8 Reasons a Psychotropic Medication May Be Discontinued

1. Iatrogenic mental status change
• A new medication is either directly or indirectly responsible for an acute change in mental status
• An acute confusional state after starting an anticholinergic medication could be due to anticholinergic delirium
• A drug-drug interaction may significantly elevate the serum level of the new medication, or the new medication may significantly raise the serum level of a drug the patient has been previously taking without incident

2. Intolerable adverse effects
• Common adverse effects are often transient, and will resolve within a few days or a few weeks
• Modify dosage to minimize the adverse effects
• If adverse effects persist, consider tapering and discontinuing the medication, even if it is effective

3. Patient decides he or she no longer needs the medication
• Explore the patient’s reason for wanting to discontinue the medication
• Provide a balanced and comprehensive risk to benefit explanation of continuing or discontinuing the medication
• If the patient’s decision to discontinue the medication is clear and informed, provide guidance for safely tapering off the medication and information in case of complications or symptom relapse

4. Change in financial or insurance status
• Medication formularies are becoming more restrictive
• Financial hardship may require change to a lesexpensive medication-or even taper and discontinuation
• Options for the prescriber exist but are time consuming (eg, applying to the pharmaceutical company’s Patient Assistance Program, providing a prior authorization form to the insurer’s medication formulary)

5. Onset of medication induced medical comorbidity
• Each psychiatric medication/class can contribute to, or be the primary cause of many medical comorbidities
• Monitoring for comorbidities and having a detailed discussion with a patient if they start to occur, is essential

6. Incarceration
• The protocol for managing incarcerated persons on psychotropics differs within US facilities
• New inmate can face cold turkey withdrawal for the first few days or weeks
• Educate patients about sudden discontinuation of medications and the interinsic various risks can equip them with information to advocate for themselves if they are incarcerated.

7. Surgery
• A list of a patient’s prescription medications may not be readily available in case of an emergency surgery
• Postsurgically, the focus is on acute recovery from surgery, which is a high risk time for delirium
• New medications started postsurgically, may increase drug-drug interactions

8. Recurrent abuse of a medication
• If medication abuse is suspected, compassionately confront the patient and allow him or her to explain
• Once medication abuse is confirmed, develop a structured prescription protocol with “no early refills” written right on the prescription
• A rapid but safe withdrawal regimen is recommended; if medication tolerance has developed, taper with small quantities of the drug dispensed sequentially

For further information, please see “Discontinuing Medications: When, Why, and How-to,” by John J. Miller, MD, on which this slideshow was based. The article concludes: “Once the decision has been made by a competent patient to discontinue medication, even if you disagree with the patient’s decision, a thoughtful and gradual tapering strategy should be designed based on the pharmacodynamic, pharmacokinetic, and disorder-specific factors that exist.”