New Research on Patient-Centered Deprescribing for Antipsychotics

Researchers review the risks and benefits of deprescribing from antipsychotic drugs and advocate for a patient-centered approach to tapering.

Zenobia Morrill
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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.”

Photo Credit: Flickr

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”

 

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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)

8 COMMENTS

  1. Since the “antipsychotics” are anticholinergic drugs, and the anticholinergic drugs are medically known to create “psychosis,” via anticholinergic toxidrome, it absolutely is a good idea not to force these “psychosis” creating “antipsychotics” onto anyone, ever.

    And they should not be called “antipsychotics” because this name, no doubt, deludes the mental health practicers into thinking this drug class gets rid of “psychosis,” rather than allowing the mental health practicers to comprehend reality, which is that the “antipsychotics” create “psychosis.”

    https://en.wikipedia.org/wiki/Toxidrome

    “CIA Flashback: ‘We’ll Know Our Disinformation Program Is Complete When Everything the American Public Believes Is False.'” The mental health practicers really were deluded. WAKE UP!

    So, of course, getting people off of these “psychosis” creating drugs is of paramount societal importance. I personally recommend getting the millions and millions of child abuse victims that have been misdiagnosed with the other DSM disorders off these drugs first, since of course child abuse is a crime and a legitimate cause of distress, not a brain disease. That would include 80 plus percent of those who were mislabeled with the “psychotic and affective disorders” and 90 plus percent of the “borderline” misdiagnosed.

    https://www.madinamerica.com/2016/04/heal-for-life/

    Why all this misdiagnosis of child abuse survivors?

    https://www.psychologytoday.com/us/blog/your-child-does-not-have-bipolar-disorder/201402/dsm-5-and-child-neglect-and-abuse-1

    I do so hope the mental health practicers soon stop breaking the law by turning child abuse survivors into the mentally ill with the psychiatric drugs en mass, since this is of course illegal behavior. And we are living through an American psychiatric holocaust of our society’s weakest members right now, which is morally repugnant.

    https://www.naturalnews.com/049860_psych_drugs_medical_holocaust_Big_Pharma.html

    I am glad you mentioned “the ‘withdrawal psychosis’ or the ‘dopamine supersensitivity psychosis’ phenomenon that can be mistaken for relapse.” Since this phenomenon is not a “return of the illness,” as millions of doctors no doubt have already misdiagnosed this phenomenon.

    I must say, I do now understand why when I was going through my “withdrawal psychosis,” which functioned as a spiritual journey for me, I do now understand why Jesus supposedly said “all the doctors are going to hell.” I do recommend the doctors and mental health practicers, who have misdiagnosed and made millions and millions of child abuse survivors and their family members sick with these neurotoxins, do utilize your malpractice insurance for what it is intended. Jesus preached repentance for forgiveness, not free forgiveness for stupid, delusional, child abuse covering up and profiteering doctors. “Don’t say I didn’t, say I didn’t, warn you.”

  2. In the second paragraph above, (below the photo of the pills & toy soldier), there’s what can only be a typo, although it’s in quotation marks. Where it says, “flawed and unequivocal at best.”, that “un” must be an error.
    “Flawed and equivocal” makes sense in context. “Flawed and unequivocal” makes NO sense in context.
    In plain English, psychiatric drugs are much less necessary, less safe, and less effective than the psychs and PhRMA want you to believe.
    In my own case, an abrupt, “cold turkey” withdrawal from “AP”‘s resulted in a near-fatal toxic withdrawal reaction. As is typical, the psychs mis-diagnosed the drug withdrawal as so-called “mental illness”.
    This is yet another example of why I proclaim the TRUTH. Psychiatry is a pseudoscience, a drugs racket, and a means of social control. It’s 21st Century Phrenology with potent neurotoxins. Psychiatry and its’ poison pills have done, and continue to do, far more harm than good. Only with more than 2 decades of recovery can I be so sure of what I know to be true. Most of the more severe “symptoms” I experienced occurred AFTER I was put on psych drugs in High School. And in the 2+ decades that I’ve been psychiatry and drug free, my so-called “symptoms” have almost completely disappeared. Gee, Doc, what happened to my (supposed) “mental illness”? The longer I avoid psychiatry and its’ poison pills, the more whole, healthy, and happy I become.
    It’s so sad. Folks I met 30 years ago in the loony bin, are now shuffling, shaking, drooling, and totally dysfunctional. Long-term use of “AP”‘s, with very few exceptions, (there MUST be SOME….), ALWAYS results in worse outcomes….
    When will you people learn?

  3. Zenobia you 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.”

    And I congratulate you on presenting these signs and symptoms that prescriptive medicine may be waking up from its nightmarish history of a word recognition, philosophy. Words like person-centered for instance, which sounds very good and even looks well on a paper of academic word formulations.

    Ah! “the infinite possibility of 20 characters or more, laid upon a page?” Who said that?

    While just this morning, Australia is outraged by TV revelations about this country’s aged care system, with so-called experts fronting TV camera’s to parrot words like person-centered. We Believe! Crys the upper management team of the aged care system, yet when pressed on the time management economics of staff allowed ten minutes to wash and dress frail elderly people each morning. The psychological response was, “well everybody is different!”

    Yet my point in making this comment on your well, word formulated article is, at age 80+ we all return to the foundations of our psychological sense-of-self, our body. And our common anatomy begins to give the lie to this heady sense of self that created by our early-life adaptation to numeracy and literacy.

    And having worked as a counselor trying to help people with addiction issues, I respectfully suggest that well-educated people like your good self, are addicted to seeing numbers and words and struggle with the more challenging issue of being truly-present within yourself and therefore with others.

    This article, like the one written by Will Hall; Did You Ever Stop Taking Antipsychotics, reminds of a report here in Australia about our much-venerated intervention program for first episode psychosis, HeadSpace. When venerated experts called for more funding, more research without once mentiong the telling words: results were marginally better than people getting no treatment.

    And as a long-term survivor now in my eleventh year of non-drug ‘affected’ (not a typo) self-regulation, I can’t remember how times I stopped taking AP’s, which are not antipsychotic drugs but are neuroleptics that clamp the nervous system. I get a little tired of these “we need to make a living in mental health” research papers from people who cannot give a first-person account of how their own thoughts are energized.

    But, I get it, for I was stuck in my head for many a long decade too, certain that I knew myself because I could recall to mind, numbers, and words, like my name and age. While this survivor comment will be perceived as little more than a whining criticism, I expect.

    I do recall R. D. Laing’s warning about the stupidity of perceiving subjectively gathered and subjectively (third-person – outside looking in a dichotomy of the conscious mind) data being regarding as Objective.

    And as I wrote in the comment section, which Stephen Fry, the much-loved narrator of The Secret Life of The Manic-Depressive, once said is people who really need to get a life. (no wonder Will didn’t respond)

    DATA DATA! SHOW US THE TRUTH! WE GOT A BAD CASE OF LOVING YOU!

    But hey, we all need to make a living, somehow. For those interested in the reporting on Australia’s Headspace program and the economics of healthcare provision, mental or otherwise, the promo and link are here:

    “Australia’s flagship youth mental health program Headspace is only providing a “small” benefit to clients, a major study has revealed, while the wellbeing of about one in 10 of its patients is going significantly backwards.

    The University of New South Wales evaluation concluded “Headspace has a small program effect”, saying results were marginally better than people getting no treatment or being treated privately.

    “While some evaluation findings are mixed, results show that there are small improvements in the mental health of Headspace clients relative to two matched control groups,” it said.”

    http://www.abc.net.au/news/2016-12-16/headspace-only-small-benefit-for-youth-mental-health/8125698

  4. As regards Dopamine Supersensitivity Syndrome – Once a person can recognise a route out of the ‘Catastrophy’ they’re mostly cured.

    I would recommend Eckhart Tolle in the ‘Power of Now’s’ approach to the ‘Pain Body’ (the store of unresolved grief that can arise and overwhelm any normal person).

    I recommend Eckhart Tolle because he explains things very well and his advice works.

  5. I am not entirely clear if many of the commentators and possibly the author herself has seen severe mental illness on a daily basis. I have had the opportunity to work with those deemed incompetent to stand trial due to psychosis, in a state residential facility for those with severe IDD and autism (non-verbal with IQ less than 30) and in a prison psychiatric hospital in a high-security pod with Death Row offenders. I have also trained at a state hospital. Regularly I see patients who lose insight and stop taking their medications. They stop eating as they believe their food is poisoned. They lose weight and become violent and self-injurious. They stop taking showers and smear feces in their cells. They stop taking their medications for diabetes and hypertension. You see the increase in symptoms. After restarting their antipsychotics, they stop smearing feces and their smile returns. They no longer assault others.

    The assertion that prescribers never consider “deprescribing” does not take into account that those with SMI regularly “deprescribe” on their own. The assertion does not account for those with severe schizophrenia, complicated by severe ASPD marked by multiple homicides, self-injurious behavior (self-nucleation, self-castration, self-ingestion, head-banging etc), substance abuse and TBI. It is a guarantee in some of these patients that once they stop their APs, their symptoms instantly reappear. Often times I attempt to lower the dose and the patient will tell me to re-increase the dose due to auditory hallucination or disorganized thoughts. I still think many of the patients are on high doses but some will know that is the dose that works. Deprescribing against clinical judgement or a patient’s wishes is not patient centered. Often times those patients with a 20+ year history of psychosis are not candidates for “deprescribing”.

    • Thank you for your comment. The thrust of the article is on changing the set practice that antipsychotic medications need to be continued indefinitely for all patients with psychosis. We do not deny that there are subsets of patients who do in fact need these medications for a long time. Clearly, the patients you describe would not be candidates for deprescribing. We do not suggest deprescribing against clinical judgment or against a patient’s wishes – the whole idea of deprescribing is based on shared decision-making and collaboration and not on an ideology of ‘cleaning up’ medication regimens.

      • The question is how many patients should get antipsychotics and how long:

        According to TAU all diagnosed schizophrenia are offered drugs. The result is that TIPS prosject medicated all, Svedberg et al. 2001 93%, and in Australia more then 90% tok psykotropic medicine (Waterreus et al., 2012).
        The result: Bjornestad, Jone et al. 2017 found in “Antipsychotic treatment: experiences of fully recovered service users”: “(b)etween 8.1 and 20% of service users with FEP achieve clinical recovery (Jaaskelainen et al. 2013)” with treatment as usual according to the standard guidelines. Recovery rates decreased: «17.7% in studies between 1941 and 1955, 16.9% in 1956–1975, 9.9% in 1976–1995, and 6.0% in studies after 1996 (P = .704; table1)» according to (Jaaskelainen et al. 2013).
        Open dialogue reports more than 80% recovery and the incidence of psychoses was reduced from 33 to 2 per 100,000 inhabitants per year (2, 12).

        Open dialogue uses approx. 60% less neuroleptics (antipsychotics) for maintenance treatment and achieves more than 60% increase in recovery (2, 12). Open dialogue reduces disability allowance/sickness to one third.

        A paradigm shift to Open dialogue achieves quadruple recovery rate, reduces schizophrenia per year to one tenth and disability allowance/sickness is reduced to one third.
        http://wkeim.bplaced.net/files/recovery-en.html
        http://wkeim.bplaced.net/files/Open-Svedberg.gif

  6. The family-oriented open dialogue approach in the treatment of first-episode psychosis: Nineteen–year outcomes

    Open Dialogue (OD) is a family-oriented early intervention approach which has demonstrated good outcomes in the treatment of first-episode psychosis (FEP).
    The control group consisted of all Finnish FEP patients who had a follow-up of 19–20 years and who were guided to other Finnish specialized mental healthcare facilities (N = 1763). No difference between the samples was found regarding the annual incidence of FEP, the diagnosis, and suicide rates. Over the entire follow-up, the figures for durations of hospital treatment, disability allowances, and the need for neuroleptics remained significantly lower with OD group. Findings indicated that many positive outcomes of OD are sustained over a long time period. Due to the observational nature of the study, randomized trials are still needed to provide more information on effectiveness of approach.

    The results indicated that with treatment commenced under OD as compared to controls, the overall need for hospital and neuroleptic treatment, and also the time spent on disability allowances, was significantly lower in a follow-up of approximately nineteen years. These findings are in line with earlier studies on OD (Seikkula et al., 2006; 2011), and also with another register-based study with 5-year follow-up, which included all Finnish first-onset schizophrenia patients between 1995 and 2003 (Kiviniemi, 2014). In that study the Western Lapland catchment area presented the lowest figures for the durations of hospital treatment and disability pensions when compared to other Finnish healthcare districts.
    https://www.sciencedirect.com/science/article/pii/S0165178117323338