Deprescribing: Does the Term Belong in the Psychiatric Lexicon?

Across all fields of science and medicine, the meaning of certain words has come under scrutiny; some words and phrases that are deemed to hold sociopolitically evocative connotations are being purged via directives to federal agencies.¹ One such technical term that has not quite made the federal banishment list yet—but nevertheless holds the potential for evoking strong emotional reactions among clinicians, patients, and the general public—is deprescribing.

Seemingly benign and rather matter-of-fact, deprescribing entered the medical lexicon in 2003 when a geriatric medicine publication² used the term to describe the purposeful elimination of redundant, no longer relevant, or otherwise pharmacologically inappropriate medications. Since then, the term has become widely adopted in nearly all areas of medicine to convey not simply the act of discontinuing medication but a more nuanced reflection of the degree of thoughtfulness (or lack thereof) behind the prescribing decision-making process.

At its core, deprescribing now implies a reversal of course in medication recommendations and acknowledgment that some correction is being made to a treatment plan. What makes a medicine (or other treatment) appropriate vs inappropriate? Therein lies the heart of a semantic debate. Inappropriateness could refer to a once-useful medication that has become obsolete or is otherwise no longer necessary. It could pertain to an undesirable pharmacokinetic characteristic—such as a drug-drug-interaction that could pose harm (eg, cytochrome P450 1A2 inhibition from fluvoxamine could substantially drive up levels of coadministered clozapine, resulting in clozapine toxicity)—or a mechanistically nullifying effect (eg, combining a centrally acting anticholinergic/antimuscarinic agent with a procholinergic/promuscarinic agent).

Inappropriate pharmacodynamic properties of a medication may be evident when a chosen treatment misaligns with a given clinical condition (eg, retaining an antidepressant during mania, treating tardive dyskinesia with an anticholinergic medication, or prescribing stimulant medications upon request for patients with self-diagnosed attention-deficit/hyperactivity disorder absent a supportive clinical history). Inappropriateness might (or might not) characterize the use of medications with potentially duplicative mechanisms of action, such as the use of antipsychotic polypharmacy.³ Or, it might be when continued prescribing runs counter to an intended therapeutic goal (eg, retaining long-term benzodiazepines in patients with alcohol use disorder who are pursuing abstinence and recovery⁴).

Another kind of inappropriateness occurs when a medication becomes relatively contraindicated because of a significant hazard that the prescriber fails to appreciate (eg, continuing lamotrigine after a serious rash develops), or when a diagnosis has been reformulated, prompting the need to substantially revise a treatment regimen. Still, another kind of pharmacodynamic inappropriateness occurs when a patient deliberately misuses a scheduled (or unscheduled) medication for purposes other than its intended effect or outside the parameters of its prescribed use. Finally, a medication might be pharmacodynamically inappropriate when its risk-benefit ratio becomes a point of dispute, especially if an alternative option exists that is more benign and equally effective.

The language of how a medication gets stopped matters when there is an implication that its continued use deviates from best care practices. That idea raises questions about whether a particular medicine should have been prescribed in the first place; whether a prescriber was remiss in not recognizing sooner that a represcribed medicine is yielding questionable benefit; or that actual risks or hazards far eclipse any benefit.

These issues have taken on a unique controversy in psychiatry that seems somehow to differ from deprescribing in other medical specialties. For example, some individuals have questioned the intrinsic value of all psychotropic medications. They have advocated for wholesale deprescribing based on the premise that the entire psychiatric pharmacopeia is inherently inappropriate because of uncertainties about the pathophysiology of serious mental illnesses.⁵ Some clinician-authors,⁶ journalists,⁷ and people with lived experience⁸ have entered the public arena to assail the use of psychopharmacology as a fundamental treatment modality, urging dissatisfied consumers to rise up against perceived oppression and independently cast off the purported chains of pharmacological bondage. That approach altogether eschews shared decision-making and fails to encourage a greater dialogue between patient and prescriber about therapeutic goals and the risks and benefits of viable treatment options—pharmacological or otherwise.

Taking this issue a sociopolitical step further, deprescribing has been commandeered by members of the antipsychiatry community who view mental illness more as the byproduct of psychosocial misfortune and adversity, rejecting the idea that environmental factors can trigger psychopathology only in those who are biologically predisposed.^5,6 Such nonmainstream formulations impart more sinister implications to the act of prescribing medications in the first place, highlighting risks from adverse effects over possible benefits, and insinuating that deprescribing is not simply the discontinuing of an obsolete or unhelpful medicine, but rather an act of redress.

The above sentiment somehow has eluded other medical specialties that have adopted the terminology of deprescribing with greater equanimity. Gynecologists sometimes deprescribe hormone replacement therapy in sexagenarian women not because it was initially wrong but because continued use beyond a certain time frame may predispose the patient to hematological or oncological complications. Gastroenterologists might deprescribe proton pump inhibitors after prolonged use because they do not necessarily prevent recurrences of gastroesophageal reflux disease but could predispose the patient to infectious complications. Polypharmacy for migraines sometimes lends itself to deprescribing if mechanisms become redundant, nonsynergistic, or even conflictual. None of these exemplify improper care so much as the need to keep pace with clinical problems that evolve over time.

Knowing when a course of treatment has reached its logical completion remains a challenge for mental health conditions that are often chronic and recurrent. The Achilles’ heel for much of clinical psychopharmacology is uncertainty about the need for indefinite treatment to manage symptoms rather than time-limited treatment exposure for a single, one-off medical event (as, for example, a defined steroid course for asthma or an antibiotic course for an uncomplicated infection).

The American Society of Clinical Psychopharmacology (ASCP) recently convened an international task force of psychopharmacology experts to identify points of consensus to help guide clinical decisions about the tapering and stopping of psychotropic medications. Top-line recommendations from the initial work of that task force, which are being presented at the ASCP Annual Meeting in Scottsdale, Arizona, May 27 to 30, 2025, are summarized in the Table.⁹

TABLE. Representative Top-Line Recommendations From the American Society of Clinical Psychopharmacology Task Force on Principles for Deprescribing Psychotropic Medications⁹

If psychiatry hopes to detoxify the word deprescribing and reclaim it as a scientifically meaningful and politically neutral term, 4 key points seem worthy of consideration.

1. The field greatly needs more randomized discontinuation trials to better inform pharmacological end points.

Practice guidelines sometimes offer general advice in this area (as when suggesting that an antidepressant medication might be tapered somewhere between 6 and 12 months after a successful treatment of a single episode of major depression) but leave many unanswered questions. For example, when should an adjunctive atypical antipsychotic be stopped after successful augmentation treatment for major depression? Does the occurrence of a single severe manic or psychotic episode always signal an automatic role for lifelong prophylactic pharmacotherapy? How can prescribers best decide when benefits outweigh risks, when risks are present but manageable, or when drug cessation is indicated? As guidelines acknowledge, the actual timing and mechanics of tapering medication with subsequent observation have received little empirical study.¹⁰ And, last but not least, how should clinicians best incorporate patients’ self-identified wishes and treatment goals in this calculus?

2. Practitioners must adopt a more proactively rigorous and continual reassessment of the appropriateness of existing medications—in all forms as described above—before passively represcribing them.

In time-limited patient encounters, reconciling the relevance, risk-benefits, and alternatives to continuing vs discontinuing every medication within a treatment regimen may be easier said than done, but remains fundamental and probably deserves formal review on a periodic basis. Similar to performance evaluations for defined position holders on a sports team, every member should have a clear role and observable degree of success to warrant contract renewal.

3. The field must reckon with the reality that not all forms of psychopathology are appropriate substrates for pharmacotherapy.

For some disorders, such as borderline personality disorder,¹¹ anorexia nervosa,¹² adjustment disorders,¹³ and simple phobias,¹⁴ the collective evidence base suggests that pharmacotherapy may, at most, play a secondary or subservient role to the more primary role of psychotherapy as the primary treatment modality. Deprescribing pharmacotherapy in favor of structured psychotherapies in such instances reflects the standards of evidence-based medicine.

4. Psychiatric providers should be educated early in (and throughout) their careers about both prescribing and deprescribing as purposeful, nonpassive aspects of routine clinical practice.

Residency programs, textbooks, and continuing education materials should discuss the greater picture and purpose of psychopharmacological options, including discussions and strategies for prescribing and deprescribing, as appropriate. Similarly, treatment guidelines could also include notations.

Concluding Thoughts

Expert oversight and curation of a pharmacotherapy regimen involve an active process of continually assessing the role for ongoing retention or modification of its core elements. Deprescribing broadly refers to the varied components of that process and the decision analytics that rightfully inform when, how, and why clinicians can best determine the relevance and appropriateness for continuing any prescribed treatment, both pharmacological and nonpharmacological, as consistent with achieving the goals of any therapeutic endeavor.

Ultimately, the focus should always be on patient care and outcomes, with treatment decisions shaped by thoughtful collaboration between clinicians and their patients. Semantics aside, leveraging medical expertise and shared decision-making allow for the best possible care, free from external pressures that may not fully consider individual patient needs. A balanced, evidence-based approach helps support both safe prescribing and deprescribing, always with the patient’s well-being at the center.

Dr Goldberg is a clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai and president of the American Society of Clinical Psychopharmacology and is a member of Psychiatric Times’ Editorial Board.

References

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