Dr. Swapnil Gupta, Dr. Sandra Steingard, and a team of researchers in the U.S. provide guidance on deprescribing from antipsychotic drugs (APs). Their approach, just recently published in Bentham Science Psychiatry Reviews, emphasizes a patient-centered process with shared decision-making, psychosocial support, and flexibility.
“In this paper, we utilize the framework of deprescribing to answer the questions of why and how to reduce and/or discontinue treatment with APs,” they write. “Prescribers have historically almost never considered the discontinuation of AP medications in persons with chronic psychotic disorders but a growing recognition of their side effects in addition to questionable long-term efficacy warrants an effort in this direction.”
In current guidelines, APs are described as a necessary step for the control of symptoms in individuals diagnosed with schizophrenia. It is recommended that APs should be started as soon as possible, and continued indefinitely. Gupta and her coauthors argue that the evidence backing these guidelines is “flawed and unequivocal at best.” Perhaps most notably, these guidelines fail to consider the potential neurological and metabolic side effects of APs, in addition to the increased mortality rate associated with their use.
Gupta and colleagues focus on deprescribing, defined by researchers as the “systemic process of identifying and discontinuing drugs in instances in which existing or potential harms outweigh existing or potential benefits taking into account medical status, the current level of functioning, patient values, and preferences.” They apply the process of deprescribing to psychiatry, specifically, pointing out that unlike other treatment scenarios, patient’s preferences regarding psychotropic drugs are particularly salient:
“In the absence of clear evidence-based guidelines, a patient’s values and preferences for the treatment of a psychotic disorder assume a greater weight in the decision-making process than for the treatment of coronary heart disease or hypertension.”
The authors begin their paper by questioning the evidence for the idea that relapse will inevitably occur if APs are discontinued. When APs are discontinued, the tapering procedures implemented often fail to consider important factors such as avoiding abrupt discontinuation, implementing psychosocial interventions, and tailoring the process to the individual patient. The authors also argue for an examination of outcomes that makes room for a fuller definition of recovery that includes patients’ autonomy, dignity, respect, community integration, and “normal” development. When these factors are considered, AP discontinuation has more promising recovery rates. Gupta and team quote the former director of the NIMH, Thomas Insel, and his acknowledgment of this recent evidence, on a recent post on his blog:
“Recently, results from several studies have suggested that these medications may be less effective for the outcomes that matter most to people with serious mental illness: a full return to well-being and a productive place in society.”
The “toxic psychosis” hypothesis is based on the idea that after one episode of psychosis, the brain becomes more susceptible to experiencing another episode. However, Gupta and team refer to studies showing that “AP’s may cause brain volume loss,” suggesting that the drugs may be implicated in future episodes. Other common practices such as polypharmacy, or the practice of combining APs to “improve treatment,” further complicate this picture. As individuals increase in age, they tend to also experience other medical complications. Given this increased risk, Gupta et al., argue that the significant side-effects associated with APs may begin to outweigh the potential benefit of continuing on the drugs.
Gupta and team highlight a patient-centered deprescribing process put forth by Reeve et al. (2014). It has since been adapted for use in psychiatry and is comprised of the following principles: “(1) Patient-centered care, (2) shared decision-making, (3) family involvement and other psychosocial interventions in psychosis, and (4) flexible and sensitive prescribing.”
Gupta et al. build upon these five steps to propose the following additional measures:
- The persons’ history should be thoroughly reviewed with information collated from multiple sources, and old charts to develop an individualized list of early signs of relapse and prepare early interventions.
- Preferences for care should be solicited from the patient as well as from their friends, family, and clinical team. This step is noted as “critical to ensure the success of the deprescribing intervention.”
- Before beginning to taper, a plan for monitoring changes in “mental state” should be developed. This is because individuals deprescribing from APs may experience withdrawal symptoms, such as insomnia, transient hallucinations, anxiety, and fleeting paranoid thoughts.
- Psychotherapeutic interventions should be initiated before the taper begins. Psychotherapy can bolster attempts to identify early, unwanted signs of relapse as well as address issues that might make relapse difficult, such as comorbid substance use.
- Changes to AP dosage should be made to only one medication at a time. In this step, Gupta and team describe the “withdrawal psychosis” or the “dopamine supersensitivity psychosis” phenomenon that can be mistaken for relapse but is actually a sign of increased dopamine sensitivity that may arise if APs are stopped too abruptly after prolonged use.
- Regular follow-ups to review and readjust the rate of taper are “an essential component of deprescribing.”
The researchers also outline challenges that may arise in the deprescribing process:
“A prescriber may face both systemic and individual challenges while considering deprescribing antipsychotic medications. Some of the systemic challenges include the lack of guidelines and training for the process and often, the lack of peer support.”
These institutional obstacles can pressure prescribers to make changes out of fear that symptoms are reappearing. Patients, on the other hand, may have a difficult time adjusting to these changes, particularly if they have been using APs for an extended amount of time.
The researchers conclude:
“Open Dialogue (OD) approaches crisis intervention and ongoing care for young people experiencing psychosis by engaging the individual and family (or other supports) in meetings and conducting open discussions of all aspects of the clinical situation and decision making. This approach has been shown to result in good clinical outcomes, higher satisfaction with care and shared decision-making”
Gupta, S., Steingard, S., Aracena, E.F.G., & Fathy, H. (2018). Deprescribing antipsychotic medications in psychotic disorders: How and why? Betham Science, 14, 26-21. (Link)