Psychiatric Deprescribing: A Narrative Review

Abstract

OBJECTIVE:

Psychiatric deprescribing is an intervention where psychiatric medications are reduced or discontinued with the goal to improve health and reduce unnecessary risks. The purpose of this study was to synthesize the literature related to psychiatric deprescribing to discuss practice and research implications.

METHODS:

A structured search of the literature was conducted from May to September 2022, yielding 29 articles meeting inclusion criteria. Articles were reviewed and synthesized.

RESULTS:

Psychiatric deprescribing is a complex process with many potential facilitators and barriers. The extant literature provides insight into current gaps in knowledge and implications for clinical practice and research.

CONCLUSIONS:

In current clinical practice, psychiatric deprescribing is a priority but there are significant barriers. Several areas of future research could be pursued to better support evidence-based practice in this area.

Keywords

deprescriptions polypharmacy drug tapering mental disorders

Get full access to this article

View all access options for this article.

References

Agency for Healthcare Research and Quality. (2022). Number of people with purchase in thousands by therapeutic class, United States 1996-2020, Medical Expenditure Panel Survey. https://datatools.ahrq.gov/meps-hc?type=tab&tab=mepshcpd

American Psychiatric Association. (2020). Practice guideline for the treatment of patients with schizophrenia (3rd ed.). https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890424841

Branford

Parker

(2020). Deprescribing in mental health care. Journal of Prescribing Practices, 2(8), 460–465. https://doi.org/10.12968/jprp.2020.2.8.460

Brody

D. J.

(2020). Antidepressant use among adults: United States, 2015–2018 (NCHS Data Brief, No. 377). National Center for Health Statistics. https://www.cdc.gov/nchs/data/databriefs/db377-H.pdf

Commonwealth of Massachusetts. (2019). MassHealth drug list. https://mhdl.pharmacy.services.conduent.com/MHDL/pubintro.do?category=Introduction+to+MassHealth+Drug+List

Coughlin

Goldie

C. L.

Tregunno

Tranmer

Kanellos-Sutton

Khalid-Khan

(2018). Enhancing metabolic monitoring for children and adolescents using second-generation antipsychotics. International Journal of Mental Health Nursing, 27(3), 1188–1198. https://doi.org/10.1111/inm.12417

Davidson

(2016). The recovery movement: Implications for mental health care and enabling people to participate fully in life. Health Affairs, 35(6), 1091–1097. https://doi.org/10.1377/hlthaff.2016.0153

Fineberg

S. K.

Gupta

Leavitt

(2019). Collaborative deprescribing in borderline personality disorder: A narrative review. Harvard Review of Psychiatry, 27(2), 75–86. https://doi.org/10.1097/HRP.0000000000000200

Framer

(2021). What I have learnt from helping thousands of people taper off antidepressants and other psychotropic medications. Therapeutic Advances in Psychopharmacology, 11, 2045125321991274. https://doi.org/10.1177/2045125321991274

10.

Gannon

J. M.

Lupu

Brar

Brandt

Zawacki

John

Carl

Chengappa

K. N. R.

(2021). Deprescribing anticholinergic medication in the community mental health setting: A quality improvement initiative. Research in Social & Administrative Pharmacy: RSAP, 17(10), 1841–1846. https://doi.org/10.1016/j.sapharm.2020.12.010

11.

Groot

P. C.

van Os

. (2020). How user knowledge of psychotropic drug withdrawal resulted in the development of person-specific tapering medication. Therapeutic Advances in Psychopharmacology, 10, 2045125320932452. https://doi.org/10.1177/2045125320932452

12.

Guina

Merrill

(2018). Benzodiazepines II: Waking up on sedatives: Providing optimal care when inheriting benzodiazepine prescriptions in transfer patients. Journal of Clinical Medicine, 7(2), 20. https://doi.org/10.3390/jcm7020020

13.

Gupta

Miller

Cahill

J. D.

(2019). Deprescribing in psychiatry. Oxford University Press.

14.

Hall

(2019). Psychiatric medication withdrawal: Survi-vor perspectives and clinical practice. Journal of Human-istic Psychology, 59(5), 720–729. https://doi.org/10.1177/0022167818765331

15.

Harding

(2023). Supported decision making: Skills and tools for clinical practice. The Journal for Nurse Practitioners, 19(4), 104497.

16.

Hawkins

E. J.

Lott

A. M.

Danner

A. N.

Malte

C. A.

Hagedorn

H. J.

Berger

Donovan

L. M.

Sayre

G. G.

Mariano

A. J.

Saxon

A. J.

(2021). Primary care and mental health prescribers, key clinical leaders, and clinical pharmacist specialists’ perspectives on opioids and benzodiazepines. Pain Medicine, 22(7), 1559–1569.

17.

Hibner

T. A.

Wakefield

A. N.

Eaves

S. M.

Gonzalvo

J. D.

Macik

M. R.

Williams

G. D.

(2020). Metabolic monitoring of second-generation antipsychotics: Evaluation of a pharmacist- and nurse-driven protocol. Journal of the American Pharmacists Association, 60(5S), S88–S92. https://doi.org/10.1016/j.japh.2020.04.016

18.

Keeshin

B. R.

Monson

(2022). Assessing and responding to the trauma of child maltreatment. Focus, 20(2), 176–183.

19.

Kendrick

(2021). Strategies to reduce use of antidepressants. British Journal of Clinical Pharmacology, 87(1), 23–33. https://doi.org/10.1111/bcp.14475

20.

Kukreja

Kalra

Shah

Shrivastava

(2013). Polypharmacy in psychiatry: A review. Mens Sana Monographs, 11(1), 82–99. https://doi.org/10.4103/0973-1229.104497

21.

Lin

S. K.

(2020). Antipsychotic polypharmacy: A dirty little secret or a fashion? The International Journal of Neuropsychopharmacology, 23(2), 125–131. https://doi.org/10.1093/ijnp/pyz068

22.

Lupu

A. M.

MacCamy

K. L.

Gannon

J. M.

Brar

J. S.

Chengappa

K. N. R.

(2021). Less is more: Deprescribing anticholinergic medications in persons with severe mental illness. Annals of Clinical Psychiatry: Official Journal of the American Academy of Clinical Psychiatrists, 33(2), 80–92. https://doi.org/10.12788/acp.0019

23.

Matsui

Tokumasu

Takekita

Inada

Kanazawa

Kishimoto

Takasu

Tani

Tarutani

Hashimoto

Yamada

Yamanouchi

Takeuchi

(2019). Switching to antipsychotic monotherapy vs. staying on antipsychotic polypharmacy in schizophrenia: A systematic review and meta-analysis. Schizophrenia Research, 209, 50–57.

24.

Maund

Stuart

Moore

Dowrick

Geraghty

A. W. A.

Dawson

Kendrick

(2019). Managing antidepressant discontinuation: A systematic review. Annals of Family Medicine, 17(1), 52–60. https://doi.org/10.1370/afm.2336

25.

Morant

Kaminskiy

Ramon

(2015). Shared decision making for psychiatric medication management: Beyond the micro-social. Health Expectations, 19(5), 1002–1014. https://doi.org/10.1111/hex.12392

26.

Nguyen

M. L.

Sunderland

Lim

Hattingh

Chalmers

(2022). A qualitative exploration of factors contributing to non-guideline adherent antipsychotic polypharmacy. Research in Social & Administrative Pharmacy: RSAP, 18(3), 2457–2467. https://doi.org/10.1016/j.sapharm.2021.03.014

27.

O’Brien

Rapp

J. T.

Kierce

E. D.

(2020). Do prescribers deprescribe psychotropic medication for children in foster care? Developmental Child Welfare, 2(1), 3–20. https://doi.org/10.1177/2516103219899668

28.

Ostrow

Jessell

Hurd

Darrow

S. M.

Cohen

(2017). Discontinuing psychiatric medications: A survey of long-term users. Psychiatric Services, 68(12), 1232–1238. https://doi.org/10.1176/appi.ps.201700070

29.

Paudel

Vyas

C. M.

Stern

T. A.

(2020). A prescription for deprescribing antipsychotics: Managing polypharmacy in schizophrenia. The Primary Care Companion for CNS Disorders, 22(6), 20f02708. https://doi.org/10.4088/PCC.20f02708

30.

Pierre

J. M.

(2018). Real-world challenges in managing “dual diagnosis” patients: Diligent assessment and judicious prescribing can help optimize outcomes. Current Psychiatry, 17(9), 25–32.

31.

Pottie

Thompson

Davies

Grenier

Sadowski

C. A.

Welch

Holbrook

Boyd

Swenson

Farrell

(2018). Deprescribing benzodiazepine receptor agonists: Evidence-based clinical practice guideline. Canadian Family Physician, 64(5), 339–351.

32.

Rhee

T. G.

Rosenheck

R. A.

(2019). Psychotropic polypharmacy reconsidered: Between-class polypharmacy in the context of multimorbidity in the treatment of depressive disorders. Journal of Affective Disorders, 252, 450–457. https://doi.org/10.1016/j.jad.2019.04.018

33.

Rice

J. N.

Gillett

C. B.

Malas

N. M.

(2018). The impact of psychotropic medications on bone health in youth. Current Psychiatry Reports, 20(11), 104. https://doi.org/10.1007/s11920-018-0960-5

34.

Rundell

Oza

Greco

Cruzado

E. O.

(2019). Caring for patients with co-occurring mental health & substance use disorders. Journal of Family Practice, 68(7), 400–404.

35.

Safer

D. J.

(2019). Overprescribed medications for US adults: Four major examples. Journal of Clinical Medicine Research, 11(9), 617–622. https://doi.org/10.14740/jocmr3906

36.

Scholten

Batelaan

Van Balkom

(2020). Barriers to discontinuing antidepressants in patients with depressive and anxiety disorders: A review of the literature and clinical recommendations. Therapeutic Advances in Psychopharmacology, 10, 2045125320933404.

37.

Scrandis

D. A.

Duarte

A. C.

(2019). Deprescribing benzodiazepines. The Nurse Practitioner, 44(2), 12–14. https://doi.org/10.1097/01.NPR.0000550253.04526.30

38.

Shapiro

B. B.

(2018). Subtherapeutic doses of SSRI antidepressants demonstrate considerable serotonin transporter occupancy: Implications for tapering SSRIs. Psychopharmacology, 235(9), 2779–2781. https://doi.org/10.1007/s00213-018-4995-4

39.

Soler

Casellas-Pujol

Fernández-Felipe

Martín-Blanco

Almenta

Pascual

J. C.

(2022). “Skills for pills”: The dialectical-behavioural therapy skills training reduces polypharmacy in borderline personality disorder. Acta Psychiatrica Scandinavica, 145(4), 332–342. https://doi.org/10.1111/acps.13403

40.

Steingard

(2018). Five year outcomes of tapering antipsychotic drug doses in a community mental health center. Community Mental Health Journal, 54(8), 1097–1100. https://doi.org/10.1007/s10597-018-0313-1

41.

Stutzman

D. L.

(2021). Long-term use of antidepressants, mood stabilizers, and antipsychotics in pediatric patients with a focus on appropriate deprescribing. The Mental Health Clinician, 11(6), 320–333. https://doi.org/10.9740/mhc.2021.11.320

42.

Substance Abuse and Mental Health Services Administration. (2021). Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health (HHS Publication No. PEP21-07-01-003, NSDUH Series H-56). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf

43.

Tomova

Hale

Kruschandl

(2021). Deprescribing in mental health: Pragmatic steps for a better quality of life. Journal of Prescribing Practice, 3(2), 60–66. https://doi.org/10.12968/jprp.2021.3.2.60

44.

Wright

D. J.

Scott

Buck

Bhattacharya

(2019). Role of nurses in supporting proactive deprescribing. Nursing Standard, 34(3), 44–50. https://doi.org/10.7748/ns.2019.e11249

45.

Zablotsky

Terlizzi

E. P.

(2020). Mental health treatment among children aged 5–17 years: United States, 2019 (NCHS Data Brief, No. 381). National Center for Health Statistics.