>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.
I’m so glad to hear you are speaking up in your setting and to good effect!
So grateful to Awais for giving clear language to this mess we’ve all been swimming in. It’s not easy to name and sort out the many problematic issues while maintaining room for complexity. This conversation about deprescribing is a long time coming. Hopefully this is just the beginning.
My comment is not directed towered Awais, but those associated with ASCP.
Why is there seldom discussion in descriptive psychiatry about the effects of sleep and lack thereof? Why is it implicitly assumed that those labeled with chronic psychosis-related disorders are getting consistent, oxygen-rich, deep sleep? Despite that the vast majority are also chronic smokers?
We already know chronic sleep deprivation (lack of oxygen) directly causes hallucinations, delusions, psychosis, and a breakdown in somatosensory coherence in that order: https://doi.org/10.3389/fpsyt.2018.00303
Is it really a coincidence that these are the criteria for the psychoses / schizophrenia spectrum?
Indeed, it might explain why people refuse to take antipsychotics long term: they directly starve the body and brain of oxygen. So when the ASPC says "We must weigh the risks and benefits", the "risks" being that someone violates society's cherished "social norms" during a temporary psychotic episode, or the so-called "benefit" of these drugs', which apparently involves dying from a disease associated with hypoxia, it should not be difficult to understand the sentiments from critical psychiatry.
It is outrageous that the general media covering psychopharmacology is calling "sleep, diet, and exercise" - activities that involve oxygen uptake - a "conspiracy theory" whenever our current health secretary prescribes them to society over pharmacology.
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.!”
Thanks for this. I would be interested to hear your opinion of the Maudsley Deprescribing Guidelines. It’s incomplete (notably missing guidance on antipsychotics) but I believe it purports to provide the kind of information (and evidence) that you would like to see.
Two other comments:
(Personal anecdote) I’ve come off of antipsychotics three times. The first was done in total ignorance and without mentioning it to my doctor. It was a disaster. (My ‘tapering regime’ consisted of throwing the remaining pills into the North Sea.) The second time I asked the doctor (UK) for help and he said “you saw what happened last time.” Well, yes I did, which is why I was asking for help. He refused and I did it myself, successfully (but painfully). Twenty years later I agreed to go back on meds but I said from the beginning that it was temporary. My doctor (USA this time) agreed, but when I said that I thought it was time to come off I was repeatedly told “not yet” and eventually I gave up on him and did it myself again. I’ve been off this last bout for 3 years now, and doing well.
(Personal rant) It seems that thoughtful psychiatrists agree that schizophrenia is not a natural kind (on TOP of the diagnostic chaos) and yet we get recommendations like “schizophrenics should maintain medication”, as if such a statement makes sense.
Honestly I think (increasingly) that one of the problems that we are facing is an unwillingness to exercise intellectual humility. The truth about many of these questions is “nobody knows”, but that’s a very difficult truth to acknowledge for many people (and for many reasons, some of them understandable).
As a practicing psychiatrist for 30 years much of which has been spent teaching, I often say that the more experience I have, the more often and confidently I say “I don’t know “ and I encourage trainees to adopt radical humility as the central tenet of practicing Psychiatry. I am overjoyed the conversation about deprescribing and the prescribing patterns in the USA are finally gaining public and intraspecialty discourse. Like Awais, I want deprescribing to be mundane boring and ordinary for every psychiatrist.
It's unfortunate that many will see the deprescribing influence as a reaction to the MAHA movement; it's something of an illusion, as the issue is not exactly brand-new. But it is an illusion that psychiatry has largely brought upon itself.
It may well be that the ASCP experts are able to outline broad principles of de-rx'ing but are, themselves, inexperienced and unpracticed in the kinds of serial conversations with patients that make it work well. It may seem simplistic, but the nuances of what the prescriber says in response to this or that issue raised by the patient are truly central. It has to go past anything like, "OK, let's try this and see how it goes." Things like (1) what to look for over what period of time (2) how to assess what's a bad day and what's a possible recurrence, among others, are the kind of things that "every psychiatrist knows" - except they don't, and so tapering has a kind of haphazard feel to it that the hyperbolic curves etc don't capture. You can be a psychopharmacology expert and still be unskilled with these conversations.
Also, I have seen de-prescribing take on a flavor of an unspoken "you're doing this against my judgment" which becomes another struggle for the patient which shouldn't be his/her concern; the doctor feels pressured to go along ( with or without good reason) and the patient senses that. It's a little ironic in that, optimally, de-rx'ing should occur at a time of sustained stability, so it can take on a 'happy occasion' feel, as if it's graduation time.
I saw this piece when it came out and wanted to think about barriers to deprescribing in my own practice.
I think there is more to the psychological component of this, both for the patient and the prescriber. It's easy to see someone who comes to you on 6-7 meds and to immediately think, let's get this pared down. That's low-hanging fruit.
What's harder is when someone has been taking something, you are no longer sure that it helps, and in fact in retrospect maybe it NEVER helped- what helped was the therapeutic relationship. But you and your patient initially agreed that "it helped." Introducing the idea of stopping or tapering off might mean that you both have to acknowledge you might have been duped or had co-created a fiction. You would have to acknowledge the fact that this idea of a medicine "working" is sometimes elusive.
Sometimes people are reluctant to come off even one of a regimen of many meds. Do we push them? Or would they get worse if we did? How do we know if their fear is linked to a reality that the medicine has helped or to their transference to the medicine?
I find myself thinking about this a lot as I learn more about the risks of things that we used to think were perfectly safe, ie. the link between anti-depressants and bone loss.
For deprescribing to really work, we'd have to talk up front with patients about the fact that there may be a time when we will re-evaluate this medication and that, even though it might create discomfort, the right thing to do may be to come off it.
I just got through grad school to become a Psych NP. I was pleasantly surprised by the consistency of the message in Advanced Pharm class that polypharmacy is a major problem. I look forward to focusing on safely deprescribing as I establish my practice
I was recently at a DEA education seminar that mapped stimulant prescription patterns over time. Unsurprisingly, the number of stimulant prescriptions has gone up substantially in the last 6 years , but the number written by psychiatrists or family docs or pediatricians has stayed the same. Meanwhile those written by NPs have followed the upswing. While MDs are guilty of poly pharmacy for sure , NPs are adding to the numbers at a rate that is frightening. Glad to hear your curriculum raised the red flag. I wish more schools did.
I believe this. I took so long to become an NP (20 yrs after becoming an RN) because I had no interest in prescribing meds. I only proceeded to apply to grad school when I finally got clear that I could be a psych NP and also a therapist. I think this orientation is quite unusual and I look forward to staying aligned with these values as I move into practice later this year.
>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.
I’m so glad to hear you are speaking up in your setting and to good effect!
So grateful to Awais for giving clear language to this mess we’ve all been swimming in. It’s not easy to name and sort out the many problematic issues while maintaining room for complexity. This conversation about deprescribing is a long time coming. Hopefully this is just the beginning.
My comment is not directed towered Awais, but those associated with ASCP.
Why is there seldom discussion in descriptive psychiatry about the effects of sleep and lack thereof? Why is it implicitly assumed that those labeled with chronic psychosis-related disorders are getting consistent, oxygen-rich, deep sleep? Despite that the vast majority are also chronic smokers?
We already know chronic sleep deprivation (lack of oxygen) directly causes hallucinations, delusions, psychosis, and a breakdown in somatosensory coherence in that order: https://doi.org/10.3389/fpsyt.2018.00303
Is it really a coincidence that these are the criteria for the psychoses / schizophrenia spectrum?
We also know that consistent administration of antipsychotics directly causes global decreases in oxygen uptake: https://doi.org/10.1016/j.euroneuro.2018.01.004
Indeed, it might explain why people refuse to take antipsychotics long term: they directly starve the body and brain of oxygen. So when the ASPC says "We must weigh the risks and benefits", the "risks" being that someone violates society's cherished "social norms" during a temporary psychotic episode, or the so-called "benefit" of these drugs', which apparently involves dying from a disease associated with hypoxia, it should not be difficult to understand the sentiments from critical psychiatry.
It is outrageous that the general media covering psychopharmacology is calling "sleep, diet, and exercise" - activities that involve oxygen uptake - a "conspiracy theory" whenever our current health secretary prescribes them to society over pharmacology.
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.!”
Thanks for this. I would be interested to hear your opinion of the Maudsley Deprescribing Guidelines. It’s incomplete (notably missing guidance on antipsychotics) but I believe it purports to provide the kind of information (and evidence) that you would like to see.
Two other comments:
(Personal anecdote) I’ve come off of antipsychotics three times. The first was done in total ignorance and without mentioning it to my doctor. It was a disaster. (My ‘tapering regime’ consisted of throwing the remaining pills into the North Sea.) The second time I asked the doctor (UK) for help and he said “you saw what happened last time.” Well, yes I did, which is why I was asking for help. He refused and I did it myself, successfully (but painfully). Twenty years later I agreed to go back on meds but I said from the beginning that it was temporary. My doctor (USA this time) agreed, but when I said that I thought it was time to come off I was repeatedly told “not yet” and eventually I gave up on him and did it myself again. I’ve been off this last bout for 3 years now, and doing well.
(Personal rant) It seems that thoughtful psychiatrists agree that schizophrenia is not a natural kind (on TOP of the diagnostic chaos) and yet we get recommendations like “schizophrenics should maintain medication”, as if such a statement makes sense.
Honestly I think (increasingly) that one of the problems that we are facing is an unwillingness to exercise intellectual humility. The truth about many of these questions is “nobody knows”, but that’s a very difficult truth to acknowledge for many people (and for many reasons, some of them understandable).
As a practicing psychiatrist for 30 years much of which has been spent teaching, I often say that the more experience I have, the more often and confidently I say “I don’t know “ and I encourage trainees to adopt radical humility as the central tenet of practicing Psychiatry. I am overjoyed the conversation about deprescribing and the prescribing patterns in the USA are finally gaining public and intraspecialty discourse. Like Awais, I want deprescribing to be mundane boring and ordinary for every psychiatrist.
It's unfortunate that many will see the deprescribing influence as a reaction to the MAHA movement; it's something of an illusion, as the issue is not exactly brand-new. But it is an illusion that psychiatry has largely brought upon itself.
It may well be that the ASCP experts are able to outline broad principles of de-rx'ing but are, themselves, inexperienced and unpracticed in the kinds of serial conversations with patients that make it work well. It may seem simplistic, but the nuances of what the prescriber says in response to this or that issue raised by the patient are truly central. It has to go past anything like, "OK, let's try this and see how it goes." Things like (1) what to look for over what period of time (2) how to assess what's a bad day and what's a possible recurrence, among others, are the kind of things that "every psychiatrist knows" - except they don't, and so tapering has a kind of haphazard feel to it that the hyperbolic curves etc don't capture. You can be a psychopharmacology expert and still be unskilled with these conversations.
Also, I have seen de-prescribing take on a flavor of an unspoken "you're doing this against my judgment" which becomes another struggle for the patient which shouldn't be his/her concern; the doctor feels pressured to go along ( with or without good reason) and the patient senses that. It's a little ironic in that, optimally, de-rx'ing should occur at a time of sustained stability, so it can take on a 'happy occasion' feel, as if it's graduation time.
I saw this piece when it came out and wanted to think about barriers to deprescribing in my own practice.
I think there is more to the psychological component of this, both for the patient and the prescriber. It's easy to see someone who comes to you on 6-7 meds and to immediately think, let's get this pared down. That's low-hanging fruit.
What's harder is when someone has been taking something, you are no longer sure that it helps, and in fact in retrospect maybe it NEVER helped- what helped was the therapeutic relationship. But you and your patient initially agreed that "it helped." Introducing the idea of stopping or tapering off might mean that you both have to acknowledge you might have been duped or had co-created a fiction. You would have to acknowledge the fact that this idea of a medicine "working" is sometimes elusive.
Sometimes people are reluctant to come off even one of a regimen of many meds. Do we push them? Or would they get worse if we did? How do we know if their fear is linked to a reality that the medicine has helped or to their transference to the medicine?
I find myself thinking about this a lot as I learn more about the risks of things that we used to think were perfectly safe, ie. the link between anti-depressants and bone loss.
For deprescribing to really work, we'd have to talk up front with patients about the fact that there may be a time when we will re-evaluate this medication and that, even though it might create discomfort, the right thing to do may be to come off it.
I just got through grad school to become a Psych NP. I was pleasantly surprised by the consistency of the message in Advanced Pharm class that polypharmacy is a major problem. I look forward to focusing on safely deprescribing as I establish my practice
I was recently at a DEA education seminar that mapped stimulant prescription patterns over time. Unsurprisingly, the number of stimulant prescriptions has gone up substantially in the last 6 years , but the number written by psychiatrists or family docs or pediatricians has stayed the same. Meanwhile those written by NPs have followed the upswing. While MDs are guilty of poly pharmacy for sure , NPs are adding to the numbers at a rate that is frightening. Glad to hear your curriculum raised the red flag. I wish more schools did.
I believe this. I took so long to become an NP (20 yrs after becoming an RN) because I had no interest in prescribing meds. I only proceeded to apply to grad school when I finally got clear that I could be a psych NP and also a therapist. I think this orientation is quite unusual and I look forward to staying aligned with these values as I move into practice later this year.