Chapter 1
Introduction to Deprescribing Psychiatric Medications

Deprescribing as an Intervention

Deprescribing is the planned and supervised process of reducing or stopping medication for which existing or potential harms outweigh existing or potential benefits.1 The term 'deprescribing' originates from geriatric medicine where polypharmacy in frail patients can cause more harm than benefit.1 Deprescribing is increasingly recognised to be a key component of good prescribing - reducing doses when they are too high, and stopping medications when they are no longer needed.2 This process cannot occur in a vacuum of theoretical concerns but should take into account the patient's health, current level of functioning and, importantly, their values and preferences.1 Deprescribing seeks to apply best practice in prescribing to the process of stopping a medication. It requires the same skill and experience as for the process of prescribing from prescribers, as well as support from pharmacists and other healthcare staff to obtain the best results. Importantly, it should place patients at the centre of the process to ensure medicines optimisation.3

There has historically been little attention paid to deprescribing in psychiatry. There is a dearth of research into a structured approach to stopping psychiatric medication, with the exception of some early studies examining stopping benzodiazepines1 and in some specific populations, like people with learning disabilities. The focus of research efforts has been predominantly the prescribing of psychiatric medications - for example, there are estimated to be about 1,000 (published and unpublished) studies on starting antidepressants and only 20 on stopping them.4 Concern about this imbalance is not specific to psychiatry with other medical specialties, such as cardiology, also engaging in a re-appraisal of long-term medication continuation, with support for developing strategies for repeated risk-benefit analyses over time.5

The context for deprescribing

Over-prescription in psychiatry

Despite evidence of benefit for psychiatric drug treatment, there have been concerns raised regarding over-prescription. 1 in 6 people in western countries are prescribed an antidepressant in any given year, with rates rising a few per cent each year.4,6 These increasing prescription numbers are mostly caused by longer periods of prescribing - the median duration of use of antidepressants is now more than 2 years in the UK and more than 5 years in the USA.6 Some commentators have suggested that the increasing duration of prescriptions in part reflect the difficulty people have in stopping these medications due to withdrawal effects.7 In practice, 30-50% of patients do not have evidence-based reasons for the continued prescription of antidepressants,8-10 prompting calls to action to reduce associated risks.6,11 There have been similar concerns about the high rates of antipsychotic use in conditions other than serious mental illness,12 as well as a reconsideration of their open-ended use in psychotic conditions for all patients.13,14 There are long-standing worries about levels of benzodiazepine and z-drug prescribing,15,16 and more recent concerns about gabapentinoid prescribing.17

High rates of medication prescribing has also gained governmental attention in the UK,17 with a particular focus on psychiatric drugs. A government report has noted that 1 in 4 adults in the UK are prescribed at least one dependence forming medication each year, with some patients having difficulties stopping these medications.18 One central concern is that short-term symptom control might be prioritised over long-term functional outcomes, especially as most studies guiding treatment protocols measure symptomatic outcomes over short time periods rather than functional outcomes (or other outcomes often valued by patients) over longer time periods.13,19,20

Alongside this disquiet regarding over-prescription there has been renewed scrutiny of the effectiveness of some psychiatric medications. There is some consensus in the UK and Europe that benzodiazepines and z-drugs have limited effectiveness in the long term, with guidance recommending against long-term treatment for anxiety and insomnia,21 matched by guidance in the USA from some health management organisations.15 Preliminary studies have recently found similar outcomes in the treatment of selected patients with first-episode psychosis with or without antipsychotics in the context of comprehensive psychosocial support,22,23 and non-drug treatment for serious mental illness has attracted increasing interest, including a large randomised controlled trial (RCT).24 There have been calls from clinicians and patients for 'minimal medication' options for the treatment of psychotic conditions, such as have been established in Norway and parts of the USA.25 There has continued to be debate regarding the efficacy of antidepressants26,27 with arguments being made for their use in selected populations.28 Concerns have emerged regarding the efficacy and safety of gabapentinoids.17 In some countries there has been a shift away from a drug-centric approach in some patient groups - for example, in England and Wales the National Institute for Health and Care Excellence (NICE) now recommends that mild depression should not be treated with antidepressants as a first-line treatment, and suggests eight equally effective (and cost-effective) non-pharmacological treatment options for severe depression, alongside medication options.29

In addition to the above, there has also been significant critical attention directed towards the relapse prevention properties of psychiatric drugs.30,31 All psychiatric drug classes are recognised to cause withdrawal effects when stopped that may be misinterpreted as relapse of the initial condition necessitating treatment.32 These withdrawal symptoms are often ignored in discontinuation studies examining relapse prevention properties.30,33,34 As a result there have been questions raised as to whether the relapse prevention properties of psychiatric drugs have been over-stated by mis-classification of withdrawal effects as relapse,30,33,34 indicating we should be cautious in our interpretation of these studies.

Research and guideline establishment in deprescribing

In recent years interest in psychiatric deprescribing has increased exponentially. Numerous studies have been conducted or are ongoing exploring reducing and stopping antipsychotics in first and multi-episode psychotic conditions, in Taiwan, France, Denmark, the Netherlands, England, Australia and Germany, including the establishment of an international research consortium.14 Some of these studies are examining gradual reductions, or hyperbolic dose reductions specifically.14,35 Alongside this there are studies looking at how to help patients stop antidepressants - in the UK,36 the Netherlands37 and in Australia38 - as well as several published studies looking at substitutions for antidepressant treatment like preventative cognitive therapy or mindfulness-based cognitive therapy.39-41

There has been increasing interest in the process of stopping medication based on the pharmacological properties of the drugs,42-45 as well as in the practical means for making gradual dose reduction (for example, using compounded tablets in very small doses).46-48 There has also been increased focus on the non-pharmacological aspects of reducing and stopping medication - the positive and negative impact on people's lives, as well as the barriers and the facilitators.1,49-52

In parallel, there has been increasing institutional interest in deprescribing in some countries. In the UK, in recent years, there has been guidance issued by the Royal College of Psychiatrists on how to safely stop antidepressants,53 as well as guidance from NICE on how to stop antidepressants, benzodiazepines, z-drugs, opioids and gabapentinoids.54 Similar guidance on how to stop antipsychotics has been called for.55 In England, the National Health Service (NHS) has introduced structured medication reviews to reduce the use of unnecessary medication, including some psychiatric drugs,56 and the Department of Health and Social Care has been tasked with upscaling deprescribing capacity in the NHS.18

Many clinicians report an interest in deprescribing and in receiving training for its practice. In total, 75% of UK clinicians working in first-episode psychosis services thought that early discontinuation of antipsychotic medication was beneficial for most patients.57 In patients with multiple psychotic episodes English psychiatrists reported that they would feel comfortable supporting about 20% of their patients to discontinue their antipsychotics, with a minority of psychiatrists comfortable to support greater proportions.58 In a survey 68% of GPs expressed a desire for more training on the withdrawal effects of...