This post is aimed at patients rather than psychiatrists or other prescribers. 2 useful resources aimed at professionals are below
RCPsych guidance about antidepressants deprescribing
Meds or no meds?
What is deprescribing?
In short, it is about stopping the medication. But, as the word suggests, it’s not about just stopping without medical advice but about “de-prescribing“, which means that a medical professional will be involved in safely reducing the medication and prescribing lower and lower doses. It can start both ways:
1. the patient (the person on medication) decides or queries stopping and initiates the discussion with their doctor
2. the doctor, nurse prescriber or pharmacist considers that it’s in the patient’s best interests to discontinue a particular medication and plans a reduction with the patient
What is not:
2. a prescriber just crossing off parts of the drug chart (it is de-prescribing in a sense, but it is not collaboratively done and can lead to discontinuation or withdrawal symptoms)
As a patient, when to discuss stopping medication
1. If you have been on medication for several weeks, you are at the maximum recommended dose, and you don’t experience any benefit
It is essential to discuss with your doctor, as apart from stopping or changing the medication, other strategies can be tried, such as augmenting the medication (adding another drug which makes the 1st more likely to work)
2. If the side effects are too unpleasant
As mentioned above, discuss it as some medications are essential to be continued (e.g. Clozapine in treatment-resistant schizophrenia), so in some cases, additional medication can be used to address side effects
3. If you developed some medical conditions and are prescribed extra medication
It is essential to discuss, as some previously safe medicines can become unsafe. For example, some psychiatric drugs can increase QTc interval (related to the electrical functioning of your heart) which can be safe but combined with further medication that has the same side effect, it can lead to arrhythmia. In practice, this shouldn’t happen as the second prescriber would know what you are already prescribed, but raise it with your doctor in case of concerns. Also, it may be a case of discontinuing the psychiatric medication to prioritise the one for physical conditions (especially in severe physical illness). Still, it should be done safely and collaboratively, ideally.
4. If you have been well with medication for a while and you think about being drug-free
There are specific recommendations about the ideal period of staying on medication depending on the condition, varying from 6 months for antidepressants after the 1st episode to indefinitely in chronic, difficult-to-treat conditions. So it’s not the same if the discontinuation refers to an antidepressant when you have been well for a few months and implemented other strategies to keep well versus stopping an antipsychotic when you had many relapses and inpatient admissions. There needs to be a comprehensive discussion about the benefits and risks.
5. If you are on a long list of medications and worry about their long-term effect on your health
With all the best will in the world, the prescribers are sometimes reluctant to discontinue medication even if the benefits are uncertain. The worry that things may get worse gets in the way. This can come from both the prescriber and the patient. The result is that, in some cases, people are prescribed an additional medication on top of one that didn’t do much, the 3rd one in time, and so on.
6. You are getting older and thinking about the increased risks of side effects.
As we age, the body is less able to clear medication effectively; the kidneys lose some of their function, so drugs that used to be safe at a younger age can have increased toxicity. Also, a medication that can cause dizziness (mainly benzodiazepines) can increase the risk of falls as we age.
7. If you are not taking your medication consistently
If, in all honesty, you notice that you are more often skipping your meds than taking them, it’s worth having an open discussion with your doctor about stopping them or finding strategies to remember taking them if necessary.
8. You reconsidered your approach to mental health and preferred being medication-free.
This can be due to various reasons: you may want to try other approaches such as psychotherapy, lifestyle choices, or meditation…In general, medication plus psychotherapy or lifestyle approaches works better. In most cases, especially for depression and anxiety, it’s a matter of preference if the condition doesn’t make you want to hurt yourself or others.
You may find my other post about self-help strategies for depression helpful.
Some specific medications
1. Benzodiazepines
They should typically be prescribed short-term, so if you have been on them for more than 2-3 weeks, you need to discuss with your doctor a plan to reduce and stop them gradually. They can cause physical and psychological addiction, have a negative effect on sleep, cause dizziness and falls (especially in older people) and negatively impact your cognitive function in time.
You can agree with your doctor on a gradual reduction plan; a rough guide is a 25% reduction every two weeks and every 12.5% reduction towards the end, or alternating drug-free days.
The highest risk is if the doses are high and the discontinuation is abrupt, after being on them for a long time. It can lead to delirium (a medical emergency when the consciousness is altered, the sufferers may experience hallucinations, and their thinking can be muddled). Therefore benzos should never be stopped abruptly (similar to alcohol when someone is alcohol dependent)
2. Antidepressants
If you consider stopping them, discuss with your doctor how to safely stop them to reduce the risk of relapse and discontinuation symptoms. Most people manage to stop without many unpleasant discontinuation symptoms, but some find it way more complicated and need a very gradual tapering over several months.
RCPsych has some helpful guidance about discontinuing antidepressants below.
3. Antipsychotics
I must say that most psychiatrists would be anxious about discontinuing these drugs, especially for someone who had several psychotic episodes. However, there are cases when it makes sense to consider a reduction in dose or discontinuation after a period of remaining well. The pros and cons need to be carefully weighed, and ideally, a plan to reintroduce medication if needed should be in place.
Why deprescribing can be controversial?
Some psychiatrists associate the word “deprescribing” with an antipsychiatry sentiment. They see any proponents of deprescribing as inherently against medication and, in consequence, against an important treatment strategy that psychiatry offers.
On the other hand, some people may feel that too many mental health conditions and, at times, even everyday suffering are medicated. They may think different approaches could work, and medication should be tried further down the line. The use of antidepressants increased significantly in the last decades, and we are not overall in better shape mentally.
Some can see medication as an easy way out, opting not to hear and support patients through their distress. It’s a more accessible option than really listening and helping someone going through a difficult time.
Nonetheless, medication can be life-saving and drastically improve lives quicker than psychotherapies or social interventions.
The middle way would be to use the medication in addition to other strategies or after other approaches have failed. This would involve quicker access to psychological therapies, social intervention and support or education about lifestyle choices. In a world where GP appointments last 7-10 minutes (in the UK), this is more of an aspiration than reality. I don’t know how things are in other parts of the world, but in my area, the waiting time for CBT is one year long, and for more complex psychological interventions, longer than that. If we don’t use medication, many people would likely get worse waiting.
I don’t mean the message to be too depressing. Other services do great work in supporting people apart from GP practices and mental health teams such as 3rd sector organisations or charities (e.g. Mind). There are also many support groups online and self-help resources or apps, especially useful for depression and anxiety disorders.
Summary
- Psychiatric medication is very important and can be life saving in many mental health conditions.
- There are situations when patients or prescribers consider stopping the medication and these need to be talked about and carefully planned collaboratively.
- The rate of discontinuation differs and the plan needs to be adjusted accordingly.
The references are in the links included
My mother was on antidepressants for 30 years. She now has severe Alzheimer’s at 66 years old. We are convinced it was because of the medication for so many years. I wish this was an option years ago. She was diagnosed at 56 years old!
Hi Eva, I am sorry to hear about your mother. Sad to have dementia, especially so young. I was going to say that antidepressants don’t increase the risk of dementia but looking it up, I came across studies both ways. Some reported an increase in risk and others a decrease. It makes sense to try and discontinue after recovery (especially if it’s one episode and other psychosocial strategies are added). Still, sometimes it’s hard to do that, in cases of severe hard-to-treat depression or multiple relapses.