Wicked problems, as characterized by Rittel and Webber, are problems that resist definitive articulation, it is hard to know when the problem has been solved, and solutions cannot be judged as true or false but only as better or worse and there is no metric standing above the interests and values of the judging parties. Once a solution is tried, it can’t be undone, and attempted solutions can generate their own uncertainties and repercussions. There’s no criterion that proves all plausible solutions have been identified, and every case is in some way unique, often nested within or symptomatic of larger issues. Wicked problems are complex but their wickedness arises from the plurality of legitimate value positions and the absence of any agreed criterion for what would count as a solution. (In case it needs to be said, “wicked” here means vicious or tricky, not ethically deplorable.)
Wicked problems resist definitive resolution in part because there are conflicting perspectives and values, extending to how the problem should be defined and what outcomes are desired or ought to be considered optimal. These conflicts may arise between different stakeholders or even within the same stakeholder group or within a single person over time. Multiple solutions will be valid, depending on whose values are given weight and how trade-offs are handled.
In a new co-authored paper led by Helene Speyer published in BJPsych Bulletin, “Clinical guidelines addressing complex and ‘wicked’ problems,” we suggest that the notion of “wicked problems” is a conceptual tool that can be used to better understand the challenges of deprescribing of psychiatric medications.
The goals and desired outcomes of deprescribing vary considerably. Some want to discontinue because of a perceived low risk of relapse and others because of the burden of adverse effects and others because of a desire for a medication-free life, and many others for many reasons. Heterogeneous illness course, degree of insight, clinical support available, and patient vs caregiver preferences yield multiple, competing framings of a person’s desire to come off medications. Patients, families, and clinicians weigh desired outcomes differently, and this plurality of evaluative standards means there may be no single correct answer, only complex negotiations.
Each attempt at deprescribing or maintenance has consequences that cannot be cleanly undone. A psychotic/manic/depressive/anxious relapse can be severe enough to alter one’s life, lose jobs, housing, relationships, treatment providers. A prolonged continuation of medication can entrench movement disorders or metabolic problems. A taper may appear to work for months before an abrupt decompensation is experienced. Continued maintenance may look like it’s working by reducing relapse but may functionally impair a person from neurolepsis. Feedback can be delayed and confounded by biological noise, so there may be no immediate test that settles the question of whether maintenance or deprescribing was the right choice. There are different ways to taper and different medications to utilize for maintenance. And each case is essentially unique with peculiarities of pharmacodynamics and psychodynamics. Prior response patterns, comorbidities, trauma history, social supports, local service capacity, and personal aims interlock in idiosyncratic ways, making rule-like generalization perilous.
Another dimension is the tension between individual autonomy and the responsibility to safeguard society. Clinicians’ primary obligation is to the patient, but this responsibility also extends beyond the individual to the society at large, creating situations in which the interests of the patient and the broader societal obligations may come into conflict.
In the case of wicked problems, deciding which explanatory framework to adopt determines the nature of the resolution. If a person is struggling after tapering their medications, whether we construe this as disorder relapse, withdrawal, rebound, disorder evolution, or something else entirely, in some ways, not entirely settled by the data; how we characterize it tells us what the appropriate resolution will be.
For each individual, not knowing whether they can remain well without medication and thereby reduce the burden of adverse effects, or whether they should accept the risk of relapse, is a deeply personal question tied to the dignity inherent in risk-taking. No one can substitute for a person’s own evaluation of what risks are worth taking. This is one of the fundamentally wicked dimensions of deprescribing that can never be reduced to recommendations in clinical guidelines.
Check out our thoughts in the paper on how clinical guidelines may approach this.
“Clinical guidelines aid decision-making, but their simplifying strength becomes a limitation in complex, value-laden situations. Once meant to summarise evidence, they now function as prescriptive standards used in quality and legal assessments. Overly rigid directives can undermine autonomy, hide uncertainty and restrict clinical judgement. Using complexity science and ‘wicked problem’ theory, we introduce ‘wicked complexity’ to better match guidelines design to real clinical challenges. Applying this to deprescribing psychoactive drugs, we show how traditional, adherence-focused guidance can prompt defensive practice. Guidelines for wicked complexity should instead clarify risks, support moral deliberation and support shared, iterative decision-making across healthcare.”
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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.