Make Deprescribing Boring
On the ASCP Consensus Statements and the MAHA Discourse
There are two broad mindsets or flavors when it comes to talk of “deprescribing” in psychiatry.
The first is the mindset of competent, collaborative, patient-centered practice, one that treats taking patients off medications that are no longer necessary, are causing harm, or no longer align with informed patient preference as part of routine psychiatric care.
The second is the mindset according to which psychiatric medications are really only helpful in a small number of extreme cases, are generally unnecessary and overall harmful, and people who take them are either misinformed or are using the medications as a crutch to avoid “doing the work” of addressing their psychological hang-ups, making necessary lifestyle changes, or cultivating a stoic attitude.
The problem is that the first mindset has been largely absent from real-world practice. People are started on medications willy-nilly and kept on them willy-nilly. Only a small fraction of patients has providers who do proper evaluations, make medication decisions in an informed and collaborative manner, periodically reassess the need for medications, and then taper them in a safe and gentle way. Mainstream medicine’s failure to embody the first mindset is precisely what created the vacuum the second mindset has filled. For decades, mainstream psychiatry willfully blinded itself to the burden and severity of withdrawal and discontinuation-related difficulties from antidepressants and other psychiatric medications, ceding this ground to radical critics out of a medical bias in favor of ongoing treatment and a tendency to interpret withdrawal and discontinuation-related rebound symptoms as relapse.
In reality, a substantial proportion of people using psychiatric medications long-term struggle to come off them. After getting no meaningful guidance from their physicians or nurse practitioners, they search online for help, discover communities of people who have been dealing with these issues, and find strategies that actually work… but the people offering that guidance have often been radicalized over the years by iatrogenic harm and by selective exposure to literature skeptical of psychiatry. Some of these people end up believing that staying on psychiatric medications is itself what caused their chronic illness and that is what is causing our mental health crisis and there is an urgent need for deprescribing on a massive scale.
For years now, “deprescribing” discourse has been the gateway to a radical critique of psychiatry… that psychiatric medications aren’t really effective, that they are inherently dangerous, that mental disorders aren’t even medical conditions. The term “deprescribing,” otherwise innocuous and with a respectable lineage in medicine, has become charged and critically tinged. It has been co-opted by people who see psychiatric medications as fundamentally suspect and sinister—useful, perhaps, for short periods in some situations, but a practice we should be wary of by default.
As the number of people struggling with withdrawal from psychiatric medications grows, and as more people search online for guidance, an ecosystem of services, largely disconnected from mainstream medicine, has emerged to offer information and guidance about safely coming off psychiatric medications. American psychiatry’s silence on the matter has been a source of embarrassment for anyone in the know.
It is in this landscape that the American Society of Clinical Psychopharmacology (ASCP) consensus statements have arrived (JAMA Network Open, Feb 2026) (see Ellen Barry’s coverage of ASCP recommendations and of MAHA initiatives in the New York Times). The timing is no coincidence in my mind; while work on developing this consensus may have been going on for a while, the publication now reads as a direct response to the public visibility of iatrogenic harm narratives and the alternative ecosystem that has grown up around them. The ASCP is making an effort to reclaim “deprescribing” and situate it within mainstream medicine as a practice that is a fundamental feature of good clinical care. They are late in the sense that they should have been published twenty years ago, at least, but better late than never. The statements address general deprescribing principles, pharmacokinetic and pharmacodynamic factors, adverse effect management, treatment adherence, special populations, and the psychological context of deprescribing.
Most of the recommendations are distillations of sensible clinical practice. I would characterize the statements as generally reasonable, sober, pragmatic, and grounded. They describe the collaborative mindset that needs to be the default in clinical practice.
A few examples illustrate the tenor:
The utility of continuing any particular psychotropic medication should be periodically reassessed, at the very least, on an annual basis. (100% agreement)
A risk-benefit analysis should be conducted before deprescribing any drug to gauge benefits vs lack of efficacy, or benefits vs adverse effects and their manageability. (100% agreement)
Patients who request to stop a medication that seems to be effective for previously poorly controlled symptoms should be guided through a risk-benefit discussion of continuation, discontinuation, or other modification to their regimen.
When considering whether to deprescribe an existing medication based on lack of efficacy, conclusions about perceived poor efficacy should not be made until the prescriber has made a careful assessment of adherence or adequacy of a trial.
Patients prescribed nonempirically supported polypharmacy for conditions for which pharmacotherapy is not indicated as a first-line treatment (eg, borderline personality disorder, PTSD) should be routinely evaluated for systematic deprescribing of non–evidence-based medications.
I was also happy to see a section devoted to psychological and psychodynamic considerations around medication treatment, including statements like:
Patients’ psychological barriers to deprescribing may include unconsciously fearing the loss of medication as a valued object, experiencing loss of medication as a rejection by the prescriber, and a threat to the medical legitimacy of their suffering.
This is the kind of careful, clinically grounded thinking that should be a default rather than an aspiration.
At the same time, it is notable that these recommendations bypass and skirt the most pressing and controversial issues in the deprescribing domain. The guidelines mostly focus on generalities and on the specifics of when to consider deprescribing, but they say almost nothing about how to deprescribe and the little they say is very problematic. There is no discussion of how to approach dose reduction as a valuable goal without necessarily leading to discontinuation, how to manage and prevent antidepressant withdrawal, different tapering strategies that clinicians can consider, how to approach protracted cases of withdrawal, or how to undertake a slow, gradual taper that requires using doses not available in standard pharmacies.
The statements defer to existing evidence on maintenance treatment without considering whether the trial results have been systematically biased by ignoring discontinuation-related effects. They generally recommend maintenance treatment for recurrent depression, bipolar I disorder, and schizophrenia, ignoring controversies in these areas. They assume, for example, that most people are correctly diagnosed when the reality is that there is widespread diagnostic chaos and medication decisions about maintenance are made under considerable uncertainty.
The guidelines operate firmly within the default thinking about maintenance treatment and tinker with it rather than confronting the assumptions that produced the present situation. They are valuable because they emphasize virtuous clinical practices. But they bypass all the big points of controversy around deprescribing, and for patients struggling with difficulties coming off their psychiatric medications and for clinicians treating them, the recommendations offer little of substance.
Mark Horowitz, in the comments he posted on the ASCP paper, has pointed out several major limitations that I also generally agree with. The reliance on Delphi consensus rather than a review of scientific evidence not only glosses over the gaps in empirical data but also allows the same epistemic community that normalized long-term use to now define the appropriate conditions of its reversal. The statements implicitly prioritize relapse prevention over discontinuation-related difficulties; increased post-reduction monitoring is described in terms of relapse risk rather than the possibility that post-reduction symptoms may also reflect withdrawal. The mechanics of deprescribing are sidestepped entirely; there is no engagement with dose-response relationships or receptor occupancy, and no mention of hyperbolic tapering.
There are points where the ASCP experts reveal their disconnect from the iatrogenic harm world in striking ways. The most gauche example is this statement, which achieved 81% agreement:
Medications with a long terminal elimination half-life (eg, fluoxetine, vortioxetine, cariprazine, aripiprazole) or long-acting injectable antipsychotics generally can be abruptly stopped without the need for a downward dose titration because they will auto-taper.
The idea that medications like fluoxetine and aripiprazole can be stopped without down-titration is, in my view, dangerous. I would not recommend that to my patients. It is astonishing to me that 80% of these experts would think that someone who has been on 60 mg of fluoxetine or 20 mg of aripiprazole for 5 years can just stop the medication because these medications “auto-taper.” Yikes! As Horowitz also notes, this claim reflects a simplistic view of neuroadaptation: receptor-level adaptations can take longer than the elimination of even long half-life drugs, and abrupt cessation can still precipitate delayed but severe discontinuation difficulties.
A statement like this one reveals that the ASCP recommendations, for all their virtues, are disconnected from the experiences of the harmed patient community and guided by the knowledge and preconceptions of an insular community of academic researchers who do not, in any sustained way, manage the patients struggling with the complexities of psychotropic withdrawal.
I want two things when it comes to deprescribing.
The first is rather superficial, more to do with institutional interests but still important. I want mainstream psychiatry to take ownership of deprescribing and tapering… to make it routine, boring, to back it with solid evidence about which dose reduction and discontinuation techniques produce the best outcomes, to conduct a dozen RCTs on tapering methods and outcomes so that disagreements can be resolved with actual data and this space is no longer ceded to speculations and no longer functions as a gateway to psychiatric skepticism.
Second, and eventually this is what really matters, I want patients who wish to come off medications to be able to do so successfully, without discontinuation difficulties, and I want patients struggling with withdrawal and unsuccessful tapers to find effective care. I have my doubts about hyperbolic tapering as the default strategy for everyone, but for people who are really struggling with withdrawal, based on what we know today, I would recommend some variety of hyperbolic tapering as the strategy most likely to help them.
Our top psychopharm experts act like the stereotype of out-of-touch elites. They need to step outside the ivory tower and spend time talking to people in the prescribed harm community with an open mind. They need to engage with the work of those who have been helping and guiding people through withdrawal for years.
I have my beefs with prominent figures in the deprescribing and iatrogenic harm communities, due to the antipsychiatry bias, dogmatic attitudes, and refusal to seriously consider the many ways in which a self-diagnosis of “withdrawal” can be erroneous, etc, and many of them see me more as an adversary than an ally (*shrug*). But they have my tremendous respect for stepping up and helping people who found little help or guidance from the medical community. I continue to be embarrassed by the failure of psychiatric leadership to address these issues with the seriousness and urgency they warrant, and I am amazed at the absence of a research program aimed at understanding and addressing iatrogenic harm. The ASCP guidelines are a half-step in the right direction, but we have a long way to go before we can make deprescribing boring and routine.
See also:
>They generally recommend maintenance treatment for recurrent depression, bipolar I disorder, and schizophrenia, ignoring controversies in these areas. They assume, for example, that most people are correctly diagnosed when the reality is that there is widespread diagnostic chaos and medication decisions about maintenance are made under considerable uncertainty.
This is one of the challenges I deal with regularly in my setting (corrections). We get a database showing the patient has been hospitalized many times, with diagnoses of Schizophrenia / Schizoaffective / Bipolar Disorder all over. Many psychiatrists automatically assume those to be valid and prescribe an antipsychotic, with the understandable goal of not missing or risking exacerbation of psychosis, Mania etc, and medications are continued indefinitely. No symptoms arise, and the psychiatrist and the system are happy. But the patient suffers, often silently.
Over the past couple years I have been more aggressive about deprescribing, when I think there is a reasonable argument that the chart diagnoses are invalid and better explained by substances / trauma / personality / billing needs, etc. A small number of patients have had authentic symptoms or disability emerge (and thankfully, in my setting those issues are fairly rapidly attended to), but the vast majority either experienced no change, or improve, and to me, that has been incredibly satisfying.
Wonderful post and I applaud you "taking back the narrative" of thoughtful medication management away from what are often anti-psychiatry shills.
My only quibble is that you seem to present RTCs as the path to resolving all issues with the result that deprescribing can become boring.
I used to tell my very well-informed internist that my middle name was not Median. He proceeded with a great deal of research-based certainty about the correct treatment of type 2 diabetes. Finally, he came up with a new research finding. "Research now reveals that it's OK for a person over 60 to have a hemoglobin A1C level of eight." I silently shouted, “Alleluia.!”