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 12
Concluding Thoughts and Future Directions

In this concluding chapter, we summarize the major points of the book and identify future directions for
research and practice in the topic of deprescribing.

What We Hope You Take Away from This Book

Over the past few years of putting this book together, the landscape around the topic of deprescribing in
psychiatry has begun to significantly shift and expand. More focus on the concerns of long-term
psychotropic drug use has been emerging in the literature as well as in the popular press. This is
evidenced by numerous publications and articles about antidepressant withdrawal symptoms (Davies &
Read, 2018; Read, Cartwright, & Gibson, 2018), the emerging epidemic of benzodiazepine addiction
(Weaver, 2018), with its similarities to the opioid crisis, and greater recognition of the lay literature and
online forums which address discontinuing psychiatric medications. On the other hand, the mainstream
literature has provided further evidence for rational polypharmacy and against safe AP discontinuation in
schizophrenia. Even mortality as an outcome may be of relative value to those favoring quality of life.
Interpretation of this literature appears to be largely dependent on the outcomes most commonly used in
these studies (hospitalization rates, positive symptoms severity, functional recovery, or cardiovascular
risk) and the usual inferential limitations of large observational studies. Patient forums offering support
and anecdotal guidance on self-tapering strategies (e.g. minute dosing via oral suspensions) are gaining
traction but are mostly unfrequented or unknown by treaters. If psychiatry does not earn a seat at the table
when critical decisions are being made by our patients, an opportunity is missed. This brings us to our
first “take home” from this book: Do ask, do tell.

Do Ask, Do Tell

Your patients may already be doing “DIY deprescribing,” and you, as the prescriber, may not know unless
you bring up the topic. If your patients express any interest in reducing or stopping their medications, it is
possible that some have already started the process if not already stopped medications completely. Seize
the opportunity to start this conversation, and do not take lightly their broaching of the topic. The power
differential between prescriber and patient should not be underestimated and can manifest as fear of
expressing the desire to reduce or stop a medication you are prescribing.
Further, one might bookmark the option of an eventual collaborative discontinuation—at the time of
initiation of a medication—interleaving deprescribing with prescribing as two sides of the same coin.
When initiating a medication, one should actively discuss with the patient both their expectations of how
long the medication will be taken as well as your own thoughts and recommendations. Our stance is that
psychiatry as a field must question the assumption and temper the implication that medications, when
initiated, should be continued indefinitely. We suggest considering deprescribing as potentially as viable
an intervention as prescribing when appropriate. New evidence can and will emerge on the level of
individual patient, and without adequate expertise in deprescribing we will not be prepared to respond.
Even the paradigm of insulin management of diabetes (so often borrowed to evoke the rationale for life-
long psychopharmacotherapy) is called into question both as the metaphor of a chemical imbalance
explaining mental illness is reconsidered, and as deprescribing of insulin is being considered for some
established cases of diabetes mellitus. Similarly, the risk/benefit ratio guiding the (previously well
accepted) recommendation of low dose aspirin for secondary prevention of cardiovascular disease has
recently shifted.
Along with introducing the deprescribing process at the initiation of a new medication, it is also
essential to remain open to discussing the possibility of decreasing or discontinuing those medications the
person is currently taking (even if contrary to your recommendation). One certainly has the responsibility
of raising the issue if there are clear and significant risks of continuing the current regimen even if the
patient may not be interested in decreasing medications. A periodic, collaborative review of the
medication list, along with a clear description of the current risks and benefits to continuing the regimen,
is important to demonstrate interest in our patient’s and judiousness in our prescribing. Accepting these
discussions may not result in a change, but as circumstances change, new evidence emerges and the
therapeutic alliance deepens, opportunities to deprescribe may present themselves.

It’s the Relationship

Working together in a collaborative fashion is key in all of medicine but particularly in psychiatry.
Keeping in mind the multiple and potentially conflicting meanings of the prescription is essential to the
process. Creating an atmosphere where deprescribing can be done together, in a way that considers the
expertise and experience of both prescriber and patient, can develop a space where issues that were not
previously raised may emerge in the process of discussing medications. Shared decision-making often
involves shared risk-taking—an endeavor which, if done right, can forge a strong therapeutic alliance.
Alongside the therapeutic relationship with the prescriber, examining a patient’s whole constellation of
relationships is important. Problematic relationships in a patient’s life might have gone unrecognized or
unaddressed by virtue of collateral effects of the now discontinued medication. The role of “identified
patient” within a family or social system may start to shift as deprescribing is implemented; how this
impacts the family constellation and the ripple effects it causes may have more dramatic effects than
anticipated.
Finally, the patient’s relationship to the medication, the treatment, and, ultimately, to him- or herself as
a person taking or not taking medications can cause other shifts. Identity around being a “patient” or
inhabiting the “sick role” may start to change. Complex feelings may emerge. There may be grief as well
as joy: joy for those who have waited a long time to stop medications and are happy with the results; and
grief at not having tried this sooner. There may be strong feelings toward former (or current) treaters,
related to the initial prescribing. All of these relationships and emerging emotions are ripe areas for
addressing and potential areas for growth.

Be Prepared

Planning ahead with the patient is another area of focus in pursuing deprescribing. Preparing the ground
for the successful trial of a reduction or discontinuation of medications requires thoughtfulness and
additional work, but it is an investment that stands to pay off in the future.
Planning how to pursue deprescribing includes working to prepare a comprehensive medication list
that includes intended/anticipated benefits and risks for the prescription of each. Identifying which
medications would be the top candidates to start the medication reduction can be helpful especially if the
patient is interested but unsure of where to start. Part of preparing for deprescribing also includes
potentially protecting extra time to check in on how the patient is doing, particularly in the beginning days
and weeks of this effort.
Preparing for reactions and discomfort from other people in the patient’s life is important. For example,
the visiting nurse who oversees medication administration may be taken aback by the idea that the
prescriber is reducing the use of an antipsychotic medication (without the introduction of another in its
place). The family, who may have experience-based fears around the patient not taking medication, can be
very distressed when they find out about this course of action if they are not prepared and on board with
the decision.
Preparation extends to creating a wellness plan with the patient or encouraging them to do so on their
own. Chapters 5 and 6 reviewed different types of preplanning tools to support the patient in reflecting on
past experiences of increased distress and in identifying specific plans in the event that the patient needs
to be hospitalized. Putting these in place prior to pursuing any reduction of medications can offer the
patient and the prescriber, as well as others involved, an increased sense of comfort and control. A
patient may choose not to share these plans with others or may only share with providers; this is a
personal choice to be respected. Finding a format, tone, and approach that feels culturally and personally
relevant is important with these plans; one size does not fit all in this very personal of processes.
Prepare the person (and their support system/treatment team) for a potential increase in feelings—
feelings they may have avoided or that may have been dulled by the sedating effects of the medication.
The recognition and management of these feelings is an important area of focus because the emergence of
strong feelings may be mistaken for a return of symptoms, especially in the case of long-term
overmedication.

“First You Leap, Then You Grow Wings”

This quote, by the theologist William Sloan Coffin (2004), illustrates the importance of allowing a “good
enough” starting point for deprescribing in psychiatry, ahead of and as we build the necessary evidence
base to support more definitive and specific clinical guidelines. The construct of clinical practice guiding
research is readily accepted (and has proved quite successful), as in the off-label use of medications.
“Off-label” prescribing (and deprescribing) must be practiced with due diligence, the full informed
consent of the patient, and in good faith. The individual sitting in front of you in your office may be
suffering or, even more insidiously, surviving but not actually thriving. In a bid to be cautious and adhere
purely to empirically supported treatments (e.g., where meta-analyses or consensus guidelines exist), we
may miss the evidence sitting in front of us. We should not forget that “evidence-based practice” must
include clinical judgment and patient preferences in equal partnership with the evidence-based treatments.
Coffin (2004), encourages us: “One must, in short, dare to act wholeheartedly without absolute certainty”.
The mandate of the complex conditions within which we treat is that we cannot let the perfect be the
enemy of the good, and at times we must act without the luxury of certain evidence.
In the same way that we must have courage in pursing changes in treatment, we need to encourage our
patients to try, to risk, to take chances, to live. Deprescribing is certainly not the only avenue to this, but to
harken back to the prologue of the book where we quoted Deegan (2004) and the experience of “what it
means to be buried under an avalanche of psychiatric drugs” for a number of the patients with whom we
work, this may in fact the status quo with which we collude. Symptoms may be reduced, but at a cost to
the person’s feeling of being alive or fully participating in their life.
To reiterate the position as laid out in this book: psychiatric medications have proved useful and
beneficial, and many, many people would attribute much of their current fulfilling lives to the assistance
and existence of these drugs. But those (often vulnerable) individuals who are ‘buried’ should be granted
the opportunity to try digging themselves out. To support and assist with the collaborative inquiry that is
deprescribing requires rigor, ethics, courage, and the wide support of the field and systems in which we
practice.

A Call for Research

The research base for deprescribing in psychiatry is in its infancy but can leverage (with caveats)
experimental and observation studies published on medication discontinuation. While we can draw from
other fields of medicine and guidelines developed around (specifically) decreasing polypharmacy in
those specialties, we have argued here that psychiatry presents a unique set of challenges and is not, in
fact, “an illness like any other.” In being an illness that is stigmatized, feared, widespread, without clear
etiology, and with huge societal ramifications, the pursuit of something like deprescribing cannot be just a
cookbook of guidelines and recommendations, but also requires considering the sociopolitical
implications that are highlighted in policy debates, differences of opinion among advocacy groups, and
promulgated each time a mass shooting is blamed on the “mental illness” of the perpetrator.
With these considerations, though, we believe strongly that a rigorous scientific investigation of
deprescribing is a priority. With some initial studies showing positive indications (cf. Ostrow, Jessel,
Hurd, Darrow & Cohen, 2017; Steingard, 2018), there is yet much work to be done in process research,
guidelines development, outcomes research, and cost-effectiveness research.
Barriers to deprescribing have been identified here and are clear from initial studies, but these need to
be further examined and elucidated. Along with identifying barriers for prescribers, we must look at
possible user-friendly tools (i.e., checklists and worksheets) to support deprescribing. Tools development
to help educate patients on the front end about the possibility of reducing or stopping medications (in
particular for more vulnerable populations) should be readily available for prescribers to use at the point
of first prescription. These kinds of decision support tools might be developed in conjunction with
existing technologies such as Deegan’s computer-based support tool, accessible directly prior to meeting
with a provider (recoverylibrary.com). As stated, it is with humility rather than hubris that we consider
this text in its first edition. We hope that our call to action falls on sympathetic, motivated, and courageous
ears; contributing neither to a fad nor a “swing of the pendulum,” but rather to a meaningful expansion of
our field.

Future Directions in Research

• Trials of medication withdrawal: As we have indicated throughout this book, clinical trials of
medication withdrawal are few and have significant limitations. Ideally, every time a new medication
is approved by the US Food and Drug Administration (FDA), indications and method of
deprescribing or discontinuation could be made a requirement for the approval. In the absence of
this, studies that have a crossover design should be required to collect and analyze data regarding
withdrawal symptoms during the washout from a new drug. Furthermore, trials of more complex
withdrawal interventions in which the tapers are individualized and supported by the addition of
individualized nonpharmacological interventions need to be conducted.
• Qualitative studies: Qualitative data from individual experiences of medication withdrawal can help
inform potential areas of further research in the field. Themes that emerge from narrative accounts of
individual medication withdrawal stories can then be further studied with quantitative
methodologies. Furthermore, interventions that were found to be anecdotally useful during
withdrawal may be subjected to clinical trials.
• Receptor neuroimaging: Although neuroreceptor changes during medication administration have
been well-studied, fewer studies examine receptor changes during medication withdrawal. These
would be particularly significant to elucidate the mechanisms of how withdrawal or rebound
symptoms are produced and how they may be treated effectively. Such studies also may (or may not)
verify the validity of syndromes, such as dopamine supersensitivity psychoses, that have only been
described clinically so far. Finally, neuroimaging may provide a way to distinguish between
withdrawal symptoms and relapse of the original underlying illness (for instance, for psychosis,
changes in dopamine transport and uptake versus changes in receptor density and sensitivity) thereby
preventing premature resumption of the psychotropic during deprescribing.
• Pharmacoeconomics and long-term mortality/morbidity data: In addition to clinical trials, it is
important to study and demonstrate the economic benefits of deprescribing. Large databases such as
Medicaid and Medicare and all payers claims databases may be tracked to determine if
deprescribing is eventually cost-effective. We should remain mindful that cost-effectiveness may not
be demonstrable in the short term as the immediate effect of deprescribing could involve more
psychosocial treatment costs or even emergency room visits and hospitalizations. This work will
hinge on multi-stakeholder agreement on meaning outcome measures and definitions of ‘cost-
effectiveness’ and ‘value’ in healthcare.
• Consumer research, informal sources, and online forums: At this time, patients who have self-
discontinued medications are an untapped resource of information about symptoms and the
management of medication withdrawal. It is becoming increasingly important to develop a
methodology to formally analyze and interpret the large amounts of qualitative data that are available
in the form of consumer forums and chat rooms. One good example is the work of Stockman et al.
(2018) which despite methodological limitations, provides a window into antidepressant withdrawal
chat rooms.

Future Directions in Clinical Practice

• Integration into behavioral health homes: Behavioral health homes, located within mental health
facilities, provide coordination of medical services for individuals with serious mental illnesses
(Alexander & Druss, 2012). As their primary function is coordination and collection of medical
information from various providers, they can form an excellent hub for the development and
disbursement of deprescribing recommendations for a given patient.
• Integration into electronic records and practice management reminders: Integration of
deprescribing prompts and resources into electronic medical records may encourage providers to use
this intervention by influencing culture of practice and empowering providers.
• Development of clinical tools and algorithms: The Beers criteria were developed to help
geriatricians determine the priorities for deprescribing within a given medication list. Within
psychiatry, medications such as anticholinergics, antihistamines, and adjunctive agents could be
possibly deprescribed without destabilizing the patient—it is important for us to develop similar
tools. Gawande (2009) proposes that simple tools such as checklists can have powerful clinical
utility.
• Deprescribing clinics: The formation of specialized deprescribing clinics that are focused on
tracking and managing withdrawal symptoms and providing peer support, group therapy, and other
nonpharmacological interventions is an important future direction.
• Deprescribing consultation services: Specialized consultation services on deprescribing (Figure
12.1) within a larger mental health service or using teleconferencing based consultation (such as the
ECHO project) may be useful to initiate the process as well as to disseminate expertise.

Figure 12.1 Model for a deprescribing consult service.

Education and Training

Medical/nursing education is the ideal time to introduce the concept of deprescribing (alongside
prescribing itself). The next generation of prescribers should be inspired to seek opportunities to identify
and discover knowledge and expertise useful to this effort, hold their seniors to account on this
burgeoning practice, and instigate innovation.
The current bias in class time towards initiating and continuing versus discontinuing medications is
striking. Psychiatry residency programs should consider incorporating training in deprescribing into their
core prescribing curricula. Knowledge, skills, and attitudes should be addressed in key competency areas
such as (1) “What to prescribe”—psychopharmacology and critical appraisal of evidence; (2) “How to
prescribe”—psychotherapeutically informed prescribing; and (3) “Why to prescribe”—ethical
consideration, shared decision-making, and social justice. Each of these questions could then be asked
again, with “deprescribing” as the subject.
The field of psychiatry should openly and nondefensively join productive public forums to consider
and debate the potential benefits and risks of medications. The spirit of shared decision-making might
also include voices from our field being heard in the wealth of consumer-driven public forums that exist
online. Concerted public education, highlighting deprescribing as an area of interest and priority for
psychiatry, may help reinforce the relevance and value of our field in these challenging times.

References
Alexander, L., & Druss, B. (2012). Behavioral Health Homes for People with Mental Health and Substance Use Conditions: The Core
Clinical Features. Washington, DC: SAMHSA-HRSA Center for Integrated Health Solutions, US Department of Health and Human
Services.
Coffin, W. S. (2004). Credo. Louisville, KY: Westminster John Knox Press.
Davies, J., & Read, J. (2018). A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are
guidelines evidence-based? Journal of Addictive Behaviors, doi.org/10.1016/j.addbeh.2018.08.027.
Deegan, P. E. (2004). Remember my name: Reflections on spirituality in individual and collective recovery. https://www.patdeegan.com/pat-
deegan/lectures/remember-my-name
Gawande, A. (2009). The Checklist Manifesto: How to Get Things Right. New York: Henry Holt and Company.
Ostrow, L., Jessell, L., Hurd, M., Darrow, S. M., & Cohen, D. (2017). Discontinuing psychiatric medications: A survey of long-term users.
Psychiatric Services, 68(12), 1232–1238.
Read, J., Cartwright, C., & Gibson, K. (2018). How many of 1829 antidepressant users report withdrawal effects or addiction? International
Journal of Mental Health Nursing, 27(6), 1805–1815.
Steingard, S. (2018). Five year outcomes of tapering antipsychotic drug doses in a community mental health center. Community Mental
Health Journal, 54(8), 1097–1100.
Stockmann, T., Odegbaro, D., Timimi, S., & Moncrieff, J. (2018). SSRI and SNRI withdrawal symptoms reported on an internet forum.
International Journal of Risk & Safety in Medicine(Preprint), 1–6.
Weaver, M. (2018). Benzodiazepines. In T. S. Schepis, ed. The Prescription Drug Abuse Epidemic: Incidence, Treatment, Prevention, and
Policy (pp. 47). Santa Barbara, CA: ABC-CLIO.
 Appendix

Collaborative Deprescribing Worksheet (Part A)

Reviewing what medications are you currently taking
Current and
What? potential . . .
Medication Dose/ form How you take it? Why do you take it? (original Discuss
name ... (directions) indication) Pros Cons
Collaborative Deprescribing Worksheet (Part B)
Deciding which medication to deprescribe
What factors are most important to you in choosing? (e.g., Who should we involve in your
number of pills, side effects, cost, preventing hospital What do you deprescribing decision? (e.g., family,
admission) hope to happen? supports, providers)
Anything you are concerned about?
What are the potential benefits and risks of deprescribing? (You might want to discuss a few options before choosing one
medication to deprescribe at this time)
Option 1 Option 2 Option 3
Benefits Risks Benefits Risks Benefits Risks

Medication to deprescribe:
Collaborative Deprescribing Worksheet (Part C)
Deprescribing plan
Supports, Resources, and Wellness Strategies
What to
expect What to try Call me if . . . Seek urgent care if . . .

Event Log
Proposed Action (med dose/directions change, Any changes you Anything you did in
Date/time appointment or activity) noticed? response?

Collaborative Deprescribing Worksheet Guidelines

• This document is designed to be completed and maintained by both the patient and prescriber as a
framework to help guide, promote, and document a person-centered collaborative deprescribing
process (it should not be overvalued as the core intervention in and of itself).
• There are three parts which can be used independently or together as one document: Part A
documents information-gathering and sharing; Part B documents a shared decision-making process;
and Part C documents details the implementation of the deprescribing plan (while allowing for
flexibility).
• In Part A, gain a shared understanding of all current medications taken (this may include alternative
remedies if relevant). Collaborate on listing both the current and potential future “pros versus cons”
of taking each medication in commonly understood language. These may include pertinent positive
and negative effects as well as other factors like cost and convenience that emerge from your
discussion. Potential side effects should be curated to those most relevant (avoid simply listing all
possible associated side effects of each medication). You should extend into further rows of the
worksheet (and an additional Part A page) if needed. As you work through the worksheet, flag up to
three medications that either the patient or the prescriber wishes to consider further for
deprescribing. It is suggested that a prescriber and patient undertake Part A periodically, whether or
not intending it to lead to a deprescribing. Part A refers to deprescribing Steps 1 through 4, detailed
in Chapter 7.
• In Part B, the patient and prescriber, soliciting additional input as appropriate, engage in shared
decision-making around which medication to deprescribe at this time. First, the patient identifies
what factors/values are most important to him or her when making this decision (responding to the
four direct questions). The patient’s ideas, concerns, and expectations are elicited. The provider may
assist the patient in identifying who else might be appropriate to involve in the deprescribing
decision process—this may include key supports, peers, other providers, or consultants (such as
pharmacists or other specialists). Once these foundations are in place, up to three medications (as
identified in Part A) are examined in detail, asking the question: What are the potential benefits and
risks of deprescribing the medication? Please note that, in contrast, in Part A, the pros and cons of
continuing each medication are examined. In Part B, the prescriber and patient list the reasons for
discontinuing the medication. Part B refers to deprescribing Steps 4 and 5 in Chapter 7.
• Part C—plan, do, study, act—refers to deprescribing Steps 6 and 7 in Chapter 7.
• At the end of each clinical encounter, the event log may be updated with agreed recommendations
(and a copy made to chart).
• Each party is invited to sign their names to reflect the collaborative nature of the process.
• Consider adding a digital version of this document to your local health informatics systems.
 Index

Page numbers followed by b, f, and t indicate boxes, figures, and tables, respectively.

For the benefit of digital users, indexed terms that span two pages (e.g., 52–53) may, on occasion, appear on only one of those
pages.

Abilify. See aripiprazole

Acceptance and Commitment Therapy (ACT), 104
clinical applications of, 104
principles of, 104–105
aches/pains, stimulant withdrawal and, 209
ACT. See Acceptance and Commitment Therapy (ACT)
AD. See antidepressant(s)
Adderall. See amphetamine salts, mixed
addiction, 199–200. See also substance use
benzodiazepine, emerging epidemic of, 217
ADHD. See attention-deficit/hyperactivity disorder
adherence. See also compliance
definition of, 36
deprescribing and, 9
in psychiatry, 36–37
in schizophrenia, 9
therapeutic alliance and, 75
trauma in psychiatric system and, 71
advance directive
development of, guidelines for, 91, 92b
psychiatric (see psychiatric advance directive)
advertising, direct-to-consumer, as barrier to deprescribing, 61
affective disorders, sleep changes in, 106
age. See also geriatric medicine
and antipsychotic therapy, 164
and medication review, 164
and remission of psychotic illness, 164
agency, human, patient’s, deprescribing and, 61, 79–80
akathisia, withdrawal-emergent, with antipsychotic discontinuation, 170t
alcohol
and benzodiazepines, additive/interactive effects of, 203–204
withdrawal
acute treatment of, benzodiazepines for, 206
management of, 189
alcohol use disorders, 189
alternatives
choosing between, in shared decision-making, 32
identifying, in shared decision-making, 31
Alternatives to Suicide, 97–98
amitriptyline, deprescribing, case example, 151, 152t
amphetamine salts, mixed, deprescribing, 199–200
antibiotics, prescribing of, 51–52
anticholinergic(s)
commonly prescribed, 161t
discontinuation syndrome related to, 167–170, 170t
anticonvulsants. See also antiepileptic agents; specific agent
in benzodiazepine withdrawal strategy, 206
deprescribing, 5
antidepressant(s). See also specific antidepressant
augmentation, with mood stabilizers, 187
commonly prescribed, 138, 139t
deprescribing, 137
 case examples, 138, 149, 150, 150t, 151, 151t, 152, 152t, 153t
planning for, 143b, 143, 144f
psychotherapeutic and behavioral interventions to support, 147
discontinuation
guidelines on, 53–54
management of, 146
recommended, lack of/not implemented, 141
discontinuation/withdrawal syndromes, 144
clinical symptoms of, 144
factors affecting, 145
vs. relapse/recurrence, 146
dose, and withdrawal symptoms, 145
duration of treatment with
recommendations for, 141
and withdrawal symptoms, 145
extended use of, potential effects of, 139
half-life, and withdrawal symptoms, 145
maintenance therapy with, 141–142
nonadherence, 146
“poop out,” 140
prescription
inappropriate, 141
in primary care, 141
and recurrence prevention, 141
and relapse prevention, 141
response to, hormones and, 146
serotonergic, withdrawal symptoms, 59
sexual dysfunction with, 139, 149
tachyphylaxis, 140
tapering schedules for, 146
tardive dysphoria with, 140
weight gain with, 139
withdrawal
literature on, 217
management of, 146
withdrawal dysphoria with, 140
withdrawal strips, 146–147
antiepileptic agents, 188. See also anticonvulsants; specific agent
deprescribing, 5
considerations in, 190
withdrawal symptoms, 191
antipsychotic(s). See also specific antipsychotic
adverse effects of, 52–53, 163–164
atypical
commonly prescribed, 161t
indications for, 165–166
augmentation, with mood stabilizers, 187
commonly prescribed, 161t
deprescribing, 159
case examples, 160, 174, 175t, 176t, 177t
challenges of, 160–162
vs. discontinuation, 165
guidelines for, 172–173
knowledge gaps in, 173–174
person-centered approach and, 164–165
psychosocial adjunctive interventions with, 170–172, 172t
and relapse, 171
strategies to support, 170
successful, risk calculator for, 165
discontinuation
challenges of, 160–162
vs. deprescribing, 165
guidelines for, 172–173
outcomes with, 167, 168t
 and relapse, 164–165
schizophrenia relapse rates after, 167, 168t
discontinuation syndromes, 167, 170t
and dopamine supersensitivity, 164, 167, 170t, 223
indications for, 161t, 165–166
long-term use
factors contributing to, 164
potential consequences of, 163
maintenance dosing of, 52, 160–161, 162–163
minimum effective regimen, 170–171
polypharmacy, 163
risk–benefit ratios for
age and, 163
duration of treatment and, 163
second-generation, as mood stabilizers, 187–188
tapering schedules for, 172–173
typical, commonly prescribed, 161t
use of
evidence base for, 160–161
guidelines for, 53–54, 160–161, 162–163
person-centered approach and, 164–165
and withdrawal-emergent dyskinesia, 167, 170t
and withdrawal/rebound psychosis, 164, 167
anxiety, with benzodiazepine withdrawal, 205–206
management of, 206
anxiety disorders, management of, 105
AP. See antipsychotic(s)
appetite, increased, stimulant withdrawal and, 209
aripiprazole, 3–4
therapeutic uses of, 161t
aspirin, low-dose, for prevention of cardiovascular disease, 218
attention-deficit/hyperactivity disorder
stimulants for, 207, 208
deprescribing, 199–200
“holiday” from, 210
and substance use, 207
autonomy, patient, 16
deprescribing and, 7

Beers criteria, 4–5, 224–225

behavioral activation, for depression, 148
behavioral health home(s)
definition of, 15
and deprescribing, 15, 224
beneficence, 16
Benefit–Risk Assessment, 32
benefits, fear of losing, as barrier to deprescribing, 58, 77
benzodiazepines
for acute treatment of alcohol withdrawal, 206
addiction, emerging epidemic of, 217
and alcohol, additive/interactive effects of, 203–204
dependence/abuse potential, 203
deprescribing, 199–200, 203
case examples, 200, 211t, 212, 212t
community strategies in, 207
education and, 207
indications for, 203
pharmacological strategies for, 205
population-based interventions and, 207
and previously unrecognized psychiatric disorder, 206
psychotherapeutic interventions in, 207
drug interactions with, 203–204
duration of therapy with, 203
indications for, 203
 long-term use of, negative effects of, 203
micro-tapering of, 205
and opioids, additive/interactive effects of, 203–204
pseudoaddiction, 203–204
recovery from, users’ experiences, 205
side effects of, 203
tapering schedules for, 205
therapeutic dose dependence, 203–204, 204b
withdrawal symptoms, 59, 201
treatment of, 205
withdrawal syndrome, protracted, 205–206
benztropine, therapeutic uses of, 161t
bias
in prescribers, 41
and patients’ decision-making, 71
toward continuing medication, 39, 39t
bibliotherapy, 96–97
biopsychosocial approach, and deprescribing, 7, 8f
bipolar disorder
diagnosis of, confirmation of, 187
management, without medication, 192
mood stabilizers for, 187–189
deprescribing, 185
overdiagnosis of, 187
psychotherapeutic interventions in, as adjunctive treatments, 191–192
relapse
after lithium discontinuation, 189–190
expressed emotion and, 96
BRA. See Benefit–Risk Assessment
bupropion
deprescribing, case example, 152, 153t
in stimulant deprescribing, 210
BZDs. See benzodiazepines

Cahill, John D., training and experiences of, xi–xii

carbamazepine
with antipsychotic, and discontinuation, 191
in benzodiazepine withdrawal strategy, 206
discontinuation, parkinsonian syndrome after, 191
indications for, 187t
monitoring with, 188
withdrawal, 190–191
cardiology, deprescribing in, 5
caregivers, and deprescribing, 57
catatonia, with benzodiazepine withdrawal, 205–206
CBT. See cognitive behavior therapy (CBT)
checklists, 224–225
chlorpromazine, therapeutic uses of, 161t
choice talk, 29, 31
cholinergic rebound, 167–170, 170t
citalopram, effects on weight, 139
clinical practice, advances in (future directions for), 224
clinics, for deprescribing, 225
clonazepam
in benzodiazepine withdrawal strategy, 206
deprescribing, case examples, 211t, 212, 212t
clozapine
deprescribing, case example, 174, 175t
therapeutic uses of, 161t
clozapine medication group, as social support, 76, 174
Coffin, William Sloan, 221
cognitive behavior therapy (CBT), 105, 110t
and antipsychotic deprescribing, 171–172
in benzodiazepine deprescribing, 207
 in bipolar disorder, 191–192
clinical applications of, 105
for depression, 147
for insomnia (CBT-I), 107, 110t, 207
Coach app for, 109
internet-based interventions for, 109
for psychosis (CBTp), 105–106, 110t, 171–172, 172t
in schizophrenia, 171–172, 172t
cognitive remediation, in schizophrenia, 172t
cognitive therapy
for depression, 147
mindfulness-based, for depression, 147
Collaborative Deprescribing Worksheet, 129–130, 131–132, 233
event log, 133–134, 233
guidelines for, 233
Part A (review of medications), 131–132, 133, 233
Part B (shared decision-making about medication to deprescribe), 131–132, 133, 233
Part C (deprescribing plan), 131–132, 133, 233
combination therapy, 12
compliance. See also adherence
definition of, 36
factors affecting, 70
person-centered approach and, 70
in psychiatry, 36–37
Concerta. See methylphenidate: extended release, deprescribing
concordance, definition of, 36–37
consultation services, for deprescribing, 225f, 225
consultation team, for deprescribing, 15–16
consumerism, 128–129, 199–200, 201–202
forced, 38
consumer research, advances in (future directions for), 224
coordinated care, and deprescribing, 62
countertransference, 130, 201–202
crisis planning, 94
guidelines for, 91, 92b
tools for, 91
in WRAP, 92–93
culture
and decision-making, 37–38
and deprescribing, 76–77
and medication use, 76–77
cytochrome P450, and deprescribing of carbamazepine taken with antipsychotic, 191

decision
definition of, 24
made by prescriber, 37–38
not to make a decision, patient’s, 37–38
Decisional Balance Worksheet, 32
decision analysis, 41
defining problem for, 30
definition of, 24
in medicine, 24–25
in psychiatry, 26, 27f
steps of, 24, 25f
decision-makers, 40
decision-making, 23. See also shared decision-making
case example, 38
collectivist culture and, 37–38
continuum from paternalism to collaboration, 37f, 37
definition of, 24
facets of, 26
influences on, in provider–patient relationship, 26, 27f
in psychiatry, 26, 27f
in psychotic disorders, 171
 stages of, 29f, 29
traditional, 24
unilateral, by provider, 25
decision support tools, 32, 63, 222–223
decision talk, 29
delirium, with benzodiazepine withdrawal, 205–206
deprescribing
action phase of, 120–124, 121t
clinical visits during, 130
and addressing irrational polypharmacy, 12
as advancement in psychiatry, 119
algorithms for, development of, 224–225
assessing timing and context for (Step 1), 121t, 124
barriers to, 63
cultural, 61
patient-related, 55
physician-related, 50, 51t
research on, 222–223
systemic, 61
as biopsychosocial intervention, 7, 8f
in cardiology, 5
challenges of, 221
clinical tools for, development of, 224–225
communicating with patients about, 218
as complex intervention, 12
coordinated care and, 62
cost-effectiveness of, research on, future directions for, 224
as critical intervention in psychiatry, 3
rationale for, 6
definition of, 4
development of, 119
vs. discontinuation of medication, 6, 49, 119, 165
documentation of, 131
ethics of, 16
and exploration of patient’s experience, attitudes, and meaning about medication (Step 3), 121t, 127
in geriatric medicine, 4–5, 224–225
guidelines on, lack of, 53
informal resources on, use of, 224
integration into behavioral health homes, 224
integration into electronic medical records, 224
key elements of, 119–120
meaning of, for patient and prescriber, 130–131
medication chosen for, deciding on (Step 5), 121t, 128, 133
and medication reconciliation (Step 2), 121t, 125
of medications with abuse potential, challenges of, 201
of medications with rewarding effects, challenges of, 201
modifications of, 130
monitoring during, 121t, 130–131
in neurology, 5
nonpharmacological aspects of, 69, 77
patient’s key supports and, 121t, 128
perceived as withdrawal of care, 61
pitfalls of, 48
plan for
in Collaborative Deprescribing Worksheet, 131–132, 133, 233
development of (Step 6), 121t, 129, 133–134
implementation, monitoring, and adjustment of (Step 7), 121t, 130, 133–134
planning for, 220
at initiation of medication, 218–219
postponement of, 125
preparation phase of, 120–124, 121t
in psychiatry, specific considerations for, 120
psychological factors affecting
case example, 80
 eliciting from patient, 74
rational, as intervention in psychiatry, ix
reactions to, from others in patient’s life, 220
as recovery-oriented practice, 9, 10f, 11t
research on, 222
risks of, 49
settings for, 14
setting the frame for (Step 4), 121t, 127, 133
steps in, 119–121, 121t
and stigmatization of mental illness, 49
strategies, for meaning-based adverse effects of medications, 73, 74b
support infrastructure and, 62
time constraints and, 62
training in, 225
trends in, 217
vs. withdrawal of medication, 6
deprescribing clinics, 225
deprescribing consultation services, 225f, 225
depression. See also antidepressant(s)
behavioral activation for, 148
cognitive behavior therapy for, 147
cognitive therapy for, 147
management of, 105
exercise in, 95
internet-based interventions for, 109
recurrence
vs. antidepressant withdrawal, 146
with antidepressant withdrawal, 140
definition of, 141
iatrogenic theory of, 142, 147
prevention of, 141, 148
risk of, 142
relapse
after antidepressant discontinuation, predictors of, 143
after lithium discontinuation, 189–190
vs. antidepressant withdrawal, 146
definition of, 141–142
prevention of, role of antidepressants, 141
sleep changes in, 106
stimulants for, 207, 208
stimulant withdrawal and, 209
treatment of, 210
well-being therapy for, 147
dexmethylphenidate, deprescribing, 199–200
diazepam, in benzodiazepine withdrawal strategy, 206
disability benefits, as barrier to deprescribing, 58, 77
discontinuation of medication. See also specific medication
vs. deprescribing, 6, 49, 119, 165
patient-initiated, 9, 218
self-managed, patients’ experience with, 53–54
distress, with medication discontinuation, management of, 57, 59, 87–88, 89–90, 207, 220
disulfiram, 171–172
divalproex
in combination therapy, 188–189
deprescribing, 188–189
case example, 192
indications for, 187t, 188–189
monitoring with, 188
documentation. See also Collaborative Deprescribing Worksheet
of deprescribing, 131
dopamine supersensitivity, 164, 167, 170t
research on, future directions for, 223
dreams, unpleasant, stimulant withdrawal and, 209
duloxetine, withdrawal symptoms, 144–145
dyskinesia, withdrawal-emergent, with antipsychotic discontinuation, 167, 170t
dysphoria
antidepressant withdrawal and, 140
stimulant withdrawal and, 209

Early Symptom Scale, 89

eating disorders, relapse, expressed emotion and, 96
education. See also psychoeducation
medical/nursing, integration of deprescribing in, 225
public, about benzodiazepines, 207
EE. See expressed emotion (EE)
electronic medical records, 14–15
deprescribing and, 224
EMPOWER, 207
empowerment
definition of, 11t
and deprescribing, 11t
peer support and, 107–108
personal medicine and, 93–94
WRAP and, 93
escitalopram, deprescribing, case example, 149, 150t
eszopiclone, deprescribing, 199–200
ethics, of deprescribing, 16
evidence-based practice, 221
exercise, as intervention, 95
for depression, 148
expert(s)
patient as, 41
prescriber as, 40
expressed emotion (EE)
definition of, 96
in families, 96
and relapse risk, 96, 106
extrapyramidal symptoms, 52

family, and deprescribing, 57

family psychoeducation, and schizophrenia relapse prevention, 171–172
family support, 95
family therapy, 95–96
in bipolar disorder, 191–192
in deprescribing plan, 129–130
in schizophrenia, 171–172, 172t
and schizophrenia relapse prevention, 171–172
fatigue, stimulant withdrawal and, 209
Fear of Recurrence (FORSE) scale, 56, 110t
feelings, emerging during deprescribing, 220–221
fluoxetine, 3–4
effects on weight, 139
half-life, and withdrawal symptoms, 145
fluphenazine, therapeutic uses of, 161t
Focalin. See dexmethylphenidate
forced consumerism, 38
friends, and deprescribing, 57

gabapentin
dependence potential, 206
indications for, 189
geriatric medicine
deprescribing in, 4–5, 52, 224–225
barriers to, 50
polypharmacy in, 4–5
goal(s), identifying, in person-centered approach, 30–31
Gupta, Swapnil, training and experiences of, xi
haloperidol
deprescribing, case example, 176, 176t
therapeutic uses of, 161t
harm-reduction approach, 199–200
health belief model, 70
Hearing Voices Movement/networks, 97–98, 172t
hope
definition of, 11t
and deprescribing, 11t
hormone(s), and mood, 146
hospitalization
alternatives to, 108
normalizing/decatastrophizing of, 108, 110t
and relapse, 48–49, 108
hypersomnia, stimulant withdrawal and, 209

identity
deficit-based, 94
disruption, deprescribing and, 60, 73–74, 219
informed consent, for deprescribing, 124, 127–128
inpatient psychiatric unit, and deprescribing, 15
insomnia
with benzodiazepine withdrawal, 205–206
management of, 206
cognitive behavior therapy (CBT-I) for, 107, 110t
Coach app for, 109
quetiapine for, 165–166
stimulant withdrawal and, 209
treatment of, 107
institutional transference, 71
insulin, 218
interpersonal therapy, in bipolar disorder, 191–192
interstitial renal disease, lithium-induced, risk of, 52–53
irritability, stimulant withdrawal and, 209

justice, ethical principle of, 16

key supports, and deprescribing, 121t, 128, 133–134, 172, 233

lamotrigine, indications for, 187t, 188–189

learned helplessness, 38
lisdexamphetamine, deprescribing, 199–200
lithium, 188
adverse effects of, 52–53
as augmenting agent, 187, 188
and discontinuation syndrome, 189–190
deprescribing, case examples, 193, 193t, 194t, 195, 195t
discontinuation syndromes, 189
indications for, 187t, 188
monitoring with, 188
tapering schedules for, 190
litigation, fear of, as barrier to deprescribing, 54
Living with Voices: 50 Stories of Recovery, 97–98

Mad Maps, 91
major depression. See depression
MAOIs. See monoamine oxidase inhibitors (MAOIs)
meaning in life
adjunctive wellness strategies addressing, 110t
and psychological well-being, 95
medication(s)
with abuse potential, deprescribing, challenges of, 201
as adaptation to difficult circumstance, 74–75
association with health rather than disease, 61
changes, as “trials,” 130
 meaning-based adverse effects of, 72–73, 73b
deprescribing strategies for, 73, 74b
meaning of, 69
exploration, in preparation phase of deprescribing, 127
for patients, 49–50, 60–61, 72, 127
patient’s attitudes about, exploration, in preparation phase of deprescribing, 127
patient’s experience with, exploration, in preparation phase of deprescribing, 127
patients’ goals for using, 88–89
reconciliation of, in preparation phase of deprescribing, 121t, 125
as reinforcing “patienthood,” 75
review of, periodic/collaborative, 218–219
with rewarding effects, deprescribing, challenges of, 201
selection of, for deprescribing, 121t, 128, 131–132, 133
as social phenomenon, 71
sociocultural significance of, 76
starting, meaning of, 72
stopping, symbolic meaning of, 72
symbolic meanings of, 71–72
withdrawal
qualitative studies of, advances in (future directions for), 223
receptor neuroimaging during, future directions for, 223
research on, advances in (future directions for), 223
medication list(s)
in Collaborative Deprescribing Worksheet, 131–132, 133
documentation of, 131, 132b
in preparation phase of deprescribing, 121t, 125, 220
methylphenidate
deprescribing, 199–200
case example, 200, 213t
extended release, deprescribing, 199–200
withdrawal symptoms, 209
Miller, Rebecca, training and experiences of, xi
mind-body splits, 87–88
minimal effective dose(s), 7–8, 49–51, 52–54, 77, 160–161
mirtazapine
weight gain with, 139
withdrawal symptoms, 144–145
monitoring, during deprescribing, 121t, 130–131
monoamine oxidase inhibitors (MAOIs)
discontinuation/withdrawal syndromes, 144
weight gain with, 139
mood disorders
relapse, expressed emotion and, 96
sleep changes in, 106
mood stabilizer(s). See also specific medication
as augmenting agents, 187
commonly prescribed, 187t
deprescribing, 185
case examples, 186, 192, 193, 195
considerations in, 190
nonpharmacological strategies to support, 191
extended use of, factors contributing to, 187
indications for, 187t
monitoring with, 188
side effects of, 188

naltrexone, 171–172
NASSAs. See noradrenergic and specific serotonergic antidepressants (NASSAs)
neurology, deprescribing in, 5
“never change a winning team” heuristic, 51–52
nonadherence rates, 70
noncompliance, 70
nonconcordance, deprescribing and, 9
nonmaleficence, 16, 51–52
 approaches to, 52–53
noradrenergic and specific serotonergic antidepressants (NASSAs), withdrawal symptoms, 144

olanzapine, therapeutic uses of, 161t

online resources, 109, 224
open dialogue, 108–109, 172, 172t
opioids, withdrawal symptoms, 59
option talk, 29, 31

PAD. See psychiatric advance directive

paliperidone, therapeutic uses of, 161t
paradoxical intention, for sleep disturbances, 107
paroxetine
effects on weight, 139
half-life, and withdrawal symptoms, 145
paternalism, 128–129, 201–202
medical model of, 25
patient
and barriers to deprescribing, 55
as expert, 41
fear of relapse, as barrier to deprescribing, 56
and power struggles with prescriber, 202
patienthood, meaning and status of, 75
Payoff Matrix (Integrated Treatment for Dual Disorders), 32
peer groups, 97–98
peer support
definition of, 107–108
in deprescribing, 107
perphenazine, therapeutic uses of, 161t
persistence, definition of, 36
personal medicine, 89, 93
person-centered care
and compliance, 70
definition of, 11t
and deprescribing, 11t
person-first language, 10–12
pharmacoeconomics, research on, future directions for, 224
polypharmacy
antipsychotic, 163
in geriatric medicine, 4–5
inadvertent, 126
irrational, 126
addressed by deprescribing, 12
prevalence of, ix–x, 12
rational, 52, 217
posttraumatic stress disorder (PTSD), treatment of
antipsychotics for, 165–166
Coach app for, 109
pregabalin, dependence potential, 206
prescriber
and barriers to deprescribing, 50, 51t
as decision-maker, 37–38
definition of, 17
as expert, 40
and power struggles with patient, 202
prescribing
as complex intervention, 12
direct-to-consumer advertising and, 61
“off-label,” 221
patient expectations and, 34
primary care physician(s), and deprescribing, 14–15, 50
problem(s)
defining, for decision analysis, 30
simple, complicated, and complex, comparison of approaches to, 12–13, 13t
progesterone, and response to antidepressants, 146
proton pump inhibitors, deprescribing, 5
Prozac. See fluoxetine
psychiatric advance directive, 90, 94, 110t, 129–130
psychodynamic psychopharmacology, 72
psychoeducation
in bipolar disorder, 191–192
in schizophrenia, 171–172, 172t
psychological reactance, 71, 202
psychomotor agitation, stimulant withdrawal and, 209
psychopathology, alternative views of, 97–98
psychosis
with benzodiazepine withdrawal, 205–206
cognitive behavior therapy for (CBTp), 105–106, 110t
diagnostic uncertainty with, 160–161
pathophysiology of, 161–162
substance-induced, 161–162
supersensitivity, 167
as syndrome, 161–162
treatment of, 161–162
psychotherapy. See Acceptance and Commitment Therapy (ACT); cognitive behavior therapy (CBT)
psychotic disorders, 173–174. See also antipsychotic(s); schizophrenia
decision-making in, 171
relapse, sleep changes and, 106
PTSD. See posttraumatic stress disorder (PTSD)
purpose in life
adjunctive wellness strategies addressing, 110t
and psychological well-being, 95

quetiapine, 3–4
therapeutic uses of, 161t, 165–166

rebound symptoms
as barrier to deprescribing, 59
preparation for, 59–60
research on, future directions for, 223
receptor neuroimaging, during withdrawal, future directions for, 223
recovery
definition of, 166
personal vs. clinical, 10
recovery-oriented practice
deprescribing as, 9, 10f, 11t
person-first language in, 10–12
recurrence, 56
definition of, 48
vs. rebound symptoms, 59
rehospitalization, fear of, as barrier to deprescribing, 54
relapse
vs. change in life circumstances, 97
definition of, 48
early warning signs of, 91–93
in deprescribing plan, 129–130
expressed emotion in families and, 96
fear of, 89, 94
adjunctive wellness strategies addressing, 110t
assessment of, 56
as barrier to deprescribing, 54, 56
management of, 57
and hospitalization, 48–49, 108
in mental illness, 48
planning for, 89
predictors of, 89
prevention strategies, in deprescribing plan, 129–130
in psychotic disorders, sleep changes and, 106
 risk of, 48
vs. withdrawal symptoms, 59
research on, future directions for, 223
relationship(s)
with family/friends/caregiver, deprescribing and, 57
in patient’s life, 57–58, 219
with prescriber, 219
with psychiatrist, deprescribing and, 58
shifts in, with deprescribing, 219
relaxation training, for sleep disturbances, 107
research
advances in (future directions for), 223
on deprescribing, 222
risk assessment, in preparation phase of deprescribing, 125
risk–benefit analysis, 5–6, 32–33
risperidone
deprescribing, case example, 176, 177t
therapeutic uses of, 161t
Ritalin. See methylphenidate
role disruption, deprescribing and, 60, 73–74, 219

schizoaffective disorder, mood stabilizers for, 187

schizophrenia
course of, 164–165
diagnostic uncertainty with, 160–162
management of, 164–165
CBT in, 105
exercise in, 95
family therapy in, 95–96
guidelines for, 53–54
and symptom control vs. recovery, 166–167
medication for, as social control, 71
nonadherence rates in, 70
nonpharmacological interventions in, 170–172, 172t
recovery and, 166–167
relapse
antipsychotic deprescribing and, 171
definition of, 48–49
expressed emotion and, 96
predictors of, 106, 171–172
relapse rates
after antipsychotic discontinuation, 167, 168t
with and without medication, 33
remission of, 166
sleep changes in, 106
treatment of, guidelines for, 162–163
SDM. See shared decision-making
seizures, with benzodiazepine withdrawal, 205–206
selective serotonin reuptake inhibitors (SSRIs)
discontinuation syndrome, 144
effects on weight, 139
withdrawal symptoms, 59
self-assessment, 18, 42, 64, 82, 98, 111, 135, 153, 177, 195, 213
self-determination, patient, 70
self-efficacy
personal medicine and, 93–94
WRAP and, 93
self-management strategy(ies), 88, 94
Seroquel. See quetiapine
serotonin-norepinephrine reuptake inhibitors (SNRIs), withdrawal symptoms, 59, 144
sertraline, effects on weight, 139
sexual dysfunction, with antidepressants, 139
shared decision-making, ix–x, 23–24, 28, 41, 219. See also deprescribing
about medication to deprescribe, in Collaborative Deprescribing Worksheet, 131–132, 133
 choosing between alternatives in, 32
constructive environment for, 33, 34t
definition of, 11t
in deprescribing, 10, 11t, 121t, 128
expansion of, 226
framework of, 29f, 29
identifying alternatives in, 31
modified, 35f, 35–36
in psychiatry, evidence for, 35
vs. safety, 202–203
shared risk-taking, 219
in deprescribing, 124
sick role, 38
side effects, risk of, minimizing, 52–53
sleep
disturbances
in psychiatric disorders, 106
treatment of, 107
management of, with deprescribing, 106
sleep apnea, 107
smartphone apps, 109
SNRIs. See serotonin-norepinephrine reuptake inhibitors (SNRIs)
social rhythms therapy, in bipolar disorder, 191–192
social support. See also key supports
adjunctive wellness strategies for, 110t
social withdrawal, stimulant withdrawal and, 209
SSRIs. See selective serotonin reuptake inhibitors (SSRIs)
stigmatization, of mental illness and its treatment, deprescribing and, 49
stimulants
abuse, and withdrawal symptoms, 209–210
for ADHD, deprescribing, 199–200
deprescribing, 207
case example, 200, 213t
indications for, 208
pharmacological strategies for, 210
diversion of, 208, 209
“holiday” from, 210
indications for, 208
misuse/dependence, 208, 209
prescribing patterns for, 208
short-term use, and deprescribing, 209
side effects of, 208–209
withdrawal symptoms, 209
stimulus control therapy, for sleep disturbances, 107
stress
anticipation of, in preparation for deprescribing, 121t, 124–125
resilience to, meaningful life activity and, 95
substance use, 199–200. See also addiction
monitoring, in preparation for deprescribing, 124
in patients with ADHD, 207
and schizophrenia relapse, 171–172
supersensitivity psychosis, 167
support groups, 97–98

tardive dyskinesia, antipsychotic-induced, risk of, 52–53

tardive dysphoria, antidepressants and, 140
TCAs. See tricyclic antidepressants
therapeutic alliance, 219
and adherence, 75
importance in deprescribing, 75
case example, 80
and wellness strategies, 110–111
therapeutic illusion, 6, 55
time constraints, and deprescribing, 62
topiramate, indications for, 189
training, medical/nursing, integration of deprescribing in, 225
trauma, in psychiatric system, 36
and adherence, 71
treatment resistance, underlying causes and, 72–73, 73b
tricyclic antidepressants
discontinuation/withdrawal syndromes, 144
weight gain with, 139
trihexyphenidyl, therapeutic uses of, 161t

uncertainty, in medicine, 40–41, 221

valproate, as augmenting agent, 187

venlafaxine
deprescribing, case example, 150, 151t
half-life, and withdrawal symptoms, 145
withdrawal symptoms, 144–145
visiting nurse
and deprescribing, 220
as social contact/support, 57–58, 60, 76, 78–79
voices, hearing, 97–98
coping with, 108
Vyvanse. See lisdexamphetamine

weight gain, with antidepressants, 139

well-being therapy, for depression, 147
wellness approach
adjunctive strategies to support deprescribing, 110–111, 110t
adopting, 88
clinical interventions and, 103, 104, 110t
collaborative strategies, 103, 129–130
definition of, 88
in deprescribing plan, 129–130, 220
online resources for, 109
self-determined, 87–88, 129–130
smartphone apps for, 109
and therapeutic alliance, 110–111
Wellness Recovery Action Plan (WRAP), 87–88, 91, 94, 110t, 129–130, 171
wellness toolbox, 91–92
withdrawal
qualitative studies of, advances in (future directions for), 223
receptor neuroimaging during, future directions for, 223
research on, advances in (future directions for), 223
withdrawal symptoms
with antidepressants, 145, 148
with antiepileptic agents, 191
as barrier to deprescribing, 59
with benzodiazepines, 59, 201
treatment of, 205
with duloxetine, 144–145
with methylphenidate, 209
with mirtazapine, 144–145
with noradrenergic and specific serotonergic antidepressants, 144
with opioids, 59
preparation for, 59–60
vs. relapse, 59
research on, future directions for, 223
with selective serotonin reuptake inhibitors, 59
with serotonin-norepinephrine reuptake inhibitors, 59, 144
stimulant abuse and, 209–210
with stimulants, 209
with venlafaxine, 144–145
with zolpidem, 205–206
with zopiclone, 205–206
withdrawal syndrome
with antidepressants, 144
clinical symptoms of, 144
factors affecting, 145
vs. relapse/recurrence, 146
with monoamine oxidase inhibitors, 144
protracted, with benzodiazepines, 205–206
with tricyclic antidepressants, 144

zaleplon, deprescribing, 199–200

z-drugs. See also eszopiclone; zaleplon; zolpidem; zopiclone
deprescribing, 199–200
indications for, 203
ziprasidone, therapeutic uses of, 161t
zolpidem
deprescribing, 199–200
withdrawal symptoms, 205–206
zonisamide, indications for, 189
zopiclone
deprescribing, 199–200
withdrawal symptoms, 205–206