Your BJPsych Bulletin article notes that clinical issues lie on a continuum of complexity and "wickedness." As I read that article and this post, I was struck that similar cautions and considerations apply to all mental health practice. Psychotherapy approaches, psychiatric nosology, psychiatric prescribing, medication non-adherence, deprescribing, and pretty much everything else we do in clinical practice are value-laden, complex problems.
While the example of deprescribing is illustrative, it may be misleading to single out any particular aspect of our work in this regard. Mental health care (and most other human endeavors, actually) are inevitably complex and "wicked." Deprescribing is not qualitatively different from the rest of practice. And practice guidelines, which by their very nature simplify complexity and wickedness, should be viewed as helpful, not sacrosanct.
"Second, guideline-driven caution can make clinicians hesitant to support a person’s desire to reduce medication. As a result, some individuals may attempt to taper or discontinue on their own, or to conceal their intentions from their care team. This behaviour increases the risk of adverse outcomes, while the clinician remains legally protected because they have adhered to the established guidelines. In other words, rigid guidelines adherence can unintentionally create a more precarious situation for the patient."
THIS! I made an overall informed decision to quit my meds in 2018. Very different from the impulsive stupid-quits I had done at earlier points in my life. But I had a terrible doc, at the time, who never listened to me. He thought symptom repression was everything, having a life and being able to do stuff was nothing. So even though the decision to quit was informed, the way I DID it - lied to my doc, quietly dropped out of psych, and went cold turkey - was, to say the least, suboptimal.
I was moving to a different part of the country, then. My doc said he'd refer me to a new doctor at my new place of residence. I assumed - correctly, as it turned out - that he would forget to do so if I didn't remind him, so I could slip out of the psych system when I moved with no one noticing. THEN, I figured it's probably more efficient to just quit everything cold turkey (including benzos) than tapering.
Fortunately, everything still worked out. But it could have gone so badly.
A little bit of self-blame: I could have done more internet-"research" on different ways of quitting, and learnt on my own that you should definitely taper. I was too impatient.
Blaming the system: If I had had a doctor who listened to me, I could have been advised by him. "Doing your own research" as a patient shouldn't be necessary in the first place.
I think the clinician needs to assess if the risk is worth taking, but the problem is so complex that it takes more interaction than 15 minute sessions once a month.
I have to second Steven’s comment below. AA is engaging with the public dialogue, but that has a “dismetria” that makes it like something composed by artificial intelligence, and disconnected from the reality of clinical practice.
I can’t speak to other specialties outside psychiatry, but the public dialogue in psychiatry appears to be getting farther and farther from reality, not closer. When did all this start? I can’t remember. Was it the automated warnings I saw when I ordered medications electronically? The twisted NYTimes exposes? So now we fuss over “deprescribing”.
In MY practice the loudest complainers insisting I “deprescribe” their medication, were patients that had not yet begun taking medication! That has always been the case. They theorize and squirm about all sorts of imagined harms they will experience, and they insist that I prescribe their medication for a very short defined period, even though I am already only writing prescriptions for a few weeks at a time and seeing them every other week or every third week.
Each patient arrives with his experience and values. I can give general a priori advice but the patient formulates them (either with my urging or naturally) for himself. Patients appear to be more assertive about this, but perhaps I am more desperate to avoid alienating them, since so much of my practice is transactional ie “here is my copay now give me my stimulant”.
When will we have discussions that more closely parallel the reality of psychiatric practice? Not AA’s response, but the entire deprescription discussion has gotten so far from useful it is nothing but a New Yorker cartoon of medicine. There was anti-psychiatry, now MAHA, the face masks change the exaggerations don’t. I am still alone and without guidelines.
Your BJPsych Bulletin article notes that clinical issues lie on a continuum of complexity and "wickedness." As I read that article and this post, I was struck that similar cautions and considerations apply to all mental health practice. Psychotherapy approaches, psychiatric nosology, psychiatric prescribing, medication non-adherence, deprescribing, and pretty much everything else we do in clinical practice are value-laden, complex problems.
While the example of deprescribing is illustrative, it may be misleading to single out any particular aspect of our work in this regard. Mental health care (and most other human endeavors, actually) are inevitably complex and "wicked." Deprescribing is not qualitatively different from the rest of practice. And practice guidelines, which by their very nature simplify complexity and wickedness, should be viewed as helpful, not sacrosanct.
That’s an excellent point! You are the right that this applies more broadly.
"Second, guideline-driven caution can make clinicians hesitant to support a person’s desire to reduce medication. As a result, some individuals may attempt to taper or discontinue on their own, or to conceal their intentions from their care team. This behaviour increases the risk of adverse outcomes, while the clinician remains legally protected because they have adhered to the established guidelines. In other words, rigid guidelines adherence can unintentionally create a more precarious situation for the patient."
THIS! I made an overall informed decision to quit my meds in 2018. Very different from the impulsive stupid-quits I had done at earlier points in my life. But I had a terrible doc, at the time, who never listened to me. He thought symptom repression was everything, having a life and being able to do stuff was nothing. So even though the decision to quit was informed, the way I DID it - lied to my doc, quietly dropped out of psych, and went cold turkey - was, to say the least, suboptimal.
I was moving to a different part of the country, then. My doc said he'd refer me to a new doctor at my new place of residence. I assumed - correctly, as it turned out - that he would forget to do so if I didn't remind him, so I could slip out of the psych system when I moved with no one noticing. THEN, I figured it's probably more efficient to just quit everything cold turkey (including benzos) than tapering.
Fortunately, everything still worked out. But it could have gone so badly.
A little bit of self-blame: I could have done more internet-"research" on different ways of quitting, and learnt on my own that you should definitely taper. I was too impatient.
Blaming the system: If I had had a doctor who listened to me, I could have been advised by him. "Doing your own research" as a patient shouldn't be necessary in the first place.
I think you'd find empowering the book "Wisdom of psychosis" by Anneke Sips.
I think the clinician needs to assess if the risk is worth taking, but the problem is so complex that it takes more interaction than 15 minute sessions once a month.
I tried to come off medication several times. My psychiatrist did not really agree, but in the end he respected what I wanted and helped me do it.
The illness kept going up and down. It badly affected my life.
Now my psychiatrist says I am on too many medications and tells me to reduce. I do not dare.
I have to second Steven’s comment below. AA is engaging with the public dialogue, but that has a “dismetria” that makes it like something composed by artificial intelligence, and disconnected from the reality of clinical practice.
I can’t speak to other specialties outside psychiatry, but the public dialogue in psychiatry appears to be getting farther and farther from reality, not closer. When did all this start? I can’t remember. Was it the automated warnings I saw when I ordered medications electronically? The twisted NYTimes exposes? So now we fuss over “deprescribing”.
In MY practice the loudest complainers insisting I “deprescribe” their medication, were patients that had not yet begun taking medication! That has always been the case. They theorize and squirm about all sorts of imagined harms they will experience, and they insist that I prescribe their medication for a very short defined period, even though I am already only writing prescriptions for a few weeks at a time and seeing them every other week or every third week.
Each patient arrives with his experience and values. I can give general a priori advice but the patient formulates them (either with my urging or naturally) for himself. Patients appear to be more assertive about this, but perhaps I am more desperate to avoid alienating them, since so much of my practice is transactional ie “here is my copay now give me my stimulant”.
When will we have discussions that more closely parallel the reality of psychiatric practice? Not AA’s response, but the entire deprescription discussion has gotten so far from useful it is nothing but a New Yorker cartoon of medicine. There was anti-psychiatry, now MAHA, the face masks change the exaggerations don’t. I am still alone and without guidelines.