Discontinuing Medications: When, Why, and How-to
Discontinuing Medications: When, Why, and How-to
CME credit for this article is now expired. It appears here for informational purposes only.
Most often, psychiatric medications are discontinued unilaterally by the patient, without the psychiatrist’s input or consent. This creates a burden on the mental health system when discontinuation of medication results in decompensation into a psychotic, manic, or severely depressed state that leads to an emergency psychiatry visit or hospitalization.
As clinicians, our best preventive strategy is educating patients and their caregivers about why the medication is being prescribed, what the adverse effects are, how to manage the adverse effects, and the risk of relapse with abrupt medication discontinuation. Setting the stage early with a discussion about medication discontinuation is time well spent. Pregnancy, medical comorbidities, extended travel abroad, relocating geographically, change in insurance/financial status, and converting to a medication-aversive religion are just a few of the occurrences that create an immediate need to discuss the risks and benefits of medication adherence.
If discontinuation of a medication is inevitable, a planned discontinuation will optimize outcomes. Table 1 lists many common scenarios in which a planned discontinuation occurs. The psychiatrist’s role is to act as a consultant to maximize the likelihood of a successful taper and discontinuation, and minimize collateral morbidities or withdrawal complications. With some disorders, including MDD, obsessive-compulsive disorder (OCD), and panic disorder, guidelines exist with a clear recommendation of a time frame for symptom remission before a taper and discontinuation are considered.
In disorders such as bipolar I and II disorders and schizophrenia, a strong case can be made for lifelong pharmacotherapy. However, even with these serious disorders, a patient or his or her guardian may request a drug holiday or medication-free trial to see if the patient can do well without continued use of the medication, with an accompanying relief of sometimes significant adverse effects. There is evidence that a minority of patients with bipolar disorder or schizophrenia remain relapse-free indefinitely after medication discontinuation.1
Once a patient has made a clear decision for a medication-free trial, it is important to collaborate with him during this process. Ideally, this includes regular follow-up visits to monitor the patient for early signs of relapse and withdrawal or discontinuation symptoms. Assure the patient that you will remain active in his treatment, despite your disagreement with the decision to stop the medication, and that you will restart the medication at any time as needed.
In rare cases, when medication discontinuation creates a risk of danger to the patient or others, legal intervention may be required, including the possibility of requesting a court-appointed guardian to make the final decision. One example of this is a patient with recurrent MDD, currently symptom-free and receiving medication, who has a history of high suicide lethality when depressed. Another example is a patient with schizophrenia, currently with remission of positive symptoms, who experiences auditory hallucinations and delusions when decompensated and places others in serious danger.
Current evidence-based guidelines
The American Psychiatric Association has developed guidelines to aid in the treatment of many major mental illnesses. For cases in which these guidelines are outdated, an updated “Guideline Watch” is often provided as a bridge to the next published practice guideline, although these are not considered comprehensive or complete.
Major depressive disorder. The practice guideline for the treatment of MDD was most recently updated in October 2010.2 The guidelines recommend that patients who have had 3 or more episodes of major depression should remain on a regimen of maintenance pharmacotherapy. Considerations that support maintenance therapy for patients with fewer than 3 episodes include severe episodes, the presence of psychosis or suicidality, family history of affective disorders, and ongoing psychosocial stressors. A higher degree of confidence for discontinuing pharmacotherapy for MDD occurs when the patient completes a course of adequate cognitive-behavioral therapy or interpersonal psychotherapy. The antidepressant medication should be slowly tapered over several weeks at a minimum.
Bipolar disorder. The practice guideline for the treatment of bipolar disorder was published in November 2005.3 The more comprehensive guideline was published in April 2002.4 An updated comprehensive guideline is pending. There is general agreement that bipolar disorder is a lifelong illness that presents with mood episodes of all types and with significant heterogeneity from person to person. The guidelines are outdated and in dire need of an update. It is common practice to treat bipolar I disorder with lifelong maintenance pharmacotherapy, but the published literature is limited on this topic. There is consensus that maintenance pharmacotherapy should follow a single manic episode.