If you’re a regular reader of this newsletter, you’re likely aware that I’ve written extensively about psychotropic medication prescribing across all medication classes. I’ve addressed best practices for the first-time psychotropic medication user, techniques for non-responsiveness across all spectrums, as well as augmentation and additive drug strategies. But what about deprescribing psychiatric medication?
Patients are often quick on the draw at wanting to abort medication causing side effects or other adverse conditions, and many prescribers will comply with discontinuing the drug(s) or at least lowering the dose. And then there is the issue concerning patients continuing with medication(s) that are unnecessary or may become riskier with advancing age. These are examples of circumstances where a patient could benefit from a deprescribing session with their prescriber.
When meeting with a patient seeking an evaluation of their existing medication regimen, I begin with this question: “what’s the underlying cause for which you were started on this medication in the first place?” This quite often yields a blank stare because here’s the way medication prescribing often starts out: the patient speaks to a problem with the prescriber, “I’m feeling depressed, anxious, or I can’t sleep;” medication is then prescribed, or people self-medicate with OTC products, with only cursory attention paid to the cause of the problem. Sleeplessness, for example, is not the problem, what’s responsible for the sleeplessness is the issue. So instead of going to actual cause, people unwittingly continue with medication which provides short-term relief or creates an alternative set of possible problems such as dependence or addiction.
A Couple of Examples Identifying Cause
When describing a sleep problem for which a new patient of mine had sought and received sleep medication, I inquired about his caffeine intake. He commented, “Oh, caffeine doesn’t bother me,” to which I replied, “well, then what’s causing your insomnia such that you’re now taking sleeping pills?” He then admitted to consuming at least 6 cups of coffee during the workday. I recommended that he cut back one cup per day with a goal of 2 cups per day and no caffeine after 3pm. He complied, is off the sleeping pills and his hand tremors have disappeared. Another patient complaining of insomnia had taken to drinking two glasses of wine each night to help him get to sleep. He reported that he was routinely awakening at 3am. I explained that alcohol significantly interrupts the sleep-wake cycle and recommended a trial of no alcohol in the evening hours for one week. This opened the door to our discussing the underlying cause for his difficulty sleeping – his business was failing. He complied with the request and stopped drinking alcohol altogether in the evening during the work week.
Deprescribing Related to Advancing Age
With older clients, I use straightforward language when discussing deprescribing: “A medication that was once appropriate for you might not be appropriate for you now.” As we age, drug absorption and excretion rates change, and we become more susceptible to central nervous system side effects. Thus, adverse events such as falls have become more commonplace, as well as excessive sedation, cognitive impairment, and dizziness. Anyone 65 and older taking a benzodiazepine or a “z” drug (zolpidem, eszopiclone, zaleplon) for anxiety or insomnia would be a good candidate for deprescribing. And some older people through a tapering and discontinuation regimen designed specifically for their unique circumstances can stop these drugs more easily because they’re now retired, and no longer stressed by the rigors of daily work.
The most important consideration for a medication prescriber is to conceptualize a reason for each drug choice prescribed to a patient. And when reasons become less apparent or age becomes an issue, it’s time for reevaluation, so that unwarranted and unnecessary medications don’t morph into polypharmacy.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.