When is deprescribing psychotropic medications appropriate?

Doctors must have greater recognition of treatment endpoints for patients prescribed psychotropic medications, according to an international panel of experts.
 
In a study published in JAMA Network Open, researchers formed an ‘international taskforce’ of 45 psychopharmacology experts, including Australians, to identify agreed circumstances that would warrant the deprescribing of psychotropic medications to treat mental illnesses.
 
The panel agreed that initial prescribing, renewing, and deprescribing of the medications should be viewed as a ‘fluid’ process with ‘active oversight and collaboration with patients’ across the course of their illness.
 
According to the study, deprescribing should be considered when benefits are absent, or the risks outweigh the benefits.
 
However, this must only be done after ensuring patients are adhering to the medication, and after considering the psychosocial ramifications of stopping.
 
‘There is a need for greater recognition of clinical psychopharmacology endpoints, including instances where specific psychotropic medications may become unnecessary, redundant, contradictory, or otherwise inappropriate and therefore merit deprescribing,’ researchers wrote.
 
Dr Karen Spielman, Chair of RACGP Specific Interests Psychological Medicine, said this research highlights the importance of a ‘careful and informed process’ of both prescribing and deprescribing psychotropic medications.
 
‘As GPs we are on the frontline of managing distress and mental health concerns in our patients and we play an important role in understanding and contextualising each person’s experience,’ she told newsGP.
 
‘It is important to understand medication is but one option for treatment that can be extremely helpful when carefully and appropriately managed, but that it can also, like many treatments, cause harm and we need to take time to inform and share decision making with our patients.
 
‘Our skill in longitudinal and whole-person care is key here.’

The expert panel also called for monitoring and periodic review of patients on these medications.
 
‘Panellists unanimously agreed that components of a pharmacotherapy regimen should undergo periodic review to ensure that treatments target relevant symptoms and have favourable risk-benefit ratios,’ the authors wrote.
 
Dr Spielman said follow up and access to ongoing care and support is vital.
 
‘Regular reviews as per prescribing guidelines and implementation of non-drug treatments like therapy and lifestyle measures are important, together with stepped care and collaboration with our psychiatrist colleagues, when necessary,’ she said.
 
‘Once these scaffolds are in place the decision to deprescribe becomes part of routine management, in other words regular reviews of efficacy and side effects and discussion of length of treatment is part of each consultation.’
 
Among key points of agreement raised in the research, international panellists emphasised that risk-benefit decisions should ‘ideally involve active patient participation within a shared decision-making model’.
 
Dr Spielman said this is an important point, as regaining self-efficacy is essential to improving overall wellbeing.
 
‘I tell my patients the days of doctors telling them what to do are long over, and that we see ourselves as helping them to make decisions by informing and empowering them,’ she explained.
 
‘They should be very active in decision making and I aim for care that is collaborative and enhances their agency.’
 
Dr Spielman added the review’s findings align with and support current RACGP guidelines.
 
The college recently released a guide for GPs on the long-term use of antidepressants without careful review as well as a patient resource to support a best practice approach to deprescribing antidepressant medications.
 
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