Deprescribing Psychiatric Drugs to Reduce Harms and Empower Patients: Interview with Psychiatrist Swapnil Gupta

Swapnil Gupta is an Associate Professor and Medical Director of Ambulatory Psychiatry at Mount Sinai Morningside Hospital. She was trained as a psychiatrist in India and the United States, at SUNY Downstate Medical Center and Yale University, and PGI Chandigarh in India. She is known for her work on deprescribing from and discontinuation of psychiatric drugs.

Dr. Gupta’s career began with research on the role of the endocannabinoid system in the pathophysiology of schizophrenia as an academic psychiatrist. Her subsequent scholarship has focused on applying deprescribing, the systematic reduction of unnecessary medications, to psychiatry by rooting it in the principles of recovery-oriented care. She has authored several peer-reviewed papers on deprescribing and co-authored a book with Rebecca Miller and John Cahill.

She is an active member of two organizations that aim to enhance stakeholder engagement in psychiatric research. She is also a part of the editorial board of the Community Mental Health Journal. Currently, she is working on creating educational resources to help people discontinue psychiatric medications and gathering information on the knowledge and opinions of psychiatrists regarding the discontinuation of such drugs.

In this interview, we discuss deprescribing from psychiatric drugs, the difficult decisions faced by patients, the importance of psychosocial support during withdrawal, and how deprescribing is central to recovery-oriented practices such as shared decision and patient choice. We will also tackle the complex issue of whether the recurrence of symptoms once a drug is tapered is a mark of relapse or withdrawal caused by the psychiatric medication.

 

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

 

Ayurdhi Dhar: What is deprescribing in psychiatry?

Swapnil Gupta: Deprescribing was initially defined in Geriatric Medicine and Palliative Care Medicine—older people get more diagnoses and more medications. Deprescribing is a way of removing drugs when their benefits do not outweigh the risks, either at the current time or at the future time. It is reducing the dose of these medications or slowly reducing them to a stop. This is done considering the patient’s medical status and values—do they want to take the meds or not? Are there other ways they can handle the same condition? How are they functioning in that environment?

 

Dhar: I once covered an article on inappropriate medication use and polypharmacy among geriatric patients, with terrifying statistics about adverse drug reactions and mortality. Tell us why and when you saw a need for deprescribing in psychiatry.

Gupta: I first worked as a psychiatrist in India. I moved to the United States in 2009, and when I saw the medication lists, I was quite surprised that the medical lists were so long. From the perspective of standard guidelines, the medication combinations didn’t make any sense. Some combinations just seemed overtly harmful. So, I was cleaning up medication regimes right from the beginning.

During my time as an attending, I realized that we needed a name for a particular intervention to discuss it, debate it, and potentially oppose it. Along with my colleagues John Cahill and Rebecca Miller at Yale, we devised the term “deprescribing” to systemize this intervention in Psychiatry. We chose this term because it has already been used in geriatric medicine.

I hope that in a few years, we won’t need it anymore because everyone is prescribing more carefully.

 

Dhar: How do you gauge when a patient needs to be tapered off their medication? Maybe their prescription still benefits them, or the risk is too high.

Gupta: Many factors go into it. If I have started the medication, then I ask the patient: how long do you envision being on it? So, this conversation of reducing or stopping the medication begins at the time of starting the medication. If I’m treating depression, and I’m offering the person an antidepressant, I very clearly ask them, “How long do you think you might be on it?”

If it’s a patient who’s been in the system, they’re passed on to me and are on high doses of antipsychotics, then the first thing is to review the records. There might be instances where this person’s doctor tried to taper their medicines, which didn’t work. Or they tried to taper the medication in an uncoordinated and abrupt fashion, like they halved the dose of the antipsychotic, which, as we all know now, is completely inappropriate and a recipe for disaster.

If a careful taper in the past led to a very distressing outcome like hospitalization, if the patient is absolutely not interested in changing their medications, then we leave it at that.

But if the patient’s life circumstances have changed, they feel more comfortable, have a good living space, good relationships, and people who can support them in this process of withdrawal, then we move ahead. The most important thing is: how does the patient respond to the suggestion of deprescribing?

 

Dhar: How common is it for a patient to come forward and initiate a conversation, “I would like to stop taking my meds,” as opposed to their physician initiating it?

Gupta: Very few patients will say, “I want to stop my medicines” because the reputation is that once you’re on a psych med, you have to be on it forever, and if you’re tapered off your medicine, your psychiatrist is going to get mad and not see you anymore, or call the police, or have you put into the hospital. So, very understandably, what I think most patients do is they tell their psychiatrist, “Yeah, I’m taking the medicine,” but they’re actually not. And I completely understand why someone would do that. If I were taking prescribed medications and there was the risk of me being hospitalized if I didn’t take them, I would lie, too.

For the patient to feel comfortable bringing up that question of tapering meds or wanting to stop them, the relationship has to be good. Both parties have to be transparent, and the doctor has to demonstrate that they care about the patient more than the fact that the patient is taking the medication.

 

Dhar: When it comes to polypharmacy (use of multiple meds) in psychiatry, what are some of the adverse effects you have observed in patients?

Gupta: Polypharmacy is when deprescribing is absolutely needed! For instance, you give somebody a Benzodiazepine like Xanax or Klonopin, along with a medication for nightmares, like Prazosin. Now, Prazosin lowers your blood pressure, and Xanax and Klonopin can cause dizziness and incoordination. Imagine a 60-year-old—they finish dinner, take their Prazosin or their Xanax and Klonopin, and they’re watching TV. They get off their couch and fall because their blood pressure has gone down and their coordination is messed up. Plus, if you’ve been taking antipsychotics for a long time, that reduces your bone density, increasing the chance of having a fracture. You end up in rehab for eight weeks after surgery.

There is an antifungal drug called Fluconazole. And everyone knows Clozapine, an antipsychotic, comes with a huge number of side effects. Both Fluconazole and Clozapine cause problems in the heart rhythm. People should not be taking them together. I had a case where my patient was given Fluconazole, I panicked, ordered an EKG, and the heart rhythm abnormalities were pretty significant. Polypharmacy is a huge issue.

There are some small things we can do. For example, people are given Risperidone and then Cogentin or Benztropine to manage the side effects of Risperidone. There’s a good chance that if you drop the dose of Risperidone by 1 or 2 milligrams, they’re not going to need the Cogentin, and Cogentin causes a lot of side effects on its own. So, there are things psychiatrists can pay attention to to reduce the side effects burden and improve quality of life.

 

Dhar: Deprescribing or discontinuation of psychiatric meds is not an easy conversation. What are usually the common reactions you see from patients and their families?

Gupta: I never open the conversation with stopping meds. It’s an open question like, “Tell me about these medications. How they’re working out for you? Are they causing any problems?”

I have to make clear that 1) I’m not going to change medications without your input or impose my will, and 2) I’m just trying to understand how you feel about these meds. I need to emphasize that I’m not worried about whether you’re taking the medications or not. I’m worried about whether you’re feeling okay or not.

Some patients say, “I’m feeling well. I don’t even want to talk about this. Just refill my prescription,” which is entirely understandable because often these are people who have been either brutalized by the police or have had horrible experiences on inpatient psychiatric units, they don’t want to end up back there. They are afraid of getting angry with family members and mistreating their family. They may have spouses who say if you don’t take your meds, I’m leaving you.

This one patient, the last time she had stopped her medicine, she had punched her mother. So, she was terrified and said, “I don’t want to stop my medicine,” and she was on a hard-to-understand regimen of medicines, but that worked for her; any change would make her anxious.

Others see the conversation as the beginning of a transparent relationship. I’ll say, “Okay, what do you think about the pink pill that you take every night?” and the patient says, “Oh, I haven’t taken that for six months.” Deprescribing opens the door to building a better relationship with the patient.

 

Dhar: In the process of reducing or stopping psychiatric medication, what is the importance of ‘right timing’ and ‘psychosocial support’?

Gupta: The timing is extremely important. I work at a site with many trainees—a substantial number of patients doctors change every year in June and July. So, that’s not a good time to change medications. One reason is that the transfer of information might not be complete, and the patient is in the process of establishing a relationship with a new doctor.

There are so many factors that make it bad timing for the patient—instability in living situation, relationship troubles, if they’ve recently lost a beloved pet or family member and they’re depressed about it, losing a person who was important to them like a therapist, if they’re physically sick, etc.

That said, I don’t think there’s ever a perfect time to do it. So, if a combination is dangerous or contraindicated, you must talk with the patient.

Regarding psychosocial interventions, there’s some pretty clear-cut evidence for Mindfulness-Based CBT and the prevention of the recurrence of depressive episodes. Connect the person with a good therapist if you’re going to taper off the antidepressant. Peer support is critical—connecting the person to resources where people talk about withdrawal symptoms and strategies for safe tapering.

One of the most important things while tapering drugs is to reassure the patient that the withdrawal symptoms they are experiencing don’t mean they’re crazy. For example, brain zaps—it’s hard to put that experience into words. I have patients moving their hands in the air, trying to explain to me what’s happening in their bodies, but they’re not quite able to.

If they connect with someone with the same experience, then two people know what the other is talking about. That’s a big relief—I’m not the only person in the world to whom this is happening, and it’s the medication doing this to me; there’s nothing else that’s terribly wrong with me.

We know so little about the process. There’s a large consumer community and tapering community, and it’s important to learn from them to figure out which strategies work.

We also try lifestyle changes and things like CBT for insomnia, for example, if you’re tapering off Seroquel. Unfortunately, Seroquel is prescribed just for sleep on many occasions. That’s an egregious thing to do. So, while tapering off the Seroquel, we offer the patient CBT for insomnia groups—a simple, harmless intervention that can replace a fairly problematic drug.

 

Dhar: Here is a difficult one—withdrawal versus relapse—which one is it when a patient’s symptoms recur after reducing or stopping a drug like antidepressant or antipsychotic? We used to think that discontinuation of antipsychotics instantly causes relapse. But there is more and more evidence around the withdrawal effects of stopping or reducing antipsychotics and dopamine super sensitivity—which looks like relapse but isn’t. How do we know what it is? Is a patient relapsing into some original condition, or is this withdrawal caused by reducing the drug? When people think about withdrawal, they think of cocaine and not medicines.

Gupta: For antidepressants, the withdrawal syndrome is a little clearer because there are a lot of physical symptoms that pop up, like brain zaps, feeling tired, feeling fatigued, in addition to some very prominent emotional symptoms like crying spells or just feeling very irritable or getting angry, even suicidal thoughts or wanting to kill yourself—so all these things come up. But I think the physical component is really prominent. It’s pretty clear that this is because of the antidepressant withdrawal.

The surest way to establish that is that as time passes, the withdrawal symptoms will hopefully slowly dwindle and disappear at some point. A small percentage of individuals will have protracted withdrawal symptoms. Some are going to taper off antidepressants without any problems. Some people will have symptoms for four to six weeks.

As far as antipsychotics go, it’s really hard to tell. I think when people abruptly stop medicines like Clozapine, the symptom appears so quickly that it’s more likely to be a withdrawal syndrome that appears first. It’s possible that as time goes past, the withdrawal syndrome subsides, and some underlying syndrome, the primary illness emerges. That’s a possibility.

There is a chance that as the withdrawal syndrome subsides, nothing will emerge from under that. But by that time, the person has already been reinstated on the antipsychotic because the withdrawal itself is so disruptive.

There are some physical symptoms of antipsychotic withdrawal as well—a series of movement disorders like generalized fasciculations all over the body that can last four to six weeks, worsening of the tardive dyskinesia, dystonia that acutely appears as you’re tapering the medicine, stiffness, and tremors can get acutely worse.

Many antipsychotics are very powerful antiemetics or drugs that prevent vomiting. So, patients can feel nauseated on discontinuation. Patients can have diarrhea or sweat too much, or have a runny nose.

Small studies and case reports are done in gastrointestinal disorder clinics where patients are given drugs to prevent vomiting for long periods of time. And when these drugs are abruptly withdrawn, patients can have transient psychotic symptoms. And these are patients who have never had psychotic symptoms before.

 

Dhar: Could you tell our listeners a little bit about dopamine supersensitivity?

Gupta: Long-term blockade of the Dopamine receptors, which is what antipsychotics do, causes the Dopamine receptors to increase in number. There’s not enough Dopamine coming through, so the number of receptors increases. Then you suddenly remove the Dopamine blockade (stop taking antipsychotics). So, that area of the brain becomes supersensitive to Dopamine. And that’s the mechanism for withdrawal psychosis or withdrawal tardive dyskinesia.

 

Dhar:  You write that deprescribing aligns with the recovery-oriented approach to mental health. The recovery movement emphasizes patient choice and patient preference. You have written about some very important things like the ‘right to fail’ and the ‘dignity of risk’ and how, for some patients, functional recovery might be more important—Can I keep my job and have a good social relationship—than just removal of symptoms like voice hearing. Tell us more.

Gupta: There are four pillars of the recovery-oriented approach—person-centered care, honoring patient autonomy, fostering hope, and empowerment. Part of person-centered care is shared decision-making as well. Deprescribing is not possible without actually adhering to these pillars. The approach is highly individualized—it’s very person-centered. It’s what works for the patient.

It’s impossible to carry it out without the patients’ okay. I’m respectful that it’s the patient taking the medication, so they know best how it’s affecting their life. Patients are mindful that I’m the person who knows about medication side effects. In a space of mutual respect and understanding, we reach a common goal—it’s also aligned with shared decision-making.

It’s empowering because it tells the patient, “Medication is not the Be-All and End-All of your Well-Being. You have a right to say that you don’t want these medicines”. There’s hope for a medication-free life, unencumbered by side effects.

When we go to the ‘right to fail’ and the ‘dignity of risk,’ that gets unnerving for physicians because we are trained to be cautious. We are taught to minimize risk. To think that I would do something that would increase the chances that this patient could end up in the hospital or could start hearing voices again—For some physicians, it’s just unthinkable. It’s important to expand physician training and have them remember it’s also your job to give the patient a good quality of life and to offer treatments that align with their values and preferences. So, if it’s an informed decision that we are going to taper the Haldol by x milligrams, but there’s a risk that the voices might increase—do we want to take that risk? That conversation needs to be had.

 

Dhar: Has that happened, patients saying “I am okay with hearing voices as long as I can do these X, Y, Z things.”

Gupta: One typical example—young people who hear voices going to college, and the voices are really well controlled with an antipsychotic. But the problem is that the medication makes them so sleepy they cannot stay awake during class. Then it becomes about a balance between if the voices increase slightly, but they can sit in class.

One patient wanted to taper the meds slightly to see if they could stay awake during class, and it worked out fine. So, we consolidated the dose and moved it to the evening, which really helped this person.

I’ve also had patients who said “I don’t care if I end up in the hospital once a year, I’m not taking this medicine”, which is not an unreasonable choice if you have to take something like Haloperidol or Fluphenazine, which can suck the joy out of your life. And, if you are in the hospital but you know the staff at the hospital, you know that in two weeks you’ll feel better and come out, then that’s not a terrible choice.

 

Dhar: Lastly, tell us about your recent work on ‘undiagnosing’. What do you mean when you say deprescribing and ‘undiagnosing’ are two sides of the same coin?

Gupta: More recently, I had some interest in ‘undiagnosing’ because in the clinic where I work, there are lots of patients who have a lot of emotional ups and downs, and when they get very stressed, they have transient symptoms that amount to psychosis. Invariably, all these patients get diagnosed with schizoaffective disorder, and they get loaded up with antipsychotics.

There has to be a process of removing this diagnosis from their health record so they don’t get labeled as schizoaffective right away and they don’t get dumped with all these antipsychotics.

‘Undiagnosing” has become a thing in Geriatric and other branches of medicine where people feel that to effectively taper off and stop medications, these diagnoses should be removed from the health record.

 

Dhar: What does ‘undiagnosing’ say about the nature of diagnosis in the first place, especially in psychiatry?

Gupta: It was a very important teaching moment for me when my department chair, who had researched schizophrenia for 30 years, walked into the room and said, “You know, some people hear voices, some people do have negative symptoms, some people do appear quite disorganized—I think schizophrenia might exist.”

These are all constructs. They’re tools for helping people improve their lives. And when the tool does not feel relevant anymore, we should abandon it and move on to another tool, otherwise it becomes a burden.

I have a young patient in his 30s who hears voices almost constantly, and he deals with it—he lives his life, has a full-time job, likes the work he does, and has children—he lives a full life by all conventional standards. According to the textbook, he would meet the diagnosis of schizophrenia and be loaded up on antipsychotics, but what purpose is that going to serve?

For another person, that diagnosis and treatment might serve a purpose. But this person is dealing with the voices, and he’s happy living his life the way he’s living it. So, in his case, this tool of psychiatric diagnosis and psychiatric medications are just not useful.

 

 

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