Deprescribing in Psychiatry: A Systematic Approach to Polypharmacy

Mena Mirhom, MD, FAPA, a board-certified psychiatrist and Psychiatric Times section editor, discussed how clinicians can approach deprescribing, which is drawing growing interest in mental health care. He noted the case of Lindsay Clancy brought attention to polypharmacy and to patients being started on many medications over a short period.

How Polypharmacy Builds Up

Mirhom said he sometimes reviews regimens with 5 to 7 psychiatric medications. Often the cause is cumulative: a new medication was added at each visit with a different clinician, or each time a new symptom appeared. He said the instinct to keep adding medications may be less helpful than reviewing what the patient already takes, what needs to stay, and where "addition by subtraction" is possible.

He also pointed to the prescribing cascade. Instead of lowering the dose of an offending drug or switching to another one, clinicians may add a second medication to counter its adverse effects.¹ "All of a sudden, you're looking at several medications," Mirhom said, "and 2 of them might be just there to counteract a side effect."

A Systematic Review

Mirhom said deprescribing should be systematic, safe, and deliberate. The first step is to match each medication to the symptom it is meant to treat. From there, clinicians can check whether the symptoms form a cluster or point to a single diagnosis that 1 medication could treat instead of several.²

When he sees polypharmacy, Mirhom advises going "back to the drawing board" with 3 questions:

1. Is the diagnosis correct?
2. Is the regimen treating individual symptoms rather than the underlying diagnosis?
3. Was a medication added only to treat an adverse effect of another drug?

Collaboration

Mirhom said the Clancy case also showed the need for better collaboration among clinicians. Reviewing a regimen together with the whole medical team makes it more likely that unnecessary medications are found and can be safely tapered. Careful review is central to the process, he said, because the reflex to add medications is common in psychiatric practice.

Dr Mirhom is past president of the New York County Psychiatric Society, an assistant professor of psychiatry at Columbia University, a Forbes contributor, and chief wellbeing officer at Athletes for Hope.

References

1. Rochon PA, Gurwitz JH. The prescribing cascade revisited. Lancet. 2017;389(10081):1778-1780.

2. Gupta S, Cahill JD. A prescription for "deprescribing" in psychiatry. Psychiatr Serv. 2016;67(8):904-907.