E287 - Deprescribing Practices in Psychiatry with Drs. Stephen Stahl and Jeffrey Strawn

Uh, deprescribing, that's a funny term.

We're used to talking about prescribing things, so why is deprescribing so important?

So one of the things that's really interesting, Andy, and I'm, I'm very curious what, what Dr. Stahl thinks here, is that we've focused on deprescribing as really the opposite of prescribing, when in reality it's part and parcel of prescribing.

And one of the things that my good friend Dr. Stahl mentioned as we were talking about the introduction for this, this textbook is that anyone that prescribes is a deprescriber.

Any prescriber is a deprescriber.

We stop medicines when they're not working.

We stop medications when a patient experiences side effects, when we need to cross titrate from one medication to another medication.

That is really, in essence, deprescribing as much as deprescribing is stopping a medication when it's no longer used, or needed, rather.

Mm-hmm.

Well, Steve, why is it that people end up on so many different medications? And it seems like people add but don't subtract.

Well, it's amazing.

Uh, those of you who are listening who are, you know, in the psychopharmacology practice will have seen this a lot.

Patients will come in, and you inherit them often on meds somebody else gave them, and, uh, they may have had a partial response, and you're afraid to stop anything because you don't know why they're better, a little bit at least, and so you just add something.

You especially see that, I think, in, in residents' clinics when a resident only takes care of a patient for six months, and then they're, they're afraid to, to stop things.

But I-- Jeff and I have talked about this, and Andy, I think we've talked about it as well.

I- if you're actually a psychopharmacologist, you actually end up stopping more medicines than you start if you're good, and you simplify the situation, and, uh, you know, it, it, it-- sometimes you need to reestablish a new baseline off a couple of the medicines before you give a new one, but it gets too complicated, and that's why they end up with sometimes twelve, fifteen medications.

Yeah.

You know, I think we've all had the experience, too, of sort of finally getting this magical combination that seems to work, and then it kind of gets us to think, "Well, now I've gotta chase that magic combination of things." Um, what do you think, Jeff? And sometimes people chase symptoms and start adding things for symptoms rather than the underlying condition.

I think absolutely, and I think another nice part to maybe bring into this discussion is the psychology of deprescribing, both for us as prescribers, for our patients, for their families, et cetera.

There's often a lot of anxiety around what if deprescribing or lowering a dose of a medication actually causes my symptoms to recrudesce or me to get worse when I finally got to what I may believe is this very tenuous state of recovery?

Yeah.

Yeah, and other things, uh, Steve, you alluded to this.

I think sometimes when your goal is to c- uh, cross taper, if you will, you get stuck in the cross.

You know, you, you, you overlap the medicines, and they seem to get better, and then you kind of lose your courage to go all the way through to just try the new medicine alone, and so people stop.

Does that happen, too?