Swapnil Gupta is an Associate Professor and Medical Director of Ambulatory Psychiatry at Mount Sinai Morningside Hospital. She was trained as a psychiatrist in India and the United States, at SUNY Downstate Medical Center and Yale University, and PGI Chandigarh in India. She is known for her work on deprescribing from and discontinuation of psychiatric drugs.
Dr. Guptaâs career began with research on the role of the endocannabinoid system in the pathophysiology of schizophrenia as an academic psychiatrist. Her subsequent scholarship has focused on applying deprescribing, the systematic reduction of unnecessary medications, to psychiatry by rooting it in the principles of recovery-oriented care. She has authored several peer-reviewed papers on deprescribing and co-authored a book with Rebecca Miller and John Cahill.
She is an active member of two organizations that aim to enhance stakeholder engagement in psychiatric research. She is also a part of the editorial board of the Community Mental Health Journal. Currently, she is working on creating educational resources to help people discontinue psychiatric medications and gathering information on the knowledge and opinions of psychiatrists regarding the discontinuation of such drugs.
In this interview, we discuss deprescribing from psychiatric drugs, the difficult decisions faced by patients, the importance of psychosocial support during withdrawal, and how deprescribing is central to recovery-oriented practices such as shared decision and patient choice. We will also tackle the complex issue of whether the recurrence of symptoms once a drug is tapered is a mark of relapse or withdrawal caused by the psychiatric medication.
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
Ayurdhi Dhar: What is deprescribing in psychiatry?
Swapnil Gupta: Deprescribing was initially defined in Geriatric Medicine and Palliative Care Medicineâolder people get more diagnoses and more medications. Deprescribing is a way of removing drugs when their benefits do not outweigh the risks, either at the current time or at the future time. It is reducing the dose of these medications or slowly reducing them to a stop. This is done considering the patientâs medical status and valuesâdo they want to take the meds or not? Are there other ways they can handle the same condition? How are they functioning in that environment?
Dhar: I once covered an article on inappropriate medication use and polypharmacy among geriatric patients, with terrifying statistics about adverse drug reactions and mortality. Tell us why and when you saw a need for deprescribing in psychiatry.
Gupta: I first worked as a psychiatrist in India. I moved to the United States in 2009, and when I saw the medication lists, I was quite surprised that the medical lists were so long. From the perspective of standard guidelines, the medication combinations didnât make any sense. Some combinations just seemed overtly harmful. So, I was cleaning up medication regimes right from the beginning.
During my time as an attending, I realized that we needed a name for a particular intervention to discuss it, debate it, and potentially oppose it. Along with my colleagues John Cahill and Rebecca Miller at Yale, we devised the term âdeprescribingâ to systemize this intervention in Psychiatry. We chose this term because it has already been used in geriatric medicine.
I hope that in a few years, we wonât need it anymore because everyone is prescribing more carefully.
Dhar: How do you gauge when a patient needs to be tapered off their medication? Maybe their prescription still benefits them, or the risk is too high.
Gupta: Many factors go into it. If I have started the medication, then I ask the patient: how long do you envision being on it? So, this conversation of reducing or stopping the medication begins at the time of starting the medication. If Iâm treating depression, and Iâm offering the person an antidepressant, I very clearly ask them, âHow long do you think you might be on it?â
If itâs a patient whoâs been in the system, theyâre passed on to me and are on high doses of antipsychotics, then the first thing is to review the records. There might be instances where this personâs doctor tried to taper their medicines, which didnât work. Or they tried to taper the medication in an uncoordinated and abrupt fashion, like they halved the dose of the antipsychotic, which, as we all know now, is completely inappropriate and a recipe for disaster.
If a careful taper in the past led to a very distressing outcome like hospitalization, if the patient is absolutely not interested in changing their medications, then we leave it at that.
But if the patientâs life circumstances have changed, they feel more comfortable, have a good living space, good relationships, and people who can support them in this process of withdrawal, then we move ahead. The most important thing is: how does the patient respond to the suggestion of deprescribing?
Dhar: How common is it for a patient to come forward and initiate a conversation, âI would like to stop taking my meds,â as opposed to their physician initiating it?
Gupta: Very few patients will say, âI want to stop my medicinesâ because the reputation is that once youâre on a psych med, you have to be on it forever, and if youâre tapered off your medicine, your psychiatrist is going to get mad and not see you anymore, or call the police, or have you put into the hospital. So, very understandably, what I think most patients do is they tell their psychiatrist, âYeah, Iâm taking the medicine,â but theyâre actually not. And I completely understand why someone would do that. If I were taking prescribed medications and there was the risk of me being hospitalized if I didnât take them, I would lie, too.
For the patient to feel comfortable bringing up that question of tapering meds or wanting to stop them, the relationship has to be good. Both parties have to be transparent, and the doctor has to demonstrate that they care about the patient more than the fact that the patient is taking the medication.
Dhar: When it comes to polypharmacy (use of multiple meds) in psychiatry, what are some of the adverse effects you have observed in patients?
Gupta: Polypharmacy is when deprescribing is absolutely needed! For instance, you give somebody a Benzodiazepine like Xanax or Klonopin, along with a medication for nightmares, like Prazosin. Now, Prazosin lowers your blood pressure, and Xanax and Klonopin can cause dizziness and incoordination. Imagine a 60-year-oldâthey finish dinner, take their Prazosin or their Xanax and Klonopin, and theyâre watching TV. They get off their couch and fall because their blood pressure has gone down and their coordination is messed up. Plus, if youâve been taking antipsychotics for a long time, that reduces your bone density, increasing the chance of having a fracture. You end up in rehab for eight weeks after surgery.
There is an antifungal drug called Fluconazole. And everyone knows Clozapine, an antipsychotic, comes with a huge number of side effects. Both Fluconazole and Clozapine cause problems in the heart rhythm. People should not be taking them together. I had a case where my patient was given Fluconazole, I panicked, ordered an EKG, and the heart rhythm abnormalities were pretty significant. Polypharmacy is a huge issue.
There are some small things we can do. For example, people are given Risperidone and then Cogentin or Benztropine to manage the side effects of Risperidone. Thereâs a good chance that if you drop the dose of Risperidone by 1 or 2 milligrams, theyâre not going to need the Cogentin, and Cogentin causes a lot of side effects on its own. So, there are things psychiatrists can pay attention to to reduce the side effects burden and improve quality of life.
Dhar: Deprescribing or discontinuation of psychiatric meds is not an easy conversation. What are usually the common reactions you see from patients and their families?
Gupta: I never open the conversation with stopping meds. Itâs an open question like, âTell me about these medications. How theyâre working out for you? Are they causing any problems?â
I have to make clear that 1) Iâm not going to change medications without your input or impose my will, and 2) Iâm just trying to understand how you feel about these meds. I need to emphasize that Iâm not worried about whether youâre taking the medications or not. Iâm worried about whether youâre feeling okay or not.
Some patients say, âIâm feeling well. I donât even want to talk about this. Just refill my prescription,â which is entirely understandable because often these are people who have been either brutalized by the police or have had horrible experiences on inpatient psychiatric units, they donât want to end up back there. They are afraid of getting angry with family members and mistreating their family. They may have spouses who say if you donât take your meds, Iâm leaving you.
This one patient, the last time she had stopped her medicine, she had punched her mother. So, she was terrified and said, âI donât want to stop my medicine,â and she was on a hard-to-understand regimen of medicines, but that worked for her; any change would make her anxious.
Others see the conversation as the beginning of a transparent relationship. Iâll say, âOkay, what do you think about the pink pill that you take every night?â and the patient says, âOh, I havenât taken that for six months.â Deprescribing opens the door to building a better relationship with the patient.
Dhar: In the process of reducing or stopping psychiatric medication, what is the importance of âright timingâ and âpsychosocial supportâ?
Gupta: The timing is extremely important. I work at a site with many traineesâa substantial number of patients doctors change every year in June and July. So, thatâs not a good time to change medications. One reason is that the transfer of information might not be complete, and the patient is in the process of establishing a relationship with a new doctor.
There are so many factors that make it bad timing for the patientâinstability in living situation, relationship troubles, if theyâve recently lost a beloved pet or family member and theyâre depressed about it, losing a person who was important to them like a therapist, if theyâre physically sick, etc.
That said, I donât think thereâs ever a perfect time to do it. So, if a combination is dangerous or contraindicated, you must talk with the patient.
Regarding psychosocial interventions, thereâs some pretty clear-cut evidence for Mindfulness-Based CBT and the prevention of the recurrence of depressive episodes. Connect the person with a good therapist if youâre going to taper off the antidepressant. Peer support is criticalâconnecting the person to resources where people talk about withdrawal symptoms and strategies for safe tapering.
One of the most important things while tapering drugs is to reassure the patient that the withdrawal symptoms they are experiencing donât mean theyâre crazy. For example, brain zapsâitâs hard to put that experience into words. I have patients moving their hands in the air, trying to explain to me whatâs happening in their bodies, but theyâre not quite able to.
If they connect with someone with the same experience, then two people know what the other is talking about. Thatâs a big reliefâIâm not the only person in the world to whom this is happening, and itâs the medication doing this to me; thereâs nothing else thatâs terribly wrong with me.
We know so little about the process. Thereâs a large consumer community and tapering community, and itâs important to learn from them to figure out which strategies work.
We also try lifestyle changes and things like CBT for insomnia, for example, if youâre tapering off Seroquel. Unfortunately, Seroquel is prescribed just for sleep on many occasions. Thatâs an egregious thing to do. So, while tapering off the Seroquel, we offer the patient CBT for insomnia groupsâa simple, harmless intervention that can replace a fairly problematic drug.
Dhar: Here is a difficult oneâwithdrawal versus relapseâwhich one is it when a patientâs symptoms recur after reducing or stopping a drug like antidepressant or antipsychotic? We used to think that discontinuation of antipsychotics instantly causes relapse. But there is more and more evidence around the withdrawal effects of stopping or reducing antipsychotics and dopamine super sensitivityâwhich looks like relapse but isnât. How do we know what it is? Is a patient relapsing into some original condition, or is this withdrawal caused by reducing the drug? When people think about withdrawal, they think of cocaine and not medicines.
Gupta: For antidepressants, the withdrawal syndrome is a little clearer because there are a lot of physical symptoms that pop up, like brain zaps, feeling tired, feeling fatigued, in addition to some very prominent emotional symptoms like crying spells or just feeling very irritable or getting angry, even suicidal thoughts or wanting to kill yourselfâso all these things come up. But I think the physical component is really prominent. Itâs pretty clear that this is because of the antidepressant withdrawal.
The surest way to establish that is that as time passes, the withdrawal symptoms will hopefully slowly dwindle and disappear at some point. A small percentage of individuals will have protracted withdrawal symptoms. Some are going to taper off antidepressants without any problems. Some people will have symptoms for four to six weeks.
As far as antipsychotics go, itâs really hard to tell. I think when people abruptly stop medicines like Clozapine, the symptom appears so quickly that itâs more likely to be a withdrawal syndrome that appears first. Itâs possible that as time goes past, the withdrawal syndrome subsides, and some underlying syndrome, the primary illness emerges. Thatâs a possibility.
There is a chance that as the withdrawal syndrome subsides, nothing will emerge from under that. But by that time, the person has already been reinstated on the antipsychotic because the withdrawal itself is so disruptive.
There are some physical symptoms of antipsychotic withdrawal as wellâa series of movement disorders like generalized fasciculations all over the body that can last four to six weeks, worsening of the tardive dyskinesia, dystonia that acutely appears as youâre tapering the medicine, stiffness, and tremors can get acutely worse.
Many antipsychotics are very powerful antiemetics or drugs that prevent vomiting. So, patients can feel nauseated on discontinuation. Patients can have diarrhea or sweat too much, or have a runny nose.
Small studies and case reports are done in gastrointestinal disorder clinics where patients are given drugs to prevent vomiting for long periods of time. And when these drugs are abruptly withdrawn, patients can have transient psychotic symptoms. And these are patients who have never had psychotic symptoms before.
Dhar: Could you tell our listeners a little bit about dopamine supersensitivity?
Gupta: Long-term blockade of the Dopamine receptors, which is what antipsychotics do, causes the Dopamine receptors to increase in number. Thereâs not enough Dopamine coming through, so the number of receptors increases. Then you suddenly remove the Dopamine blockade (stop taking antipsychotics). So, that area of the brain becomes supersensitive to Dopamine. And thatâs the mechanism for withdrawal psychosis or withdrawal tardive dyskinesia.
Dhar:Â You write that deprescribing aligns with the recovery-oriented approach to mental health. The recovery movement emphasizes patient choice and patient preference. You have written about some very important things like the âright to failâ and the âdignity of riskâ and how, for some patients, functional recovery might be more importantâCan I keep my job and have a good social relationshipâthan just removal of symptoms like voice hearing. Tell us more.
Gupta: There are four pillars of the recovery-oriented approachâperson-centered care, honoring patient autonomy, fostering hope, and empowerment. Part of person-centered care is shared decision-making as well. Deprescribing is not possible without actually adhering to these pillars. The approach is highly individualizedâitâs very person-centered. Itâs what works for the patient.
Itâs impossible to carry it out without the patientsâ okay. Iâm respectful that itâs the patient taking the medication, so they know best how itâs affecting their life. Patients are mindful that Iâm the person who knows about medication side effects. In a space of mutual respect and understanding, we reach a common goalâitâs also aligned with shared decision-making.
Itâs empowering because it tells the patient, âMedication is not the Be-All and End-All of your Well-Being. You have a right to say that you donât want these medicinesâ. Thereâs hope for a medication-free life, unencumbered by side effects.
When we go to the âright to failâ and the âdignity of risk,â that gets unnerving for physicians because we are trained to be cautious. We are taught to minimize risk. To think that I would do something that would increase the chances that this patient could end up in the hospital or could start hearing voices againâFor some physicians, itâs just unthinkable. Itâs important to expand physician training and have them remember itâs also your job to give the patient a good quality of life and to offer treatments that align with their values and preferences. So, if itâs an informed decision that we are going to taper the Haldol by x milligrams, but thereâs a risk that the voices might increaseâdo we want to take that risk? That conversation needs to be had.
Dhar: Has that happened, patients saying âI am okay with hearing voices as long as I can do these X, Y, Z things.â
Gupta: One typical exampleâyoung people who hear voices going to college, and the voices are really well controlled with an antipsychotic. But the problem is that the medication makes them so sleepy they cannot stay awake during class. Then it becomes about a balance between if the voices increase slightly, but they can sit in class.
One patient wanted to taper the meds slightly to see if they could stay awake during class, and it worked out fine. So, we consolidated the dose and moved it to the evening, which really helped this person.
Iâve also had patients who said âI donât care if I end up in the hospital once a year, Iâm not taking this medicineâ, which is not an unreasonable choice if you have to take something like Haloperidol or Fluphenazine, which can suck the joy out of your life. And, if you are in the hospital but you know the staff at the hospital, you know that in two weeks youâll feel better and come out, then thatâs not a terrible choice.
Dhar: Lastly, tell us about your recent work on âundiagnosingâ. What do you mean when you say deprescribing and âundiagnosingâ are two sides of the same coin?
Gupta: More recently, I had some interest in âundiagnosingâ because in the clinic where I work, there are lots of patients who have a lot of emotional ups and downs, and when they get very stressed, they have transient symptoms that amount to psychosis. Invariably, all these patients get diagnosed with schizoaffective disorder, and they get loaded up with antipsychotics.
There has to be a process of removing this diagnosis from their health record so they donât get labeled as schizoaffective right away and they donât get dumped with all these antipsychotics.
âUndiagnosingâ has become a thing in Geriatric and other branches of medicine where people feel that to effectively taper off and stop medications, these diagnoses should be removed from the health record.
Dhar: What does âundiagnosingâ say about the nature of diagnosis in the first place, especially in psychiatry?
Gupta: It was a very important teaching moment for me when my department chair, who had researched schizophrenia for 30 years, walked into the room and said, âYou know, some people hear voices, some people do have negative symptoms, some people do appear quite disorganizedâI think schizophrenia might exist.â
These are all constructs. Theyâre tools for helping people improve their lives. And when the tool does not feel relevant anymore, we should abandon it and move on to another tool, otherwise it becomes a burden.
I have a young patient in his 30s who hears voices almost constantly, and he deals with itâhe lives his life, has a full-time job, likes the work he does, and has childrenâhe lives a full life by all conventional standards. According to the textbook, he would meet the diagnosis of schizophrenia and be loaded up on antipsychotics, but what purpose is that going to serve?
For another person, that diagnosis and treatment might serve a purpose. But this person is dealing with the voices, and heâs happy living his life the way heâs living it. So, in his case, this tool of psychiatric diagnosis and psychiatric medications are just not useful.
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“For another person, that diagnosis and treatment might serve a purpose. But this person is dealing with the voices, and heâs happy living his life the way heâs living it. So, in his case, this tool of psychiatric diagnosis and psychiatric medications are just not useful.”
Excellent point, which points out why psychiatric treatment should not be forced, on anyone ever.
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Nor should forced, or coerced, “treatments” … including untested and experimental “vaccines” … ever be forced and/or coerced, on anyone ever again … let alone the whole of the population of the world. Yet, they were, via the Covid debacle.
IMHO, big Pharma lost their minds, and acted like three year olds, when being confronted with the loss of the scientific validity of their “cash cow” – which is the force drugging, iatrogenic illness creating, psychiatric industry, as I, and others, have previously medically pointed out on this website.
And a confession of big Pharma’s systemic crimes, was actually caught on tape.
https://video.search.yahoo.com/yhs/search?fr=yhs-ima-verticalculator&ei=UTF-8&hsimp=yhs-verticalculator&hspart=ima&p=veritas+pfizer+video&type=q3030_D3YY7_gn_bsfq#id=2&vid=37772ed2db07aa9ede059443b35f7399&action=click
Gosh, maybe it’s possible for an ethical, well researched, former marketing major – to help point out the systemic illegal marketing crimes – of big Pharma?
Albeit, while conceding that the “counselor,” who talked me out of being admitted into the architecture school, that I’d been admitted to, when I was a naive young woman, may not have given me bad advice, to encourage me to study business, instead of architecture.
Let’s hope and pray all are some day judged fairly by God … and I’m quite certain He’s been keeping track of the money of the bad globalist banksters’ system, and other bad societal systems … so He may judge all fairly, in His own time.
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IMO there’s no such thing as “psychiatric treatment”, only psychiatric enslavement.
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I was left permanently disabled by Yale doctors after ECT and anti-psychotics prescribed for borderline personality disorder and now they’re threatening to take away my disability because apparently they forgot what they did to me. No one ever helped me with withdrawals or deprescribing.
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i need on Bipolar 2
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Meds etc
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“I need to emphasize that I’m not worried about whether you’re taking the medication or not. I’m worried about whether you’re feeling okay or not.”
This is how psychiatry ought to be practiced — if it has to be practiced at all.
Dr. Gupta’s recovery-oriented approach is the only one that makes any sense because healthcare without the dignity of informed choice isn’t healthcare.
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Thank you so much for this interview and for your work toward dignified treatment. We need more Drs who understand that meds are a tool to be used FOR the patient. Not to be used AGAINST the patient.
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I guess I was never lucky enough to have the borderline label removed. That label led to so much additional trauma as well as my being denied trauma therapy repeatedly while I did everything I could to get “stable” during the 15 years post ECT during which the poly-drugging never ceased and there were multiple repeated violations to any sense of safety, all of which went unacknowledged and were twisted into more evidence against me. I could not have been more unlucky as I tried to “get better” during the height of the chemical imbalance theory and unquestioned “Dr knows best” attitude and “the only hope for borderline is DBT” era. At 57, looking back at the detritus of my life, it’s very difficult for me to convince myself there’s a chance of a life of dignity and safety to be had. Every direction I turn is another door closed in my face.
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Psychiatrists who haven’t fully internalized psychiatry’s punitively narrow tunnel vision are rare indeed.
Swapnil Gupta is one of the rare exceptions.
It may take another generation for there to be more clinicians who practice like she does—intelligently, ethically and compassionately—but I don’t think so, because thanks to the internet the world has changed even though psychiatry refuses to face these things…
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Empowerment means loss of profit and control. Docs don’t like that!
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Most are like kids who don’t like to be told “no”.
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Gupta, thank-you….you’re like a new student in psychiatry, and I’m a long-retired professor.
You’re on the right track.
Psychiatry is a pseudoscience drug racket and social control mechanism. It’s 21st Century Phrenology with potent neurotoxins. Psychiatry has done, and continues to do, FAR MORE HARM than good….So-called “mental illnesses” are exactly as “real” as presents from Santa Claus, but NOT more real. The DSM-5 is best seen as a catalog of billing codes. Everything in it was either invented or created, NOTHING in it was discovered. Think about that a mnute….
YO!, Gupta, rsvp?….I’m a surviving victim of psychiatry…..
Whachew gotta say 2 ME?….
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Hmmmm….looks like I scared him into silence….
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