In this presentation, Dr. Steve Grcevich will... Explore the rationale for regular consideration of deprescribing in children, teens and adults with mental health conditions. Examine the indications for deprescribing in individual patients. Consider a process for simplifying complex medication regimens in patients with suboptimal therapeutic benefits and/or unacceptable adverse effects.

1. The “Why and How” of
Deprescribing in
Psychiatry
Stephen Grcevich, MD
Family Center by the Falls, Chagrin Falls OH
Associate Professor of Psychiatry, NEOMED
Stark County Mental Health and Recovery Board
March 17, 2021

2. Learning objectives
Participants will…
• Explore the rationale for regular consideration
of deprescribing in children, teens and adults
with mental health conditions
• Examine the indications for deprescribing in
individual patients
• Consider a process for simplifying complex
medication regimens in patients with
suboptimal therapeutic benefits and/or
unacceptable adverse effects

3. Does this
ever happen
to you?
• You inherit patients on complex
regimens and neither the patient
or family knows…
• What medication they’re taking
• What their medicines are for
• If their medicine is working
• A patient returns from a four-day
hospital stay on three more
medications than they left with
• A new patient presents on four
different medicines and the family
is begging you for more

4. A definition for deprescribing…
• A process of pharmacologic regimen
optimization through reduction or cessation of
medications for which benefits no longer
outweigh risks
• Structured approach to drug discontinuation
• Prescribing designed to provide the minimum
effective dose and number of medications.
Gupta S, Cahill JD. Psychiatr Serv. 2016 Aug 1;67(8):904-7

5. Indications for
deprescribing
• Medication suspected to
cause, exacerbate symptoms
of a mental health condition
• Shifts in risk/benefit ratio of
medicine over time
• AEs outweigh benefits
• Strengthen therapeutic alliance
• Improved adherence with relief
from undesired side effects
• Minimize polypharmacy risks
• Expense

6. Why does the
need to
consider
deprescribing
arise so often
in community
psychiatry?
• More turnover of
prescribers
• Confounding psychosocial
variables (trauma, ACEs)
• Fear of discontinuing
medication in patients with
suicidal ideation,
aggression
• Brief appointments don’t
lend themselves to
thoughtful reevaluation,
discussion of alternatives

7. Deprescribing is a
routine component
of clinical care
• How long should we treat
patients who are doing well?
• Patients responding positively to
antidepressants
• With depression
• Anxiety disorders
• OCD
• ADHD medication?
• Can a patient on combination
therapy be managed with a single
medication?
• Switching from one drug
providing suboptimal benefits to
another within the same class

8. Enlisting
support from
patients,
families,
caregivers
• Taking the time to thoroughly understand the
nature of the patient’s problem is essential.
• You earn trust by helping them make sense of
why previous treatments didn’t work.
• What’s the plan if things get worse?
• Addressing messages communicated by
previous prescribers

9. The first step -
thoughtful
re-evaluation
• Is your diagnosis and
clinical formulation
consistent with the
medication regimen?
• Importance of a detailed
medication history

10. Components of a detailed
medication history
• Medications taken for all medical conditions
• List of all psychotropic medication
• For each psychotropic…
• Why was it prescribed?
• How long did they take the medication?
• Maximum dose
• Concomitant medications
• If discontinued, why?
• Response (What got better, what got worse?)
• Adverse effects

11. Where to start deprescribing in
a “target-rich” environment?
• Is medication precipitating, exacerbating
symptoms of another mental health condition?
• SSRIs use associated with suicidal behavior
• Mania, behavioral activation with antidepressants
• Irritability, aggression associated with ADHD meds
• Side effects resulting in increased health risks
• Pre-diabetes, signs of hyperprolactinemia on a second-
generation antipsychotic
• Medication prescribed with no clear indication
• Especially medications for which no FDA indication or
evidence basis exists for the condition in question
• Medication ineffective for intended condition
Adapted from Bellonci C et al. Child and Adolescent Psychopharmacology News 2016;21(6):1-9

12. More targets for deprescribing…
• Concomitant medical conditions, behavior alter
risk/benefit ratio of medication
• Pregnancy, unprotected intercourse
• Substance use
• Other treatment modalities effective in reducing
symptoms
• CBT produced improvement in anxiety, depression
• A medication-free trial is appropriate as a result
of persistent improvement
• 12 months symptom-free on an antidepressant

13. Timing
issues in
simplifying
medication
• ADHD meds…during school year when
teachers know kids well enough to spot
differences in functioning
• Avoid stopping medication at the very
beginning of the school year
• Antidepressants, anxiolytics
• Avoid changes during major life
transitions
• Taper after successfully settling into a
new school, work experience

14. Five principles
of
deprescribing
• Take away medications one
at a time
• Reassess need for medicine
an appropriate time after
discontinuation
• If regression occurs, resume
medication at last effective
dose
• Consider response in major
life domains, environments
• Home
• School/Work
• Peer relations
• Coordinate with other
treatment professionals

15. Conclusions
• Good clinicians should develop a process for
assessing need for ongoing pharmacotherapy
• Consider the possibility that medication may be
causing or worsening symptoms in struggling
patients on complicated regimens
• When in doubt about the effectiveness of a
patient’s medication regimen, consider re-
establishing baseline!