What is Evidence-based Medication Deprescribing?
Evidence-based medication deprescribing is the systematic process of tapering or stopping medications guided by research evidence, clinical guidelines, and the systematic evaluation of each medication's ongoing appropriateness for a patient. Healthcare providers evaluate each medication against current research and clinical evidence, considering whether the original indication still exists, whether benefits continue to outweigh harms, and whether treatment goals have changed. This process is aimed at eliminating or reducing medications that may no longer be beneficial, may be causing harm, may be duplicative, or where the risks outweigh the benefits. Evidence-based deprescribing relies on research studies, systematic retrospective reviews, and clinical trials that examine outcomes when medications are prescribed, reduced, or discontinued. This includes evidence about safe tapering protocols and potential withdrawal side effects. Evidence-based deprescribing follows structured protocols that specify how to safely taper medications, what monitoring is needed, and what outcomes to expect. Research has demonstrated that when done appropriately, medication deprescribing can reduce adverse events, improve quality of life, and sometimes even reduce mortality without worsening the conditions the medications were treating.
Why Deprescribing Matters in Psychiatry
Several compelling reasons make medication deprescribing an essential consideration in psychiatric practice. Polypharmacy, the use of multiple medications simultaneously, has become increasingly common in psychiatry. Patients may accumulate medications over years, with each new symptom or side effect potentially leading to another prescription. This cascade can result in complex medication regimens that become difficult to manage and may actually worsen outcomes rather than improve them. Psychiatric medications, like all drugs, carry potential side effects. Antipsychotics (such as Seroquel, Abilify, Risperidal, Zyprexa, Latuda, and Invega; brand names) can cause metabolic syndrome (a cluster of conditions that occur together and increase your risk of heart disease, stroke, and type 2 diabetes) and movement disorders (neurological conditions characterized by abnormal voluntary or involuntary movements). Mood stabilizers (such as Lithium, Depakote, Lamictal, Tegretol, and Trileptal; brand names) may negatively affect kidney, liver, and thyroid function. Benzodiazepines (such as xanax, Ativan, Klonopin, Valium, and Restoril; brand names) carry risks of dependence, cognitive impairment, and the possibility of fatal outcomes if abruptly stopped. When medications are no longer serving their intended purpose, these risks become harder to justify their continued use.
Additionally, some conditions may genuinely improve or remit over time, while life circumstances change in ways that may reduce the need for medication. A person who required intensive pharmacological support during a particularly difficult period may find that benefit from psychotherapy (talk therapy), lifestyle changes, or improved social support have reduced their need for the same level of medication. Additionally, the financial burden of psychiatric medications can be substantial, and for some patients, simplifying their regimen can significantly improve both their quality of life and their ability to adhere to truly necessary and beneficial treatments.
The Challenges of Psychiatric Medication Deprescribing
Deprescribing in psychiatry presents unique challenges that distinguish it from that in other medical specialties. Foremost is the understandable anxiety both patients and clinicians may have about the possible destabilization of someone's mental health. Such destabilization can have serious negative consequences to ones life. Additionally, the subjective nature of many psychiatric symptoms makes it difficult to establish clear markers for improvement or stability. Unlike measuring blood pressure or blood glucose, assessing mental state requires careful attention to subtle changes in patterns of emotions, thoughts, and behaviors. Additionally, many psychiatric medications can produce significant withdrawal symptoms or discontinuation syndrome. Antidepressants, particularly SSRIs (such as Zoloft, Lexapro, Prozac, Celexa, and Paxil; brand names) and SNRIs (such as Effexor, Cymbalta, and Pristiq; brand names), can cause discontinuation symptoms that may be mistaken for relapse. Discontinuation syndrome is a cluster of physical and psychological symptoms that occur when certain medications, particularly antidepressants (SSRI’s and SNRI’s), are stopped abruptly or tapered too quickly after regular use. Common Symptoms are Physical: dizziness, nausea, headache, fatigue, flu-like symptoms, "brain zaps" (electric shock sensations), tremor, sweating; Psychological: anxiety, irritability, mood swings, insomnia, vivid dreams, confusion; or Sensory: balance problems, visual disturbances, tingling sensations. Benzodiazepines and certain other medications require extremely gradual tapering to avoid dangerous or potentially fatal withdrawal effects. There is also the phenomenon of psychological dependence on medication, not in the sense of addiction, but rather the security that being on a medication targeted to treat certain symptoms can provide. A person may fear that they cannot function without their medications, even when evidence suggests otherwise.
When to Consider Medication Deprescribing
Several situations warrant consideration of medication deprescribing in psychiatric practice. When someone is taking a medication that was prescribed for a time-limited indication, but has continued indefinitely, it is worth reassessing whether it remains necessary. This commonly occurs with sleep medications or anti-anxiety agents prescribed during acute stressful times. If a patient’s sleep and symptoms have been stable for an extended period of time and has developed stronger coping skills, psychological resilience, and enhanced social support, a trial reduction may be appropriate. When medications were layered on sequentially to address side effects of other medications, simplifying the regimen by removing the initial offending agent may allow other medications to be discontinued as well. Additionally, medications prescribed during diagnostic uncertainty that have not shown clear benefit after an adequate trial should be reconsidered for potential deprescribing. Life transitions such as pregnancy planning, aging, or development of medical conditions that interact with psychiatric medications may also necessitate initiating a deprescribing protocol.
Best Practices for Safe Medication Deprescribing
Successful deprescribing requires a thoughtful, collaborative, and evidence-based approach. The decision to deprescribe a medication should always involve shared decision-making between the psychiatrist and the patient. Understanding the patient’s goals, fears, and preferences is essential. Some patients may be eager to reduce medications, while others may need considerable reassurance and support. When appropriate to taper, an evidence-based gradual reduction is almost always preferable to abrupt discontinuation in psychiatry. The rate of tapering should be individualized based on the medication, duration of use, patient history, and response to reductions. Some medications may require tapering over many months. Close monitoring during the deprescribing process is crucial, with more frequent check-ins than might be needed during stable maintenance treatment. This allows for early detection of withdrawal symptoms or emerging signs of symptom relapse. Patients should be educated about what to expect during the process, including potential discontinuation symptoms, how to distinguish those from relapse, and when to seek help. Having a clear plan for what to do if problems arise can reduce anxiety and improve safety. Ensuring patients have strong non-pharmacological supports in place, such as psychotherapy, lifestyle interventions, social support, and stress management techniques, can make medication deprescribing more successful and sustainable.
The Role of Hyperbolic Medication Tapering
Recent research has highlighted that the traditional approach of reducing medications by a fixed percentage over a particular timeframe may not align with how the body responds to dose changes. Hyperbolic or gradual tapering, where dose reductions become smaller as the total dose decreases, may better account for receptor occupancy dynamics (how drugs binding to receptors changes over time) and reduce withdrawal symptoms. Understanding these dynamics helps predict dosing schedules, drug interactions, tolerance development, and why some drugs have long-lasting effects even after they are cleared from the bloodstream. While more research is needed, this approach shows promise particularly for medications like antidepressants, antipsychotics and benzodiazepines.
Looking Forward
Medication deprescribing deserves greater emphasis in psychiatric training and practice. Just as clinicians develop skills in choosing appropriate medications and dosages, they should cultivate expertise in safely reducing and discontinuing medications when appropriate. This requires overcoming therapeutic inertia, the tendency to continue existing treatments even when they may no longer be optimal. Additionally, psychiatrists and patients' fears of possible symptom relapse must be considered, but not prevent the use of evidence-based medication decision-making. The goal is not to minimize medication use for its own sake, but rather to ensure that every medication a patient takes serves a clear purpose and provides benefits that greatly outweigh risks and burdens. For some patients, this may mean long-term or even lifelong medication use. For others, it may mean successfully reducing or eliminating medications that are no longer needed. Psychiatry must embrace medication deprescribing as an integral component of comprehensive care, one that honors the complexity of mental health conditions while respecting patients' autonomy and optimizing their overall well-being. As the field of psychiatry continues to evolve, thoughtful, evidence-based medication deprescribing done collaboratively, carefully, and with appropriate support, represents not a rejection of pharmacotherapy, but rather its maturation into a more nuanced and person-centered practice.
