As patients age and treatment courses evolve, ongoing medication reassessment becomes critical to minimizing risk and optimizing safety. In this practical session, Dr. Jessica Gurley reviews indications for deprescribing psychiatric medications, high-risk medication classes, common barriers, and structured tapering strategies—including the A-TAPER model. Emphasis is placed on risk–benefit evaluation, patient engagement, and individualized taper plans to reduce adverse outcomes while maintaining clinical stability.
Good morning everyone. My name is Jessica Gurley. I'm a psychiatrist and the director of medical operations for behavioral health in the South Side. I field a lot of questions from primary care, from other behavioral health providers about deprescribing. What is it appropriate? What is it? Why do we do it? Why do we need to do it? It's really big going into uh this year and looking at. Our patients, patient safety, patients and how they're doing with their medications. One big problem that we're encountering is retirement of providers and the new wave of providers coming in. Sometimes it gets very difficult if you disagree with the provider's prescribing habits, but what do you do then? Because now a patient has been on these medications for a while. What's appropriate? What's not appropriate? Today, we just want to talk about deprescribing, kind of set a framework for it and give you some good guidance about where to start and really what you should be thinking about and how to start working on it and working with primary care and behavioral health to maximize the patient's health. We've all been there and we've inherited a patient on many medications that you're really unsure what is up and down. When you're looking at polypharmacy and looking at deprescribing, some of the considerations we want to look at is, what is the side effect burden? What is the age of the patient? What risks are associated with these medications? What concerns does the patient have? What medications may be contributing to those concerns? Are there any drug-drug interactions? Looking at a patient over 65, are any of these medications falling in the beer's criteria where we really need to be tapering them down? Is the patient symptom free? Are they still on medications, although they're symptom free. And also we want to look at comorbidities because with age and metabolism, things start changing for patients. When we inherit patients, and with our own patients, we tend towards status quo. Patients are doing well and they're doing just fine on their medications. And when we start talking about tapering, people start getting a little worried. But then we also need to look at what is the risks, because we want to keep patients healthy and happy and have a long life. There are a couple of different classes of medications that really want to be red flags when looking at um our medication reconciliations. Benzodiazepines, these are the ones that have the biggest risk for falls, altered mental status, sedation, and drug-drug interactions. SSRI's and SNRI's can also have problems, especially at older ages, because we have the increased risk of SIADH, falls, postural sway, bleeding, and high blood pressure. Anti-convulsants can also have problems. Drug-drug interactions and toxicity significantly increases patients' age. Antipsychotics can also cause problems as patients age, and patients with, uh, dementia, it also increases the risk of death. Trazodone, which usually is a pretty mild, uh, medication for insomnia, also increases the risk of sedation and falls as patients age. And antihistamines, we all know that these cause sedation and they can cause over sedation, and we also want to worry about anticholinergic effects as patients age too and the impact of that on cognition. When addressing deprescribing, there can be a lot of clinical barriers that pop up. One of them being time. We don't have a lot of time with our patients in appointments. We also really come up against a barrier of fear of discontinuation. Patients have been on these medications for a very long time, since the dawn of time, as some patients tell me. And they really get fearful of coming off of them because how are they going to feel afterwards. We and the patients can be averse to changing medications because we don't know how they're going to react or how it's gonna work. And we also need to talk about to patients about the potential benefits of this change, but also the potential benefits of staying versus staying on the medication. Some patients don't necessarily understand the risk. Some patients haven't been educated on the risks. And also, we really need to address our own personal biases because it's easy to Monday morning quarterback when looking at a patient's medication reconciliation. We have to take into account that we don't know where the other provider is coming from, and also they did their best, we need to assume that they did their best to help the patient. And now it's just a new data where we can go forward and help the patient even further as far as their next steps to become healthy and happy. The medication class that I get the most questions about deprescribing are the benzodiazepines. People get very uncomfortable with benzodiazepines, and understandably. When we're looking at patients who are on it, let's talk about why and the FDA recommendations for benzodiazepines. We really want to only be using them for less than 4 months, and if they are used for anxiety less than 4 months, and for insomnia, it's only about 12 to 10 to 28 days. They should not be first line for any medi uh, any anxiety. And it also is of note to be self-reinforcing. So when they are self-reinforcing, that increases the risk of overuse and misuse. And when we talk about misuse and abuse, there's a difference. Misuse is taking it at times other than as directed. Abuse though, is taken for recreational non-medicinal reasons. Tolerance does not mean that it is abuse or misusing the medication, and abuse does not necessarily mean that they have a substance use disorder. When we talk about self self-reinforcing, um, these medications, when we take them, our, our brain gets a reward for that and therefore it really wants to take it again. The reality is that these benzodiazepines are less reinforcing than opiates or cocaine or amphetamines, but self-reinforcing behavior is really more common and more prominent in patients with substance use disorders, young adults, so 15 to 35. And concurrent moderate alcohol use. When we do see these patients, we really need to be mindful that this is not a good patient to be using benzodiazepines, and when we are inheriting patients that are on, that have these risks and they're on the medication, that's when we should think about deprescribing. When a patient is on a long-term benzodiazepine use, whether, whether it's you're inheriting the patient or it's your patient, we need to evaluate the risk of coming off of the medication, because there is a risk of problems coming off the medication. Untreated anxiety associate can be associated with medic many medical risks, and so mortality rates can also increase when you do start trying to decrease the benzodiazepine with the deprescribing. We have to evaluate the patient. We have to assess whether this patient coming off of the medication would be worse than staying on the medication and vice versa. So again, this is a conversation with the patient. This is an evaluation of the chart, and if you have a trial trying to come off this medication. Then, and it's failed, then maybe that's the time that we need to just kind of re-evaluate what's the next step. A couple of examples of when to consider deprescribing or when to maybe hold or pause would be, for instance, a 90 year old female who's been on diazepam for over 50 years. That might seem really ridiculous and the first thought might be, we need to get this off, this patient off of this medication. However, there probably is going to be a lot more difficulty coming, having the patient come off of this medication with side effects or discontinuation symptoms than maintaining them on. This may be a case where I would decrease to the best of our ability without increasing symptoms and just maintaining to a safe, um, a level and watching the other medications that potentially are on board to interact with this medication. So that's one example. However, another example would be the 67-year-old male who's been on the medication for 10 years with no other comorbidities. This may be a guy who would tolerate coming off with support and with a lot of education and understanding of the risks to be coming for the future on this medication as well. Again, what we really need to be doing is engaging the patients, evaluating the patient, evaluating their comorbidities and approach it as a team to decrease this medication. Providers approach me often about how to start deprescribing with patients. How do I, where do I start? What do I look for? What's appropriate for me to do? And there is a really good framework that has been studied and looked at, um, called the ATAR model. And ATAR is an acronym for assess medication use, talk about risks versus benefits, look at the alternatives, plan next steps, engage the patient. And then reduce the dose. Starting with the first A, we want to look at assessing the medication use. What is the appropriateness of the medication? What is the length of therapy? How effective has it been? Has it been interacting with other medications? Have there been adverse effects? Is the patient compliant with it? And is there any potential for misuse or the diversion? When you're considering it, look at when the medication was prescribed. How many times have you changed the dose? Have they tried, anybody tried deprescribing or tapering? And what were the results? And what are the patients and or the family's views regarding the deprescribing? This can really help get you buy-in and help look at uh the patient's readiness and um and thoughts towards deprescribing. The next step is talking about the risks and benefits. Discussing the risks and benefits before the deprescribing and having a what could be a multi multi-appointment discussion can help the patient identify the risks and the Benefits of staying on this medication as well as withdrawal. The next day is for alternatives. We want to implement non-pharmacological interventions and or alternate medications that can target the symptoms which the medication was originally prescribed for. So, again, if the patient is on a benzodiazepine, but they're not on an SSRI, let's assess why, and if it's, they've never been on one, let's try to get them on it. And then reevaluate why and when they needed that medication. The next level is planning for next steps. Let's prioritize the medication to be tapered and substituted. We really want to talk about the final goal of the medication where it might be just to decrease it to the most minimally effective dose, because if the patient can't be weaned off, what is the next goal? We also need to determine the incremental dose reduction to implement, and that's patient by patient uh determine. And we also want to note that while there's specific guides to this, it might have to be personalized to the patient. So we want to complete a taper agreement where the patient acknowledges that they are going to be willing to come down. We want to select the appropriate medications. We also want to identify clinical and social support. So that might be our MAs or our nurses, and we want to establish routine follow-up where the patient feels comfortable coming back. E is for engaging the patient. We want to include the patient and the caregiver in each step of this process. Personalization is going to help increase engagement and using motivational interviewing techniques is really important to help get the patient involved. An example would be, so I'm hearing that you're taking it 3 times a day as the bottle says, but your anxiety isn't as bad in the evenings to warrant that 3rd dose. Do you think this, this is the dose that you could drop the, the next few weeks? And the patient may say, yes, let's go ahead and do it. And then the next question that you could ask them is, what do you think is a reasonable daily dose reduction for you? And they may say, I can try a half a tab a day, and that is good enough, and we're going to take it. R is for reducing the dose, so we're going to educate the patient on the signs and symptoms of withdrawal, dispose of any unused medications, dispense the appropriate number of medications to reflect your plan, and we want to provide monitoring and support. This is the time to engage our nursing staff and MAs for those phone calls and check-ins. And if you're willing and available, potentially using MyChart for these updates so that the patient feels that you're available to them. Your clinical team is vital to the, the benefit and the improvement of this and the implementation of this with your patients. Treatment guidelines are for benzodiazepine taper, recommend taking a look at whatever medication they're on and converting it to an equivalent dose of the diazepam. Diazepam is longer acting, but we also want to be careful and and cautious in older adults because it can be much more sedating by switching to diazepam, compared to alprazolam or lorazepam. If the diazepam equivalent dosing is over 14 mg, decrease by 2 mg every 1 to 2 weeks. If the diazepam equivalent is less than 14 mg, we want to decrease by 1 mg every 1 to 2 weeks. Please consider remaining on the current medication, uh, or the current uh benzodiazepine because if the patient's age or risk factors. Uh, require you to maintain the current medication, that's OK. Then you just want to decrease the dose by 5 to 20% every 2 to 4 weeks. And just be mindful that that last 25% of the tapering is very difficult for usually for the patient to tolerate, so you might want to go slower than the 2 to 4 week recommendation. Lastly, I just wanted to talk about my pearls that I've used and garnered through my time as a provider. I really try to start with having the patients on their own, trying to taper on their own within a framework that you uh aligned with them. You can start with every other day reduction or engagement for them to really try to prove that things won't necessarily worsen if they try to reduce that um medication dosing. For patients with multiple daily dosing, so BID or TID dosing, and they're taking it as frequent as that, I really try to get them to engage when their anxiety is at the worst and when it's not as bad, and when it's not, that dose when it's not as bad is targeting that one to reduce that specific dosage. Always consider pausing and the reduction of um any sort of tapering based on the patient's reactivity. Patients with severe anxiety may have declines in their anxiety naturally, and that's when we want to kind of step back and pause any sort of tapering. Also, remember to be flexible because things won't always go as you plan it. And also, let's acknowledge that discontinuation may not be possible. And then when that's the case, having that discussion with the patient and saying, hey, we're just gonna get you to that minimal effective dose. We always want to be minimizing risk as much as possible. And with that, the patient can know that you're also on their side, but they're also going to trust you that what you're doing is the right thing.
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