Taking Deprescribing One Step at a Time
When deprescribing, psychiatrists must consider a broad range of individual, environmental, and risk factors for the patient.
Add together drug-drug interactions, large doses of individual medications, age-related changes in drug metabolism, and multiple comorbidities, and the result is a high risk of inappropriate polypharmacy. Yet the standard way of deprescribing—reviewing the patient’s medications, identifying which ones should be stopped, and planning a deprescribing regimen such as a taper—does not fully account for the needs of patients with mental illness, according to experts speaking at APA’s Mental Health Services Conference.
“The three-step approach doesn’t really resonate with me, because it doesn’t reflect what I see in my clinical practice,” said Heather Wobbe, D.O., M.B.A., director of emergency psychiatry at Summa Health in Akron, Ohio.
Individual factors, environmental factors, and risk are especially important considerations in deprescribing in psychiatry, said Heather Wobbe, D.O., M.B.A.
Terri D’Arrigo
Special Considerations
Citing a 2016 paper in Psychiatric Services, Wobbe described the special considerations for deprescribing in psychiatry as falling into three buckets: individual factors, environmental factors, and risk.
Individual differences involve timing (when a medication should be deprescribed), how the patient makes meaning of their illness, the strength of the alliance between the patient and care team, and the patient’s coping strategies. “What someone needs at one point in life to stay stable from a mental health perspective may not be what they need now, but you also have to think about patient preferences and the potential rebound effects of deprescribing,” Wobbe said.
Environmental factors include housing, finances, employment, relationships, and season. “I’m from Ohio, and I [think twice] about taking patients off antidepressants in winter because it usually doesn’t work. If you changed up a patient’s medications right after they get fired, that probably isn’t going to go so well either,” Wobbe said. “That’s the reality of it.”
Risks that psychiatrists must consider include relapse, hospitalizations, suicide/homicide, and mandated treatment. “The risk of destabilization is a lot higher for some patients than for others,” Wobbe said.
“If you know your patient has an extensive history of suicide attempts, you have to take that very seriously,” she said. “If a patient sells their house, gets divorced, and moves to Vegas, you’d want to be more cautious with [deprescribing for] them than someone whose manic episodes are less severe.”
Dwight Kemp, M.D., M.S., a psychiatrist in the extended care unit at Kings County Hospital in New York, noted that older patients have their own age-specific risks to consider with medications—such as the increased risk of falls when taking benzodiazepines.
“If a senior falls, there is a risk of head injury, a broken hip, and other events that require hospitalization, which then raises the risk of delirium,” Kemp said. “Long-term use of benzodiazepines is also associated with cognitive impairment.”
Psychiatrists should consider where the opportunities for deprescribing lie, such as admission or discharge from the hospital, said Dwight Kemp, M.D., M.S.
Terri D’Arrigo
Yet one size does not fit all for deprescribing for older patients. “Geriatric patients are some of the most diverse patients we have,” Kemp said. “If you’ve seen one 71-year-old, you’ve seen one 71-year-old. Some are relatively healthy, active, and thriving, and others have lots of comorbidities.”
Step by Step
Wobbe described seven steps for psychiatric deprescribing as outlined in the Psychiatric Services paper:
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Choose the right time: Avoid times of crisis, ensure the patient has social supports to quickly identify and manage a relapse, and use caution if a patient is actively using substances.
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Compile a list of all the patient’s medications: Document dose, route, expected duration, original indication, and current therapeutic and adverse effects; estimate potential drug-drug interactions and the future risk-benefit ratio of the deprescribing.
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Initiate a discussion with the patient: Explore the meaning of illness and the meaning of medications with the patient; find out the patient’s beliefs about the role, risks, and benefits of medication; and explore the idea of managing the illness without medication.
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Introduce deprescribing to the patient: Inform the patient about potential indications for and the process of deprescribing, get insight into the patient’s past deprescribing history and periods when the patient didn’t take medications as prescribed, solicit the patient’s concerns, and get the patient’s buy-in.
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Identify which medication(s) would be most appropriate for deprescribing: Discuss treatment guidelines and evidence, collaboratively weigh the pros and cons of deprescribing each medication, target unjustifiable polypharmacy, and solicit the patient’s preferences.
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Develop a plan: Set a start date and rate of taper, consider whether switching to another medication is indicated, tell the patient about the possible effects of discontinuing the medication, and agree on monitoring, a follow-up schedule, and a crisis plan.
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Monitor the patient and adapt as necessary: Adjust the rate of taper, treat discontinuation syndrome or relapse, and if needed, stop or defer deprescribing.
Kemp encouraged psychiatrists to consider their workflow and where the opportunities might lie for deprescribing.
“When a person is admitted or discharged from the hospital, that can be a time to do a comprehensive review of their medications, so you can consider whether there are things you need to eliminate,” he said. “See if it’s possible to put a pop-up in the electronic medical record that says [when] it’s time to review medications or consider deprescribing. ■
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Published online: 22 November 2024
Published in print: December 1, 2024 – December 31, 2024
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