- Deprescribing Medications for Mental Health in Australia
Yes, there are guidelines and clinical resources to help clinicians reduce or stop some psychiatric medications.
Unfortunately, the evidence base for deprescribing is much less developed than the evidence base for initiating and titrating medication. As a result, there is no single evidence-based approach that suits every patient. However, the available guidance is consistent on one key point: deprescribing should be planned, monitored, individualised, and then adjusted according to the patient’s response.
Useful resources for clinicians and prescribers include:
Just like when starting a psychotropic medication, every patient is different. Therefore the approach to stopping needs to be individualized as well.
As shown in the research literature, many patients, particularly after only brief use of medication with less time to develope tolerance, will tolerate stopping with little or no difficulty. Others can build up to develop withdrawal symptoms after missing even one dose, or may experience symptoms between doses with shorter-acting medications. This is more likely after long-term use, higher doses, previous withdrawal symptoms, or medications with shorter half-lives.
A common clinical challenge is distinguishing between:
– recurrence of the original condition
– symptoms caused by a new stressor
– withdrawal symptoms from medication reduction or cessation.
Withdrawal symptoms often begin within hours or days of a reduction, although this can be delayed with long-acting antidepressants such as fluoxetine. Symptoms may include dizziness, nausea, insomnia, anxiety, irritability, “brain zaps”, sensory symptoms, gastrointestinal symptoms, mood changes, and agitation.
Withdrawal is not just about the time taken for the medication to get out of the body (hours, days or weeks), but it is also about the body readjusting at a receptor and neurotransmitter level to the previous downregulation effects (weeks, months or even years.)
Serious or clinically important issues to watch for include
– severe agitation or akathisia,
– emergence (new-onset or recurrence) or suicidal thinking,
– severe insomnia
– marked functional deterioration, mania or psychosis
– persistent sexual dysfunction or genital numbness after SSRI/SNRI treatment.
For benzodiazepines, abrupt cessation or rapid dose reduction can also be dangerous. Potential serious withdrawal effects include
– severe insomnia,
– seizures, agitation, delirium, psychosis
– suicidal ideation
– protracted withdrawal syndromes, sometimes theorized as a benzodiazepine-induced neurological dysfunction (BIND)
This means every guideline is only a starting point.
The taper needs to be adjusted according to how the individual patient responds.
We still do not have a single reliable treatment that predictably eliminates withdrawal symptoms once they occur. The main practical approach remains prevention, early recognition, pausing or slowing the taper, considering dose reinstatement or smaller reductions where appropriate, and close follow-up.
As prescribers, our role is to help patients make informed decisions, prepare properly, recognise problems early, and adjust the plan so they can reduce or stop medication as safely and tolerably as possible.
There is a lot of new information and research emerging in this area. As better evidence becomes available, I will update this website.
Watch this space!
